70 There, nephrology specialists discuss stricter lifestyle and medications[28,29], and, if needed, renal replacement therapies[30]. In end stage CKD, the psychological consequences and disease burden play a more prominent role in consultations[31,32]. Evidence lacks on whether the above strategies suit the needs of patients with LHL. This longitudinal, qualitative study aims to identify strategies to optimize selfmanagement by exploring experiences with and barriers for self-management, from the perspectives of both patients with mild to end stage CKD and LHL and HCPs. This method provides the opportunity to learn how experiences of people develop[33,34], and supports reflection upon and confirmation of results from earlier phases of data collection[35]. METHODS The COnsolidated criteria for REporting Qualitative research (COREQ) checklist was used during the development and reporting of the study[36]. STUDY DESIGN We performed a longitudinal, qualitative research with semi-structured, indepth interviews with CKD patients with LHL (n=24) and in-depth interviews and focus group discussions (FGDs) with HCPs (n=37). In line with guidelines[37], we used purposive sampling until data saturation was met[38]. Interviews and FGDs were recorded, transcribed and analysed following the principles of thematic analysis[39]. However, within the concepts of interest, we used a grounded theory approach[40]. Additionally, we administered a questionnaire on background characteristics and, for patients, the All Aspects of Health Literacy Scale (AAHLS) [41]. The Medical Ethical Committee of the University Medical Centre Groningen (UMCG) approved the study (number: 201800346). PARTICIPANT RECRUITMENT Participants were recruited from three general practices (primary care), two nephrology clinics and two dialysis centres (secondary care) in Groningen, the Netherlands. Patients were eligible if they: 1) were adult, 2) experienced >3 months of mild to end stage CKD, and 3) had LHL, based on a total score ≤25 (max. 30) or a critical HL domain score ≤7 (max. 12) on the AAHLS. Inability to speak Dutch,
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