40 Self-care management 25 studies gave generally weak evidence for an association of LHL with a variety of mediating factors related to self-care management. We found strong evidence for an association of LHL and current smoking[7,33,34]. Three studies provided weak evidence for mediation, finding associations of LHL with worse perceived CKD treatment knowledge[41], less healthy lifestyle patterns[34] and choosing to spend money on expenses other than medications[40], and, additionally, associations of these mediating factors with health outcomes. For other factors, evidence was weak or inconsistent. LHL was associated with worse control of blood pressure[43,44], lower medication adherence confidence[45,46] and lower quality of life[47]. For worse treatment and self-care knowledge[7,37,41,46,48–51], worse self-care behaviors[7,43,49,52,53], including lifestyle[34,52,53], and adherence problems[8,46,53–55] some studies found an association with LHL, while others did not. LHL was not associated with CKD-awareness[56,57], treatment preferences[35], disaster preparedness[58] and phosphate regulation[59]. According to multidomain screeners, patients perceived self-care management as their biggest HL challenge, especially in severe CKD-stages[60–62]. Utilization of care 23 studies provided generally weak evidence for an association of LHL with factors related to utilization of care. We found strong evidence that LHL is associated with a suboptimal transplant process, illustrated by a lower likelihood of being wait-listed for[36,38,39], or referred to[35] transplantation and ‘not knowing the next step in the transplant process’[37]. Connected, we found weak evidence that LHL is more prevalent in non-waitlisted and deceased donor patients compared to waitlisted and living donor patients[33,44]. For other transplant factors, such as treatment preference[35,63] or attending evaluations[37], no HL associations were found. Further, we found weak evidence LHL was associated with visiting the nephrologist more often[8], problems to use digital health information[64] and missing dialysis[42,65]. For associations of LHL with higher rates of hospitalization[54,55,65–67] and more emergency department visits[65,66] studies confirmed and denied HL associations. LHL was not associated with abbreviating dialysis[42,65]. According to multidomain
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