15 To be effective in self-management, patients need to develop or possess several competences. First, patients need good communicative health literacy, for example to ask questions during consultations with HCPs. This helps to understand the nature of CKD and the treatment. Second, patients need competences to form partnerships with the care team and their social network to share their needs and barriers in self-management, so that this can be improved. Third, at home, they have to adhere to the treatment and act proactively in their self-care, for example by monitoring their symptoms or taking medications. Fourth, to maintain changed health behaviors, patients have to feel confident and remain convinced their self-management is beneficial for their health and well-being[37]. Furthermore, multiple barriers may reduce the patients’ capacity to self-manage effectively. First, poor understanding of the disease and treatment complicates effective self-management[42]. Second, ineffective communication with HCPs has a negative influence on the patient’s self-management[43]. Third, changes in the patient’s identity, such as physical, social or mental problems, interfere with active participation in self-management[42]. Last, the absence of symptoms in mild to moderate CKD lead to lacking urgency to self-manage, while the severe disease and treatment burden in kidney failure may result in giving up on self-management[19,42]. Despite this knowledge, it remains uncertain how interventions, but also HCPs, can best optimize self-management, and what the precise role is of LHL remains unclear. THE ROLE OF LIMITED HEALTH LITERACY IN CHRONIC KIDNEY DISEASE LHL seems to have a role in the development and progression of CKD. In CKD patients, LHL is prevalent and associated with socio-economic characteristics, such as being of lower education or less able to speak the language of the country of residence[44]. The more severe CKD becomes, the more prevalent LHL is among the patient population[45]. This could indicate these patients have more problems to prevent kidney deterioration. It is known patients with LHL have a higher chance of CKD related mortality, fast kidney deterioration[3], developing CKD[45], worse kidney transplant outcomes, missing dialysis
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