13 Race Education Age Occupation Employment Income Social Support Culture Language Vision Hearing Verbal Ability Memory Reasoning HEALTH LITERACY HEALTH OUTCOMES ACCESS AND UTILIZATION OF HEALTH CARE Patient Factors Navigation Skills Self-Efficacy Perceived Barriers System Factors Complexity Acute Care Orientation Tiered Delivery Model PROVIDER-PATIENT INTERACTION Patient Factors Knowledge Beliefs Participation in Decision Making Provider Factors Commmunication Skills Teacher ability Time Patient-Centered Care SELF-CARE Patient Factors Motivation Problem Solving Self-Efficacy Knowledge/Skills Extrinsic Factors Support Technologies Mass Media Health Education Resources Figure 1.1 Causal Pathway model of Paasche-Orlow explaining the influence of health literacy on care access and utilization, communication and self-management, and how these mechanisms contribute to health outcomes. CHRONIC KIDNEY DISEASE CKD is defined as having abnormalities of kidney structure or function, present for three months, with implications for health[29]. In 2017, worldwide, 697.5 million people were diagnosed with CKD, of whom 1.2 million died as a result. In 2040, an expected 2.2 to 4.0 million people will decease because of CKD[30]. According to the Dutch Kidney Foundation, the prevalence of CKD in the Netherlands is 12% and thereby comparable to the global estimate[31]. Non communicable diseases, such as diabetes and hypertension, and ageing, are important causes of the rising prevalence of CKD[32]. On the other hand, CKD is a risk factor for developing cardiovascular diseases[33]. CKD is generally irreversible, and progresses through five stages, with each stage reflecting a decline in kidney function. In CKD-stages 1 to 3, there is only a mild to moderate decline in function. Symptoms are often absent or mild, and patients are not always aware of having CKD. Underdiagnoses and insufficient
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