228 inequalities[37,38]. These results illustrate the utility of co-creation, especially when developing interventions for hard-to-reach target groups, such as those with LHL or with lower socio-economic status. Our process evaluation revealed that most participants used GoYK as intended and found it useful, albeit this was less among participants in general practices compared to patients from nephrology clinics (Chapter 5). In general, cocreation improves the acceptability and implementation of interventions[39], and we expect this is, in general, also the case for GoYK. However, our results illustrate that a process of co-creation might not address all relevant contextual factors that influence the acceptability and implementation. We noticed the care processes and the approach in care consultations by HCPs differed between the participating general practices in our studies. It is plausible that the discussions in our co-creation study, with a relatively small number of participants, were insufficient to guarantee acceptability in the different general practices in our quasi-experimental study. In addition, when we compare the methods in our research with co-creation theories, we could have focused more on implementation. For example, the Double Diamond, a theoretic framework, describes four process steps to co-create interventions[40]. Our efforts focused mostly on discovering the target groups’ needs, defining the intervention objectives and designing the intervention, which are the first three steps in the Double Diamond. With more resources and time, we could have better unraveled barriers and facilitators of the intervention delivery, as this optimizes the implementation of interventions[41]. Effectiveness and cost-effectiveness of health literacy interventions The developed intervention, GoYK, was effective and cost-saving. Goyk reduced the number of patients with hypertension, and improved the quality of consultations and the competences of HCPs to support patients with LHL. We found no significant effect on our primary outcome, self-management. Based upon the result for hypertension, we estimated that the intervention would be cost saving and if it were more widely implemented, it would avert deaths and dialyses (Chapter 6).
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