THE DEVELOPMENT OF THE THAI VERSION

OF
THE DIABETES MANAGEMENT SELFFFICACY SCALE
FOR OLDER ADULTS WITH TYPE 2 DIABETES

Dissertation Defense
Wipa Iamsumang, RN, MSN, GCNS, PhD-c
March 27th , 2009

ACKNOWLEDGEMENT
Dissertation

Committee

Dr. Sherry Pomeroy, Dissertation Co-Chair

Dr. Yvonne K. Scherer, Dissertation Co-Chair
Dr. Yow-Wu Bill Wu, Committee member

Participants
Sigma

Theta Tua International (Gamma Kappa Chapter)

Mark Diamond Research Foundation
Translation team

Dr. Timothy Harigan

Carolyn Montgomery PhD-c.
William Drischler PhD-s

Expert

Dr. Viliporn Runkawatt

Diane Ryan PhD-c.
Mr. Nakarate Runkawatt

team

Dr. Sutatana Chomson

Dr. Thaworn Lorga
Mrs. Sukunya Kumwan

Dr. Duagrudee Lasuka

Ms. Jaruwon Srithong

CONTENTS OF PRESENTATION
Background
Purpose

of the Study

Research

Questions

Sample
Data

Collection

Data

Analysis

Results
Limitations
Implications

BACKGROUND

In 2008, 11 % of the older adults in the total Thai population

Life expectancy 73 yr. :

70 yr. for males
77 yr. for females

Aging
23

in 2003 to 50 in 2008

Aging
14

Index (elders/100 children)

Dependency Ratio (elders/100 adults)

in 2003 to 16 in 2008

(National Statistic Office of Thailand , 2008)

BACKGROUND:
BACKGROUND EPIDEMIOLOGIC
DATA

In 2005, 50% of the older adults had chronic illness

Diabetes was the 2nd cause of their chronic illness
Known to reduce life expectancy in the older adults.
Associated with increased mortality & morbidity
In

2004, the 3rd cause of disability for female , the 8th

for male.
In

2007, the 2nd leading cause of death for older females

(Diabetic nephropathy)
(National Statistics Office of Thailand, 2008)

BACKGROUND : DIABETES MANAGEMENT

Two main goals of diabetes education

Support Patients with diabetes:

(Funnell, et al., 2008; Plodnaimuang, 1999).

Decision-making
Self-care behaviors
Problem-solving
Active collaboration with the health care team

Improve their diabetes outcomes:

Clinical outcomes
Health status
Quality of life

BACKGROUND: DIABETES MANAGEMENT

Empirical evidences support factors to improve the
education outcomes

Involving patients in their own care

Guiding them in actively learning about the disease

Exploring their feeling about having behavior to

control their own health outcomes

Thus, one of the goals for diabetes education is to

improve their individuals self-efficacy , accordingly,
their self-management behavior.

BACKGROUND : SELF-EFFICACY
A major construct of
the Social Cognitive Theory

Peoples judgments of their

capacities to do something
When individuals perceptions of
their abilities to perform health
behaviors are high, they likely
will be more successful in
changing health behaviors to
decrease their risk of illness

BACKGROUND: SELF-EFFICACY & DIABETES

MANAGEMENT

A strong predictor of self-care behaviors

(Hurley & Shea, 1992 ; Sigurardottir, 2005)

Associated with self-managements

(e.g. diet, exercise, SMBG, and foot care)

Thailand:

Among older adults : positive self-efficacy & general self-care

behavior

Type 2 diabetes:

Self-efficacy has been shown not only to be important in managing diabetes,

but also to predict their self-care behaviors

THEORETICAL FRAMEWORK
Person

Behaviors
*Diet
*Exercise
*Medication
*Monitoring
complications

The older adults

with type 2
diabetes

Perceived
Self-efficacy
I think Im able to select
the right food

Outcome
expectations
If I have the right
food, my blood sugar
will improve.

Sources of Selfefficacy
*Performance accomplishments
*Vicarious experiences
*Verbal persuasion
*Physiological feedback

Outcome
*Normal Blood
glucose
Lower HbA1c

SIGNIFICANCE

A necessary step was to develop a valid & reliable

diabetes management self-efficacy instrument for
Thai older adults with type 2 diabetes
The

Thai Version of the Diabetes Management

Self-Efficacy Scale (T-DMSES)

This instrument can be used to:

Guide behavioral & educational interventions aimed at

improving older adults diabetes self-management

PURPOSE OF THE STUDY

RESEARCH QUESTIONS
1. How was the content validity of this instrument
established by the judgment of a panel of experts?
2. How much did the data support the desired
validity of this instrument, including factor
analysis, convergent validity & concurrent validity?
3. How much did the data support the desired
reliability of this instrument, including internal
consistency & test-retest reliability?

METHODOLOGY

Two phases derived from procedures of DeVellis

(2003)
Phase

I : Instrument development

Phase

II: Instrument psychometric properties

Validity

Reliability

PHASE I: INSTRUMENT
DEVELOPMENT

Two steps
Instrument formation

Define the concept

Perceived Self-efficacy of Type 2 diabetes

Review the existing instruments

Blindly

back translation

INSTRUMENT FORMATION:
DEFINITION OF PERCEIVED SELF-EFFICACY OF TYPE 2
DIABETES

Judgments of the older adults with type 2 diabetes

on their own capacities related to situational
behaviors, and their confidence to perform the
diabetes management activities.

Three domains based on diabetes self-care

activities (Pennings-van der Eerden, 1992)

Performing essential activities for treatment of diabetes

Self-monitoring

Self-regulation

Review the Existing Instruments

Name

Type of
Instrument

Domains

Respondent
With Mean age

Evaluation

DSES and
DSES-R
(Crabtree,
1986)

Self-report
18 items

Diet, exercise, medication-taking,

and general management of
diabetes on a routine basis

Adults with type

2 diabetes
(59 yr.)

Most of items rely heavily on dietrelated items, and are too general.

DES
(Anderson,
et al., 2000)
DES-SF
(Anderson,
et al., 2003)

Self-report
28 items
Self-report
8 items

Managing the psychosocial

aspects of diabetes

Adults with type

1 diabetes,
type 2 with
insulin,
and type 2
without insulin
(50.415.8)

A useful outcome measure for a

variety of educational interventions
related to diabetes. Most items are
concerned with psychosocial issues
instead of self-care behavior.

CIDS
(Weinger, et
al., 2000)

Self-report
20items

Following recommendations
about food, exercise, foot care,
insulin admonition, and selfmonitoring of blood glucose; selfregulation of blood sugar, and
detecting and treating high or low
levels of blood glucose; asking
friends for help.

Adults with type

I diabetes
(42.613.1)

High psychometric for cross-culture

but never used in type 2 diabetes.

DMSES
(van de
Bijl., 1999)

Self-report
20items

Performing, self-monitoring, selfregulation

Adults with type

2 diabetes
(64)

With high psychometric properties

for cross-culture in the older adults
with type 2 diabetes.

DIABETES MANAGEMENT SELF-EFFICACY SCALE:

DMSES
(VAN DER BIJL, VAN POELGEEST-EELTINK & SHORTRIDGE-BAGGETT, 1999)

A domain-specific instrument

Diabetes self-care activities with a central place in self-efficacy

Three domains with 20 items

Domain

Performing essential activities (9 items)

Self-monitoring (4 items)
Self-regulation (7 items)

Activities
Diet/exercise/medication
Blood sugar/body weight/complication
Correction of hypo-and hyperglycemia;
Adjust diet /illness/stress

All items are objective & easy to understand

Well established psychometrics

(CVI = .78; Cronbachs = .81; test-retest = .79)

Has been well used cross culturally

Australia/Turkey/Taiwan

1. Initial
translation
by
first 2
bilinguals,
independently

2. Synthesis of translation
Panel discussion

BACK TRANSLATION METHOD

The
original
English
version of
DMSES

The 1st draft

of T-DMSES

3. Blindly back
translation
by a bilingual

The 2nd draft

of T-DMSES

The
English
backtranslated
version of
DMSES

Semantic Testing
by 3 native
speakers

BACK TRANSLATION METHOD (CONT.)

The 2nd
draft of
TDMSES

4. Expert Consulting
For content validity

The 3rd draft

of T-DMSES

5. Pilot Study
10 Thai older adults with
type 2 diabetes

The Final T-DMSES

Psychometric testing
With 209 Thai older adults with type 2 diabetes

Phase II :

Instrument psychometric properties

Survey

To

Study

evaluate psychometrics of the T-DMSES

Validity

Reliability

SAMPLE
Participants from 8 hospitals in 4
parts of Thailand selected from 2
provinces in each part
Convenient sampling

Inclusion Criteria
Type 2 diabetes
Age 60 years old
Attendance in out-patient diabetic
clinics during October-December
2007

Exclusion Criteria
Cognitive impairment
(Thai Mental State Exam < 24)

DATA COLLECTION
PROCEDURE

DATA ANALYSIS
Tests

Statistics

1. Semantic equivalence

ICC model 3 (2-way random effect)

2. Content Validity

Content Validity Index (CVI)

3. Exploratory Factor Analysis (EFA)

EFA using a principal component analysis

with varimax rotation

4. Confirmatory Factor Analysis (CFA)

Chi-square, Goodness of fit indexes

5. Convergent validity with T-GSES

Pearsons product-moment correlation

coefficient

(Thai Version of the General Self-efficacy Scale)

6. Concurrent validity with T-RSES

(Thai Version of the Rosenbergs Self-esteem Scale)

Pearsons product-moment correlation

coefficient

7. Internal consistency reliability

Cronbachs coefficient alpha

8. Test-retest reliability

ICC model 6 (2-way mixed model)

RESULTS

SEMANTIC EQUIVALENCE OF THE TDMSES

PARTICIPANT CHARACTERISTICS

n = 209
North 26 %
Lampang 27
Phayao 28

Northeast 26 %
Lopburi 28
Ayuthaya 27

Central 26 %
KhonKaen 27
SiSaket 27

South 22 %
Surat Thani 17
Phangnga 28

DEMOGRAPHIC CHARACTERISTICS
Characteristics

Gender
Female
Male

129
80

61.7
38.3

Age (M = 67, SD = 5.5 )

60 69
70 79
> 80

148
54
7

70.9
25.8
3.3

Marital Status
Married
Widowed
Single
Divorced
Separated

142
51
10
3
3

67.9
24.4
4.8
1.4
1.4

DEMOGRAPHIC CHARACTERISTICS
Characteristics
Education
No school
Elementary
Lower secondary
Upper secondary
Bachelors Degree
Higher

17
136
14
15
11
16

8.1
65.1
6.7
7.2
5.3
7.7

12

10.0

Income per month (n = 121)

< 1,000 ($30)
1,000 ($30)

5,000 ($150)

57

47.1

5,001 ($151) -

10,000 ($300)

26

21.6

10,001 ($ 301) 50,000 ($1,500)

25

20.7

> 50,000 ($1,500)

.6

DURATION OF DIAGNOSIS, COMORBIDITY,

Characteristics
n
& ofHEALTH
PROBLEM
Duration
Diagnosis

(M = 9.4, SD = 7.4)
Short-DM (< 15 years)
Long-DM ( 15 years)

178
31

85.2
14.8

Co-morbidity (n = 187 )
Hypertension
Hyperlipidemia
Arthritis
Other

138
95
35
31

73.8
50.8
18.7
16.6

Health Problem
Vision
Taste
Hearing
Smell

120
46
40
34

57.4
22.0
19.1
16.3

CONTENT VALIDITY OF T-DMSES (20

ITEMS)
Eliminating

one item

Item

13 (follow diet) & 14 (adjust diet) : same word

in Thai language control

Adding

one item

Vision

Problem :

: the most chronic complication of diabetes in older adults

Item-level

Content Validity Index (I-CVI)

I-CVI = .80 1
Scale-level

Content Validity Index (S-CVI)

S-CVI = .96

EXPLORATORY FACTOR
ANALYSIS
Kaiser-Meyer-Olkin (KMO) measure was .92.

Bartletts test of Sphericity was highly significant

(2 [190], n=209) =3544.75, p < .0001

EFA after
A three

Item

factor solution explained 69% of the variance.

Analysis:

From

extraction

the R-matrix: inter-item correlation

Item 4 (choose the right food) & item 5 (choose variation in nutrition)
redundancy
Item 4 more meaning & understandable

19

items remained in the T-DMSES

NAMES & DESCRIPTIONS OF

FACTORS
Description
Content
FATOR1Item
: DIET & EXERCISE (10 ITEMS)
Behaviors in a
diet & exercise
Self-regulating
in case of extraexercise,
illness, stress,
away from
home/vacation.

4
10
11
12
15
16
17
9
12

I think I can choose the right foods to eat.

I think I can adjust my diet when Im ill.
I think I can care of myself and eat suitable food almost
of the time.
I think I can adjust my food suitably when I am away from
home.
I think I can care for myself by eating suitable food when
I am on days off, at festivals, on holidays, or on vacation.
I think I can follow my food when I go to parties.
I think I can adjust my diet suitably when I am under
stress/pressure.
I think I can get enough exercise by doing things such as
walking or riding a bike.
I think I can increase my level of exercise if the doctor tells

FACTOR 2: SELFMONITORING/REGULATING(6 ITEMS)

Description

Item

Contents

Behaviors in selfcontrol/observation
complication,
Reporting on blood
glucose, body
weight
Correction of hypoor hyperglycemia

I think I can check my blood sugar level if I have to.

I think I can adjust my blood sugar level back to normal

when the level of my blood gets too high.

I think I can adjust my blood sugar level back to normal

when the level of my blood gets too low.

I think I can control my weight.

I think I can check to see if there are problems with the

skin on my feet, such as the color or if there are
bruises, wounds, or inflammations.

FACTOR 3 : ESSENTIAL ACTIVITIES FOR MEDICAL

TREATMENT

(3 ITEMS)
Description
Behaviors in using
medication
&Consulting
physicians for
diabetes control

Item

Content

18

I think I can go to see the doctor every time I

have an appointment to check my diabetes.

19

I think I can take my medicine as prescribed

by the doctor.

20

I think I can adjust my medication when I

get sick.

CONFIRMATORY FACTOR
ANALYSIS
19

items were structured into a three factor model

To

confirm the hypothesized factor structure of the TDMSES

CFA

Modifying the model by adding parameter relationship

based on the modification indexes (MI)

CONFIRMATORY FACTOR
ANALYSIS
Goodness
of Fit Test
Initial Factor Model
Chi-square
df
Normed Chi-square
Absolute fit indexes
GFI
AGFI
RMR
RMSEA
Lo90
Hi90
Incremental fit indexes
CFI
IFI
NFI
** p < .01

891.30**
152
5.9
.71
.64
.37
.15
.14
.16
.77
.77
.73

Modified Factor Model

328.63**
131
2.5
.87
.81
.05
.09
.074
.097
.94
.94
.90

RESULTS:
RESULTS VALIDITY & RELIABILITY
Test

Results

Convergent Validity
T-DMSES & T-GSES

r = .36, p < .01.

Concurrent validity
T-DMSES & T-RSES

r = .43, p < .01

Internal Consistency reliability

= .95 (total)
= .94 (subscale 1)
= .88 (subscale 2)
= .80 (subscale 3)

Test-retest reliability

ICC = .69
( p <.01, 95% CI: .54-.80)

DISCUSSION
The T-DMSES

EFA suggested a three factor model

diet and exercise, self-monitoring/regulating , and

essential activities for medical treatment

Comparisons

The original DMSES with 4 factors

(ven der Bijl, et al., 1999)

The Turkish version of the DMSES with 3 factors

(Kara, van der Bijl, Shortridge-Baggett, Asti, & Erguney, 2006)

The Chinese version of the DMSES with 4 factors

(Wu, 2008)

DISCUSSION: EFA (CONT.)

The

3- factor model of the T-DMSES differed

from others.
Modified by changing, eliminating, and
adding

The T-DMSES has clear three clusters of selfcare activities which patients with type 2
diabetes have to perform to prevent short & long
term complications.

DISCUSSION: CONVERGENT
VALIDITY
A significantly

positive correlation between the T-DMSES

(specific self-efficacy) & the T-GSES (global self-efficacy):
Same construct but differ in the scope

The

result was similar to the previous studies:

The Australian/English version of the DMSES & GSE
scale with r = .52, p < .01(McDowell, et al, 2005)
The Chinese version of the DMSES & the Chinese
version of GSE scale with r = .55, p < .01 (Wu, 2008)

DISCUSSION: CONCURRENT
VALIDITY
This

result provided the evidence of the positive correlation

between T-DMSES (judgment of capability) & T-RSES (judgment
of self-worth): different construct but same phenomenon

Evidences

from meta-analysis (75 studies) supported the positive

correlation between self-efficacy & self-esteem with = .85
(Judge, et al., 2002).

Among

diabetes, there was a positive relationship between

self-efficacy & self-esteem (Crabtree, 1986; Grossman, Brink, & Hauser, 1987).
Among older adults, there were positive correlations among
perceived self-efficacy, self-esteem, and self-care behavior
(Homnan, 1996).

DISCUSSION : TEST-RETEST
RELIABILITY

ICC was at acceptable level for a new instrument

(ICC = .69; p< .01, 95% CI: .54-.80).

Possible reasons:
Aging is one of the common sources of bias & error in testretest situations (Strauss, Sherman, & Spreen, 2006).

Participants had to do retest by themselves or with family, lack

of understanding.

Retested by mail
Typical of the experience with older adult populations
(Andresen, Bowley, Rotheenberg, Panzer, & Katz, 1996)

Ones sense of self-efficacy is determined by an array of

personal, social and environmental factors (Bandura, 1986).

CONCLUSION

The T-DMSES with 3 subscales has acceptable validity

and reliability.

The T-DMSES can be used to identify self-efficacy of

Thai older adults with type 2 diabetes.

LIMITATIONS

Generalization was limited:

Majority

30 % of Thai older adults have never attended school

Older

of the participants were educated.

adults with a short-DM

Most of Thai older adults with type 2 diabetes were diagnosed as a long-DM

Using the same data to conduct the CFA

IMPLICATIONS
NURSING
PRACTICE
The T-DMSES
with 3 subscales can be used to:

Help HCP in assessing patients self-efficacy in the

management of their diabetes

Guide interventions to improve knowledge and skills in areas

where self-efficacy is low.

Evaluate the effectiveness of interventions targeted at

improving self-efficacy among the older adults with type 2
diabetes.

FUTURE RESEARCH

Closer examination of the individual items & some

modifications of the model is likely needed to improve its
goodness-of-fit.

Larger sample size to conduct factor analysis both EFA &

CFA in separate group of data

Using to predict performance of diabetic self-care

behaviors

(e.g. diet, exercise, and medication-taking behavior).

Testing the instrument in older adults with long -DM,

less education

Khop Khun Mak Kha

(Thank you so much)

SUPPLEMENTAL INFORMATION

ICC
Limitations of Pearsons Product-Moment correlation
Why did I choose the SCT?
Why did I choose type 2 diabetes?
Related concepts
Power Analysis to determine SS
Bilingual participant

General Self-efficacy Scale (GSES)

Rosenbergs Self-esteem Scale

ICC

Model 1
One-way random effect model.
The sources of errors cannot be separated & are pooled.
Rater is viewed as measurement error.

Model 2
Two-way random effect model
Sources of errors can be separated
Rater & subject as random effects

Model 3
Two-way mixed model
Rater are seem as fixed effect
Subject/targets are a random effect

LIMITATIONS OF PEARSONS PRODUCT-MOMENT

CORRELATION

Cannot detect the existence of a systematic error

(bias)
Does not provide a measure of agreement but ICC
provides both degree of correspondence &
agreement among ratings

 Other models of health behavior are concerned only with

WHY
DID I CHOOSE THE SCT?
predicting health habits, and they offer little guidance on how

to change health behavior.

Provides guidelines on how to structure goals and incentive
systems to heighten motivation for personal change.
Supplies a body of knowledge on how to build resilience to the
demoralizing effects of difficulties and setbacks.
The SCT embeds its determinants of health behaviors (e.g.
self-efficacy, outcome expectations, goals and impediments)
in a large body of knowledge that specifies the mechanisms
through which they operate and how to enlist them to enhance
human health.

WHY DO I CHOOSE THE SCT?

Health Belief Model (HBM) (Rosenstock, 1974),
Transtheoretical Model (TTM)( Prochaska & DiClemente, 1983),
Theory of Reasoned Action (TRA) (Fishbein & Ajzen, 1975,1980)
and Theory of Planning Behavior (TPB) (Ajzen, 1985), and
the Social Cognitive Theory (SCT) (Bandura, 1988).
Only SCT consists of all psychosocial determinants
of health behavior (Bandura, 2004);

self-efficacy
outcome expectations (physical, social, and self-evaluative)
goals (proximal and distal)
impediments (personal, situational, and health system)

WHY DID I CHOOSE TYPE 2

DIABETES?

Although both types of DM are chronic,

type1 with short-term complications requiring
immediate treatment is clearly manifest as a disease
type 2 with long-term complications can exist without
being detected
the complexity and challenge of diabetes management
behaviors for patients with type 1 differ than those for
patients with type 2.

RATIONALES FOR SELECTING THE DMSES

A domain-specific instrument to assess the judgments of patients

with type 2 diabetes on their capacities for diabetes management.
A well designed construction of sound self-efficacy scales because it
relies on a good conceptual analysis of the relevant domains of
functioning to self-management in patients with type 2 diabetes.
Developed to assess the strength dimension of self-efficacy among
people with type 2 diabetes. The strength dimension of self-efficacy
makes the instrument easier to use for the older adults than
magnitude dimension and generality dimensions (Bandura, 1997).
Instrument format of the DMSES with a simple 5-point rating scale
was found as a usable format for the older adults (Lenz & ShortridgeBaggett, 2002).

RELATED CONCEPT
Self-esteem
Self-esteem is judgment of self-worth whereas selfefficacy is a judgment of capability.
Among the patients with diabetes, there was a
positive relationship between self-efficacy and selfesteem (Crabtree, 1986; Grossman, Brink, & Hauser, 1987).
In the older adults, there were positive correlations
among perceived self-efficacy, self-esteem, and selfcare behavior (Homnan, 1996; Parent & Whall, 1984).

POWER ANALYSIS
(TEST-RETEST)

For test-retest
Based on the

previous studies (McDowell et al., 2005; van der Bijl et al., 1999),
the test-retest reliability of the DMSES were r = .76, and
.79, respectively. In order to achieve the power of .80 at
= .05, n = 28 for sig. r is needed. Considering missing
values, 10% will be added.
At least 31 participants will be required

POWER ANALYSIS
(CRITERION-RELATED VALIDITY/ CONCEPTUAL
EQUIVALENCE)

Based on the previous study (McDowell et al., 2005), the TDMSES and the GSE scale were correlated to assess
the strength of relationship with r =.52.
To achieve the power of .80 at = .05, n = 28 for
sig. r
combines 10% of missing values are needed, as well.
At least 31 participants will be required
Conceptual equivalence between the T-DMSES and
RSES

BILINGUAL PARTICIPANT

The development of the T-DMSES Phase

Bilingual participant

First two translators

have medical/clinical background in taking care the older adults

The other translator

18 years old or older

fluent with reading, writing, and understanding both English and
Thai languages

not be aware nor informed of the concepts in the original version

of the DMSES
Native language will be English

Monolingual

Native speakers of English

THE GENERAL SELF-EFFICACY SCALE

(GSES)

The GSES is a 17-item scale that consists of a 5-point Likert

scale ranging from strongly disagree to strongly agree.
This scale is a subscale of the self-efficacy scale based on
Banduras self-efficacy theory.
The GSES was used to
measure generalized perceived self-efficacy
depending on past experiences & tendencies to attribute
success to skill as opposed to chance.

Thai version of the GSES which was translated by other

researchers (Yamchanchai, 1995; Chomson, 2006).
The internal consistency of the total scale was 0.85 (Chomson,
2006).

ROSENBERGS SELF-ESTEEM SCALE

(RSES)
In Thailand, this scale was translated and modified
to measure self-esteem among the older adults
(Homnan, 1996).
This scale contains 10 items.
Responses to each item are made on a four-point
scale-from strongly agree to strongly disagree.
The scale has both positive items and negative
items.
The investigator used the Thai version of RSES
which was translated and modified for the older
adults by Homnan (1996). The internal consistency
of the total scale was 0.87 (Homnan, 1996).

EXAMPLE OF SEMANTIC
QUESTIONNAIRE
Item

1. I think Im
able to check
my blood sugar
if necessary
1. I think I can
check blood
sugar if I have
to.

Different
Meaning
1

Almost Same
Meaning
2

Same

Meaning
3

Exactly
Same

Meaning
4

EXAMPLES OF INTERVENTION
BASED ON SELF-EFFICACY

Mastery (learn by doing)

Discuss

behavioral currently performed

Find & remind strengths from past experience
Goal setting

Vicarious Experience (role models)

Observing/sharing

performances of similar others

Verbal Persuasion

Decreasing Emotional or Physical arousal