248 and professionals. Regarding mediation, the included studies provided, in general, weak evidence of an association of LHL with factors related to selfmanagement and utilization of care. For example, we found weak evidence that LHL was associated with worse CKD and treatment knowledge, worse self-care behaviors, including lifestyle and medication adherence, and more frequent doctors’ visits. However, we found strong evidence for an association of LHL with current smoking. We also found strong evidence LHL was associated with going through processes of kidney transplantation slower. Regarding health literacy interventions, we identified only six studies. These studies provided weak evidence that these interventions improved knowledge, decision-making, and health behaviors in CKD patients. In Chapter 3, we describe the findings from in-depth interviews and focus group discussions with 24 CKD patients with LHL and 37 health care professionals, conducted following a longitudinal study design. From our data, several themes arose that influence self-management of CKD patients with LHL. Patients, especially in earlier stages of CKD, reported to be unaware of their diagnosis. They also mentioned the information given by health care professionals was suboptimal to fully understand CKD and self-management. Additionally, they stated to experience barriers to act upon professionals’ advices regarding lifestyle and treatment. Negative emotions, low risk perceptions and avoidance stood in the way to take the driver’s seat regarding the management of CKD. Patients also said it was challenging to keep self-managing on the long-term, for example, when they fell for temptations or valued quality of life over a strict treatment regime. Professionals experienced problems to identify and support patients with LHL, and a lack of knowledge on the indicators of LHL. In addition, they reported their routine communication strategies to provide information or motivate patients, to be not effective for patients with LHL. Based upon the above results, we developed a multi-component health literacy intervention targeting CKD patients with LHL and health care professionals. In Chapter 4, we describe the development process, combining the intervention mapping protocol with co-creation methods. First, we developed a change model. From patients, we learned important change objectives related to understanding the risks of CKD, discussing lifestyle barriers during consultations and preventing relapse. Second, we developed and produced a four-
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