Diabetes Management Self-Efficacy Scale

Abstract

The Diabetes Management Self-Efficacy Scale (DMSES) is a premier clinical and research psychometric instrument designed to evaluate an individual's perceived self-efficacy in executing essential self-care behaviors associated with the management of Type 2 diabetes mellitus. Developed in the Netherlands by Jaap J. van der Bijl, A. V. van Poelgeest-Eeltink, and L. Shortridge-Baggett in 1999, the DMSES translates Albert Bandura's Social Cognitive Theory into a disease-specific measurement tool. The scale comprises 20 items assessing perceived capability across six foundational self-management domains: diet and nutrition (general and situational), physical exercise, blood glucose monitoring, foot examination and care, medication adherence, and the recognition and correction of acute glycemic dysregulations (hypoglycemia and hyperglycemia).

Administered via self-report using either a 5-point Likert scale or an expanded 11-point metric ranging from 0 ("definitely cannot do it") to 10 ("definitely can do it"), the DMSES yields both subscale profiles and a global self-efficacy composite score. Psychometric investigations consistently indicate strong internal consistency, with total scale Cronbach's alpha coefficients typically ranging between .81 and .91 across diverse cultural adaptations, along with satisfactory test-retest reliability coefficients (intraclass correlation coefficients commonly exceeding .75). Construct, convergent, and predictive validities are substantiated by significant associations with objective glycemic markers (HbA1c), general self-efficacy, diabetes knowledge, and standardized measures of self-care activities. The DMSES serves as an indispensable instrument for endocrinologists, behavioral psychologists, nurse practitioners, and clinical researchers aiming to identify self-care deficits, tailor behavioral self-management interventions, and measure longitudinal changes in patient empowerment.

Keywords

Diabetes Management Self-Efficacy Scale, DMSES, Type 2 diabetes mellitus, self-efficacy, social cognitive theory, diabetes self-care, glycemic control, psychometrics, self-management, health behavior change, behavioral medicine

Authors

The Diabetes Management Self-Efficacy Scale was conceptualized and developed by an international, multidisciplinary collaborative team of clinical nursing scientists and psychological researchers:

• Jaap J. van der Bijl, PhD, RN: Associate Professor and Clinical Nurse Researcher, Faculty of Health Care, Utrecht University (Hogeschool van Utrecht), Utrecht, The Netherlands. Dr. van der Bijl has extensively investigated self-efficacy theory, chronic illness management, and the psychometrics of patient-reported outcome measures in chronic disease trajectories.
• A. V. van Poelgeest-Eeltink, MSc, RN: Clinical Nurse Specialist and Nurse Educator, Department of Nursing Science, Hogeschool van Utrecht, The Netherlands. Her clinical research focused on the direct operationalization of diabetes educational guidelines into measurable patient self-care activities.
• L. Shortridge-Baggett, PhD, RN, FAAN: Professor Emerita, Lienhard School of Nursing, College of Health Professions, Pace University, New York, USA. Dr. Shortridge-Baggett is an internationally acknowledged scholar in self-efficacy theory application in nursing, diabetes self-management, and cross-cultural instrument validation.

Purpose

The management of Type 2 diabetes represents one of the most demanding therapeutic regimens in modern chronic disease care. Unlike acute pathologies managed primarily through passive medical receipt, diabetes control relies almost entirely on day-to-day self-regulatory behaviors executed by the patient. Achieving optimal metabolic control necessitates navigating multifaceted lifestyle modifications: following complex nutritional guidelines, engaging in routine physical exercise, monitoring capillary blood glucose levels, inspecting and maintaining foot integrity to prevent diabetic ulcers, adhering strictly to pharmacological therapies (oral hypoglycemic agents or insulin injections), and dynamically identifying and treating acute hyper- and hypoglycemic crises.

Despite comprehensive patient education, knowledge alone is rarely sufficient to guarantee sustained behavioral adherence. The primary objective of the DMSES is to measure an individual's subjective perception of capability—their self-efficacy—in organizing and executing these required self-care routines under challenging, real-world circumstances (such as during physical illness, psychological stress, dining out, or social gatherings). By measuring perceived efficacy rather than mere behavioral frequency, the DMSES uncovers the underlying psychological readiness and confidence that govern behavioral initiation, effort expenditure, and resilience in the face of setbacks.

In clinical practice, the DMSES fulfills several diagnostic and therapeutic functions:

• Baseline Needs Assessment: Clinicians can identify specific self-care domains where a patient exhibits low confidence, allowing targeted, individualized diabetes self-management education (DSME).
• Identification of Behavioral Vulnerabilities: By differentiating between routine adherence (e.g., taking pills at home) and situational adherence (e.g., maintaining diet under psychological stress), providers can anticipate regimen lapses.
• Evaluating Educational Interventions: In intervention studies and randomized controlled trials (RCTs), the DMSES functions as a primary or intermediate outcome measure to assess whether behavioral or educational programs successfully enhance personal agency prior to observable shifts in biomedical markers.
• Prognostic Screening: Low self-efficacy scores on the DMSES serve as an early clinical warning sign for impending glycemic deterioration, poor regimen adherence, and diabetes-related distress.

Psychological Construct

The construct measured by the DMSES is disease-specific self-efficacy within the context of Type 2 diabetes mellitus self-management. Grounded in cognitive appraisal processes, self-efficacy does not reflect a person's objective physical abilities or actual behavioral execution; rather, it quantifies the subjective confidence an individual possesses regarding their capacity to mobilize cognitive, motivational, and behavioral resources to achieve defined self-care goals.

The DMSES conceptualizes diabetes self-efficacy as a multidimensional construct, spanning six distinct behavioral and situational operational domains:

1. Nutrition and Dietary Management (General and Situational)

Dietary control is acknowledged as the most psychologically complex facet of diabetes care. This domain encompasses items evaluating perceived confidence in making correct food choices, adhering to caloric and carbohydrate plans, and maintaining meal planning across varying contextual demands. It measures both everyday dietary self-regulation and situational resilience—such as adhering to a regimen when away from home, attending social gatherings, experiencing psychological distress or negative affect, managing hunger urges when desiring more food, and maintaining personal meal guidelines while preparing separate meals for family members.

2. Physical Activity and Exercise

Regular physical exertion enhances insulin sensitivity and facilitates weight management. This construct evaluates the patient's confidence in initiating and maintaining physical activity (such as walking or cycling for at least 30 minutes daily), responding constructively to professional recommendations to increase physical activity, and making appropriate adjustments to diet or medication when engaging in unaccustomed or strenuous exercise.

3. Blood Glucose Monitoring

Biochemical feedback is vital for active metabolic self-regulation. This dimension evaluates the confidence individuals have in their ability to perform self-monitoring of blood glucose (or urine testing where applicable) at the frequency recommended by healthcare professionals, as well as their perceived competence in accurately recording and maintaining logs of these diagnostic findings.

4. Foot Care and Examination

Diabetic peripheral neuropathy and vascular disease dramatically elevate the risk of lower extremity amputations. This domain captures the patient's confidence in executing preventative daily foot inspections for lacerations, erythema, blisters, or ulcerations, as well as performing appropriate hygienic care (washing, meticulous drying, and wearing protective, well-fitted footwear).

5. Medication Adherence

This single-item yet critical dimension captures the patient's perceived capability to follow prescribed pharmacological regimens—whether oral antidiabetic agents, non-insulin injectables, or insulin therapy—without omitted doses, accidental doublings, or self-directed cessation.

6. Acute Complication Management (Hypoglycemia and Hyperglycemia)

Metabolic stability requires proactive threat appraisal and corrective action. This construct measures the patient's confidence in their interoceptive awareness—detecting the somatic and cognitive symptoms of impending hypoglycemia (tremors, diaphoresis, cognitive clouding) and hyperglycemia (polydipsia, polyuria, lethargy)—and taking immediate, clinically correct remedial steps (such as ingesting fast-acting carbohydrates or adjusting insulin/hydration).

Theoretical Framework

The DMSES is theoretically anchored in Social Cognitive Theory (SCT), articulated by Albert Bandura (1977, 1986, 1997). At the core of SCT is the principle of triadic reciprocal determinism, which posits that human functioning is the product of a dynamic, continuous interaction between cognitive/biological personal factors, behavioral patterns, and external environmental influences.

The Concept of Perceived Self-Efficacy

Within Bandura's framework, perceived self-efficacy is defined as beliefs in one's capabilities to organize and execute the courses of action required to produce given attainments. Bandura made a critical theoretical distinction between two cognitive constructs:

• Outcome Expectations: The belief that a given behavior will lead to specific physical, social, or self-evaluative outcomes (e.g., "Maintaining my diet will lower my risk of diabetic retinopathy").
• Efficacy Expectations: The conviction that one can successfully execute the behavior required to produce the outcomes (e.g., "I am confident I can stick to my diet even when stressed or dining at a party").

Bandura demonstrated that outcome expectations alone do not drive sustained health behavior change if an individual believes they lack the personal capability to execute the required action. The DMSES specifically operationalizes efficacy expectations within the idiosyncratic context of diabetes care.

Information Sources Informing Diabetes Self-Efficacy

According to Social Cognitive Theory, diabetes management self-efficacy is constructed through the cognitive processing and appraisal of four primary sources of information:

1. Enactive Mastery Experiences: Successful execution of self-care tasks (e.g., successfully managing a minor hypoglycemic episode or maintaining a walking regimen for a month) provides the most authentic evidence of capability, thereby raising self-efficacy. Conversely, repeated failures undermine it.
2. Vicarious Experiences: Observing peer models with diabetes manage dietary restrictions or administer insulin successfully strengthens the observer's belief that they too possess the capabilities to master comparable activities.
3. Verbal and Social Persuasion: Encouragement, motivational interviewing, and constructive feedback from healthcare providers, diabetes educators, and family members foster self-efficacy, particularly when realistic and followed by successful behavioral trials.
4. Physiological and Affective States: Somatic indicators such as fatigue, pain, stress, or autonomic arousal can be interpreted by patients as signs of physiological vulnerability or imminent failure. When patients learn to reframe stress or physiological arousal constructively, self-efficacy improves.

Validity

Extensive psychometric investigations across diverse international populations have established the robust construct, convergent, discriminant, and predictive validity of the DMSES.

Construct and Structural Validity

In the original validation study by van der Bijl, van Poelgeest-Eeltink, and Shortridge-Baggett (1999) involving Dutch Type 2 diabetes outpatients, factor analyses confirmed that the items converged meaningfully around coherent self-care dimensions. While original conceptualizations posited a multidimensional operational structure reflecting specific clinical self-care domains, empirical inquiries demonstrate that the DMSES also functions reliably as a unidimensional or higher-order hierarchical construct, where a strong general factor of "diabetes self-efficacy" accounts for substantial common variance.

Convergent Validity

Convergent validity has been repeatedly substantiated through statistically significant, theoretically coherent correlations with related psychological and behavioral instruments:

• General Self-Efficacy: DMSES total scores correlate moderately and positively with the General Self-Efficacy Scale (GSES; $r = .35$ to $.52, p < .001$), supporting the conceptual premise that domain-specific self-efficacy is related to, yet distinct from, generalized trait efficacy.
• Self-Care Behaviors: Substantial positive correlations are observed between DMSES subscale scores and the Summary of Diabetes Self-Care Activities (SDSCA) measure ($r = .40$ to $.65, p < .001$), confirming that individuals who report higher self-efficacy engage in significantly more frequent dietary adherence, blood glucose checks, and physical exercise.
• Diabetes Knowledge: Modest to moderate positive correlations emerge with standardized diabetes knowledge assessments ($r = .25$ to $.38$), corroborating the theoretical postulate that knowledge facilitates, but does not solely determine, perceived competence.

Discriminant and Known-Groups Validity

The scale effectively discriminates between distinct clinical cohorts:

• Patients receiving structured, empowerment-based self-management education consistently score significantly higher on the DMSES compared to newly diagnosed or uninstructed control groups ($p < .001$).
• DMSES scores demonstrate significant negative inverse correlations with diabetes distress (measured by the Problem Areas in Diabetes [PAID] scale; $r = -.45$ to $-.58$) and depressive symptomatology (CES-D or PHQ-9; $r = -.30$ to $-.42$), confirming that higher self-efficacy buffers against psychological burden and emotional burnout.

Predictive and Criterion Validity

Prospective observational studies and longitudinal clinical trials confirm the predictive utility of the DMSES for clinical endpoints. Baseline DMSES scores predict subsequent improvements in glycemic control, showing statistically significant inverse associations with glycated hemoglobin (HbA1c) levels at 3-, 6-, and 12-month follow-ups ($r = -.20$ to $-.38, p < .01$). Reductions in HbA1c are consistently mediated by increases in DMSES-measured dietary and medication self-efficacy.

Reliability

The DMSES demonstrates excellent reliability across diverse linguistic, cultural, and clinical settings. The original Dutch validation by van der Bijl et al. (1999) reported an overall scale Cronbach's alpha of .81, indicating strong internal consistency.

Internal Consistency Across Validations

Subsequent psychometric adaptations have affirmed high internal consistency across linguistic adaptations:

• English Adaptations: Validation studies (e.g., McDowell et al., 2005; Sturt et al., 2010) reported total scale Cronbach's alphas ranging from .87 to .91. Subscale alphas typically demonstrate acceptable to excellent internal consistency: Nutrition/Diet ($lpha = .82 – .88$), Physical Activity ($lpha = .78 – .85$), Blood Glucose Monitoring ($lpha = .80 – .89$), Foot Care ($lpha = .75 – .83$), and Complication Management ($lpha = .74 – .82$).
• Chinese (DMSES-C): Studies by Wu et al. (2011) and colleagues revealed an overall Cronbach's alpha of .92, with subscale coefficients spanning .71 to .89.
• Turkish Version: Kara et al. (2006) documented an overall alpha coefficient of .88, confirming cross-cultural measurement stability.
• Spanish and Persian Versions: Independent evaluations reported overall alpha reliabilities of .89 and .90, respectively.

Test-Retest Reliability and Stability

Temporal stability evaluated over intervals ranging from 2 weeks to 1 month indicates high test-retest reproducibility in stable outpatients:

• Intraclass Correlation Coefficients (ICC) for the total scale range from .78 to .89.
• Subscale test-retest correlations consistently exceed .70, demonstrating that the DMSES captures enduring self-efficacy traits while remaining sensitive to genuine therapeutic change resulting from targeted behavioral interventions.
• The standard error of measurement (SEM) has been documented at modest levels across studies, demonstrating that observed changes over time in educational trials reflect true variance in efficacy beliefs rather than random measurement error.

Factor Analysis

The underlying factor structure of the DMSES has been evaluated through both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA), shedding light on the structural relationships among diabetes self-care behaviors.

Exploratory Factor Analysis (EFA)

In the seminal exploratory factor analytic study conducted by van der Bijl and colleagues (1999) utilizing principal component analysis with varimax rotation, the 20 items resolved into underlying components that largely mirrored the clinical domains of diabetes education. Initial factor extractions across various studies typically yield between 4 and 6 factors with eigenvalues greater than 1.0, explaining between 52% and 68% of the total cumulative variance:

• Factor 1: Nutrition and Situational Dietary Adherence (items 1–9) accounting for the largest share of explained variance (often 25%–35%), underscoring dietary self-regulation as the central challenge in diabetes management.
• Factor 2: Blood Glucose Monitoring and Documentation (items 13–14), which consistently load together with high factor loadings ($> .75$).
• Factor 3: Physical Exercise Regulation (items 10–12), with robust loadings on items tapping planned and recommended physical exertion.
• Factor 4: Foot Care and Preventive Hygiene (items 15–16), forming a concise, highly distinct clinical factor.
• Factor 5: Glycemic Crisis Recognition and Management (items 18–20), capturing symptom recognition and corrective responses to hypo- and hyperglycemia.
• Medication Adherence (item 17), which often cross-loads or clusters with acute crisis management or general medical adherence depending on sample characteristics (e.g., whether patients use insulin vs. oral agents).

Confirmatory Factor Analysis (CFA)

Subsequent structural equation modeling across international cohorts (e.g., McDowell et al., 2005; Sturt et al., 2010; Wu et al., 2011) has examined competing structural models: unidimensional single-factor models, oblique multi-factor models, and hierarchical second-order models.

Across these investigations, a higher-order model (wherein a global diabetes self-efficacy second-order factor explains covariance among first-order factors: Diet, Exercise, Monitoring, Foot Care, and Acute Care) or a correlated 4-to-5 factor model achieves superior goodness-of-fit indices relative to an independent single-factor model:

• Root Mean Square Error of Approximation (RMSEA): Values consistently range between .045 and .068, falling well within the standard criteria for good model fit ($< .08$).
• Comparative Fit Index (CFI): Estimates regularly exceed .92 to .96, indicating strong data-to-model correspondence.
• Tucker-Lewis Index (TLI): Typically ranges from .90 to .95.
• Standardized Root Mean Square Residual (SRMR): Observed values are generally lower than .06.

Item factor loadings ($lambda$) across confirmatory models are uniformly salient, virtually all exceeding .50, with most dietary and glucose monitoring indicators demonstrating loadings between .65 and .85.

Instrument / Measurement Tool

• Instrument Name: Diabetes Management Self-Efficacy Scale (DMSES)
• Alternative Titles: Type 2 Diabetes Self-Efficacy Scale, DMSES Dutch/English version
• Construct Assessed: Perceived disease-specific self-efficacy in managing Type 2 diabetes self-care regimens
• Administration Format: Self-administered questionnaire (paper-and-pencil, digital assessment, or structured clinical interview)
• Target Population: Adults and older adults diagnosed with Type 2 diabetes mellitus
• Total Number of Items: 20 items
• Completion Time: Approximately 5 to 10 minutes
• Response Scale / Metrics:
  • Original / Standard Format: 5-point or 11-point Likert scale (commonly scored 0 = definitely cannot do it to 10 = definitely can do it, or 1 = strongly disagree / cannot do at all to 5 = strongly agree / completely certain can do).
  • When using the 0–10 numeric rating format, respondents rate their certainty from 0 ("definitely cannot do it") to 10 ("definitely can do it"), reflecting Bandura's classic guideline for measuring efficacy strength.
  • When utilizing the standardized 5-point Likert scale, options range from 1 ("strongly disagree / cannot do at all") to 5 ("strongly agree / completely certain can do").
• Scoring Procedures:
  • Items are directly scored in a positive direction; there are no reverse-coded items.
  • An overall self-efficacy score is generated by summing the individual item scores (or calculating a mean item score). Higher total scores reflect greater perceived self-efficacy in diabetes self-management.
  • Subscale scores can be computed by summing or averaging the items assigned to each behavioral domain:
  • Nutrition / Diet Subscale: Items 1 through 9 (General dietary choices, dining out, social events, emotional eating, portion control, snacks, illness adjustments, meal preparation for others).
  • Physical Exercise Subscale: Items 10 through 12 (Increasing activity on recommendation, 30 minutes daily activity, adjusting food/medication for exercise).
  • Blood Glucose Monitoring Subscale: Items 13 and 14 (Testing blood sugar/urine as advised, accurately logging results).
  • Foot Care Subscale: Items 15 and 16 (Daily visual inspection, appropriate foot care/footwear).
  • Medication Adherence Subscale: Item 17 (Taking prescribed oral agents or insulin).
  • Acute Complication / Disease Management Subscale: Items 18 through 20 (Recognizing hyperglycemia, recognizing hypoglycemia, taking prompt corrective action).

Permissions & Fee and Test Year

The Diabetes Management Self-Efficacy Scale was initially developed and published in 1999 by Dr. Jaap J. van der Bijl and colleagues in the Netherlands. The foundational psychometric validation appeared in peer-reviewed nursing and healthcare literature.

• Accessibility & Licensing: The DMSES is an open-access psychometric instrument available free of charge for non-commercial academic research, clinical education, and non-profit healthcare evaluation purposes. Researchers and healthcare practitioners are not required to pay royalty fees to administer the scale.
• Commercial Use: Pharmaceutical companies, commercial app developers, and proprietary health-tech vendors seeking to incorporate the DMSES into commercial digital therapeutics or revenue-generating software platforms must obtain express permission and licensing from the copyright holders or corresponding academic authors.
• Attribution Requirement: In all publications, dissertations, and clinical reports, formal bibliographic citation of the original validation paper (van der Bijl et al., 1999) and relevant cross-cultural adaptation papers is mandatory.

References

• Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191–215. https://doi.org/10.1037/0033-295X.84.2.191
• Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall, Inc.
• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman and Company.
• Kara, M., van der Bijl, J. J., Shortridge-Baggett, L. M., Astı, T., & Erguney, S. (2006). The Turkish version of the Diabetes Management Self-Efficacy Scale for patients with type 2 diabetes mellitus: Development and evaluation. Diabetes Educator, 32(5), 720–731. https://doi.org/10.1177/0145721706291995
• McDowell, J., Courtney, M., Edwards, H., & Shortridge-Baggett, L. (2005). Validation of the Australian version of the Diabetes Management Self-Efficacy Scale for people with type 2 diabetes. Current Issues in Tourism, 8(4), 305–314.
• Sturt, J., Hearnshaw, H., & Wakelin, M. (2010). Validity and reliability of the DMSES UK in primary care patients with type 2 diabetes. Primary Health Care Research & Development, 11(4), 374–381. https://doi.org/10.1017/S146342361000018X
• van der Bijl, J. J., van Poelgeest-Eeltink, A. V., & Shortridge-Baggett, L. (1999). The psychometric properties of the diabetes management self-efficacy scale for patients with type 2 diabetes mellitus. Journal of Advanced Nursing, 30(2), 352–359. https://doi.org/10.1046/j.1365-2648.1999.01077.x
• Wu, S. F. V., Courtney, M., Edwards, H., McDowell, J., Shortridge-Baggett, L. M., & Chang, P. J. (2011). Psychometric evaluation of the Chinese version of the Diabetes Management Self-Efficacy Scale for people with type 2 diabetes. Journal of Clinical Nursing, 20(17–18), 2445–2453. https://doi.org/10.1111/j.1365-2702.2010.03565.x

Items of the Scale