247 • To determine the objectives and strategies for a multi-component intervention targeting CKD patients with LHL and health care professionals. Moreover, to design, produce and evaluate the intervention to meet the needs of the target groups (Chapter 4). • To assess the effect of the intervention on self-management of health behaviors, patient activation, clinical parameters, quality of consultations, and the health care professionals’ use of health literacy strategies. Moreover, to evaluate the use and usefulness of, and satisfaction with the intervention (Chapter 5). • To analyze the cost-effectiveness of the intervention by evaluating the effects of the intervention on quality-adjusted life years and healthcare costs in the Netherlands compared to care as usual (Chapter 6). To reach the aims, we conducted multiple studies. Below, we describe the results of these studies and the content of the general introduction (Chapter 1) and general discussion (Chapter 7). In Chapter 1, we provide background information, introduce important concepts and show our main aims. First, we describe the concept health literacy and provide information on CKD and the organization of CKD care in the Netherlands. Then, we introduce the concept self-management and explain barriers and facilitators for self-management, with specific attention for communication between the patient and the professional. Next, we describe the role of LHL in CKD, and how evidence is lacking by which mediating mechanisms health literacy is leading to worse kidney health outcomes. Then, we explain promising health literacy intervention strategies, as well as theories and methods for intervention development. Last, we introduce how the effectiveness and costeffectiveness of such interventions can be determined. In Chapter 2, we present evidence from a systematic review on factors potentially mediating the relationship between LHL and health outcomes, and on the effectiveness of CKD health literacy interventions. In the review, we could include 48 studies, which were mostly of low quality and on patients in later stages of CKD, and not covering communication between patients
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