69 INTRODUCTION In 2017, 697.5 million people were diagnosed with Chronic Kidney Disease (CKD) of whom 1.2 million died[1]. The latter is expected to rise to 2.2-4.0 million in 2040[2]. An estimated 25% of CKD patients with limited health literacy (LHL) are at risk[3], since they experience faster kidney deterioration and higher mortality[4,5]. Health literacy (HL) is defined as the degree to which people are able to access, understand, appraise and communicate information to engage with the demands of different health contexts to promote and maintain good health across the life course[6]. To prevent and slow down the rise of CKD, actions that support patients with LHL are needed. Health care professionals (HCPs) promote self-management to maintain kidney function[7–9]. Self-management refers to the individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a chronic condition[10], and is difficult for patients with LHL. These difficulties are illustrated by an association of LHL with worse treatment knowledge[11,12], lifestyle[4,13–16] and medication management[9,12]. The self-management experiences and barriers of CKD patients with LHL remain largely unknown. Communication barriers between HCPs and patients with LHL may influence self-management, but evidence in CKD is scarce. For example, HCPs often overestimate patients and lack competencies to communicate with them effectively[17–19]. Additionally, patients often hide their LHL[20] and struggle to take part in decision-making[19,21,22]. In general, CKD patients consider information during consultations[23–25] or in self-help materials[26] as insufficient or difficult. A deeper understanding of these communication barriers is essential to identify strategies to optimize self-management. It is important to know if common strategies to promote self-management are effective for patients with LHL. In the Netherlands, every inhabitant has a general practitioner (GP), who delivers primary care in case of illness, and is gatekeeper of the more specialized secondary care. The GP increases CKD awareness and stimulates lifestyle changes to stabilize kidney function[27]. The GP will refer to hospital care when patients experience moderate to severe CKD.
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