Marco Boonstra

53 Our review is, to our knowledge, the first to unravel associations of LHL in CKD with a specific intervention focus; previous reviews have instead focused on predictors and prevalence of LHL in CKD[5,11] or on associations of LHL with outcomes[6,11]. Our review has a number of strengths. A first strength is our inclusion of several study designs to provide a complete overview of potential intervention targets and strategies. A second is its comprehensive search strategy, used to search three databases. The study selection, data extraction and quality assessment were set up and reported according to PRISMA guidelines. A third strength is our use of the Pathway of Paasche-Orlow and the IROHLA model, offering a theory-based approach to summarize the evidence and to identify research gaps. This review also has limitations. A first limitation is our use of two different quality assessment tools, possibly resulting in differences in quality rating between quantitative and qualitative studies. However, because we used a strict classification system to increase comparability, we expect no major biases. A second limitation is that we did not ask for grey literature and excluded several study types. We therefore might have missed information, but since we still provide an extensive overview, it is our opinion that such additional evidence would not greatly affect our conclusions. A third limitation is that we could not assess the effects of the way of measuring HL. Most studies measured functional HL, the ability to read and understand written and oral health information. Broader definitions and measures of HL, which include communication and critical literacy and contextual factors, have become more common only recently. The used measure may affect the associations found with mediating factors, for which we could not account. Our findings imply that health care organizations need to take action. Although the best intervention strategies remain underexplored, organizations could best start with targeting smoking behavior and transplantation processes. The web-based strategies that we identified are promising for improving knowledge and decision-making, and need further implementation in health care settings. Additionally new strategies need to be developed. Policy makers should seek ways to simplify navigation in the health system to improve care access.

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