231 as salt intake, smoking and physical exercise. It is possible our results may have changed had we analysed to what extent patients improved the combination of health behaviors. Related to GoYK’s effect on hypertension we found the intervention could save costs, gain QALYs for CKD patients across their life course, avert deaths, and prevent the need for dialysis treatment among patients with severe CKD (Chapter 6). Our findings illustrate that relatively simple interventions targeting at-risk populations can reduce costs and improve the patients’ health. However, analysing the cost-effectiveness of a health literacy intervention is still uncommon. In an extensive review on health literacy interventions, we only found one study examining the cost-effectiveness of an intervention to promote adherence to congestive heart failure medication. This multi-component pharmacist-led intervention showed trends toward cost savings compared with care as usual when considering the intervention, outpatient, and inpatient costs[55]. Compared to that study, the cost-reduction due to our intervention is large. This large effect stems mainly from averting the high expenses of dialysis treatment, along with the low costs of the intervention. If over the long-term GoYK can improve other clinical parameters, such as eGFR, then we may be underestimating the cost-effectiveness of our intervention. We did not have sufficient data to study this effect, but expect this is plausible as some topics in our intervention, such as ‘exercising more’ or ‘drinking less alcohol’ are not specific for CKD. METHODOLOGICAL CONSIDERATIONS In this project, we applied multiple methods to stepwise develop and evaluate a health literacy intervention targeting CKD patients with LHL and HCPs. Below we discuss advantages and disadvantages of combining a systematic review, qualitative and quantitative methods. Thereafter, for these methods, we address the quality of our samples, the quality of the information in our studies and the issues of causality and confounding. Combining multiple methods The use of multiple methods in the various studies on which this thesis reports is a strength as they complement each other. Together these methods led to
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