Introduction
The Cardiac Self-Efficacy Scale (CSES) serves as a vital psychometric instrument designed to measure perceived self-efficacy in managing symptoms and functioning in patients with coronary heart disease. Originally developed by Mark D. Sullivan, Andrea Z. LaCroix, Joan Russo, and Wayne J. Katon in 1998, With over 380 citations in scientific literature, the questionnaire evaluates how confident patients feel when confronting chest pain, managing medication regimens, or maintaining physical and social obligations. Because higher self-efficacy directly correlates with better functional status, understanding and implementing this scale remains essential for optimizing person-centered care and tracking therapeutic progress.
This article delves into the core structural components, psychometric validation, and practical clinical applications of the CSES for modern researchers and clinicians.
Key Features of the Cardiac Self-Efficacy Scale (CSES)
Purpose and Use
The primary purpose of the CSES is to measure perceived self-efficacy in managing symptoms and functioning specifically in patients with coronary heart disease. By utilizing this instrument, clinical teams can systematically evaluate how confident a patient feels when confronting potential chest pain, managing medication regimens, or maintaining physical and social obligations. Ultimately, these insights allow investigators to identify individuals with low self-efficacy who may require targeted cardiac rehabilitation or behavioral interventions to prevent functional decline.
Target Population
The CSES is validated for use with adults aged 18 years and older. Because coronary heart disease impacts a wide demographic spectrum, the scale is regularly applied across various adult life stages, including:
- Young adults (18–24 years)
- Middle-aged adults (25–44 years)
- Older adults (45–64 years)
- Seniors (65+ years)
It is specifically tailored for individuals experiencing coronary heart disease, acute coronary syndrome, or general cardiovascular disease.
Structure
The finalized version of the CSES consists of 13 items. Although the original development study initially assessed 16 questionnaire items, the authors excluded 3 items during preliminary testing due to high non-applicability among respondents. The remaining 13 items capture distinct behavioral domains, which typically load onto two main subscales:
- Control Symptoms
- Maintain Function
This questionnaire comprehensively assesses a patient’s confidence in controlling cardiac symptoms and maintaining daily functioning in coronary heart disease. Specifically, the items cover the control of chest pain and breathlessness, medication use, knowing when to seek medical advice, communicating concerns to a doctor, appropriate physical activity, and maintaining social, family/home, work, sexual, and aerobic exercise activities.
Note on structural variations: Although the original CSES utilizes this two-subscale framework, later validation studies have occasionally reported an additional factor termed “Control Illness.” Therefore, depending on the specific translation or population used, researchers may encounter a three-factor structural model in contemporary literature.
Scoring Method
Each of the 13 items on the CSES is rated using a 5-point Likert confidence scale, ranging from 0 (“Not at all confident”) to 4 (“Completely confident”), with 1 representing “Somewhat confident”. To calculate the final score for each subscale, researchers compute the mean of the rated items within that specific domain. Later validation studies also provide strong statistical support for calculating a total global score by averaging all items across the entire instrument.
Higher scores indicate a greater level of cardiac self-efficacy. Conversely, it is important to note that clinical cut-off scores are not established in the literature; the CSES is interpreted dimensionally to track relative confidence levels rather than categorically to diagnose dysfunction.
Administration Format
Because the CSES is a free, open-access, and self-administered questionnaire, it demands minimal institutional resource overhead. Healthcare teams can easily integrate the tool across multiple administrative modalities, including:
- Paper-based formats
- Digital (online) platforms
- In-person clinical interviews
- Phone or video calls
The scale typically requires only 5 to 10 minutes to complete, which makes it exceptionally practical for busy cardiovascular clinics and large-scale, multi-center research registries.
Applications of the Cardiac Self-Efficacy Scale (CSES)
The CSES provides versatile clinical and empirical utility across multiple settings:
- Monitoring: Clinicians can track patient confidence during recovery phases, observing changes in self-efficacy following major cardiac events or surgical interventions.
- Treatment Planning: The scale helps multidisciplinary teams design tailored cardiac rehabilitation programs by highlighting specific areas where a patient lacks confidence, such as returning to work or engaging in aerobic exercise.
- Research: The CSES serves as a primary or secondary outcome measure in clinical trials evaluating the efficacy of self-management programs, tele-health interventions, and person-centered behavioral therapies.
Languages and availability
To facilitate cross-cultural research and support global health initiatives, international researchers adapted the CSES across a broad range of languages. Independent research teams successfully validated and published the instrument in the following languages:
- Arabic
- English
- Mandarin Chinese
- Spanish
- Swedish
- Turkish
- And others.
This broad linguistic range eliminates communication barriers in diverse clinical environments and simplifies international data aggregation. Furthermore, the original authors provide the CSES as a free, open-access tool for global clinical and academic use.
Reliability and Validity
The CSES is recognized globally as a highly reliable and valid psychometric instrument. Its internal consistency is exceptionally robust, as evidenced by a Cronbach’s alpha of 0.90 for the Control Symptoms subscale and 0.87 for the Maintain Function subscale. Furthermore, its predictive validity has been demonstrated over time, showing a clear prospective relationship with self-reported functional status in longitudinal observations.
- The original validation study link.
- Validation of the Chinese version study link.
- Validation of the Spanish version study link.
- Validation of the Arabic version study link.
- Validation of the Turkish version study link.
- Validation of the Swedish version study link.
- Validation of the Korean version study link.
- Validation of the Persian version study link.
- Validation of the Portuguese Version study link.
Limitations and Considerations
Despite its strengths, the CSES has a few limitations:
- Self-report measure: The CSES relies entirely on subjective patient feedback, which can introduce response bias based on how patients perceive their own health status.
- Social desirability bias: Patients might overestimate their confidence level or functional abilities to please their healthcare providers during evaluation.
- Narrow focus: The scale restricts its assessment to specific domains of cardiac symptom control and physical functioning, omitting other quality of life aspects.
- Age restrictions: Clinicians cannot apply this instrument universally across all age categories, as it primarily targets adult cardiovascular populations.
- Cultural bias: Independent translation and adaptation processes across different global environments can reveal cultural variations in how patients interpret the questions.
Other Versions And Related Questionnaires
When designing a comprehensive cardiovascular research protocol, investigators often pair the CSES with other validated tools to capture a holistic view of patient health. Depending on the exact study objectives, researchers might consider alternative self-efficacy instruments or complementary functional measures:
Related Self-Efficacy Scales
- General Self-Efficacy Scale (GSE/GSES)
- Heart Failure Self-Efficacy Scale
- Self-Efficacy for Managing Chronic Disease Scale (SEMCD)
Complementary Cardiac Outcome Measures
- Seattle Angina Questionnaire (SAQ)
- Minnesota Living with Heart Failure Questionnaire (MLHFQ)
Additional Resources
- The Original Validation Study link.
- For inquiries, contact Prof. Mark D. Sullivan, the first author of the questionnaire at sullimar@uw.edu.
Frequently Asked Questions (FAQ)
- Who can use the CSES?
Clinicians, researchers, and healthcare providers use the CSES for patients aged 18 and older with coronary heart disease or general cardiovascular conditions.
- Who can use the CSES?
- How long does it take to complete the CSES?
Patients typically take 5 to 10 minutes to complete the CSES, which makes it highly feasible for use in clinical and research settings.
- How long does it take to complete the CSES?
- How is the CSES administered?
Healthcare teams can administer the questionnaire via paper, digital, in-person interview, or phone/video call formats—offering excellent flexibility in usage.
- How is the CSES administered?
- Is there any cost to using the CSES?
The CSES is completely free to use and operates under an open-access model, allowing investigators to utilize the items published in the original literature without licensing fees.
- Is there any cost to using the CSES?
A Word from ResRef about the Cardiac Self-Efficacy Scale (CSES)
The Cardiac Self-Efficacy Scale (CSES) is a reliable disease-specific measure of patients’ confidence in controlling cardiac symptoms and maintaining functioning in coronary heart disease. It is useful for cardiovascular research, outcome evaluation, and person-centred care planning. It is not diagnostic and has no established clinical cut-off score.
References
- Sullivan, Mark D. MD, PhD; LaCroix, Andrea Z. PhD; Russo, Joan PhD; Katon, Wayne J. MD. Self-Efficacy and Self-Reported Functional Status in Coronary Heart Disease: A Six-Month Prospective Study. Psychosomatic Medicine 60(4):p 473-478, July/August 1998. link.
- Zhang X, Zhan Y, Liu J, Chai S, Xu L, Lei M, Koh KWL, Jiang Y, Wang W. Chinese translation and psychometric testing of the cardiac self-efficacy scale in patients with coronary heart disease in mainland China. Health Qual Life Outcomes. 2018 Mar 12;16(1):43. link.
- Arenas A, Cuadrado E, Castillo-Mayén R, Luque B, Rubio S, Gutiérrez-Domingo T, Tabernero C. Spanish validation of the cardiac self-efficacy scale: a gender invariant measure. Psychol Health Med. 2024 Jan-Jun;29(2):334-349. link.
- Barham A, Ibraheem R, Zyoud SH. Cardiac self-efficacy and quality of life in patients with coronary heart disease: a cross-sectional study from Palestine. BMC Cardiovasc Disord. 2019 Dec 13;19(1):290. link.
- Tunc Suygun, E., Vardar Yagli, N., Suygun, H. et al.Validity and reliability of the Turkish translation of the heart health self-efficacy and self-management scale in patients with chronic heart disease. BMC Psychol 13, 1210 (2025). link.
- EuroHeartCare 2014, European Journal of Cardiovascular Nursing, Volume 13, Issue 1_suppl, 1 April 2014, Pages S1–S91. link.
- Park, Jin-Hee, et al. “Psychometric Testing of the Korean Version of the Self-Care of Coronary Heart Disease Inventory Version 3.” Asian Nursing Research, vol. 18, no. 3, Aug. 2024, pp. 238–245. link.
- Sharif-Nia, Hamid, et al. “Self-Efficacy Scale among Iranian Cardiovascular Patients: Persian Translation, Validity, and Reliability Assessment.” Journal of Nursing Measurement, vol. 32, no. 3, 18 Jan. 2024, pp. 404–414, https://doi.org/10.1891/jnm-2023-0001. Accessed 5 Feb. 2025. link.
- Almeida, Jose Alexandre Barbosa, et al. “Self-Efficacy Instruments for Individuals with Coronary Artery Disease: A Systematic Review Protocol.” BMJ Open, vol. 12, no. 7, 1 July 2022, p. e062794, bmjopen.bmj.com/content/12/7/e062794. link.
