145 indicate, as is stated by Brach et al, that health care organizations should indeed focus on designing audiovisual information and implementing HL strategies in consultations to improve care for patients with LHL. Our work also shows the relevance of including the patient in the design and evaluation of HL strategies, by using methods of co-creation in the various stages[27,37,56]. In addition to existing knowledge, we show the type of care, patient’s competences, and disease severity, have influence on the preferred intervention strategies. For example, both the high-intensity dialysis schedule and fear to speak up for themselves, which is associated with LHL[12,13], hindered the patient’s willingness to visit group meetings. While, patients with mild to severe CKD expected to benefit more from improved consultations, as they felt to lack information and some topics were not discussed. Considering our found preferences, it is contradictory many HL interventions in CKD are web-based[18,23,57]. We show several patients mention to lack skills or devices to use these strategies. Our study illustrates the importance of offering intervention flexibility. For example, when patients lack reading skills, they benefit from the website as text is read aloud. While, with limited digital skills, a brochure fits better. However, when patients lack both reading and digital skills, or do not speak Dutch, we think our intervention still has shortcomings. Our pilot testing revealed the intervention was useful, comprehensible and fitting the needs of both patients with LHL and HCPs. It also revealed barriers for implementation, such as the length and accessibility of the intervention, which lead to refinements. The added value of the IM protocol mainly lied in the exploration of implementation barriers. Other studies with similar interventions, not developed according to our methods, have limited attention to the incorporation in daily practice[20,37,47]. Our results indicate the intervention has potential to promote self-management among CKD patients with LHL, but a high-quality randomized control trial with a process evaluation is needed to learn about effectiveness and implementation[56]. We successfully combined the IM protocol with co-creation methods to develop Grip on your Kidneys. The protocol sets the framework to determine the objectives and strategies, and produce and evaluate the intervention. Cocreation methods, within the different steps, heightened the relevance of the intervention and the chance of successful implementation. As the IM protocol is
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