You will be presented with a collection of medical randomized controlled trial (RCT) reports addressing a shared clinical question -- for instance, the efficacy of a medical intervention on a disease or condition. Given the titles and abstracts of these reports, your task is to generate the conclusion of the systematic review article synthesizing the key findings. Your conclusion should be a few sentences long. In your response, include only the conclusion and no other text. The RCT reports are below.



Title 1:
Self-care, quality of life and clinical outcomes of type 2 diabetes patients: an observational cross-sectional study
Abstract 1:
Abstract Aims To describe self-care of T2DM patients and to evaluate outcomes associated with self-care in T2DM patients . Methods A multicentre cross-sectional study was conducted on a sample of 302 r and omly selected T2DM patients . Clinical and socio-demographic data were collected by medical records . The Summary of Diabetes Self-care Activities was used to measure  self-care about diet , blood testing , exercise and foot care .  The EQ-5D was used to measure perceived quality of life . Multiple regression models were used to evaluate the associations between self-care and body mass index ( BMI ) , glycated haemoglobin ( HbA1c ) , presence of diabetes complications and quality of life ( QoL ) . Results Self-care was lower about exercise ( median = 2.0 ) and foot care ( median = 3.5 ) than about diet ( median = 5.2 ) and blood testing ( median = 4.5 ) . HbA1c was associated with diet ( p = 0.025 ) , exercise ( p = 0.017 ) and blood testing ( p = 0.034 ) . BMI was associated with exercise ( p = 0.0071 ) . Diabetes complications were associated with exercise ( p = 0.031 ) and blood testing ( p < 0.009 ) . QoL was associated with exercise ( p < 0.0001 ) , blood testing ( p = 0.032 ) and foot care ( p = 0.013 ) . Conclusions Self-care influences both clinical outcomes and quality of life of T2DM patients . Although exercise is more frequently associated with positive outcomes , it is particularly poor in T2DM population . Blood testing and foot care should be performed to prevent complications and not only when a health problem is already occurred . Interventions aim ed to improve exercise are recommended . Further research is needed to explore barriers to exercise


Title 2:
Development and validation of the Nursing Profession Self-Efficacy Scale.
Abstract 2:
AIM This study describes the development and validation of the  Nursing Profession Self-Efficacy Scale . BACKGROUND Self-efficacy can be useful in predicting performance , job satisfaction or well-being . In the nursing field , there is a shortage of studies on self-efficacy with regard to nurses ' global confidence in coping ability across a range of everyday , challenging work situations . METHODS To define the theoretical framework of nursing professional self-efficacy , two focus groups and a literature review were performed . An empirical study was then conducted to test validity and reliability . Face and content validity , construct validity , concurrent validity , internal consistency and test-retest reliability were examined . The content validity index was evaluated by 12 experts who suggested deleting 11 redundant items . The final developed tool was tested for construct analysis using a cross-validation approach , r and omly splitting the overall sample of 917 nurses in two sub-groups . FINDINGS The construct validity indicated two dimensions . The face and content validity were adequate . Test-retest reliability displayed a good stability , and internal consistency ( Cronbach 's α ) was acceptable . Moreover , concurrent validity using the Generalized Self-Efficacy Scale was in line with the theoretical framework . CONCLUSION The scale showed evidence of validity and reliability . The major limitation is the strong influence of the Italian context in the tool development . IMPLICATION S FOR NURSING AND HEALTH POLICY The Nursing Profession Self-Efficacy Scale could be a fruitful tool that facilitates the application of theories ( i.e. social-cognitive theory ) in the nursing field and even development of interventions . Furthermore , a measurement of self-efficacy could be used to predict nursing clinical performance


Title 3:
Investigating burnout situations, nurses' stress perception and effect of a post-graduate education program in health care organizations of northern Italy: a multicenter study.
Abstract 3:
BACKGROUND Burnout ( BO ) is increasingly considered a public health problem : it is not only harmful to the individual , but also for the organization . Therefore , in recent years , research has given particular attention to the study of the phenomenon and its antecedents among the nursing profession . In the last ten years , the literature shows the prevalence of BO in different clinical setting s , but there are few recent data describing the phenomenon and its relationship with educational preventive programs . OBJECTIVES The aims of this study are : a ) to describe the prevalence of nurses ' risk of BO in the northern Italy area b ) to describe nurses ' coping and their perception of the BO antecedents . c ) to describe the effects of education on the nurses ' coping and their recognition of BO antecedents . METHODS The study is structured into two main parts . The first was cross-sectional , the second was prospect i ve .  Burnout Potential Inventory ( BPI ) question naire was used in the cross-sectional part to survey risk of BO in three big hospitals in Northern Italy . The  Health Profession Stress and Coping Scale ( HPSCS ) was used in the prospect i ve part to survey the nurses ' stress perception and their coping mechanisms in a post-graduate educational program . RESULTS  Nurses ' BO risk is within the normal range , although the BPI highlighted three borderline subscales : poor team work , work overload and poor feedback .  Post-graduate education had a positive effect on the stress perception , but it is not sufficient to improve coping mechanisms . CONCLUSIONS The study revealed the more stressful work situations and the effect of post-graduate education to prevent the effects of stress . This topic needs further investigation in the light of the result of this study


Title 4:
Influence of patient literacy on the effectiveness of a primary care-based diabetes disease management program.
Abstract 4:
CONTEXT Low literacy is an important barrier for patients with diabetes , but interventions to address low literacy have not been well examined . OBJECTIVE To examine the role of literacy on the effectiveness of a comprehensive disease management program for patients with diabetes . DESIGN , SETTING , AND PARTICIPANTS Analysis of the influence of literacy on glycemic control and systolic blood pressure using data from a r and omized controlled trial ( conducted from February 2001 through April 2003 ) of a comprehensive diabetes management program . Participants were 217 patients aged 18 years or older with type 2 diabetes and poor glycemic control ( glycosylated hemoglobin [ HbA1c ] levels > or = 8.0 % ) and presenting to a US academic general internal medicine practice . INTERVENTIONS All communication to patients was individualized and delivered to enhance comprehension among patients with low literacy . Intervention patients received intensive disease management from a multidisciplinary team . Control patients received an initial management session and continued with usual care . MAIN OUTCOME MEASURES Achievement of goal HbA1c levels and systolic blood pressure at 12-month follow-up for control and intervention patients stratified by literacy status . RESULTS Complete 12-month data were available for 193 patients ( 89 % ) . Among patients with low literacy , intervention patients were more likely than control patients to achieve goal HbA1c levels ( < or = 7.0 % ) ( 42 % vs 15 % , respectively ; adjusted odds ratio [ OR ] , 4.6 ; 95 % confidence interval [ CI ] , 1.3 to 17.2 ; P = .02 ) . Patients with higher literacy had similar odds of achieving goal HbA1c levels regardless of intervention status ( 24 % vs 23 % ; adjusted OR , 1.0 ; 95 % CI , 0.4 to 2.5 ; P = .98 ) . Improvements in systolic blood pressure were similar by literacy status . CONCLUSIONS Literacy may be an important factor for predicting who will benefit from an intervention for diabetes management . A diabetes disease management program that addresses literacy may be particularly beneficial for patients with low literacy , and increasing access to such a program could help reduce health disparities


Title 5:
Associations of health literacy with dialysis adherence and health resource utilization in patients receiving maintenance hemodialysis.
Abstract 5:
BACKGROUND Although limited health literacy is common in hemodialysis patients , its effects on clinical outcomes are not well understood . STUDY DESIGN Observational study . SETTING & PARTICIPANTS 260 maintenance hemodialysis patients enrolled in a r and omized clinical trial of symptom management strategies from January 2009 through April 2011 . PREDICTOR Limited health literacy . OUTCOMES Dialysis adherence ( missed and abbreviated treatments ) and health re source utilization ( emergency department visits and end-stage renal disease [ESRD]-related hospitalizations ) . MEASUREMENTS We assessed health literacy using the Rapid Estimate of Adult Literacy in Medicine ( REALM ) and used negative binomial regression to analyze the independent associations of limited health literacy with dialysis adherence and health re source utilization over 12 - 24 months . RESULTS 41 of 260 ( 16 % ) patients showed limited health literacy ( REALM score , ≤60 ) . There were 1,152 missed treatments , 5,127 abbreviated treatments , 552 emergency department visits , and 463 ESRD-related hospitalizations . Limited health literacy was associated independently with an increased incidence of missed dialysis treatments ( missed , 0.6 % vs 0.3 % ; adjusted incidence rate ratio [ IRR ] , 2.14 ; 95 % CI , 1.10 - 4.17 ) , emergency department visits ( annual visits , 1.7 vs 1.0 ; adjusted IRR , 1.37 ; 95 % CI , 1.01 - 1.86 ) , and hospitalizations related to ESRD ( annual hospitalizations , 0.9 vs 0.5 ; adjusted IRR , 1.55 ; 95 % CI , 1.03 - 2.34 ) . LIMITATIONS Generalizability and potential for residual confounding . CONCLUSIONS Patients receiving maintenance hemodialysis who have limited health literacy are more likely to miss dialysis treatments , use emergency care , and be hospitalized related to their kidney disease . These findings have important clinical practice and cost implication


Title 6:
Leveling the field: addressing health disparities through diabetes disease management.
Abstract 6:
OBJECTIVES To examine the relationships among patient characteristics , labor inputs , and improvement in glycosylated hemoglobin ( A1C ) level in a successful primary care-based diabetes disease management program ( DDMP ) . STUDY DESIGN We performed subanalyses to examine the relationships among patient characteristics , labor inputs , and improvement in A1C level within a r and omized controlled trial .  Control patients  received usual care , while  intervention patients received usual care plus a comprehensive DDMP . METHODS The primary outcome was improvement in A1C level over 12 months stratified by intervention status and patient characteristics . Process outcomes included the number of actions or contacts with patients , time spent with patients , and number of glucose medication titrations or additions . RESULTS One hundred ninety-three of 217 enrolled patients ( 88.9 % ) had complete 12-month followup data . Patients in the intervention group had significantly greater improvement in A1C level than the control group ( -2.1 % vs -1.2 % , P = .007 ) . In multivariate analysis , no significant differences were observed in improvement in A1C level when stratified by age , race/ethnicity , income , or insurance status , and no interaction effect was observed between any covariate and intervention status . Among intervention patients , we observed similar labor inputs regardless of age , race/ethnicity , sex , education , or whether goal A1C level was achieved . CONCLUSIONS Among intervention patients in a successful DDMP , improvement in A1C level was achieved regardless of age , race/ethnicity , sex , income , education , or insurance status . Labor inputs were similar regardless of age , race/ethnicity , sex , or education and may reflect the nondiscriminatory nature of providing algorithm-based disease management care
Areas of consensus are HL definition , HL measurement tools , and the relationship between T2DM patient knowledge ( or literacy ) and his/her HL .
The gaps in knowledge were the assessment of the relations between HL and health outcomes and self-efficacy , the gender differences , the effectiveness of interventions to improve HL , the cost-effectiveness study of interventions to improve HL , and the underst and ing of the influence of organizational environment on HL .