21 filtration rate, blood pressure, and BMI, was assessed. A cost-effectiveness analysis was performed according to the Dutch guideline for economic evaluation in healthcare[78]. In this analysis, a Markov Model was used. This model assumes patients stay in one cycle (i.e., a defined health state, for example CKD-stage 3) for a certain time and then make a transition to another cycle (for example CKD-stage 4). The Markov Model is used to extrapolate the effects found in the quasi-experimental study on a lifetime horizon[79]. Such a model was needed, as the timespan of our intervention study was nine months, and insufficient to find effects for a longer period. We included different parameters in the model, such as mortality, CKD progression, quality of life and medical costs. Combined with an estimation of the costs of the intervention, these parameters help to determine if the intervention is cost-effective. More information on the above is in Chapter 5 and 6. RESEARCH GAPS In this thesis, we address several research gaps, also mentioned above. At the start of our research, it was unclear which factors should be a priority for interventions aiming to optimize self-management of CKD patients with LHL. Additionally, the barriers HCPs experience when treating patients with LHL, were unknown. Therefore, the first step in our research intended to identify what interventions need to target to support both CKD patients with LHL and HCPs to overcome health literacy related barriers. Second, there were only few tailored interventions to mitigate the effects of LHL in CKD setting. The existing interventions targeted only patients, mainly with severe CKD. The best intervention strategies for prevention, and to support patients with LHL and HCPs in earlier stages of CKD, were unknown. Therefore, we aimed to identify these strategies and develop an intervention with input of patients and HCPs. Third, there were almost no high-quality studies analyzing the effect of health literacy interventions in CKD health setting. We performed a quasi-experimental study to analyze the effectiveness of the developed intervention. We evaluated if the intervention was able to improve clinical outcomes, several competences of CKD patients, such as self-management and communication competences, and the competences of HCPs to support patients with LHL. Additionally, we determined if the developed intervention was cost-effective.
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