226 psychological well-being, the social network, and self-management. This is an important addition to health literacy theories, such as the Causal Pathway model of Paasche-Orlow in Figure 7.2[27]. This pathway describes how health literacy influences health through three mechanisms: self-care, communication and utilization of care. Together these mechanism lead to worse health outcomes in patients with LHL[27–29]. We show these theories need to be enriched by including more emotional and contextual factors. These factors provide new targets for interventions that, to our knowledge, were not yet addressed in existing health literacy CKD interventions[30], but are also relevant for other health contexts. Figure 7.2 Causal Pathway model of Paasche-Orlow explaining the influence of health literacy on care access and utilization, communication and self-management, and how these mechanisms contribute to health outcomes. Co-creation of health literacy interventions During the development of GoYK, we applied co-creation methods. We learned this was useful to determine and enrich the intervention objectives, and to develop an intervention that meets the context, needs and competences of CKD patients with LHL and their HCPs. Our approach facilitated a fit of GoYK with the Race Education Age Occupation Employment Income Social Support Culture Language Vision Hearing Verbal Ability Memory Reasoning HEALTH LITERACY HEALTH OUTCOMES ACCESS AND UTILIZATION OF HEALTH CARE Patient Factors Navigation Skills Self-Efficacy Perceived Barriers System Factors Complexity Acute Care Orientation Tiered Delivery Model PROVIDER-PATIENT INTERACTION Patient Factors Knowledge Beliefs Participation in Decision Making Provider Factors Commmunication Skills Teacher ability Time Patient-Centered Care SELF-CARE Patient Factors Motivation Problem Solving Self-Efficacy Knowledge/Skills Extrinsic Factors Support Technologies Mass Media Health Education Resources
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