***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: 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 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 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 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 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 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 
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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 .