175 This confirms the usefulness of training professionals on health literacy[16,21]. Potentially, the unique strategies of GoYK contributed. GoYK builds the competences of patients and professionals, and guides the discussion of important health literacy related barriers. Thereby, the specific needs of these patients[27] are, expectedly, better integrated in consultations. However, GoYK was not meeting all patients’ needs: the effect on consultation related outcomes was lower for patients with LHL. Perhaps these patients might benefit more from simpler interventions targeting one problem at once[28]. We noticed that patients from general practices considered the intervention less useful. CKD is often not explained well by general practitioners[5]. Improving disease awareness is a precondition to engage in self-management, even more in patients with LHL[29]. GoYK could have targeted this more, to create a sense of urgency, before addressing self-management. In addition, we noticed 25% of the patients were suboptimal users of the intervention. To optimize use, the intervention needs better integration in the organizations’ care processes. For example, we suggest the card is sent with a consultation invite, or the dietician hands out lifestyle information. Study strengths are the thorough study design including organizations in primary and secondary care, the use of validated and objective measures, and a process evaluation. The work also has limitations. First, in quasi-experimental studies, there is a performance bias risk. Treatment policies within different organizations potentially influenced our results. Second, we did not find an effect on our primary outcomes, which may suggest other routes by which the intervention leads to reduction of hypertension than we hypothesized originally. Third, people with very low health literacy seem underrepresented, because consent procedures might preclude people facing difficulties with reading or language proficiency from participating, for example when they need to read information letters. Our study holds implications for research. Our intervention[15] is a blueprint for researchers aiming to optimize self-management and consultations in many care settings and contexts. We advise the development and testing of more interventions for patients in general practices, as GoYK was less effective for them. At the same time, we suggest replication of our work to better understand how the intervention works exactly. In addition, considering the participation rate
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