221 MAIN FINDINGS To reach the main aim, mentioned above, we conducted multiple studies. The separate aims and findings for each study are summarized below, per chapter. In the second chapter, we aimed to identify potential targets and strategies for our health literacy intervention by summarizing the evidence on: (i) patient- and system-level factors potentially mediating the relation between LHL and health outcomes; and (ii) the effectiveness of health literacy interventions customized to CKD patients. To reach this aim, we conducted a systematic review. In the review, we could include 48 studies, which were often of low quality. Studies including patients in earlier stages of CKD, and on communication of patients and HCPs, were scarce. In general, we found weak evidence for an association between LHL and potential mediating factors of the relationship between LHL and health outcomes. For example, we found weak evidence LHL was associated with worse CKD and treatment knowledge, worse self-care behaviors, including lifestyle and medication adherence, and more frequent doctors’ visits. We found strong evidence for an association of LHL with current smoking. We also found strong evidence LHL was associated with delayed kidney transplantation processes. We identified only six studies with health literacy interventions. These were effective in improving knowledge, decision-making, and health behaviors in patients with CKD and LHL, but evidence was weak. In the third chapter, we aimed to identify targets and strategies to optimize self-management by exploring experiences with and barriers for selfmanagement, from the perspectives of both patients with CKD and LHL and of HCPs. To reach this aim, we conducted a longitudinal, qualitative study. Several themes arose from the interviews and focus group discussions. Patients, especially in earlier stages of CKD, shared to be unaware about their diagnosis, and to lack knowledge regarding CKD and self-management. They also mentioned the information given by HCPs was suboptimal to fully understand CKD and self-management. In addition, patients mentioned to have problems to act upon the advices of HCPs. Negative emotions, low risk perceptions and avoidance stood in the way to self-manage medication and lifestyle. Patients
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