33 INTRODUCTION In the last few decades the number of people suffering from chronic kidney disease (CKD) has steadily increased[1,2]. In the United States, people between the ages 30 and 49 have a 54% chance of experiencing CKD during the course of their lives[3]. Often, kidney deterioration is almost unnoticeable, potentially leading to End Stage Kidney Disease (ESKD), which is associated with high morbidity, mortality and economic burden[3]. The growing prevalence of CKD indicates a need to prioritize the development of interventions to retard or prevent this disease[4]. About 25% of the CKD patients experience limited health literacy (LHL)[5]; this has been shown to be associated with worse health outcomes[6], such as faster kidney deterioration[7,8] and higher mortality[9]. Health Literacy (HL) is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions[10]. Previous systematic reviews have summarized the evidence on predictors[5,11] and serious negative impact of LHL in CKD[6,11]. However, these did not address the available evidence on the mechanisms by which LHL leads to worse health outcomes and on how interventions can target these mechanisms to improve that situation. The Pathway of Paasche-Orlow provides a theory of patient- and system-level mechanisms, which contain multiple factors that might mediate the relation between LHL and health outcomes[12]. Targeting these mediating factors with interventions potentially improves the health of patients with LHL. Patient-level factors refer to the patients’ capacities for self-management (e.g. medication adherence), utilization of care (e.g. seeking and obtaining professional help), and patient-provider interaction (e.g. effective communication). However, these capacities highly depend on system factors, such as health system complexity, the patient’s social context, and the capacities of the health care professional[12]. In other research fields, LHL has been found to be associated with several of these mediating factors[13–16], but the role of these factors in CKD is unclear.
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