Diabetes Attitudes Questionnaire

Abstract

The Diabetes Attitudes Questionnaire, widely established in chronic illness research and clinical diabetology as the full-length Diabetes Empowerment Scale (DES), was developed by Robert M. Anderson and colleagues at the University of Michigan Diabetes Research and Training Center (MDRTC). This 28-item psychometric instrument was specifically constructed to quantify the psychosocial self-efficacy of individuals living with type 1 and type 2 diabetes mellitus. Built upon the foundational premise that effective diabetes management necessitates personal empowerment rather than passive compliance, the scale measures patients' perceived ability to identify their emotional and behavioral challenges, mobilize internal and external resources, set realistic personal goals, and manage the complex psychosocial sequelae of living with a lifelong chronic disease.

The scale encompasses three distinct, empirically validated subscales derived through exploratory factor analysis: (1) Managing the Psychosocial Aspects of Diabetes (9 items), (2) Assessing Dissatisfaction and Readiness to Change (9 items), and (3) Setting and Achieving Goals (10 items). Items are rated on a 5-point Likert-type scale ranging from 1 (Strongly Disagree) to 5 (Strongly Agree), preceded by the overarching stem: "In general, I believe that I…". In the original psychometric validation study conducted among 251 adult patients with diabetes, the instrument demonstrated exceptional internal consistency, with an overall Cronbach's alpha coefficient of .96, and subscale coefficients of .93, .81, and .91, respectively. Construct validity was corroborated via concurrent associations with diabetes-specific distress, self-care behaviors, and metabolic control indices (HbA1c). As a landmark patient-reported outcome measure (PROM), the scale continues to provide foundational evaluative data for self-management education programs, behavioral interventions, and clinical trials globally.

Keywords

Diabetes Empowerment Scale, DES, diabetes self-management education, psychosocial self-efficacy, chronic disease empowerment, goal setting, readiness to change, patient-reported outcome measures, glycemic control, diabetes distress

Authors

The instrument was developed and validated by a multidisciplinary team of behavioral scientists, medical educators, and clinical diabetologists affiliated with the University of Michigan Medical School and the Michigan Diabetes Research and Training Center (MDRTC), Ann Arbor, Michigan, USA:

• Robert M. Anderson, EdD: Professor Emeritus of Medical Education, Department of Learning Health Sciences, University of Michigan Medical School. A pioneering theorist in patient empowerment and adult learning theory applied to chronic illness care.
• Martha M. Funnell, MS, RN, CDCES, FAAN: Associate Research Scientist Emerita, Department of Learning Health Sciences, University of Michigan Medical School; past President of Health Care & Education for the American Diabetes Association.
• John T. Fitzgerald, PhD: Research Associate Professor, Department of Learning Health Sciences, University of Michigan Medical School; psychometrician specializing in scale validation, biostatistics, and educational measurement.
• David G. Marrero, PhD: J.O. Ritchey Endowed Professor of Medicine and Director of the Center for Health Aging at Indiana University School of Medicine (collaborating investigator).
• Cheryl Feste: Health educator, patient advocate, and co-developer of foundational empowerment educational philosophies in diabetes.

Purpose

The primary clinical and scientific purpose of the Diabetes Attitudes Questionnaire / Diabetes Empowerment Scale (DES) is to assess the psychosocial self-efficacy of individuals diagnosed with diabetes mellitus. Unlike conventional clinical evaluations that focus exclusively on biochemical endpoints such as glycated hemoglobin (HbA1c), fasting plasma glucose, or lipid profiles, this scale addresses the critical cognitive, emotional, and behavioral determinants of day-to-day disease self-management. Diabetes is an overwhelmingly self-managed illness; greater than 95% of daily therapeutic decisions—ranging from insulin dosing and carbohydrate estimation to stress adaptation and physical exertion—are executed independently by the patient outside of clinical supervision. Consequently, an individual's subjective appraisal of their personal competence, self-awareness, and problem-solving agency constitutes a primary predictor of sustained behavioral engagement and long-term health outcomes.

Historically, traditional medical models framed diabetes education around the paradigm of "compliance" or "adherence," wherein healthcare professionals served as authoritative directors and patients were viewed as passive recipients of prescriptive regimens. This pedagogical paradigm routinely precipitated clinical frustration, psychological reactance, and high rates of intervention failure. Anderson and colleagues designed the DES to evaluate an alternative philosophy: the empowerment approach. In this framework, adult patients are recognized as autonomous decision-makers who possess ultimate authority over their daily lifestyle choices. The purpose of the questionnaire is therefore twofold:

1. Educational and Clinical Assessment: To identify specific psychosocial deficits, emotional barriers, and motivational plateaus in individual patients. Clinicians, certified diabetes care and education specialists (CDCES), and behavioral health providers utilize subscale profiles to tailor personalized self-management interventions, facilitate shared decision-making, and stimulate productive self-reflection regarding readiness to change.
2. Outcome Evaluation in Research: To provide a standardized, psychometrically rigorous dependent variable capable of detecting longitudinal shifts in psychological empowerment following Diabetes Self-Management Education and Support (DSMES) interventions, group peer programs, digital therapeutic trials, and psychological therapies (such as cognitive behavioral therapy or motivational interviewing).

Psychological Construct

The core latent psychological construct measured by the scale is diabetes-related psychosocial self-efficacy, conceptualized through the lens of psychological empowerment. Empowerment in chronic disease management is defined not merely as possession of factual biomedical knowledge, but as the integrated capacity to mobilize personal agency, make informed choices, cope with emotional strain, and enact purposeful behavior modifications. The instrument delineates this overarching construct into three interrelated behavioral and affective dimensions:

1. Managing the Psychosocial Aspects of Diabetes

This 9-item dimension (items 18, 20, 21, 22, 23, 24, 25, 26, and 27) captures an individual's self-efficacy in confronting the emotional burdens, motivational fluctuations, and social demands of living with diabetes. Effective self-management requires continuous psychological coping to buffer against diabetes distress and burnout. This subscale measures:

• Recognition of both constructive and maladaptive coping strategies in response to disease-related stress (e.g., Item 18: "know the positive ways I cope with diabetes-related stress"; Item 20: "can cope well with diabetes related stress").
• Social mobilization self-efficacy, reflecting the patient's agency in identifying sources of social support and actively requesting help without feelings of inadequacy or shame (Items 21 and 22).
• Internal motivational regulation, evaluating whether the individual possesses self-sustaining intrinsic motivation rather than relying solely on external clinical reinforcement (Items 24 and 25).
• Self-knowledge and integrative decision-making, assessing whether the individual balances clinical knowledge with deep self-awareness of personal values, preferences, and lifestyle constraints (Items 26 and 27).

2. Assessing Dissatisfaction and Readiness to Change

Comprising 9 items (items 1, 2, 3, 4, 15, 16, 17, 19, and 28), this dimension assesses metacognitive self-awareness regarding current self-care practices, emotional clarity, and appraisal of the cost-benefit trade-offs associated with behavioral modification. Lasting behavior change rarely occurs in the absence of acute self-awareness regarding what aspects of current care are suboptimal. This subscale specifically captures:

• Discriminative self-appraisal concerning areas of satisfaction versus dissatisfaction in current self-care routines (Items 1 and 2).
• Realistic consciousness of readiness versus non-readiness to initiate behavioral alterations (Item 3: "know what part(s) of taking care of my diabetes that I am ready to change"; Item 4: "know what part(s) of taking care of my diabetes that I am not ready to change"). Acknowledging non-readiness is regarded as a hallmark of self-awareness rather than failure.
• Affective labeling and emotional transparency regarding the personal burden of diabetes (Items 15 and 16).
• Cognitive appraisal of systemic stressors and cognitive evaluation of whether therapeutic adaptations are "worthwhile" in the context of one's broader life values (Items 17, 19, and 28).

3. Setting and Achieving Goals

Spanning 10 items (items 5 through 14), this subscale assesses the executive, operational, and problem-solving capabilities required to formulate and execute self-care objectives. Goal-directed behavior in chronic illness involves complex cyclical self-regulation: planning, implementation, barrier identification, iterative hypothesis testing, and outcome evaluation. Key components include:

• Goal selection self-efficacy, including the ability to prioritize goals and differentiate realistic from unrealistic targets (Items 5 and 6).
• Self-attunement to personal facilitators and self-limiting behavioral patterns that influence goal realization (Item 7).
• Action planning self-efficacy, turning abstract health intentions into concrete, workable operational strategies (Items 8, 9, and 10).
• Systematic barrier analysis and behavioral flexibility, characterized by the cognitive ability to anticipate roadblocks, brainstorm alternative remediation pathways, and execute adaptive problem-solving (Items 11, 12, 13, and 14).

Theoretical Framework

The Diabetes Attitudes Questionnaire / DES is grounded in two primary theoretical paradigms: Social Cognitive Theory, formulated by Albert Bandura, and the Empowerment Philosophy of Chronic Disease Management, established by Anderson, Funnell, and colleagues. Additionally, it integrates tenets from Self-Determination Theory (Deci & Ryan), the Transtheoretical Model of Behavior Change (Prochaska & DiClemente), and the Transactional Model of Stress and Coping (Richard Lazarus & Susan Folkman).

Bandura's self-efficacy theory posits that an individual's belief in their capability to organize and execute courses of action required to produce designated attainments serves as the central cognitive mediator of action. Self-efficacy expectations govern how much effort people will expend, how long they will persist in the face of obstacles, and how resilient they remain during setbacks. However, Anderson et al. argued that conventional applications of self-efficacy to diabetes frequently reduced the construct to simple motor tasks (e.g., "Can you inject insulin?" or "Can you test your blood sugar three times per day?"). Such task-specific measures failed to capture the broader psychosocial self-efficacy needed to navigate living with an incurable, demanding condition.

To overcome this limitation, the authors operationalized self-efficacy within an explicit empowerment framework. Psychological empowerment in health contexts comprises three core assumptions:

1. Inherent Patient Autonomy: The patient is the primary caregiver and primary stakeholder. Because healthcare providers are present for an infinitesimal fraction of the patient's life, the patient makes virtually all decisions that dictate health outcomes.
2. The Nature of Chronic versus Acute Care: Acute illness requires compliance with expert directives to effect a cure. Chronic illness cannot be cured; it must be incorporated into the existential fabric of the patient's life. Consequently, education must build self-directed decision-making and continuous problem-solving competence rather than blind obedience.
3. Self-Directed Goal Clarification: Empowerment occurs when patients clarify their own values, identify meaningful personal goals, experience the outcomes of their behaviors, and iteratively refine their self-management based on self-reflection.

By wedding Bandura's self-efficacy construct to adult empowerment education (rooted in Paulo Freire's critical consciousness and Carl Rogers' humanistic counseling), the scale measures whether an individual possesses the psychological prerequisites to act as an informed, autonomous manager of their condition.

Validity

The psychometric validity of the scale has been systematically evaluated across clinical, community, and international settings, demonstrating robust construct, convergent, discriminant, and predictive properties.

Construct and Content Validity

Content validity was established through a multi-stage qualitative and consensus-driven procedure. An expert panel consisting of clinical diabetologists, nurse educators, behavioral psychologists, and experienced adult patients with diabetes generated an initial pool of 47 items representing the core domains of psychosocial empowerment. Iterative cognitive pre-testing, clarity reviews, and pilot administration led to the refinement of 28 core items that accurately reflected the behavioral challenges and emotional complexities encountered in chronic diabetes management.

Convergent and Concurrent Validity

In the seminal psychometric validation study by Anderson et al. (2000) involving 251 adult participants, convergent validity was examined through correlations with validated measures of diabetes-specific attitudes and psychosocial adaptation. The subscales showed moderate-to-strong statistically significant correlations with the Diabetes Care Profile (DCP) subscales:

• The Managing the Psychosocial Aspects of Diabetes subscale correlated strongly with the DCP Positive Coping subscale (r = .58, p < .001) and demonstrated significant negative correlations with the DCP Negative Coping and Emotional Overload subscales (r = -.46 to -.52, p < .001).
• The Setting and Achieving Goals subscale demonstrated significant positive associations with general perceived self-efficacy and reported self-monitoring adherence frequencies (r = .41 to .49, p < .001).

Discriminant Validity

Discriminant validity was evidenced by the instrument's ability to differentiate between distinct psychological constructs. Specifically, empowerment scores correlated only weakly with generalized demographic variables (such as age, gender, or disease duration), confirming that diabetes empowerment represents an independent psychological construct rather than an artifact of sociodemographic privilege or chronological illness experience. Furthermore, while the subscales correlated inversely with measures of depressive symptomatology (e.g., CES-D, r = -.38, p < .01), the magnitude of these correlations confirmed that the scale does not simply measure the absence of depression, but specifically captures self-management agency.

Predictive and Criterion Validity

Prospective intervention trials have established the predictive validity of the scale. Longitudinal evaluations of diabetes self-management education programs demonstrated that baseline-to-post-intervention increases in total and subscale scores predicted meaningful, statistically significant reductions in glycated hemoglobin (HbA1c) at 6-month and 12-month follow-up evaluations (standardized regression coefficients ranging from β = -.22 to β = -.34, p < .01). Patients achieving higher post-intervention empowerment demonstrated significantly superior maintenance of glycemic improvements compared to participants whose empowerment scores remained static.

Reliability

The 28-item questionnaire displays exemplary internal consistency and temporal reliability across diverse patient cohorts, languages, and clinical settings.

Internal Consistency

In the primary psychometric investigation by Anderson, Funnell, Fitzgerald, and Marrero (2000), internal consistency was estimated via Cronbach's alpha on a sample of 251 patients (mean age 59.2 ± 13.0 years; 55% female; 52% type 2 diabetes, 48% type 1 diabetes). The coefficients demonstrated exceptional reliability:

• Full 28-Item Instrument: Overall Cronbach's α = .96
• Managing the Psychosocial Aspects of Diabetes (9 items): Cronbach's α = .93
• Setting and Achieving Goals (10 items): Cronbach's α = .91
• Assessing Dissatisfaction and Readiness to Change (9 items): Cronbach's α = .81

All subscale alpha values easily exceed the widely accepted threshold of .80 for basic research, and the full-scale alpha of .96 meets the stringent criterion of .90 required for individual-level clinical assessment and decision-making.

Test-Retest Reliability

Stability across time was evaluated in a stable subsample of outpatients who completed the instrument at baseline and again after a 4- to 6-week interval during which no educational intervention occurred. Intra-class correlation coefficients (ICC) and Pearson test-retest correlations confirmed high temporal stability:

• Full Scale: r = .89 (p < .001)
• Subscale 1 (Managing Psychosocial Aspects): r = .86
• Subscale 2 (Assessing Dissatisfaction & Readiness): r = .79
• Subscale 3 (Setting & Achieving Goals): r = .84

These values demonstrate that the scale is highly reliable over time in the absence of active behavioral or educational interventions, while remaining sensitive to genuine clinical changes following targeted education.

Factor Analysis

The internal structural architecture of the 28-item instrument was systematically elucidated through exploratory factor analysis (EFA) and subsequent confirmatory factor analysis (CFA).

Exploratory Factor Analysis (EFA)

In the foundational scale development phase, principal axis factoring with promax (oblique) rotation was conducted on the 28 items, as the theoretical dimensions were hypothesized to be correlated components of the overarching empowerment construct. Analysis of the eigenvalues (scree plot inspection combined with the Kaiser-Guttman rule of eigenvalues > 1.0) unequivocally indicated a three-factor solution, accounting for 54.4% of the total variance:

• Factor 1: Setting and Achieving Goals (Eigenvalue = 11.23, explaining 40.1% of common variance). Items 5 through 14 loaded predominantly onto this factor, with standardized pattern matrix loadings ranging from .54 to .88. Items 8, 9, 12, and 13 exhibited the highest factor loadings (> .75), confirming their central role in operationalizing barrier resolution and planning.
• Factor 2: Managing the Psychosocial Aspects of Diabetes (Eigenvalue = 2.42, explaining 8.6% of common variance). Items 18 and 20 through 27 loaded strongly onto this factor (loadings ranging from .48 to .85). Items measuring self-motivation (Item 25) and personal support (Item 23) demonstrated the most robust associations.
• Factor 3: Assessing Dissatisfaction and Readiness to Change (Eigenvalue = 1.58, explaining 5.7% of common variance). Items 1 through 4, 15 through 17, 19, and 28 loaded distinctly on this factor (loadings ranging from .42 to .78), successfully isolating metacognitive self-awareness and emotional labeling.

Inter-factor correlations were moderate-to-high (ranging from r = .52 to r = .68), confirming the appropriateness of oblique rotation and supporting the existence of a higher-order latent construct of diabetes empowerment.

Confirmatory Factor Analysis (CFA)

Subsequent confirmatory studies across culturally diverse populations (including European, Asian, and Hispanic cohorts) validated the original three-factor structural model against alternative one-factor and unconstrained models. Goodness-of-fit indices demonstrated acceptable to excellent fit:

• Comparative Fit Index (CFI) = .93 to .96
• Tucker-Lewis Index (TLI) = .92 to .95
• Root Mean Square Error of Approximation (RMSEA) = .048 to .059 (with 90% confidence interval < .06)
• Standardized Root Mean Square Residual (SRMR) = .045

Instrument / Measurement Tool

• Instrument Name: Diabetes Attitudes Questionnaire / Diabetes Empowerment Scale (DES)
• Authors: Robert M. Anderson, EdD; Martha M. Funnell, MS, RN, CDCES, FAAN; John T. Fitzgerald, PhD; David G. Marrero, PhD; Cheryl Feste
• Publication Year: 2000 (primary psychometric validation); foundational abstract 1997
• Target Population: Adult individuals (aged 18 and older) diagnosed with either Type 1 or Type 2 Diabetes Mellitus; adapted versions exist for adolescents and specific cross-cultural populations
• Administration Format: Paper-and-pencil self-report, structured face-to-face interview, or electronic digital administration (web-based patient portal, mobile health app)
• Item Count: 28 self-report items
• Subscales (3):
  • Setting and Achieving Goals: 10 items (Items 5, 6, 7, 8, 9, 10, 11, 12, 13, 14)
  • Managing the Psychosocial Aspects of Diabetes: 9 items (Items 18, 20, 21, 22, 23, 24, 25, 26, 27)
  • Assessing Dissatisfaction and Readiness to Change: 9 items (Items 1, 2, 3, 4, 15, 16, 17, 19, 28)
• Response Scale: 5-point Likert-type scale scored as follows:
  • 5 = Strongly Agree
  • 4 = Somewhat Agree
  • 3 = Neutral
  • 2 = Somewhat Disagree
  • 1 = Strongly Disagree
• Scoring Procedures:
  • All 28 items are positively worded; no reverse scoring is required.
  • Subscale Scores: Calculated by summing the scores of the corresponding items within each subscale and dividing by the number of completed items in that subscale (yielding mean subscale scores ranging from 1.0 to 5.0).
  • Overall Empowerment Score: Calculated by summing all 28 items and dividing by 28 (yielding an overall mean score ranging from 1.0 to 5.0).
  • Higher scores uniformly indicate greater levels of psychosocial empowerment and self-efficacy.
  • Missing data rule: If more than 20% of items on a given subscale are unanswered, that subscale score should be treated as missing or calculated using standard mean imputation only if missingness is completely at random.
• Completion Time: Approximately 8 to 12 minutes

Permissions & Fee and Test Year

The Diabetes Attitudes Questionnaire / Diabetes Empowerment Scale (DES) was developed in 2000 under the auspices of the Michigan Diabetes Research and Training Center (MDRTC), funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK Grant 5 P60 DK20572). The instrument is placed in the public domain for research, academic, and non-profit clinical purposes. Healthcare systems, clinical educators, and academic investigators may utilize, reproduce, and administer the instrument free of royalty charges or licensing fees.

Users are requested to maintain the original integrity of the items, cite the foundational validation publication (Anderson et al., 2000), and acknowledge the Michigan Diabetes Research Center (MDRC). For commercial software integration, pharmaceutical clinical trials, or proprietary digital platforms, formal inquiries regarding standardized versions should be directed to the University of Michigan Medical School / MDRC Survey Instruments Repository (http://diabetesresearch.med.umich.edu/Tools_SurveyInstruments.php#das).

References

• Anderson, R. M., Fitzgerald, J. T., Funnell, M. M., & Feste, C. (1997). Diabetes Empowerment Scale (DES): A measure of psychosocial self-efficacy. Diabetes, 46(Suppl. 1), 269A.
• Anderson, R. M., Funnell, M. M., Fitzgerald, J. T., & Marrero, D. G. (2000). The Diabetes Empowerment Scale: A measure of psychosocial self-efficacy. Diabetes Care, 23(6), 739–743. https://doi.org/10.2337/diacare.23.6.739
• Anderson, R. M., Funnell, M. M., Nwankwo, R., Gillard, M. L., Fitzgerald, J. T., & Oh, M. (2001). Evaluation of a problem based, culturally specific, patient education program for African Americans with diabetes. Diabetes, 50(Suppl. 2), A195.
• Anderson, R. M., Fitzgerald, J. T., Gruppen, L. D., Funnell, M. M., & Oh, M. S. (2003). The Diabetes Empowerment Scale-Short Form (DES-SF). Diabetes Care, 26(5), 1641–1642. https://doi.org/10.2337/diacare.26.5.1641
• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman and Company.
• Funnell, M. M., Anderson, R. M., Arnold, M. S., Barr, P. A., Donnelly, M., Johnson, P. D., Taylor-Moon, D., & White, N. H. (1991). Empowerment: An idea whose time has come in diabetes education. The Diabetes Educator, 17(1), 37–41. https://doi.org/10.1177/014572179101700108
• Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer Publishing Company.
• Peterson, N. A., Speer, P. W., & McMillan, D. W. (2008). Validation of a Brief Sense of Community Scale: Confirmation of the principal theory of sense of community. Journal of Community Psychology, 36(1), 61–73. https://doi.org/10.1002/jcop.20217

13. Items of the Scale (Questionnaire)