23 OVERVIEW OF THE THESIS An overview of this thesis with research phases, chapter numbers, methods and study aims is in Figure 1.3. This thesis consists of seven chapters. This Chapter 1 provided background information. Chapter 2 describes the results of a systematic review, in which we analyzed 48 scientific articles regarding HL and CKD. In this chapter, we summarize the strength of the evidence on relationships between health literacy and a variety of patient- and system-level factors, and on the effectiveness of HL interventions customized to CKD patients. Based upon the results, we identify promising intervention targets and strategies. Chapter 3 gives the results of a longitudinal qualitative study with in-depth interviews and focus group discussions. We give an overview of experiences and barriers for self-management from the perspectives of patients with LHL and HCPs. Chapter 4 describes the development of Grip on Your Kidneys, based upon the intervention mapping protocol and methods of co-creation. First, we show the process of determining the intervention objectives and strategies of a multi-component intervention targeting CKD patients with LHL and HCPs in CKD health settings. Second, we describe the designing and producing of the intervention, and the perceived usability and comprehensibility of the intervention and its fit to needs of the target groups. Chapter 5 gives the results of a quasi-experimental study with an intervention and control group. In this chapter, we describe to what extent the intervention is able to improve patient activation, clinical parameters, quality of consultations, and the HCPs’ use of health literacy strategies. We also share the results of a process evaluation upon the use and usefulness of, and satisfaction with the intervention. Chapter 6 describes the results of a cost-utility analysis, using a Markov model. We extrapolated the effects found in the quasi-experimental study on a lifetime horizon, to learn if the intervention leads to a cost-reduction, compared to careas-usual. Chapter 7 is a general discussion in which we reflect upon our most important results, methodological considerations and recommendations for practice and future research.
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