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Social Cognitive Theory in Diabetes Exercise Research: An Integrative Literature

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 The Diabetes Educator
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Social Cognitive Theory in Diabetes Exercise Research: An Integrative Literature Review

Nancy A. Allen
The Diabetes Educator 2004; 30; 805
DOI: 10.1177/014572170403000516

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Social Cognitive Theory in Diabetes
Exercise Research: An Integrative
Literature Review
Nancy A. Allen,
PhD-c, APRN, BC-ANP
From the Graduate School of Nursing,
University of Massachusetts, Worcester.
Correspondence to Nancy
A. Allen, 47 Pine Knoll Road, Lenox,
MA 01240 (e-mail: ncallen@adelphia.
net).
Reprint requests may be
sent to The Diabetes Educator, 367
West Chicago Avenue, Chicago, IL
60610-3025.
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T h e D i a b e t e s E d u c a t o r
Volume 30, Number 5 • September/October 2004 8 0 5
t PURPOSE
his integrative review critically examined the
literature on diabetes research using Social Cognitive
Theory (SCT) to determine its predictive ability in
explaining exercise behavior and to identify key
interventions that enhance exercise initiation and
maintenance.
METHODS
Literature published between 1985 and 2002 was searched
using the following keywords: SCT, self-efficacy, diabetes
mellitus, non-insulin-dependent diabetes mellitus, insulin-
dependent diabetes mellitus, physical activity, and exercise. The
databases searched were CINAHL, Medline, and PsychInfo. Of
the 38 articles retrieved from databases, 13 were reviewed.
RESULTS
A statistically significant relationship between self-efficacy and
exercise behavior was found in correlational studies. Results
from the predictive study support the predictability of self-
efficacy for exercise behavior. Mixed results were found for the
predictive ability of outcome expectancies for exercise behavior.
Self-efficacy was predictive of exercise initiation and maintenance
over time. The evidence for successful interventions to increase
self-efficacy and exercise behavior over time was inconclusive.
CONCLUSIONS
To better understand exercise behavior and to develop effective
exercise interventions, a microanalytic, theory-driven approach
to studying exercise behavior is needed. Several suggestions are
offered to strengthen exercise self-efficacy.
 Self-Efficacy Theory in Diabetes Research T h e D i a b e t e s E d u c a t o r

8 0 6 Allen Volume 30, Number 5 • September/October 2004

b etween 1990 and 2000, the prevalence of

diabetes mellitus in the United States in-
creased by 49%, reflecting a progressively
overweight and sedentary population.1
Approximately 11.1 million people have been diag-
nosed with this chronic progressive disease, and an ad-
ditional 5.9 million are estimated to have undiagnosed
individuals with diabetes; these theories are the Trans-
theoretical Model,30 the Health Belief Model,31 and the
Theory of Planned Behavior.32 Unfortunately, many di-
abetes education studies targeting behavioral strategies
have lacked a theoretical framework from which a co-
herent, progressive body of knowledge can be built.33
The self-efficacy construct, which is part of
diabetes.2 Individuals with diabetes have a 2- to 4-times
Bandura’s Social Cognitive Theory (SCT),34 has been
greater risk of heart disease and stroke, as well as en-
used to understand behavior related to many compo-
during blindness, nerve damage, and renal failure.2 Ed-
nents of the diabetes self-care regimen. In the last 17
ucating people with type 2 diabetes about lifestyle
years, evidence has been amassed about the impor-
modifications, such as losing weight and exercising,
tance of self-efficacy in metabolic control,35-37 health-
may improve metabolic control, reduce disease compli-
related quality of life,38 coping and problem solving,39
cations, and improve quality of life.
self-care adherence,35,40 diet adherence,41 insulin ther-
Exercise, an important cornerstone of diabetes apy,42,43 blood glucose testing,37,44-47 and exercise
therapy, has significant psychological and physiological adherence.23,35-37,40,44-48
benefits for people with diabetes mellitus. A single bout
SCT appears to have promise for helping dia-
of exercise can markedly increase rates of glucose dis-
betes healthcare providers understand exercise behav-
posal3-6 and increase insulin sensitivity.3,5,7,8 These ef-
iors and for developing behavioral interventions that
fects can last for several hours following exercise5,9,10
promote exercise activity. The predictive ability of SCT
and have beneficial effects in terms of metabolic control
in exercise research was examined in a previous integra-
and regulation of glucose homeostasis. A frequently
tive review of exercise studies on a variety of patient
overlooked benefit of exercise training is its ability to
populations.49 These studies, however, did not include
significantly decrease hemoglobin A1c (A1C), inde-
people with diabetes. A statistically significant relation-
pendent of weight loss.11 Additional benefits of exercise
ship between self-efficacy and exercise behavior was re-
include reduction of hypertension,12 hyperlipidemia,13,14
ported in all 14 descriptive studies included in that
and cardiac risk factors.15-20 Psychological benefits of
review.49 In the 3 exercise intervention studies reviewed,
regular exercise for individuals with diabetes have been
participation in an exercise program was found to pro-
suggested.21 Despite the potential benefits of exercise,
mote self-efficacy, and programs designed to increase
an estimated 37% to 60% of people with diabetes do
outcome expectations and self-efficacy significantly in-
not exercise22,23 or have not been given specific exercise
creased exercise behavior.49 The purpose of this integra-
advice or an exercise prescription by their healthcare
tive review is to critically examine the empirical
providers.24
diabetes literature related to SCT and exercise, with an
Exercise is an understudied component of the emphasis on the predictive ability of SCT in explaining
self-care regimen for people with type 2 diabetes,25 and exercise behavior, and to identify key interventions that
is often rated as one of the most difficult lifestyle enhance exercise initiation and maintenance.
changes to make.25-27 Because of the complexity of
OVERVIEW OF SOCIAL COGNITIVE THEORY
human behavior, just giving information about the im-
Social Cognitive Theory incorporates a triadic causa-
portance of exercise is often ineffective at motivating in-
tion reciprocal model to represent its perspective of
dividuals to make difficult behavior changes.28
human functioning34 as a dynamic interplay of person-
Therefore, the current standard of care for diabetes ed-
al, behavioral, and environmental influences. For ex-
ucation includes a combination of educational and be-
ample, how people interpret the consequences of their
havioral strategies.29 Several behavioral theories have
own behavior informs and alters their environment and
been proposed to guide understanding of human be-
their personal factors (cognitive, affective, and biologi-
havior, behavior change, and motivation, as well as to
cal events), which, in turn, inform and alter subsequent
support the development of effective interventions for

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Self-Efficacy Theory in Diabetes Research T h e D i a b e t e s E d u c a t o r

Allen Volume 30, Number 5 • September/October 2004 8 0 7

SOCIAL COGNITIVE THEORY APPLIED TO EXERCISE IN DIABETES*

Person
Behavior Outcome
Individual with type 2
Exercise Regular exercise
diabetes

Efficacy
Outcome
expectations
expectations
“I feel confident that I
“If I increase my
can get up early, even
exercise, my health
on the weekends, to
will improve.”
exercise.”

Four information
sources
Performance
accomplishements,
vicarious experience,
verbal persuasion,
physiological
feedback

*Adapted from Bandura50 and Shortridge-Baggett and van der Bijl.78

behavior. Self-efficacy, a major construct of SCT, repre-
sents confidence, or lack thereof, in one’s ability to per-
form a particular behavior to accomplish a specific
goal.50 Outcome expectancies reflect one’s belief that
performing a particular behavior will result in a partic-
ular consequence.50 Self-efficacy beliefs are theorized to
affect behavior initiation and cessation, effort and per-
sistence, motivation, thought patterns, and emotional
reactions.50
According to Bandura’s SCT, both self-efficacy
and outcome expectancies influence behavior change
and are strengthened or weakened through 4 informa-
tion sources50 (see the Figure). The following specific
exercise examples are provided to clarify these sources.
The first and strongest information source consists of
performance accomplishments which are derived from
prior personal experience with exercise, for example,
mastering an exercise routine. The second information
source, vicarious experience, includes seeing others
similar to oneself exercise successfully. Vicarious
experiences are often operationalized by using role
models to demonstrate a particular behavior. Verbal
persuasion, the third information source, entails en-
couraging belief in one’s ability to master an exercise
behavior change and persuading individuals that exer-
cise change can be beneficial to their diabetes. The
fourth information source, physiological feedback, is
produced when performing a particular behavior, in
this case, exercise. For example, individuals with high
self-efficacy are likely to view physiological indicators,
such as elevated endorphins or weight loss, as energiz-
ing, arousing, and facilitating performance. On the
other hand, individuals with low self-efficacy may view
pain and fatigue as debilitating, thus discouraging
performance.
METHODS
Integrative literature reviews examine and summarize
previous research by drawing conclusions from many
separate studies that are believed to address related hy-
potheses.51 Cooper’s scientific guidelines were used for

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 Self-Efficacy Theory in Diabetes Research
8 0 8 Allen
conducting this integrative research review, which in-
cludes 5 review stages: problem formulation, data col-
lection, data evaluation, analysis and interpretation,
and public presentation.51
Problem Formulation
The problem addressed in this review was formulated
by Cooper’s first research question, “What evidence
should be included in the review?” An a priori model49
was modified and used to guide the collection of evi-
dence for this review. The criteria used for including an
article in this review were a clear statement of (1) a the-
oretical link to self-efficacy and diabetes in adult popu-
lations, (2) the definition of self-efficacy, and (3) an
indication of physical activity or exercise as an outcome
variable.
Data Collection
The data collection stage addressed the research ques-
tion “What procedures should be used to find relevant
evidence?”51 The research literature was extensively
searched for studies on adult diabetes and self-efficacy
published between 1985 and 2002. Sources for the
review included Medline, the Cumulative Index to
Nursing and Allied Health Literature (CINAHL), Psy-
chological Abstracts (PsychInfo), and relevant citations
in published articles. Multiple text word combinations
used in the search included the following keywords: di-
abetes mellitus, non-insulin-dependent diabetes melli-
tus, insulin-dependent diabetes mellitus, self-efficacy,
social cognitive theory, physical activity, and exercise.
The literature search yielded 33 articles from databases
and 5 dissertations demonstrating a theoretical link be-
tween self-efficacy and diabetes in adult populations.
Only 12 articles and 2 dissertations clearly defined self-
efficacy and indicated physical activity or exercise as an
outcome variable.
Data Evaluation
The data evaluation phase involved applying criteria to
separate valid from invalid studies and addressed the re-
search question “What retrieved evidence should be in-
cluded in the review?”51 The methodological quality of
each study was evaluated using Smith and Stullenbarg-
er’s integrative literature review instrument.52 Each arti-
cle was rated in 22 categories across 4 dimensions:
introduction, methodology, data analysis and results,
and conclusions and recommendations. The possible
range of quality scores was 0 to 66, with a score of 33
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T h e D i a b e t e s E d u c a t o r
Volume 30, Number 5 • September/October 2004
set for inclusion in the review. The scores of studies in-
cluded in the review ranged from 48 to 61, with an av-
erage score of 53. One study was eliminated because of
lack of sufficient sample size to support significant find-
ings, leaving 11 journal articles and 2 dissertations.
Nine studies had predictive correlational designs, 1 had
a descriptive correlational design, and 3 were interven-
tion studies.
Study Samples
The 13 studies had sample sizes ranging from 46 to 185
(mean=118). No study included an estimated effect
size, but all studies had sufficient sample size for the sta-
tistical analyses employed.53,54 The participants tended
to be female (in 8 of 13 studies), have type 2 diabetes
(10 of 13 studies), and were an average of 52 years old.
Of the 8 studies reporting ethnicity, 6 included white
participants, 1 had an exclusively female African Amer-
ican sample, and 1 study had an entirely Yugoslavian
sample. All studies were conducted in an outpatient
setting.
Study Measures
All of the studies used a variety of instruments to mea-
sure self-efficacy. Four studies used McCaul and col-
leagues’44 self-efficacy instrument; 2 studies used
Crabtree’s55 instrument; and one study each used Hur-
ley and Shey’s42 instrument, Grossman and colleagues’56
instrument, and Boykin’s57 instrument (Table 1). Of the
remaining 4 studies, 3 developed self-efficacy meas-
ures23,35,58 and one did not identify the instrument
used.46 A reliability coefficient of 0.80 is considered the
lowest acceptable value for a well-developed psychoso-
cial measurement instrument and 0.70 for a newly de-
veloped psychosocial instrument.59 The instrument
reliability in 9 studies reporting internal consistency
ranged from 0.58 to 0.95 (mean=0.73). Outcome ex-
pectancies were measured in 5 of the 13 studies, with 3
studies44,45,47 having alphas between .54 and .72 and the
remaining 246,57 studies having alphas of .85 and .50, re-
spectively, resulting in a mean alpha of .66 for the 5
studies. Exercise was measured as minutes per week,
energy expenditure, treatment adherence, self-care
scale, or a self-monitoring activity log. The reliability of
these exercise measures was not reported in 11 studies.
However, the remaining 2 studies reported an alpha of
.79 for the Diabetes Self-Management Questionnaire
and .92 for the revised Insulin Management Diabetes
Self-Care Scale.
Self-Efficacy Theory in Diabetes Research
Allen
Table 1.
Summary of Diabetes Self-Efficacy and Exercise Research, 1985-2002
Authors Sample
Boykin,57 1995 N=63; 100% type 2
diabetes; 55% fe-
male; race not re-
ported; mean
age=57 y
Crabtree,55 1986 N=143; 81% type 1
diabetes; 18% type
2 diabetes; 61% fe-
male; 80% white;
mean age=44 y
Glasgow et al,47 N=127; 98.4% type
1989 2 diabetes; 67% fe-
male; 98% white;
mean age=61 y
Glasgow et al,48 N=102; 100% type
1992 2 diabetes; 63.5%
female; race not re-
ported; mean
age=67 y
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Scale(s)
Boykin’s Self-Effica-
cy, Outcome Ex-
pectancy Scales
(SEOES); Summary
of Diabetes Self-
Care Activities Scale
(SDSCA); Standford
7-Day Physical Ac-
tivity Recall Inter-
view
Crabtree’s Diabetes
Self-Efficacy Scale
(DSES); Diabetes
Self-Management
Questionnaire
(DSMQ)
McCaul’s SE and Not reported
Outcome Expectan-
cy Scale—Revised;
Glasgow’s Summary
of Diabetes Self-
Care Activities; self-
monitoring records
Standford 7-Day
Recall; McCaul’s
Self-Efficacy
Scale— Revised
T h e D i a b e t e s
Volume 30, Number 5 • September/October 2004
Reliability/Validity
SEOES exercise
self-efficacy (SE)
subscale
alpha=.95, exercise
outcome expectancy
subscale=0.85;
SDSCA not report-
ed; Standford 7-Day
Recall not reported
DSES exercise sub-
scale alpha=.60;
DSMQ exercise sub-
scale alpha=.71
Not reported
E d u c a t o r
Intervention/Design Results
Correlational predic-
tive design to devel-
op a scale to assess
diabetes SE, out-
come expectancy,
and outcome value
for diet, exercise,
medication taking,
blood glucose moni-
toring, and foot care
Correlational
predictive design to
investigate the rela-
tionships among
self-efficacy, social
support, and their
effects on self-care
Correlational,
predictive design to
evaluate the social
learning measures
hypothesized to be
related to diabetes
self-care activities
10-session self-
management train-
ing intervention to
enhance problem
solving and self-effi-
cacy; measures
taken at baseline
and 6 mo
continued on page 810
8 0 9
Exercise SE and out-
come expectancy
were correlated with
exercise adherence
when measured by
SDSCA (r=0.52,
P<.01) but not by
Standford 7-Day Re-
call; exercise out-
come expectancy
was correlated with
SDSCA (r=0.24,
P<.05); exercise
self-care was the
only significant pre-
dictor of exercise SE
(R2=0.27)
Self-efficacy was the
only variable that ex-
plained exercise be-
havior (R2=0.35,
n=92, F=36.42,
P<.001)
Exercise level was
predicted by social
learning variables
(r=0.49, P<.001);
participants’ confi-
dence to exercise
was significantly
lower than other self-
care activities, de-
spite high outcome
expectations
Exercise increased
significantly in imme-
diate treatment at 6
mo (baseline
mean=36.2 min/d
[SD=5.2], 6-mo
mean=50.8 min/d
[SD=4.7]); and in
delayed treatment
group (baseline
mean=3.7 d/wk
[SD=2.6], 6-mo
mean=4.6
[SD=1.9]); SE did
not increase, due to
possible ceiling
effect
 Self-Efficacy Theory in Diabetes Research T h e D i a b e t e s E d u c a t o r

8 1 0 Allen Volume 30, Number 5 • September/October 2004

Table 1.

Summary of Diabetes Self-Efficacy and Exercise Research, 1985-2002 (continued)

Authors Sample Scale(s) Reliability/Validity Intervention/Design Results

Kavanagh et al,35 N=63; 62% type 2
1993 diabetes; 21% fe-
male; race not re-
ported; mean
age=49 y
Ludlow and Gein,36 N=136; 100% type
1995 2 diabetes; 49.3%
female; mean age
not reported; race
not reported
Kingery and Glas- N=127; 100% type
gow,45 1989 2 diabetes; 66% fe-
male; 98.4% white;
mean age=61 y
McCaul et al,44 1987 N=107; 91% type 1
diabetes; 53% fe-
male; 100% white;
mean age=31.3 y
Self-efficacy ques- Self-efficacy
tionnaire; Treatment alpha=.62; adher-
Adherence Measure; ence alpha=.52
both designed for
this study
Hurley’s Insulin
Management Dia-
betes SE Scale
(IMDSES)—
Revised; Insulin
Management Dia-
betes Self-Care
Scale (IMDSCS)—
Revised
McCaul’s SE
Scale—Revised; Di-
abetes Belief Ques-
tionnaire (outcome
expectancies); Sum-
mary of Diabetes
Self-Care Activities
Self-efficacy and
outcome expectan-
cies scale developed
for this study; exer-
cise measured by
self-report, activity
monitor,
questionnaire
Revised IMDSES
and IMDSCS sub-
scales for exercise
alpha=.66 and .73,
respectively
Exercise SE
alpha=.58; Diabetes
Belief Questionnaire
alpha=.54; Exercise
Self-Care alpha=.55
Self-efficacy scale
alpha=.58 to .64;
Outcome expectan-
cy scale alpha=.70
to .74.
Correlational
predictive design;
compared SE expec-
tations with self-
care behaviors at
baseline and 2 mo,
and ability of SE to
predict adherence
Descriptive, correla-
tional, cross-sec-
tional design to
determine relation-
ship between self-
efficacy and
self-care
Correlational predic-
tive design to exam-
ine SE and outcome
expectations at
baseline and 6 mo
in predicting self-
care levels
Correlational predic-
tive design to deter-
mine psychosocial
variables that predict
different regimen be-
haviors at baseline
and 6 mo
continued on page 812
Pretest SE correlated
to exercise adher-
ence at posttest
(r=0.54, P<.001);
exercise self-efficacy
was significant pre-
dictor of exercise
(R2=0.30, F change
25.14, P<.001)
Diabetes self-efficacy
scores highly corre-
lated with diabetes
self-care scores (ex-
ercise subscale
r=0.83, n=134,
P<.01)
Exercise self-care
correlated with SE
(baseline r=0.40,
P<.05; 6 mo
r=0.29, P<.05) and
outcome expecta-
tions (baseline
r=0.36, P<.05; 6
mo r=0.30, P<.05);
exercise at baseline
and 6 mo was pre-
dicted by SE
(R2=0.17, F=5.96,
P<.001) and out-
come expectations
(R2=0.21, F=6.18,
P<.001); explained
25% of exercise self-
care behaviors
SE correlated to exer-
cise adherence
(r=0.35, P<.01); no
significant correlation
between outcome ex-
pectancy and exer-
cise adherence; SE
and outcome ex-
pectancies did not
predict exercise lev-
els at baseline, but
predicted 6-mo levels
(R2=0.044, P<.05)

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Self-Efficacy Theory in Diabetes Research
Allen
RESULTS
Data Analysis and Interpretation
The data were synthesized to answer 2 questions: (1) Is
SCT related to exercise adherence? and (2) Can SCT
predict exercise initiation and maintenance? (Table 1).
To answer the first question, the relationship between
SCT and exercise in individuals with diabetes was ana-
lyzed. Ten studies reported a significant relationship be-
tween self-efficacy and exercise. In 9 studies using a
predictive design, the variance explaining self-efficacy
for exercise behavior ranged from 15% to 53%, with
one outlier of 4.4%. Two studies defined adherence as
following a specific exercise regimen, and both report-
ed that self-efficacy predicted adherence.35,40 Eleven
studies defined adherence as self-report of self-care ac-
tivities and/or exercise level.23,36,37,44-48,55,57,58 In 7 predic-
tive studies using the self-report definition, self-efficacy
also predicted adherence.23,44-47,55,57 Five studies exam-
ined outcome expectancies with mixed results.44-47,57
Three studies reported that outcome expectancies
significantly predicted adherence,44,45,47 while the re-
maining 2 studies did not find evidence of this relation-
ship.46,57 Of the 2 studies that reported an insignificant
relationship between outcome expectancies and exer-
cise, 1 reported a low instrument reliability (alpha
.50),46 while the other had a strong instrument reliabili-
ty (alpha .85),57 making it difficult to draw conclusions.
The second question, “Does SCT predict exer-
cise initiation and maintenance?” was addressed by ex-
amining the studies that reported self-efficacy
measurements over time. Of the 7 studies that exam-
ined the predictability of self-efficacy over time, 5 had
correlational predictive designs23,35,44-46 and 3 were in-
tervention studies.37,48,58 Of the correlational predictive
studies, 1 examined self-efficacy at baseline and 2
months,35 1 examined self-efficacy at baseline and 4
months,46 and 3 studies examined self-efficacy at base-
line and 6 months.23,44,45 Pretest self-efficacy significant-
ly predicted adherence to exercise at 6 months
(R2=0.54).35 Of the several behavioral processes exam-
ined, only self-efficacy predicted energy expenditure at
baseline and 6 months.23 Self-efficacy significantly pre-
dicted the exercise self-care practices of 118 African
American women at baseline (R2=0.417) and 4 months
(R2=0.185).46 The difference in predictability of self-ef-
ficacy and exercise from baseline to 4 months suggests
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T h e D i a b e t e s E d u c a t o r
Volume 30, Number 5 • September/October 2004 8 1 1
some instability of this relationship over time. Con-
versely, a more stable relationship was reported over
time (baseline, R2=0.20; 6-months, R2=0.22) in a pop-
ulation that was mostly Caucasian.45 Differing from
these 4 studies, other researchers found a lack of signif-
icant self-efficacy predictability for concurrent exercise
and a comparatively smaller amount of variance ac-
counted for at 6 months (R2=0.044).44 Findings from
the 5 correlational predictive studies suggest that self-ef-
ficacy is related to the initiation and maintenance of ex-
ercise, although the strength of this relationship may
t
vary over time.
hree intervention studies examined exercise self-
efficacy and exercise over time.37,48,58 In a study
of exercise self-efficacy with pretest, posttest,
and 6-month evaluations following a 5-day out-
patient education program, self-efficacy and amount of
exercise significantly increased at all measured inter-
vals.37 In a second study, a 10-session, self-management
training intervention did not significantly increase self-
efficacy up to 6 months after the intervention,48 and the
amount and frequency of exercise significantly in-
creased in a mixed pattern. Prior to the intervention,
both the control and intervention groups had exercised
3.7 and 4.4 days, respectively, and had reported high
preintervention self-efficacy. Only the intervention
group significantly increased its average exercise dura-
tion, from 36.3 minutes per day (SD=5.2) to 50.8 min-
utes per day (SD=4.7), and its energy expenditure
(pretest mean=3099.6, SD=762.2; posttest
mean=4227.8, SD=895.5). The control group, howev-
er, significantly increased the number of days exercised,
from 3.7 to 4.6 days. The insignificant self-efficacy find-
ings in this study are likely related to a ceiling effect
from the high pretest scores. Finally, no significant in-
crease in self-efficacy or minutes of exercise per week
was found following a multidisciplinary intervention in
a randomized controlled trial.58 Only one item in the
self-efficacy instrument was related to exercise, and the
exercise content and instruction of the intervention
were unclear. The 3 intervention studies used strategies
from SCT, including goal setting and problem solving,
but with mixed results.
CONCLUSIONS
This integrative literature review identified 13 studies
that examined the relationship between SCT, self-effica-
cy, and exercise. Of these studies, 12 examined exercise
 Self-Efficacy Theory in Diabetes Research T h e D i a b e t e s E d u c a t o r

8 1 2 Allen Volume 30, Number 5 • September/October 2004

Table 1.

Summary of Diabetes Self-Efficacy and Exercise Research, 1985-2002

continued from page 810

Authors Sample Scale(s) Reliability/Validity Intervention/Design Results

Padgett,40 1991 N=147; 100% type
2 diabetes; 51% fe-
male; 100% Yu-
goslavs; mean
age=59 y
Rubin et al,37 1989 N=165; 62% type 2
diabetes; 42% fe-
male; 70% white;
mean age=47 y
Sadur et al,58 1999 N=185; Both type 1
and type 2 diabetes
(unknown percents);
43% female; 71%
white; mean
age=44 y
Crabtree’s Diabetes DSES internal con- Correlational predic-
Self-Efficacy Scale sistency=0.77 tive design to exam-
(DSES)—Revised; ine factors that
adherence rated by might be associated
MD and patients with self-efficacy
beliefs
Grossman Diabetes Not reported 5-day outpatient ed-
Self-Efficacy ucation intervention
Scale—Modified; to improve self-care
Self-Care practices, emotional
Questionnaire well-being, and
metabolic control;
measures taken at
baseline and 6 mo
Self-efficacy mea- Not reported Randomized trial of
sured by a re- 6-mo, multidiscipli-
searcher-developed nary, cluster inter-
instrument; self-re- vention to improve
port measure of ex- self-care practices;
ercise (min/wk) measures taken at
baseline and 6 mo
postintervention
SE correlated with
self-rated adherence
(r=0.40, P<.01) and
with MD-rated adher-
ence (r=0.20,
P<.05); self-rated
adherence predicted
33.5% of variance in
self-efficacy
SE increased from
baseline
(mean=11.3,
SD=1.4) to postpro-
gram (time):
(mean=124.8,
SD=1.3, P<.001);
from baseline to 6
mo (mean=121.8,
SD=1.4, P<.001);
exercise levels in-
creased from base-
line (mean=13.3
x/mo, SD=1.0) to 6
mo (mean=16.9
x/mo, SD=0.8,
P<.001)
Only one SE question
about exercise; exer-
cise SE did not differ
between control
(baseline mean=6.8,
6-mo mean=6.5)
and intervention
groups (baseline
mean=7.3, 6-mo
mean=7.0); exercise
did not differ between
control (baseline
mean=107 min/wk,
6-mo mean=111)
and intervention
groups (baseline
mean=89, 6-mo
mean=106)

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Self-Efficacy Theory in Diabetes Research T h e D i a b e t e s E d u c a t o r

Allen Volume 30, Number 5 • September/October 2004 8 1 3

Table 1.

Summary of Diabetes Self-Efficacy and Exercise Research, 1985-2002 (continued)

Authors Sample Scale(s) Reliability/Validity Intervention/Design Results

Plotnikoff et al,23 N=46; 84.4% type
2000 2 diabetes; 50% fe-
male; race not re-
ported; mean
age=43 y
Skelly et al,46 1995 N=118; 100% type
2 diabetes; 100% fe-
male; 100% African
American; mean
age=57 y
Social measures
scale included SE,
energy expenditure
calculated from self-
report, exercise level
from self-report
Self-Efficacy Ques-
tionnaire (SEQ), Out-
come Expectancies
Questionnaire
(OEQ), Diabetes
Self-Care Log
Social measure Corelational, predic-
scale in this popula- tive, population-
tion=alpha .85 to based survey to
.89. determine exercise
prevalence and psy-
chosocial constructs
of exercise behavior
at baseline and 6
mo
SEQ alpha=.92, Correlational predic-
Test-retest=0.92; tive design to as-
OEQ alpha=.50, sess the influence of
test-retest=0.93 baseline SE and out-
comes expectancies
related to a diabetes
self-care regimen;
data collected at 1
and 4 mo
Self-efficacy differen-
tiated individuals
considering exercise
and those exercising
(t=–3.0, P<.005);
SE predicted energy
expenditure at base-
line (β=.24, P<.05)
and 6 mo (β=.21,
P<.21) and was the
only predictor of en-
ergy expenditure
from baseline to 6
mo (R2=0.02)
SE correlated with
outcome expectan-
cies at baseline
(r=0.78, P=.001)
and 4 mo (r=0.25,
P<.05); exercise
correlated with SE
(1-mo r=0.73,
n=75; 4-mo r=0.54,
n=39) and outcome
expectancies (1-mo
r=0.60, n=76; 4-mo
r=0.03, n=39); bi-
variate analysis at 1
mo: SE accounted for
53% of variance in
exercise behavior,
confidence in out-
comes explained
37% of exercise be-
havior; bivariate
analysis at 4 mo: SE
explained 29% of
variance in exercise
behavior; SE predict-
ed exercise adher-
ence at 1 mo
(R2=0.42, P<.05),
and 4 mo (R2=0.19,
P<.05); outcome ex-
pectancies did not
predict exercise
adherence

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 Self-Efficacy Theory in Diabetes Research
8 1 4 Allen
behavior as part of a self-care regimen (eg, glucose test-
ing, diet, medication adherence, and general manage-
ment), and only 1 study exclusively examined exercise
behavior.23 All 10 correlational studies reported a signif-
icant relationship between self-efficacy and exercise be-
havior. Results from the 8 predictive studies support the
predictability of self-efficacy for exercise behavior. The
results were mixed regarding the predictive ability of
outcome expectancies for exercise behavior. Self-effica-
cy was predictive of exercise initiation in 4 of 5 studies
and of maintenance in 5 of 5 studies over time. The 3
intervention studies provided inconclusive evidence that
self-efficacy and exercise behavior increased over time.
LIMITATIONS
The small number of studies found for analysis limits
the generalizability of the findings of this integrative re-
view. Additionally, only 3 intervention studies were
found, of which only 1 used a randomized control de-
sign. Only 1 study exclusively examined exercise behav-
ior, while the remaining 12 examined exercise as part of
a self-care regimen that included diet, glucose testing,
general disease management, and/or insulin and med-
ication management. Most of the subjects in the studies
reviewed were female, middle-aged, and had type 2 di-
abetes, precluding generalization of the findings to
other populations such as individuals with type 1 dia-
betes, males, and the very young or old. The lack of in-
formation on sample ethnicity, combined with a
majority of white participants in 6 studies, leaves incon-
clusive evidence to inform practice or research involv-
ing minority populations. Lastly, a variety of
instruments were used to measure the constructs of so-
cial cognitive theory, with varying reliabilities.
RESEARCH IMPLICATIONS
The use of theoretical models and constructs in diabetes
research are important for understanding behavior
change and guiding the development of effective inter-
ventions. Developing theory-based approaches to car-
ing for individuals with diabetes can create a more
progressive, coherent body of knowledge to assist
healthcare providers in effectively teaching patients dia-
betes self-care. All 13 reviewed studies demonstrated
strong correlations between self-efficacy and exercise,
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T h e D i a b e t e s E d u c a t o r
Volume 30, Number 5 • September/October 2004
but only 3 examined interventions designed to increase
self-care behaviors. None of the exercise interventions
were based on all 4 of Bandura’s information sources,
which SCT postulates would strengthen the relation-
ship between self-efficacy and desired behavior. Because
exercise can significantly contribute to reduction of
blood glucose levels3-6 and insulin resistance,3,5 and
many people with diabetes fail to exercise,22,23 microan-
alytic or focused strategies are needed to exclusively
study exercise behavior. Exercise-specific self-efficacy
instruments60,61 are available, but their reliability in dia-
betes populations needs to be tested. An additional
method for strengthening diabetes exercise research is
to use objective measures of exercise rather than subjec-
tive self-report or self-monitoring tools with unknown
reliability. Exercise physiology and sports medicine re-
searchers use pedometers and accelerometers to mea-
sure activity counts and energy expenditure, with highly
t
valid and reliable results.62
heory-based, randomized, controlled, longitudi-
nal intervention studies are needed to specifical-
ly target exercise behavior in individuals with
diabetes. Lastly, because type 2 diabetes dispro-
portionately affects African American, Native Ameri-
can, and Hispanic individuals,2 culturally sensitive
exercise research is warranted in these populations.
PRACTICE IMPLICATIONS
Diabetes healthcare providers can use the findings
from this integrative review to improve their under-
standing of exercise behavior and to develop strategies
that may assist individuals with diabetes in adopting
exercise recommendations. Self-efficacy beliefs (eg, “I
feel confident that I can stick to my exercise program”)
are related to exercise behavior and can be used in as-
sessing patients’ perceptions and readiness to start and
maintain an exercise program. If an individual’s self-ef-
ficacy is weak, Bandura’s 4 information sources can be
used to strengthen exercise self-efficacy (Table 2).
When coupled with education about diabetes, the
most effective behavioral strategies are goal setting,
self-monitoring, self-reward, personal feedback, and
contracting.28,63-65
Self-Efficacy Theory in Diabetes Research T h e D i a b e t e s E d u c a t o r

Allen Volume 30, Number 5 • September/October 2004 8 1 5

Table 2.

Behavioral Strategies Based on Bandura’s Four Information Sources

Information Source Behavioral Strategy

Performance Develop goals and exercise prescriptions with patients
accomplishment Rehearse desired behaviors
Conduct brief guided walks to practice taking heart rates and pace setting
Teach group exercise classes
Use continuous glucose monitoring feedback to demonstrate the effect of exercise on blood glucose levels
Use pedometers to measure exercise and provide feedback
Use activity logs to provide feedback
Vicarious Use teachers (as role models) who have embraced exercise behaviors
experience Use videotapes of role models demonstrating exercise behavior and problem solving
Organize role models to start walking or group exercise programs
Verbal persuasion Describe the physiological benefits of exercise on blood glucose levels, independent of weight loss
Provide verbal encouragement of progress
Attribute accomplishments to each individual’s own efforts
Incorporate significant others into the intervention to increase support and reinforce behaviors
Physiological Problem solve before physical discomforts related to exercise might arise
feedback Assist in accurate interpretation of symptoms related to exercise (eg, fatigue is normal when beginning to
exercise but improves over time)
Start relaxation training programs to decrease anxiety and feelings of physical inefficacy
Discuss relapse prevention strategies

Specific strategies to enhance exercise self-effi-
cacy through performance accomplishments include
developing realistic exercise goals with patients66,67;
using incremental steps to enhance success68-70; rehears-
ing intended exercise behavior (brief guided walks)69;
providing feedback (telephone or clinic follow-up)70;
and using pedometers,69 continuous glucose monitor-
ing,71 activity logs/diaries,68,70 and progress reports.69
Clinicians can use vicarious experiences to build self-ef-
ficacy by role modeling their own exercise behaviors,70
using videotapes of peer role models who are exercis-
ing,68 having role models conduct group exercise pro-
grams, and organizing social support.70 Verbal
persuasion should emphasize the positive psychological
benefits of exercise (eg, improved sense of well-being,
and decreased anxiety and depression)72 and its physio-
logical benefits (eg, decreased A1C independent of
weight loss,11 and decreased blood pressure,16,73,74 hy-
perlipidemia,13,14 coronary heart disease,18,19 and
stroke).75-77 Finally, clinicians can enhance self-efficacy
by coaching patients to positively appraise physiologi-
cal responses associated with exercise. For example, fa-
tigue and muscle aches may occur initially during any
form of exercise, but clinicians can help patients to an-
ticipate these discomforts, interpret them positively,
problem solve before physical discomforts arise (eg, use
moist heat or massage), and discuss relapse prevention
strategies. Strategies based on research and theories of
human behavior can assist practitioners in developing
effective exercise interventions for individuals with dia-
betes and may improve their metabolic control and ul-
timately reduce disease complications.

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 Self-Efficacy Theory in Diabetes Research
8 1 6 Allen
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