Marco Boonstra

146 not prescribing to involve the target groups in all steps, we advise a combination of those methods to facilitate intervention development. This study has several strengths. First, our methodology enabled to produce an intervention, which is tailored towards the specific needs of patients with LHL, their HCPs, and the context of CKD care. Second, with the AAHLS and recruitment procedure, we managed to include patients with measured LHL, and often of low education. They are often underrepresented in research and the most important target group for HL research. Third, our evaluation indicated the intervention was to the satisfaction of the target groups and seemed to have impact on knowledge and competences. Also limitations are worth mentioning. First, only four patients pilot-tested the intervention, which may limit the generalizability of our findings. However, as patients and the advisory board participated in earlier steps and the assessment tools gave good results, we expect our findings to be applicable for CKD setting. Second, the intervention for HCPs was only tested with nurses. Despite that, we expect findings to be generalizable to other CKD professionals, as an evaluation of the training of Kaper et al, yielded similar results among HCPs from different professional backgrounds[38]. Third, it is possible our interviews did not reveal all relevant objectives and determinants. Teasdale et al., for example, mention experiences, such as uncertainty about CKD causation and perceived loss of freedom [59], which were not mentioned by the participants. Our study has implications for both research and practice. For researchers, we show the principles of IM and co-creation are useful when developing interventions, for example to uncover unexpected objectives or select the best strategies. We also illustrate it is possible to align interventions for patients and HCPs, strengthening their communication, and we invite researchers to develop similar interventions. More HL interventions, targeting communication and self-management behaviors need to be researched, preferably using strong intervention designs, such as randomized control trials, in larger groups of participants. For practice, our study has several implications. First, our study revealed patients with LHL need improved support to maintain behavior chances and

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