Marco Boonstra

11 The main aim of this thesis was to develop and test a multi-component health literacy intervention to optimize self-management of CKD patients with LHL, and to strengthen communication between these patients and their HCPs. We aimed for an intervention optimizing care in both general practices and nephrology clinics, as those settings are responsible for treating patients in different stages of CKD. First, we identified potential targets and strategies for our health literacy intervention. Second, we developed the multi-component intervention, targeting the barriers of both CKD patients and HCPs. Last, we assessed the effectiveness and cost-effectiveness of our intervention. In this introduction, we provide background information on the topics addressed in this thesis. First, we describe the concept health literacy and potential mechanisms by which health literacy influences health outcomes. Second, we provide information on CKD and on kidney care in the Netherlands. Third, we describe the importance of self-management and communication in CKD and the role of LHL in CKD. Fourth, we provide information on promising health literacy intervention strategies. Fifth, we describe the development process of our health literacy intervention, as well as how we evaluated the effectiveness and cost-effectiveness. This section includes the methodologic approaches used, i.e. Intervention Mapping, co-creation, and Markov modeling. Last, we conclude with the specific research objectives and an overview of this thesis. HEALTH LITERACY Health literacy is defined as the degree to which people are able to access, understand, appraise and communicate information to engage with the demands of different health contexts to promote and maintain good health across the life course[13]. Many people have difficulties to maintain their health due to limited health literacy. For example, in the adult European Union population, a study conducted among 8000 people reported 47% of the participants experience LHL. In the Netherlands, the prevalence of LHL is estimated at 29%, and is higher among males, people with low education and low perceived socio-economic status[1,22]. People need various health literacy skills to maintain good health and to engage with the demands of health contexts. Most researches focus on functional

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