225 patients with LHL the most, as they find it challenging to ask for clarification or use other informational resources. As LHL is a widespread problem, also in other patient groups and health contexts[18], targeting communication is promising to optimize the health of people with LHL. Of note, in our review, we did not find studies on the health literacy competences of HCPs in CKD care settings (Chapter 2), although HCPs mentioned lacking the competences to appropriately recognize and support CKD patients with LHL (Chapter 3). It is widely recognized that HCPs have limited education and practice opportunities to develop the competences to support patients with LHL[19,20]. An explanation for this finding is that health literacy research initially focused on improving the competences of patients[21]. As a result, research on interventions targeting HCPs, and on more complex interventions that target both patients and HCPs simultaneously, is limited. This lack of evidence potentially explains why education about health literacy has not yet been sufficiently incorporated into practice. Existing studies often focus on the competences of HCPs to provide simple information and check patients’ understanding[22]. Building upon the work of Kaper et al.(26,27) and the conclusions in the review by Coleman et al.[22], our work adds important targets for trainings. For example, we show that HCPs in chronic disease care settings need competences that go beyond the provision of information, such as the ability to enable shared decision-making and to support long-term self-management. Furthermore, our results indicate that it is important to adapt trainings to the context of separate diseases. HCPs mentioned CKD-specific obstacles when supporting patients with LHL, which illustrates that more generic health literacy trainings do not meet all of their needs[20,23]. We also showed that CKD patients with LHL face a wide range of barriers to optimize and maintain their long-term self-management, especially regarding health behaviors. For example, patients mentioned how mental problems, falling for temptations, seeing few risks of having CKD, and limited social support hindered their self-management (Chapter 3 and 4). Our work complements previous studies conducted in people with diabetes and heart failure that found LHL is associated with lower self-efficacy, more mental health concerns and lower social support[6,24–26]. In addition to these findings, our results indicate an interplay between health literacy, awareness, knowledge, disease perceptions,
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