88 Our study also has limitations. First, the Dutch health system is very accessible and has a universal health insurance coverage, which may have resulted in fewer experienced barriers related to care access than may occur in other countries. Second, two patients and six nephrology specialists knew the interviewer from his previous job as communication advisor in their dialysis centre. This familiarity could have resulted in self-censoring but this seems rather unlikely, as he was not involved in direct patient care. Last, our sampling via HCPs, mentioned as strength, can also cause selection bias. When HCPs only recruited patients with clearly visible LHL or patients failed to attend an appointment, and fill out a consent form, this could have led to underestimation of the challenges for the group with very low HL. IMPLICATIONS We show both GPs and nephrology specialists fail to provide patients with a complete overview on CKD, and its relation with co-morbidities and selfmanagement. To improve, nephrology specialists should share their knowledge with GPs, e.g. in refresher courses. Specialists need to look beyond their specialism (i.e. nephrology, diabetes, cardiovascular diseases) to truly support patients with LHL and multiple diseases. Our study also indicates a need for the development of person-centred strategies, based on behavioural approaches. Existing HL interventions predominantly target the patient’s knowledge and communication competencies[60–63], but strategies aimed at eliminating barriers or strengthening competencies to maintain health behaviours are missing. Since multi-component interventions are absent, but according to other studies most effective[64] to optimize self-management and health[65,66], we suggest researchers to develop and pilot-test these interventions for CKD settings. Our study also calls for interventions to improve the HCPs’ competencies to recognize and support patients with LHL. A recent review showed learning objectives for HCPs to deliver person-centred care for patients with LHL[67], which suit the three routes we suggest. Researchers need to adopt these objectives in a training for HCPs in CKD care, and test the effect on competencies and skills of the HCP, but also on self-management and health outcomes of patients with LHL.
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