Health Literacy and Guideline-Adherent Lifestyle in People with Chronic Kidney Disease (CKD): Exploring Factors Associated with Usage Intention of a Structured E-Health Program and Pilot Data on Actual Behavior Change

Laura I. Schmidt^1*Mario R Jokisch²Lea Espey¹Viet Anh-Thu Hentschel³Daniela Rose⁴Susanne Fleig⁵Malte Waldeck⁶Jan David Best⁷Jürgen Wagner⁸

• ¹Heidelberg University, Institute of Psychology, Heidelberg, Germany
• ²Bavarian Center for Digital Health and Social Care, Kempten University of Applied Sciences, Kempten, Germany
• ³Nephrologicum Lausitz, Cottbus, Germany
• ⁴NEDD*Grünstadt, Nephrology, Endocrinology, Diabetology and Dialysis, Grünstadt, Germany
• ⁵RWTH Aachen University Hospital, Aachen, Germany
• ⁶RWTH Aachen University, Aachen, Germany
• ⁷Center for General Medicine and Geriatrics, University of Mainz, Mainz, Germany
• ⁸MediClin Staufenburgklinik, Durbach, Germany

Background: Although medical guidelines for chronic kidney disease (CKD) clearly recommend measures such as blood pressure control, dietary changes, regular physical activity, and consistent medication adherence, individuals frequently encounter challenges in implementing these behavioral modifications. In medical practices, there is a lack of resources to comprehensively support CKD patients and low-threshold (digital) interventions aimed at enhancing patient activation are needed. We analyzed acceptance and usage intention (Study 1) and the contribution to health literacy and behavioral change (Study 2) of a m-health program for CKD. The "Oska" program combines personal counseling via video calls with app-based support and is theoretically grounded in the Health Action Process Approach (HAPA), with strong emphasis on fostering self-efficacy and promoting implementation in daily routines. Method: Study 1: An online survey was conducted via the provider Appinio among N=401 individuals with CKD and/or hypertension, obesity, type 2 diabetes, or coronary heart disease (age: 50–89 years, M=64.1, 49% female). Participants were presented with a vignette illustrating the Oska program and answered questionnaires on usage intention, desired support, compatible health benefits, health literacy, and perceived usefulness. Study 2: N=109 participants with CKD, who already took part in the Oska program for an average of 4.7 months (age: 29–84 years, M=62.3, 64% female), completed established questionnaires on working alliance, kidney-specific health literacy, and behavior change. Analyses were conducted using structural equation models and linear regression. Results: Study 1: Acceptance and usage intention were high and explained by compatible health benefits, health literacy, and perceived usefulness, but largely independent of sociodemographic and health-related variables. Study 2: higher health literacy was fostered by longer program participation and, most notably, by a positive trust relationship (working alliance) (R²adj=.48) Successful behavior change was primarily attributed to a positively evaluated working alliance and Oska’s contribution to health literacy, rather than sociodemographic factors or the number/type of diagnoses (R²adj=.14). Discussion: Digitally delivered coaching combined with app-based support is acceptable and may be particularly effective for CKD patients with low health literacy and comorbidities. Relevant determinants include a trusting coaching relationship and a focus on health literacy and self-efficacy in implementing measures in everyday life.