121 INTRODUCTION At least 25% of chronic kidney disease (CKD) patients have limited health literacy (LHL)[1], which is associated with faster kidney function decline and higher mortality[2,3,4]. Health literacy (HL) is ‘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’[5]. To improve the health outcomes of CKD patients with LHL, it is necessary to tailor healthcare to their needs[6]. Patients with LHL often have insufficient self-management capacities[7,8,9]. Self-management is defined as the ability to manage the symptoms, treatment, physical and psychosocial consequences, and lifestyle changes inherent in living with a chronic condition. Efficacious self-management encompasses the ability to monitor one’s condition and to affect the cognitive, behavioral and emotional responses necessary to maintain a satisfactory quality of life[10]. Interventions directed at patients have been proven effective at optimizing selfmanagement[10]. To support self-management, healthcare professionals (HCPs) not only need to provide patients with information, but also help them to build the confidence and skills to fulfill self-management activities[11]. However, several communication barriers between HCPs and patients with LHL exist that may hinder effective self-management. For example, patients are less able to discuss their needs and have problems retrieving and understanding information provided during consultations[12,13]. HCPs often fail to recognize patients’ LHL, tend to overestimate patients, and lack the competence to mitigate HL-related problems effectively[14,15]. Recently, we uncovered multiple additional self-management and communication barriers related to LHL that are CKD specific. These are the starting point of the intervention development in this study. Details are in Supplementary File 1. In brief, the main barriers are that HCPs have problems responding to HL problems and provide limited information when patients experience mild to moderate CKD. Patients with severe or end-stage CKD consider information to be overwhelming, and self-management of lifestyle
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