Feature Article / Self-Efficacy, Self-Care, and Glycemic Control

Association of Self-Efficacy and Self-Care With Glycemic

Control in Diabetes
Carla Moore Beckerle, DNP, APRN, ANP-BC, and Mary Ann Lavin, DSc, APRN, ANP-BC, FNI, FAAN

Abstract

Address correspondence to Carla

Moore Beckerle, DNP, APRN,
ANP-BC, Vice President of Clinical
Programs, Esse Health, 12655 Olive
Blvd., St. Louis, MO 63141.
172

Successful daily self-management of

diabetes is essential to the achievement of positive health outcomes.
Basic to successful self-management
of any disease is a sense of selfefficacy, or the feeling of confidence
in ones self-management abilities.
This study examined the association of these variables on the
achievement of glycemic control,
specifically A1C levels.
This study used a retrospective
cohort design to evaluate the predictive relationship of self-efficacy and
self-care behaviors on A1C level.
After Institutional Review Board
approval was obtained, 60 medical
records were accessed of people 18
years of age with type 1 or type 2
diabetes who were seen consecutively
in a primary care practice located in
an urban setting.

Data analysis revealed no statistically significant relationships

between global measures of selfefficacy and self-care and A1C levels.
However, there were two questions
from the Stanford Diabetes SelfEfficacy for Diabetes Scale found
to be significantly related to A1C
(P < 0.009). Those whose diabetes
was well controlled were confident
in selecting appropriate foods when
hungry and in their ability to exercise
for 1530 minutes, four to five
times per week. These findings,
if replicated in future studies, may
provide clinicians an opportunity
to develop and test targeted selfmanagement interventions yielding
the highest probability of improved
glycemic control.

The incidence of diabetes has escalated in the United States, with the
estimated number of those diagnosed
with the disease doubling in the past
several years to 8.3% of the population.1 Successful daily management
of diabetes and the use of self-management techniques require a positive
expectation of outcomes and confidence in ones ability to manage the
disease. Factors that influence diabetes control include the association
between self-efficacy and self-care
behaviors.2 When diabetes control is
achieved, micro- and macrovascular
complications decline.3
According to the American
Diabetes Association (ADA)
Standards of Medical Care in
Diabetes,4 achieving adequate
glycemic control requires behavioral

changes to increase activity levels,

change eating patterns, comply with
medication regimens, perform selfmonitoring of blood glucose, and
monitor carbohydrate intake. An
explanation of how such behavioral
changes require self-efficacy and selfcare management is appropriate.
Bandura5 defined self-efficacy as
peoples beliefs about their capabilities to produce designated levels of
performance that exercise influence
over events that affect their lives.
Self-efficacy beliefs determine how
people feel, think, motivate themselves, and behave over time. A
judgment regarding self-efficacy may
determine how much effort a person
expends when confronted by challenges. This means that people with
an adequate sense of self-efficacy feel

Diabetes Spectrum Volume 26, Number 3, 2013

Feature Article / Beckerle et al.

confident in their ability to perform,

whether that means administering their medications correctly,
adjusting their diet as indicated,
preventing hypoglycemia, or exercising appropriately. A strong sense of
self-efficacy is necessary to master
challenges inherent in these activities. The perception of being capable
influences the thought patterns
necessary to perform such tasks.
Bandura advocates evaluating
self-efficacy beliefs in terms of judgments of capability (I am capable
of . . . or I feel confident that I
can . . .).6 He further recommends
that peoples judgment about their
capability be measured across realms
or domains of activity, with different
degrees of task difficulty and under
different situational circumstances.
For people with type 1 or type 2 diabetes, a sense of confidence in their
ability to performing daily self-care
activities seems basic to successful
glycemic control.
According to Bandura, self-care
behavior is the end result of cognitive
processes that people employ when
acquiring knowledge.7 Knowledge
acquisition, in turn, is the result of a

teaching and learning process. The

aim of self-care is to appropriately
fulfill the daily regimen of tasks that
individuals need to carry out to manage diabetes. Self-care behavioral
skills in people with diabetes can be
challenging for individuals because
self-care poses many demands
regarding such areas as dietary
choices, exercise, glucose monitoring, and medication adherence.8
Although self-efficacy and selfcare influence the choices people
make, some people may have a high
degree of both but may still choose
unhealthy behaviors. Two examples
would be a physician with diabetes
who does not adhere to dietary recommendations or a registered nurse
with diabetes who does not take
steps to decrease portion sizes. Yet,
these individuals would answer that
they have confidence in their ability
to implement these behaviors. Still,
enhancing self-efficacy and self-care
is thought to be a strategy for accelerating the implementation of new
behaviors.
This study evaluates self-efficacy
and self-care and its predictive relationship to A1C levels. Its hypothesis

is that, as self-care and self-efficacy

increase, A1C levels decrease.
Background
A literature review was performed
using the key words self-efficacy,
diabetes, glycosylated hemoglobin
levels, and self-care. Databases
searched included PubMed, OVID,
and CINAHL.
The stability of self-efficacy
and self-care behaviors has been
examined in people with diabetes.
In one study of 221 participants,9
self-efficacy and self-care behaviors
were evaluated at three points in
time over 9 months. Participants
beliefs about their abilities (i.e., selfefficacy) in general were unchanged,
but their reported ability to perform diabetes self-care increased
over time. Outcomes were limited
to patient reports. No measures of
glycemic control were obtained.
However, the authors did make
an important distinction between
self-efficacy (a persons beliefs about
or confidence in his or her abilities
around specific disease management behaviors) and self-care (actual

Table 1. Self-Efficacy for Diabetes Scale

I would like to know how confident you are in doing certain activities. For each of the following questions, please
choose the number that corresponds to your confidence that you can do the tasks regularly at the present time.
1. How confident do you feel that you can eat your meals every 4 to 5
hours every day, including breakfast every day?

Not at all 1 2 3 4 5 6 7 8 9 10
Confident

2. How confident do you feel that you can follow your diet when you
have to prepare or share food with other people who do not have
diabetes?

Not at all 1 2 3 4 5 6 7 8 9 10
Confident

3. How confident do you feel that you can choose the appropriate foods
to eat when you are hungry (for example, snacks)?

Not at all 1 2 3 4 5 6 7 8 9 10
Confident

4. How confident do you feel that you can exercise 15 to 30 minutes, 4

to 5 times a week?

Not at all 1 2 3 4 5 6 7 8 9 10
Confident

5. How confident do you feel that you can do something to prevent your
blood sugar level from dropping when you exercise?

Not at all 1 2 3 4 5 6 7 8 9 10
Confident

6. How confident do you feel that you know what to do when your
blood sugar level goes higher or lower than it should be?

Not at all 1 2 3 4 5 6 7 8 9 10
Confident

7. How confident do you feel that you can judge when the changes in
your illness mean you should visit the doctor?

Not at all 1 2 3 4 5 6 7 8 9 10
Confident

8. How confident do you feel that you can control your diabetes so that
it does not interfere with the things you want to do?

Not at all 1 2 3 4 5 6 7 8 9 10
Confident

This scale is free to use without permission. Stanford Patient Education Research Center, 1000 Welch Road,
Suite 204, Palo Alto, CA 94304. Funded by the National Institute of Nursing Research.
Diabetes Spectrum Volume 26, Number 3, 2013

173

Feature Article / Self-Efficacy, Self-Care, and Glycemic Control

implementation of specific disease

management behaviors).
Self-care education may benefit
from standardization and prioritization. Preferred methods now in use
may become standardized practices
in the future. These include the use
of lifestyle coaches located within
community settings,10,11 who cover
a variety of topics (i.e., wellness
behavior, relaxation techniques,
person-provider communication,
and self-reported health status
methods)12,13 and who employ written action plans to achieve greater
glycemic control.14,15 Although
self-care education for chronic illness
(including diabetes) and the resultant
heightening of self-efficacy appear
to be associated with positive health
outcomes,1621 we do not know
the amount of variance in specific
outcomes (e.g., glycemic control)
brought about by improvements in
self-efficacy. This study examines
how well self-care and self-efficacy
measures predict A1C values.
Study Methods
The study site, Esse Health, comprises 31 private primary care offices
in a large, Midwestern suburb. Esse
Health serves patients with Medicare
and commercial insurance, as well as
those who self-pay for health care.
Esse Health encourages innovation to improve chronic disease care.
A quality improvement committee
oversees the design and implementation of numerous projects at these
sites. At the time of this study, one
of the innovations was the inclusion of the Stanford Self-Efficacy
for Diabetes Scale (SES) (Table 1)22
and the Self-Care Inventory (SCI)
(Table 2)23 in the assessment process.
The Esse Health dietitians were
responsible for documentation of
the two surveys in the health care
records of people with type 1 or type
2 diabetes.
This innovation prompted analyses of baseline self-efficacy and
self-care management data and their
relationship to glycemic control. The
specific questions asked were:
1. What is the association between
self-efficacy and self-care? Does
the risk of poor self-care increase
as self-efficacy decreases?
174

2. What is the association between

self-efficacy and A1C? Does the
risk of poor glycemic control
increase as self-efficacy decreases?
3. What is the association between
self-care and A1C? Does the risk
of poor glycemic control increase
as self-care decreases?
4. Given that the above associations
are positive, what percentage
of the variance in A1C values is
accounted for by self-care or selfefficacy measures?
To answer these questions,
archived data were retrieved for all
cognitively unimpaired people, aged
18 years, with type 1 or type 2
diabetes seen between 10 February
and 10 March 2012. The specific
data reviewed included SES and SCI
scores and all A1C results conducted
within the 12-month period preceding the visit that occurred between
10 February and 10 March 2012.
Charts missing the required data
were excluded. For adequate power,
it was determined that 60 records
were needed for a sample size large
enough to detect a 33% improve-

ment in the proportion of people

with well-controlled glycemia a level
of = 0.05. All data collected were
de-identified and entered into SPSS
Statistics for Windows, version 17
(SPSS Inc., Chicago, Ill.) for analysis.
The study focused on two
independent variables and one
dependent, or outcome, variable.
The independent variables were the
SES and SCI scores. The SES is an
eight-item questionnaire. Each item
requires a response on a 10-point
Likert scale, with 1 being not at
all confident and 10 being totally
confident. The SCI is a 14-item
questionnaire with a 5-point Likert
scale with 1 being I do not do what
is recommended and 5 being I
always do what is recommended.
The dependent, or outcome, variable was glycemic control, defined
as the ADA-recommended A1C
value of < 7.0%. Lack of glycemic
control refers to a value 7.0%. If
A1C is within the target range, the
recommended frequency of testing
is every 6 months; if it is not, the
recommended testing frequency is
every 3 months. Patients mean A1C

Table 2. Self-Care Inventory

Please rate each of the items according to how well you followed your
prescribed regimen for diabetes care in the past month.
Scale: 1 = Never do it; 2 = Sometimes follow recommendations, mostly
not; 3 = Follow recommendations about 50% of the time; 4 = Usually do
this as recommended, occasional lapses; 5 = Always do this as recommended without fail; and NA = Cannot rate this item/not applicable
1. Glucose testing 1 2 3 4 5 NA
2. Glucose recording 1 2 3 4 5 NA
3. Administering correct insulin dose 1 2 3 4 5 NA
4. Administering insulin at right time 1 2 3 4 5 NA
5. Adjusting insulin intake based on blood glucose values 1 2 3 4 5 NA
6. Eating the proper foods; sticking to meal plan 1 2 3 4 5 NA
7. Eating meals on time 1 2 3 4 5 NA
8. Eating regular snacks 1 2 3 4 5 NA
9. Carrying quick-acting sugar to treat reactions 1 2 3 4 5 NA
10. Coming in for appointments 1 2 3 4 5 NA
11. Wearing a medic alert ID 1 2 3 4 5 NA
12. Exercising regularly 1 2 3 4 5 NA
13. Exercising strenuously 1 2 3 4 5 NA
Diabetes Spectrum Volume 26, Number 3, 2013

Feature Article / Beckerle et al.

was, therefore, usually based on a

minimum of two values per year. If
only one value was available in the
medical record, this single value was
used in lieu of a mean.
Data analysis addressed each of
the study questions. Pearson 2 and
Fishers exact tests were used to determine the association between high
and low self-care and self-efficacy
scores and A1C levels 7.0% and
< 7.0% (uncontrolled and controlled
glycemia, respectively). These results
were also stratified to examine age
and sex effects. The influence of
ethnicity was not examined, because
this information was not collected
by Esse Health at the time of the
project.
The distribution of the self-care
and self-efficacy scores were plotted
to examine how well self-care and
self-efficacy scores predicted A1C
values. If the distribution appeared
normal, then the variables were to be
evaluated as continuous variables. If
the distributions did not appear normal, then the relationship was to be
tested using nonparametric statistics
(Spearmans correlation coefficient).
Study Results
Initially, 60 medical records were
evaluated, but only 57 contained
completed data. Therefore, 57
medical records were reviewed
and included. Table 3 presents the
age and sex distribution of people
comprising the retrospective cohort.
There was relatively even distribution
between the sexes. Age was distributed by adults (1862 years), older
adults (6374 years), and very old
adults (7599 years). This distribution was established to generally

Figure 1. Distribution of SES and SCI scores by number of patients included

in study. 2 = 7.86, df = 1, P = < 0.001; = 0.537, P < 0.000 (two-tailed).
reflect the working population
(1862 years) and the younger and
older retired populations. It was
thought that members of the older
retired population may experience
an escalating number of chronic
illnesses and a decreased ability to
self-manage their diabetes. If such
differences existed, the investigators
wanted to identify them. 2 analyses
were used to determine the associations between controlled versus
uncontrolled A1C and sex (male vs.
female) and each of the three age categories. No statistically significant
findings were detected.
Figure 1 addresses the first
question: What is the association
between self-efficacy and self-care?
The distribution of SES and SCS
responses were examined. Note
that self-efficacy and self-care vary
together (2 = 7.86, degrees of free-

Table 3. Age and Sex Distribution of the Retrospective

Study Cohort*
Age (Years)

Sex

Total

Male (52%)

Female (48%)

1862

15

6374

14

16

30

7599

12

Total

26

31

57

*At the time of this study, Esse Health did not collect data on race and
ethnicity. Therefore, these parameters were not included.
Diabetes Spectrum Volume 26, Number 3, 2013

dom [df] 1, P < 0.009; Spearmans

correlation coefficient [] = 0.537,
P < 0.000). In other words, high SES
is associated with high SCI and vice
versa. This supports Banduras work
among people with diabetes.
The second question asked
whether there was a difference in
mean A1C values between patients
with high and low self-efficacy and
self-care scores. No significant differences were found. Self-efficacy and
self-care scores varied together.10
These findings evoked a closer
examination of the SES and SCI
items and why they may or may not
be related to glycemic control. The
question asked was: Why would selfcare items such as how well a person
obtains or records glucose values in
the past month be poorly correlated
with A1C? The answer may be that,
regardless of how well glucose values
are recorded, they will yield glycemic
control if the prescribed regimen was
less than optimal.
This study did not examine
provider compliance with ADA
guidelines. For example, it did
not look at records to see whether
metformin dosages were increased
in response to high A1C levels.
Similarly, the frequency with which
a person obtains and records glucose
values will not yield better A1C values if the person was nonadherent to
a prescribed regimen. Unfortunately,
a medication possession ratio was
175

Feature Article / Self-Efficacy, Self-Care, and Glycemic Control

Figure 2. Correlation of composite scores for items 3 and 4 in the SES

and A1C.

not included in the records of study

participants.11,24
Thus, if A1C outcomes are to
be used, then only self-care measures that are directly related to
A1C (e.g., I take my medication as
prescribed) must be used, with the
response checked against a medication possession ratio for reliability.
A deeper analysis of the relationship between SES and A1C was also
undertaken. Even if not all items
were associated with greater glycemic control, perhaps specific items
on the SES were directly related to
glycemic control. Therefore, each
item was evaluated independently.
The results indicated that two
items may serve as proxy measures
for self-efficacy in general among
people with diabetes. The first
(item 3) was: How confident are you
that you can choose the appropriate
foods to eat when you are hungry?
Although the association with A1C

Table 4. Clinical Decision-Making Based on Self-Efficacy Assessment, Diagnosis, and A1C

Outcomes and Related Interventions
Self-Efficacy Assessment Self-Efficacy Diagnosis
(answers to SES items 3
and 4)

176

A1C Outcomes and Related Interventions

Controlled

Uncontrolled

Both responses positive

High self-efficacy

Continue to reinforce patients Initiate interventions to check

confidence in self-management. medication possession ratio. If
the patient is compliant, check
the adequacy of the providers
adherence to ADA recommendations for drug therapy and
adjust as needed.

One response positive,

the other negative

Moderate self-efficacy

Continue to reinforce patients

confidence to self-manage well
with the one variable. Initiate
interventions to build self-confidence in the other variable.

Continue to build confidence

in the patients ability to selfmanage, while also checking
patients medication possession ratio. If the patient is
compliant, check the adequacy
of the providers adherence to
ADA recommendations for
drug therapy and adjust as
needed.

Both responses negative

Low self-efficacy

Congratulate patient on the

degree of glycemic control,
while initiating interventions
to build self-confidence in
these two self-management
areas.

Continue to build confidence

in the patients ability to selfmanage, while also checking
the patients medication possession ratio. If the patient is
compliant, check the adequacy
of the providers adherence to
ADA recommendations for
drug therapy and adjust as
needed.

Diabetes Spectrum Volume 26, Number 3, 2013

Feature Article / Beckerle et al.

was not statistically significant, the

responses approached significance
(P < 0.06). The second item (item 4)
was: How confident do you feel that
you can exercise 1530 minutes, four
to five times per week? The association here with A1C was statistically
significant (P < 0.016).
When the two items were computed together as a composite score,
they yielded a probability of < 0.009
(Figure 2). Those who scored high on
the composite score of items 3 and 4
were more likely to have an A1C of
< 7%. The slope of the line indicated
that, as scores decrease, so too does
glycemic control, manifested by
higher A1C values. Finally, the blue
area in Figure 2 indicates that there
were some patients who scored well
on the composite items (above the
slope) but still had poorly controlled
glycemia (A1C values well above
7%). These were people who felt
confident in their ability to exercise
and properly portion their food but
who may not do so or who may have
a subtherapeutic drug regimen.
Figure 2 also raises questions
applicable to future research. For
example, assuming appropriate
medication possession ratios and a
therapeutic, guideline-based drug
regimen, could time and money
be saved and effectiveness boosted
by using these two items to gauge
patients self-efficacy? Could interventions aimed at increasing patients
confidence in incorporating exercise into their routine and selecting
appropriate foods enhance glycemic
control more effectively than current
standard care?
There were some limitations
involved in the implementation
of this study. Although each item
was read to patients at the time of
patients interview with the dietitian, some patients may not have
fully understood how to scale their
responses. The ability to scale
responses may require a conceptual clarity that some patients did
not possess. In future studies, it is
recommended that the intra-rater
reliability of patient responses be
evaluated and enrollment limited to
the records of patients with acceptable reliability scores.

Another possible limitation

involved the SCI. It is possible that
people may have found it difficult
to report to a dietitian who is part
of the health care team that they did
not do what the team recommended.
This may have been especially
true when patients saw that their
responses were to be recorded in
their health record.
Summary
This retrospective chart review suggests that increased confidence of
patients with diabetes with regard
to selecting appropriate foods when
hungry (SES item 3) and working
exercise into their daily routine (SES
item 4) seems to be correlated with
improved glycemic control. On the
basis of these results, these two questions were inserted into the nutrition
screening tool at Esse Health, and
their relationship to glycemic control
will continue to be evaluated. In
addition, a clinical decision-making
tool was developed (Table 4).
This tool is a simple assessment
and diagnosis of self-efficacy and its
relationship to glycemic control and
related interventions. Future studies
will report on the results obtained
through the use of this tool. The
evaluation of such an approach is an
important area for future research.
Finally, when glycemic control is
the outcome variable being evaluated
for clinical or research purposes, it is
highly recommended that medication
possession ratios and the adequacy
of patients therapeutic regimen be
considered variables that should
be controlled, if results are to be
interpreted correctly. Clinically,
medication possession ratios and the
adequacy of patients therapeutic
regimen should be evaluated at each
clinic visit at which it is determined
that glycemic control has not been
achieved. This study suggests that
a two-item self-efficacy assessment
(Table 4) should also be performed at
these same visits.

Glasgow R, Toobert D, Riddle M, Donnelly

J, Mitchell D, Calder D: Diabetes-specific
social learning variable and self-care behaviors among persons with type II diabetes.
Health Psychol 8:285303, 1989
2

World Health Organization: Definition

and diagnosis of diabetes mellitus and
intermediate hyperglycemia. Available from
http://www.who.int/diabetes/publications/
Definition%20and%20diagnosis%20of%20
diabetes_new.pdf, 2006. Accessed 23 March
2012
3

4
American Diabetes Association: Standards
of medical care in diabetes2013. Diabetes
Care 36 (Suppl. 1):S11S66, 2013
5
Bandura A: Self-Efficacy: The Exercise of
Control. New York, Prentice-Hall, 1994

Bandura A: Social Foundations of Thought

and Action: A Social Cognitive Theory.
Englewood Cliffs, N.J., Prentice-Hall, 1986
6

Bernal H, Woolley S, Schensul J, Dickinson

J: Correlations of self-efficacy in diabetes selfcare among Hispanic adults with diabetes.
Diabetes Educ 26:673680, 2000
7

Bandura A: Health promotion by social

cognitive means. Health Educ Behav
31:143164, 2004

9
Rapley P, Passmore A, Phillips M: Review of
psychometric properties of the diabetes selfefficacy scale: Australian longitudinal study.
Nurs Health Sci 5:289297, 2003
10
Sousa V, Zauszniewski J, Musil C, Price LP,
Davis S: Relationships among self-care agency,
self-efficacy, self-care, and glycemic control.
Res Theory Nurs Pract 19:217230, 2005
11
Norris S, Nichols P, Caspersen C, Glasgow
R, Engelgau M, Synder S, Carande-Kulis K,
Isham G, Garfield S, Briss P, McCulloch D:
Increasing diabetes self-management education in community settings: a systematic
review. Am J Prev Med 22:3966, 2002

Lorig K, Ritter P, Villa F, Armas J:

Community-based peer-led diabetes selfmanagement: a randomized trial. Diabetes
Educ 35:641651, 2009
12

13
Diabetes Prevention Program Research
Group: The Diabetes Prevention Program
(DPP): description of lifestyle intervention.
Diabetes Care 25:21652171, 2002

Handley M, MacGregor K, Schillnger D,

Sharifi C, Wong S, Bodenheimer T: Using
action plans to help primary care patients
adopt healthy behaviors: a descriptive study. J
Am Board Fam Med 19:224231, 2006
14

15
Connell C, Davis W, Gallant M, Sharpe
P: Impact of social support, social cognitive
variable, and perceived threat on depression
among adults with diabetes. Health Psychol
13:263273, 1994

Judge T, Erez A, Bono J, Thoresen C: Are

measures of self-esteem, neuroticism, locus of
control, and generalized self-efficacy indicators of a common core construct? J Pers Soc
Psychol 83:693710, 2002

16

References
Expert Committee on the Diagnosis and
Classification of Diabetes Mellitus: Follow-up
report on the diagnosis of diabetes mellitus.
Diabetes Care 26:31603167, 2003

Diabetes Spectrum Volume 26, Number 3, 2013

17
Clark M, Hampson S, Avery L, Simpson R:
Effects of a brief tailored intervention on the

177

Feature Article / Self-Efficacy, Self-Care, and Glycemic Control

process and predictors of lifestyle behavior

change in patients with type 2 diabetes.
Psychol Health Med 9:440449, 2004
Siebolds M, Gaedeke O, Schwedes U: Selfmonitoring of blood glucose: psychological
aspects relevant to changes in HbA1c in type
2 diabetic patients treated with diet or diet
plus oral antidiabetic. J Behav Med 22:345
351, 2006

18

19
Lo R: Adherence to health regime self-efficacy scale. J Adv Nurs 30:418421, 1999

Anderson M, Funnel M, Butler M,

Fitzgerald T, Fesse C: Patients empowerment: results of a randomized controlled trial.
Diabetes Care 18:943949, 1995
20

178

21

Mulcahy K, Maryniuk M, Peeples M,

Peyrot M, Tomky D, Weaver T, Yarborough
P: Diabetes self-management education core
outcomes measures. Diabetes Educ 29:768
770, 773784, 2003

24

22
Stanford Patient Education Research Center:
Diabetes self-efficacy scale. Available from
http://patienteducation.stanford.edu/research/
sediabetes.html. Accessed 5 July 2013

Carla Moore Beckerle, DNP,

APRN, ANP-BC, is vice president
of clinical programs at Esse Health
in St. Louis, Mo. Mary Ann Lavin,
DSc, APRN, ANP-BC, FNI, FAAN,
is an associate professor at the St.
Louis University School of Nursing
in Missouri.

23
Weinger K, Butler HA, Welch GW,
LaGreca AM: Measuring diabetes self-care:
a psychometric analysis of the Self-Care
Inventory-revised with adults. Diabetes Care
28:13461352, 2005

Diabetes Spectrum Volume 26, Number 3, 2013

Ward W, Armbrecht E, Lavin MA:

Medication possession and glycemic control
among uninsured type 2 diabetics. J Nurse
Pract 8:528533, 2012