222 found it challenging to maintain improvements in lifestyle on the long-term. They mentioned to fall for temptations, to give up, or to value their quality of life over a strict treatment regime. HCPs experienced problems to identify and support patients with LHL. They said to lack knowledge on how to recognize patients with LHL during consultations. In addition, they shared the communication strategies they normally used to provide information or motivate patients, was not effective for patients with LHL. In the fourth chapter, we stepwise developed a multi-component health literacy intervention targeting CKD patients with LHL and HCPs, based upon the results of chapters 2 and 3. First, we aimed to determine the objectives and strategies for the intervention. Second, we aimed to design and produce the intervention and evaluate if it was usable, comprehensible, and met the needs of the target groups. To reach this aim, we combined the principles of the intervention mapping protocol[11] with methods of co-creation. First, we developed a change model. From patients, we learned important change objectives related to understanding the risks of CKD, discussing lifestyle barriers during consultations and preventing relapse. Second, we developed and produced a four-component intervention, Grip on Your Kidneys (GoYK). Patients and HCPs helped to select intervention strategies to ensure these fitted the competences of patients with LHL and the context of CKD. The final intervention consisted of a website, consultation card and brochures to improve patients’ CKD knowledge and their competences to prepare, act upon, and maintain self-management. In addition, we developed an e-learning and workshop to train HCPs to better identify and support patients with LHL. Evaluation showed the different components of the intervention were usable, useful and comprehensible for CKD patients with LHL and HCPs. In the fifth chapter, we assessed the effect of the GoYK intervention on selfmanagement of health behaviors, patient activation, clinical parameters, quality of consultations, and the HCPs’ use of health literacy strategies. Additionally, we evaluated the use and usefulness of, and satisfaction with the intervention. To reach this aim, we conducted a quasi-experimental study. We found GoYK to be effective in reducing hypertension and improving the
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