16 treatment, and hospitalization[3]. They suffer more often from co-morbid diseases, such as diabetes, high blood pressure or depression[3]. The Causal Pathway model of Paasche-Orlow, mentioned earlier, describes potential mediating mechanisms explaining why patients with LHL have worse health outcomes[28], but evidence for these mechanisms is lacking in CKD settings. However, there are some studies showing health literacy is associated with factors related to self-management and utilization of care. For example, LHL is associated with worse knowledge regarding kidney disease, transplantation care and medication[10,12,46–50]. LHL is also associated with health behaviors, for example with worse lifestyle and worse medication adherence[6,8,10,48,51]. In addition, patients with LHL have a lower likelihood of being waitlisted for or referred to transplantation[9,52], and visit the nephrologist more often[53]. However, several mechanisms within the pathway lack evidence, for example regarding the mediating role of patient-provider interaction and the role of system factors. More insight in these mechanisms is important to develop effective health literacy interventions. First, the impact of LHL on patientprovider interaction is largely unexplored in CKD research. As a result, the role of LHL during care consultations, and more specific the association of LHL with communication competences of both patients and HCPs, is unclear. In addition, there are no studies focusing on the role of CKD health care organizations and HCPs, and to what extent they are able to support patients with LHL. From studies in other health settings, it is known HCPs lack competences to communicate with patients with LHL effectively[5,21]. Patients often hide their health literacy problems[54], and struggle to derive meaning from consultations, or to take part in decision-making[55,56]. Last, there are not many health literacy studies in earlier CKD-stages. Consequently, evidence is limited to support strategies to prevent further kidney decline. HEALTH LITERACY INTERVENTIONS IN CHRONIC KIDNEY DISEASE The above illustrates that health literacy interventions targeted at patients and HCPs are important, however there is limited evidence on the effectiveness of such interventions. Existing studies in CKD only target patients and not HCPs.
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