Marco Boonstra

12 health literacy. This encompasses if a person has ‘sufficient basic skills in reading and writing to be able to function in everyday situations’. The emphasis on selfmanagement, since the beginning of 21st century, broadened the perspective on health literacy[23]. To be able to self-manage health, disease and treatment, people need ‘more advanced cognitive and literacy skills which together with social skills, can be used to actively participate in everyday activities, to extract information and derive meaning from different forms of communication, and to apply new information to changing circumstances’. These skills are referred to as communicative or interactive health literacy. Additionally, people need ‘skills to critically analyze information, and to use this information to exert greater control over life events and situations’, referred to as critical health literacy[24]. Health literacy has long been treated as an individual asset. However, the role of the healthcare system has gained attention. LHL negatively influences someone’s capacity to self-manage, to communicate with HCPs and health outcomes[25]. On the other hand, HCPs often lack competences to communicate with patients with LHL effectively, while healthcare systems are often complex. By optimizing the healthcare system and empowering communities, for example by including the patient in the development of care strategies and policy, the negative effects of LHL can be mitigated[26,27]. An important model to understand how health literacy may influence health outcomes is the Causal Pathway model of Paasche-Orlow (Figure 1.1). According to this model, the patient’s health literacy affects three different mediating mechanisms: the utilization of care, communication between patients and HCPs, and self-management. Within these mechanisms, LHL has a negative impact on patient factors, for example when patients are less able to gain knowledgeable on self-care, or less competent in making care decisions with the HCPs. In addition the model shows the role of system factors. Worse outcomes for patients with LHL are expected when care is difficult to access or HCPs lack teaching ability or communication skills[28]. Together these patient and system factors, can either optimize or worsen health outcomes[28]. To improve the health outcomes of CKD patients with LHL, the precise influence of LHL on selfmanagement, CKD care and communication between patients and HCPs needs further unraveling.

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