Summary of Diabetes Self-Care Activities (SDSCA)

1. Abstract

The Summary of Diabetes Self-Care Activities (SDSCA) measure is one of the most widely utilized, validated, and psychometrically robust self-report instruments designed to assess multidimensional adherence to diabetes self-management regimens. Developed by Deborah J. Toobert, Sarah E. Hampson, and Russell E. Glasgow, and comprehensively revised in 2000, the SDSCA evaluates the frequency with which individuals with type 1 or type 2 diabetes mellitus perform essential medical self-care tasks over the preceding seven-day period. The instrument captures distinct behavioral domains, including General Diet, Specific Diet, Physical Exercise, Blood-Glucose Testing, Foot Care, Medication Adherence, and Cigarette Smoking, alongside supplementary items evaluating dietary supplement consumption and alternative therapies.

Unlike unidimensional behavioral checklists, the SDSCA is grounded in behavioral and self-regulatory theories demonstrating that diabetes self-care is inherently multidimensional; compliance in one behavioral domain (such as pharmacotherapy) rarely correlates strongly with compliance in others (such as aerobic exercise or dietary restriction). The standard core instrument comprises 11 to 17 items scored on a 0-to-7-day continuous response scale, providing an intuitive, clinically meaningful, and statistically flexible index of behavioral performance. Psychometric evaluations across diverse clinical and community cohorts demonstrate moderate-to-high internal consistency (mean inter-item correlation $r = .47$), stable test-retest reliability ($r = .40$ to $.78$), and strong convergent, concurrent, and predictive validity against objective physiological biomarkers such as glycated hemoglobin (HbA1c), electronic blood glucose logbooks, dietary recalls, and accelerometry-derived activity data. The SDSCA serves as an indispensable tool in clinical trials, behavioral interventions, epidemiologic surveillance, and routine endocrinology and primary care consultations worldwide.

2. Keywords

Summary of Diabetes Self-Care Activities, SDSCA, diabetes mellitus, self-management, glycemic control, treatment adherence, health behaviors, psychometrics, blood glucose monitoring, foot care, dietary adherence, physical activity, behavioral medicine, chronic disease self-regulation.

3. Authors

The SDSCA was developed and iteratively standardized by a team of prominent clinical behavioral psychologists and health services researchers:

• Deborah J. Toobert, Ph.D.: Senior Research Scientist at the Oregon Research Institute (ORI), Eugene, Oregon, USA. Dr. Toobert’s scholarship focuses on chronic disease self-management, behavioral interventions in cardiovascular health and diabetes, and the translation of lifestyle interventions to real-world community and primary care settings.
• Sarah E. Hampson, Ph.D.: Senior Research Scientist at the Oregon Research Institute, USA, and Professor Emeritus of Psychology and Health at the University of Surrey, United Kingdom. Dr. Hampson is internationally recognized for her empirical contributions to personality psychology, lifespan health behaviors, illness representations, and pediatric and adult diabetes self-management.
• Russell E. Glasgow, Ph.D.: Research Professor and Director of the Dissemination and Implementation Science Program at the Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, Colorado, USA. Formerly at the Oregon Research Institute and the National Cancer Institute (NCI), Dr. Glasgow is a world-renowned authority on behavioral medicine, self-care measurement, and the creator of the RE-AIM implementation framework.

4. Purpose

Diabetes mellitus is an arduous, progressive metabolic disorder whose long-term clinical prognosis is governed predominantly by daily behavioral actions enacted by the patient rather than by episodic clinical interventions. Optimal glycemic control and the mitigation of microvascular complications (e.g., retinopathy, nephropathy, neuropathy) and macrovascular sequelae (e.g., myocardial infarction, stroke) require patients to orchestrate a complex regimen. This regimen encompasses caloric moderation, carbohydrate spacing, daily physical exertion, self-monitoring of blood glucose (SMBG), foot examinations, meticulous hygiene, and strict adherence to oral hypoglycemic agents or injectable insulin regimens.

Historically, investigators and clinicians relied on fragmented, non-standardized ad-hoc surveys or global compliance measures that conflated these disparate behaviors into single, unidimensional indices. Such aggregate measures obscured vital clinical realities: an individual might exhibit near-perfect adherence to pharmaceutical regimens while simultaneously exhibiting complete non-adherence to dietary recommendations or foot examinations. Furthermore, earlier measurement protocols often imposed substantial administrative and cognitive burden on respondents, incorporating exhaustive 24-hour food diaries, complex nutritional recall inventories, or intensive multi-page logs that proved unfeasible for busy outpatient clinics and large-scale epidemiological investigations.

The SDSCA was engineered to fulfill the critical clinical and empirical demand for a brief, standardized, cost-effective, multidimensional, and psychometrically defensible measurement tool. Its core purposes include:

• Behavioral Profiling and Needs Assessment: Establishing a granular baseline profile of an individual’s self-care behaviors across distinct regimen domains to identify specific behavioral deficits requiring tailored psychoeducational intervention.
• Intervention Evaluation: Serving as a responsive, reliable primary or secondary outcome measure in behavioral medicine, health psychology, and randomized controlled trials evaluating diabetes self-management education (DSME), digital health solutions, or pharmacological regimens.
• Clinical Monitoring and Longitudinal Surveillance: Providing primary care physicians, certified diabetes care and education specialists (CDCES), and endocrinologists with a rapid, 5-minute screening instrument that facilitates collaborative goal-setting and tracks behavioral fluctuations over time.
• Empirical Research into Health Behavior Mechanisms: Offering researchers an operationalized instrument to test structural models examining the relationships between psychological constructs (e.g., self-efficacy, health literacy, social support, illness representations) and clinical endpoints (e.g., HbA1c, quality of life, hospital admissions).

5. Psychological Construct

The psychological construct assessed by the SDSCA is Diabetes Self-Care Behavior, defined as the proactive, goal-directed performance of self-regulatory health actions undertaken by an individual diagnosed with diabetes to sustain physiological homeostasis, optimize glycemic control, prevent acute hypo- and hyperglycemic crises, and avert long-term vascular complications. Rather than conceptualizing self-care as a global, unitary personality trait or a generalized compliance orientation, psychometric theory posits that diabetes self-care is a multidimensional, domain-specific behavioral construct. The SDSCA delineates this behavioral domain into several distinct, operationalized subscales:

5.1. General Diet

The General Diet subscale assesses the respondent’s macro-level adherence to a structured, healthful nutritional plan. It captures both the proximal performance of a healthy diet over the preceding week (Item 1) and the habitual, normative pattern of dietary self-regulation over the preceding month (Item 2). This dimension measures an individual’s cognitive-behavioral intention and consistency in organizing daily nutrition around medically established therapeutic lifestyle guidelines.

5.2. Specific Diet

Recognizing that general dietary self-perceptions may be vulnerable to self-serving attribution or vague operational definitions, the Specific Diet subscale targets concrete, nutritional micro-behaviors. It evaluates the consumption of nutrient-dense, cardioprotective foods—specifically assessing the ingestion of five or more daily servings of fruits and vegetables (Item 3)—as well as the avoidance of atherogenic, high-saturated-fat options such as red meat or full-fat dairy products (Item 4). The expanded version extends this construct to assess the temporal distribution of carbohydrate intake across meals (Item 5A), reflecting adherence to contemporary medical nutrition therapy.

5.3. Exercise / Physical Activity

The physical activity dimension captures energy expenditure across two distinct conceptual strata: total accumulated lifestyle activity and intentional, structured physical exercise. Item 5 assesses participation in at least 30 minutes of continuous physical activity (such as brisk walking), capturing the baseline lifestyle exertion recommended by public health guidelines. Item 6 assesses participation in planned, vigorous or structured exercise sessions (e.g., swimming, cycling, intentional fitness workouts) independent of domestic chores or occupational physical demands, capturing discretionary health-promoting behavior.

5.4. Blood Glucose Testing

This subscale evaluates the respondent’s adherence to self-monitoring of blood glucose (SMBG). It measures both the absolute behavioral volume of monitoring—operationalized as the number of days blood glucose was tested in the preceding week (Item 7)—and the individual’s compliance with their personalized clinical prescription—operationalized as the frequency of testing the exact number of times recommended by the healthcare provider (Item 8). This distinction is critical because clinical recommendations vary substantially across patient populations (e.g., multiple daily tests for patients on intensive basal-bolus insulin vs. less frequent testing for patients on stable oral monotherapy).

5.5. Foot Care

Targeting the primary behavioral defense against peripheral diabetic foot ulcerations and lower-extremity amputations, the Foot Care subscale measures preventative vigilance. The core items capture visual or tactile inspection of the feet (Item 11) and inspection of the interior surfaces of shoes for foreign objects or structural seams that induce pressure sores (Item 12). The expanded scale integrates essential hygiene behaviors, including daily foot washing (Item 13/9A), thorough interdigital drying to prevent fungal infections (Item 11A), and the active avoidance of deleterious actions such as prolonged foot soaking (Item 10A), which compromises epidermal barrier integrity.

5.6. Medication Adherence

The medication dimension assesses pharmacological compliance across oral hypoglycemic formulations and subcutaneous insulin injections. Items measure the consistent ingestion of prescribed oral tablets (Item 10, Item 8A), the administration of prescribed insulin dosages (Item 7A), and overall concordance with the overarching pharmaceutical regimen (Item 9, Item 6A). Because pharmacological non-adherence remains one of the primary drivers of secondary treatment failure in diabetes, isolating this domain from discretionary lifestyle factors provides indispensable diagnostic clarity.

5.7. Substance Use and Complementary Self-Care Modalities

The expanded SDSCA integrates secondary health behaviors that exert marked influence on cardiovascular risk and metabolic stability. Smoking status is captured both categorically (any cigarette use over the past week) and quantitatively (average daily cigarette consumption), along with questions on clinical cessation counseling. Alcohol consumption is quantified through average standard drinks consumed per day. Furthermore, the instrument evaluates complementary and alternative medicine (CAM) behaviors, assessing the weekly frequency of taking unauthorized dietary supplements, vitamins, herbal preparations, or folk remedies to manage glycemic parameters without explicit medical supervision.

6. Theoretical Framework

The SDSCA is deeply anchored in contemporary behavioral medicine, health psychology, and cognitive-behavioral theories of chronic disease management. Its conceptual framework synthesizes principles from Social Cognitive Theory, Self-Regulation Theory, and the Independence of Regimen Areas Hypothesis.

6.1. Social Cognitive Theory and Self-Efficacy

Rooted in the theoretical paradigms established by Albert Bandura, the SDSCA conceptualizes self-care behaviors as the overt manifestations of reciprocal determinism among personal cognitive factors, environmental influences, and behavioral patterns. Bandura’s constructs of self-efficacy (an individual’s confidence in their ability to execute specific behaviors across varying challenging circumstances) and outcome expectancies (the conviction that enacting those behaviors will yield desired health improvements) serve as the primary cognitive engines of self-care. Because self-efficacy is inherently domain-specific—a patient may possess exceptionally high efficacy regarding medication ingestion yet harbor profound self-doubts regarding exercise initiation or dietary self-restraint—the SDSCA’s multi-subscale architecture directly mirrors the compartmentalized cognitive architecture described by Social Cognitive Theory.

6.2. The Common-Sense Model of Self-Regulation

The instrument draws conceptually on the Common-Sense Model of Self-Regulation, formulated by Howard Leventhal and colleagues. This model asserts that individuals construct dynamic cognitive and emotional illness representations (concerning identity, timeline, consequences, cause, and controllability/cure). In diabetes, these representations directly dictate which coping procedures (self-care behaviors) are selected and maintained. For example, if a patient perceives diabetes as an acute or fluctuating condition governed strictly by medication, they will demonstrate high adherence on SDSCA medication items while neglecting foot examinations or physical exertion. The SDSCA acts as an operational readout of an individual’s behavioral coping responses within Leventhal’s feedback loop, reflecting how patients continuously evaluate and adjust their daily self-management behaviors.

6.3. The Independence of Regimen Areas Hypothesis

A foundational theoretical insight advanced by Russell Glasgow and colleagues during the early development of the SDSCA is the Multicomponent Regimen Independence Hypothesis. Early psychosomatic models erroneously conceptualized “patient compliance” as a general trait: individuals were presumed to be either fundamentally “compliant” or “non-compliant.” Extensive empirical investigations refuted this premise, showing near-zero or low-to-moderate intercorrelations across distinct diabetes self-care behaviors. Glasgow and Toobert emphasized that diabetes self-care behaviors operate under entirely different behavioral economics, schedule demands, response costs, and reinforcement contingencies:

• Pharmacological adherence entails discrete, habit-chained behaviors with minimal immediate physical discomfort or lifestyle disruption.
• Dietary self-regulation requires relentless, continuous inhibitory control and resistance to ubiquitous social and environmental cues.
• Physical activity demands substantial behavioral activation, time allocation, physical exertion, and overcoming physical fatigue or orthopedic discomfort.
• Blood glucose testing requires intrusive, painful skin punctures, logistical management of supplies, and psychological willingness to confront adverse feedback (high glucose readings).
• Foot care necessitates daily physical flexibility, cognitive vigilance, and anticipation of distal, abstract ulceration risks.

Because each behavioral domain is governed by distinct proximal barriers and reinforcement schedules, the SDSCA was theoretically designed to treat each domain as an autonomous subscale, intentionally rejecting the clinical utility of a single composite “total self-care” score.

7. Validity

The validity of the SDSCA has been rigorously examined across dozens of psychometric investigations, clinical trials, and multi-center studies spanning diverse socioeconomic, age, and cultural populations.

7.1. Construct and Structural Validity

The construct validity of the SDSCA is substantiated by its ability to reflect the multidimensionality of the self-care domain. In their landmark psychometric synthesis across seven independent clinical trials comprising over 1,988 individuals with diabetes, Toobert, Hampson, and Glasgow (2000) evaluated inter-subscale correlations. As theoretically predicted, correlations among the primary subscales were uniformly low-to-moderate (ranging from $r = .10$ to $r = .47$, with a mean inter-scale correlation of $r = .23$). This low intercorrelation confirms that the subscales measure discrete behavioral constructs rather than a singular underlying compliance propensity. Multitrait-multimethod matrix analyses and item-to-scale convergent/discriminant correlations consistently show that individual items load substantially higher on their designated subscale than on competing subscales.

7.2. Convergent and Concurrent Validity

The convergent validity of the SDSCA has been established by benchmarking self-reported scores against validated objective instruments, standardized dietary logs, and physiological parameters:

• Diet: SDSCA General Diet and Specific Diet subscale scores correlate significantly with multi-day food frequency questionnaires (FFQs), 24-hour dietary recalls, and the Block Fat Screener, with validity coefficients ranging from $r = .35$ to $r = .58$ ($p < .001$).
• Exercise: SDSCA Exercise subscale scores exhibit robust positive correlations with the 7-Day Physical Activity Recall interview ($r = .45$ to $.61$) and objective accelerometry-derived energy expenditure metrics ($r = .38$ to $.52$).
• Blood Glucose Testing: Self-reported testing frequencies on the SDSCA correlate strongly with objective, electronic memory microprocessor downloads extracted directly from patients’ glucometers ($r = .68$ to $.84$), confirming that patients report past-week testing behavior with high fidelity.
• Medication Adherence: Medication subscale scores demonstrate strong concordance with electronic pill-bottle caps (Medication Event Monitoring Systems; MEMS) and pharmacy refill adherence records ($r = .50$ to $.72$).

7.3. Criterion and Predictive Validity

The clinical criterion validity of the SDSCA is documented through its systematic associations with key biological markers of glycemic control and metabolic syndrome. Numerous studies report significant negative correlations between SDSCA total dietary and exercise scores and HbA1c (typically ranging between $r = -.15$ and $r = -.32$, $p < .01$). Although these correlations are modest in magnitude, this is expected in behavioral medicine, given that HbA1c is influenced by an array of non-behavioral biological parameters, including endogenous insulin reserve, hepatic insulin resistance, pharmacogenetics, and erythrocyte turnover kinetics. Furthermore, longitudinal studies indicate that baseline and changes in SDSCA scores prospectively predict clinically meaningful reductions in HbA1c, improvements in high-density lipoprotein (HDL) cholesterol, decreases in body mass index (BMI), and reduced 5-year incidence of diabetic foot ulcerations.

7.4. Discriminant Validity

The SDSCA demonstrates clean discriminant validity from generalized psychological distress, major depressive disorder (e.g., via the PHQ-9), and generalized trait anxiety (e.g., via the GAD-7). Furthermore, social desirability evaluations (e.g., utilizing the Marlowe-Crowne Social Desirability Scale) reveal negligible correlations ($r < .12$, non-significant), indicating that the SDSCA's concrete, time-delimited (last 7 days) behavioral frequency phrasing effectively buffers against self-enhancement or social approval biases.

8. Reliability

The reliability of the SDSCA has been comprehensively evaluated across internal consistency metrics, item-total correlations, and temporal stability (test-retest) analyses.

8.1. Internal Consistency

Because the subscales of the SDSCA are brief (consisting of two or three items per domain), internal consistency values evaluated via Cronbach’s alpha are naturally constrained, as alpha is mathematically dependent on scale length. Nevertheless, internal consistency estimates for the core SDSCA subscales in the validation meta-synthesis by Toobert et al. (2000) and subsequent international validation cohorts demonstrate solid reliability:

• General Diet: Mean inter-item correlation $r = .57$; Cronbach’s $\alpha = .70 – .85$.
• Blood-Glucose Testing: Mean inter-item correlation $r = .69$; Cronbach’s $\alpha = .80 – .92$.
• Foot Care: Mean inter-item correlation $r = .53$; Cronbach’s $\alpha = .65 – .78$.
• Exercise: Mean inter-item correlation $r = .59$; Cronbach’s $\alpha = .68 – .83$.
• Specific Diet: Mean inter-item correlation $r = .10 – .28$; Cronbach’s $\alpha = .20 – .45$. The deliberate retention of the Specific Diet scale despite low internal consistency represents a recognized psychometric compromise: consuming fruits and vegetables (Item 3) and avoiding dietary fat (Item 4) are nutritionally distinct behaviors that do not necessarily correlate within individuals. Researchers are advised to analyze these items individually or treat them as an aggregate behavioral index rather than an internally consistent latent scale.

8.2. Test-Retest Temporal Stability

The temporal stability of the SDSCA has been corroborated across numerous observational studies and control arms of randomized trials over intervals ranging from 2 weeks to 4 months. In the absence of intervening clinical education or behavioral interventions, test-retest reliability coefficients remain solid, with intertemporal correlation coefficients ranging between $r = .40$ and $r = .78$ across subscales (overall pooled mean $r = .47$). The Blood-Glucose Testing and Medication Adherence subscales consistently exhibit the highest stability ($r > .70$), whereas dietary and exercise dimensions show slightly higher variability, reflecting natural day-to-day lifestyle fluctuations.

8.3. Sensitivity to Change

The SDSCA displays notable responsiveness and sensitivity to clinical and behavioral interventions. Following participation in structured diabetes self-management education (DSME), lifestyle modification programs, or nurse-led behavioral coaching, SDSCA subscale scores routinely demonstrate statistically significant gains characterized by medium-to-large effect sizes (Cohen’s d ranging from $0.35$ to $0.72$), confirming the tool’s utility for evaluative intervention trials.

9. Factor Analysis

The latent structural integrity of the SDSCA has been investigated utilizing both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) across diverse epidemiological samples.

9.1. Exploratory Factor Analysis (EFA)

Initial principal components and principal axis factoring analyses conducted with varimax and oblimin rotations on the core 10 to 11 behavioral items consistently extract a clear five-factor orthogonal or oblique solution, accounting for approximately 65% to 75% of the total variance. The five extracted latent factors precisely mirror the theoretical subscales:

• Factor 1 (General Diet): Defined by high, primary factor loadings from Item 1 (healthful eating plan; loading $> .80$) and Item 2 (monthly adherence to eating plan; loading $> .75$).
• Factor 2 (Exercise): Defined by substantial loadings from Item 5 (30 minutes of physical activity; loading $> .82$) and Item 6 (structured exercise sessions; loading $> .78$).
• Factor 3 (Blood-Glucose Testing): Anchored by Item 7 (testing blood sugar; loading $> .88$) and Item 8 (testing as recommended by provider; loading $> .85$).
• Factor 4 (Foot Care): Characterized by robust loadings from Item 11 (inspecting feet; loading $> .78$) and Item 12 (inspecting inside of shoes; loading $> .72$).
• Factor 5 (Medication Adherence / Specific Diet): Loading patterns reflect pharmacological compliance (Items 9 and 10; loadings $> .80$) or separate into distinct lifestyle components.

Cross-loadings across divergent behavioral factors are consistently minimal (rarely exceeding $.20$), supporting the construct independence of each behavioral dimension.

9.2. Confirmatory Factor Analysis (CFA)

Subsequent large-scale CFA investigations have evaluated competing structural models, comparing a unidimensional model (positing a single overarching general self-care factor) against an oblique, correlated multi-factor model. The unidimensional model consistently yields poor fit indices (e.g., RMSEA $> .14$, CFI $< .65$), definitively indicating that diabetes self-management cannot be reduced to a single latent variable. Conversely, the correlated multi-factor model demonstrates strong psychometric fit indices across independent cohorts:

• Comparative Fit Index (CFI): $.94 – .98$
• Tucker-Lewis Index (TLI): $.92 – .97$
• Root Mean Square Error of Approximation (RMSEA): $.035 – .058$ ($90% \text{ CI: } .028 – .065$)
• Standardized Root Mean Square Residual (SRMR): $.032 – .049$

These CFA findings reaffirm that the SDSCA represents a structurally sound, multidimensional self-report measurement model across adult populations with type 1 and type 2 diabetes.

10. Instrument / Measurement Tool

Below is the structured overview of the operational characteristics and scoring architecture of the SDSCA:

• Instrument Designation: Summary of Diabetes Self-Care Activities (SDSCA); revised 2000 edition.
• Target Respondent Population: Adolescents and adults (aged $ge 16$) diagnosed with either Type 1 or Type 2 Diabetes Mellitus.
• Administration Format: Paper-and-pencil self-administered questionnaire, digital/electronic survey (web or mobile application), or structured clinical interview.
• Administration Time: Approximately 5 to 8 minutes for the core scale; 10 to 12 minutes for the expanded version.
• Number of Items:
  • Core Brief Scale: 11 primary self-care items (encompassing diet, exercise, testing, foot care, and smoking).
  • Expanded Scale: 17 core items, plus up to 14 additional contextual and clinical recommendation items (Items 1A through 14A).
• Response Metric: Continuous integer scale ranging from 0 to 7, reflecting the exact number of days during the preceding week (last 7 days) on which the specified behavior was performed. Categorical and count responses are utilized for smoking and alcohol items.
• Scoring Rules:
  • General Diet: Calculate the mean score of Items 1 and 2: $\text{Mean}(\text{Item 1}, \text{Item 2})$. Range: 0 to 7.
  • Specific Diet: Reverse score Item 4 ($7 – \text{Item 4}$), then calculate the mean of Item 3 and the reversed Item 4: $\text{Mean}(\text{Item 3}, 7 – \text{Item 4})$. Alternatively, because of low inter-item correlation, report Items 3 and 4 individually.
  • Exercise: Calculate the mean score of Items 5 and 6: $\text{Mean}(\text{Item 5}, \text{Item 6})$. Range: 0 to 7.
  • Blood-Glucose Testing: Calculate the mean score of Items 7 and 8: $\text{Mean}(\text{Item 7}, \text{Item 8})$. Range: 0 to 7.
  • Foot Care: Calculate the mean score of Items 11 and 12 (or Items 9 and 10 in the alternative numbering): $\text{Mean}(\text{Item 11}, \text{Item 12})$. Range: 0 to 7.
  • Medication Adherence: Calculate the mean of Items 9 and 10 (or Items 6A, 7A, 8A in the expanded module). Range: 0 to 7.
  • Smoking Status: Scored categorically ($0 = \text{non-smoker}$, $1 = \text{smoker}$) and quantitatively (average number of cigarettes smoked per day).
  • Total Score: The authors explicitly advise against calculating a composite total score across subscales due to the empirical and theoretical independence of the regimen areas.

11. Permissions & Fee and Test Year

The modern, standardized revised version of the SDSCA was published in 2000 by Deborah J. Toobert, Sarah E. Hampson, and Russell E. Glasgow in the peer-reviewed medical journal Diabetes Care (Vol. 23, Issue 7, pp. 943–950), updating the initial 1994 iteration. The instrument is dedicated to the public domain for research, academic, and non-commercial clinical purposes. It is freely accessible to investigators and clinical teams globally without the imposition of licensing fees or royalties. The developers grant blanket permission for its use, reproduction, translation, and adaptation in empirical studies and routine healthcare delivery, provided that appropriate scholarly attribution is accorded to the original 2000 publication.

12. References

• Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall.
• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman.
• Glasgow, R. E., & Anderson, R. M. (1999). In search of excellence in diabetes self-management education. Annals of Behavioral Medicine, 21(1), 33–40. https://doi.org/10.1007/BF02895031
• Glasgow, R. E., Hampson, S. E., Strycker, L. A., & Ruggiero, L. (1997). Personal-model approaches to health-behavior change: Setting the stage for diabetes self-care interventions. Diabetes Care, 20(4), 556–561. https://doi.org/10.2337/diacare.20.4.556
• Glasgow, R. E., McCaul, K. D., & Schafer, L. C. (1987). Self-care behaviors and glycemic control in type I diabetes. Journal of Chronic Diseases, 40(5), 399–412. https://doi.org/10.1016/0021-9681(87)90176-1
• Leventhal, H., Nerenz, D. R., & Steele, D. J. (1984). Illness representations and coping with health threats. In A. Baum, S. E. Taylor, & J. E. Singer (Eds.), Handbook of Psychology and Health: Vol. IV. Social Psychological Aspects of Health (pp. 219–252). Lawrence Erlbaum Associates.
• Schmitt, A., Gahr, A., Hermanns, N., Kulzer, B., Huber, J., & Haak, T. (2013). The Diabetes Self-Management Questionnaire (DSMQ): Development and evaluation of an instrument to assess self-care activities associated with glycaemic control. Health and Quality of Life Outcomes, 11, Article 138. https://doi.org/10.1186/1477-7525-11-138
• Toobert, D. J., & Glasgow, R. E. (1994). Assessing diabetes self-management: The Summary of Diabetes Self-Care Activities questionnaire. In C. Bradley (Ed.), Handbook of Psychology and Diabetes (pp. 351–375). Harwood Academic Publishers.
• Toobert, D. J., Hampson, S. E., & Glasgow, R. E. (2000). The Summary of Diabetes Self-Care Activities measure: Results from 7 studies and a revised scale. Diabetes Care, 23(7), 943–950. https://doi.org/10.2337/diacare.23.7.943

13. Items of the Scale (Questionnaire)