230 GoyK also increased the quality of consultations and the competences of HCPs to recognize and support patients with LHL. This adds to the evidence showing that health literacy interventions can optimize patientprofessional communication[45,46]. This is important as high-quality, patientcentred communication is key to improve self-management and health outcomes[47–49]. A possible explanation for our findings is that the training of HCPs, in conjunction with the consultation cards, improved shared decisionmaking. We know communication competences, specifically information quality and engagement of patients, are key elements of shared decision-making[50]. These elements were likely influenced by the intervention, with patients‘ engagement and information quality being increased by their filling in of the topics or barriers they wanted to discuss, and HCPs gaining the competences to respond to these. GoYK may have decreased hypertension via improved communication. If this is true, our findings provide evidence that supports a proposed mechanism in the pathway of Paasche-Orlow (Figure 7.2). This pathway describes communication as a mediator between health literacy and health outcomes[27]. Our finding then illustrates enhancing communication can lead to better health outcomes[51]. GoyK did not have an effect on self-management of health behaviors and its effects were weaker in general practices and in patients with lower levels of health literacy. Many other studies do not find an effect of interventions on health behaviors, especially over the long term[31]. This may be explained in several ways. First, the interplay between CKD, hypertension, but also diabetes, is complicating self-management. Over time, self-management can become more and more challenging, when patients become more ill and the burden of their different diseases is growing[52,53]. In our study, many patients experienced multiple diseases for many years, which may have made self-management more challenging. We expect our intervention may be more effective when targeting patients who have recently been diagnosed with CKD. Second, the multicomponent approach of GoYK might not fit the needs of patients in general practices or with LHL well enough. Interventions with simpler designs, tackling one very specific problem and with a lower burden for the patient, have been suggested to be more effective in improving self-management[54]. Last, we analysed improvements in self-management for separate health behaviors, such
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