174 DISCUSSION GoYK did not affect patients’ self-management of health behaviours. However, it reduced hypertension and improved the use of health literacy strategies by professionals and the consultation quality. Patients and professionals considered the intervention useful, though it was less suitable for patients with LHL and from general practices. The intervention had no significant effect on self-management or patient activation. Behavioural interventions often show no effect[20]. Some reasons could explain our results. First, patients, in general, showed good lifestyles and patient activation at baseline, which probably induced a ceiling effect. This finding might seem incompatible, considering our focus on patients with LHL. However, many patients have experienced CKD for years, and we expect this to be the result of years of treatment. Second, another study found that lower patient activation is associated with having a lower eGFR[21]. Potentially, the more complex healthcare needs of many patients in our sample make improvements in activation and self-management difficult. Third, the use of selfreported measures has limitations, and objective measures might show lifestyle improvements better[22]. The decrease in hypertension in the intervention group is promising for preventing kidney function deterioration[23]. GoYK appears to be the first CKD health literacy intervention affecting a clinical parameter [14]. We hypothesize the intervention induced a variety of lifestyle improvements in patients with inadequate health behaviours, leading to these better blood pressures. Our study then adds evidence intervening on lifestyle can improve hypertension[24]. The Causal Pathway model of Paasche-Orlow and Wolf helps to understand the mechanisms behind this finding. The model theorizes that health literacy influences self-management and patient-professional communication, resulting in the generally worse health outcomes of patients with LHL[25]. Following this model, improved communication may have contributed to the reduction in hypertension[26]. This effect of communication is plausible, as GoYK improved the use of health literacy strategies by professionals and the perceived quality of consultations.
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