CC-SC-CII v2 (English)

Adapted by

Ercole Vellone, PhD, RN, FAAN, FESC

Associate Professor in Nursing Science

Department of Biomedicine and Prevention
University of Rome “Tor Vergata”,
Via Montpellier, 1 – 00133 Rome, Italy
Phone + 39 06 72596802
Fax + 39 0672596961
Mobile + 393387491811
Skype: ercole.vellone
email: ercole.vellone@uniroma2.it

We are interested in the support you give and get from relationships

CAREGIVER CONTRIBUTION TO SELF-CARE OF CHRONIC ILLNESS INVENTORY v.2

All answers are confidential.

SECTION A

Here below are listed common behaviors of personal care that people with chronic diseases may apply. During the last month, how often did you recommend the person you care for the following behaviors? Or, how often did you these activities because the person you care for is not able to do them.

 

 

Never

Rarely
Sometimes

Often

Always

1.     Make sure to get enough sleep?

1

2

3

4

5

2.     Try to avoid getting sick (e.g., flu shot, wash your hands)?

1

2

3

4

5

3.     Do physical activity (e.g., take a brisk walk, use the stairs)?

������� 1

2

3

4

5

4.     Eat special foods or avoid certain foods?

1

2

3

4

5

5.     Keep appointments for routine or regular health care?

1

2

3

4

5

6.     Take prescribed medicines without missing a dose?

1

2

3

4

5

7.     Do something to relieve stress (e.g., mindfulness, yoga, music)?

1

2

3

4

5

 

SECTION B

Listed below are things that people with chronic diseases commonly monitor. How often do you recommend to the person you care for to do the following things? Or, do the following things because the person you care for is not able to do them.

 

Never

Rarely
Sometimes

Often

Always

8.     Monitor the health condition?

1

2

3

4

5

9.     Monitor for medication side-effects?

1

2

3

4

5

10. Pay attention to changes in how one feels?

1

2

3

4

5

11. Monitor whether one tires more than usual doing normal activities?

1

2

3

4

5

12. Monitor for symptoms?

1

2

3

4

5

 

13. Many patients have symptoms due to their health condition or due to the treatment they receive for it. The last time the person you care for had a symptom, how quickly did you recognize it as a symptom of health condition of the person you care for?

      He/she never had a symptom. If you check this box, skip to Section C below.

      He/she had a symptom but I did not recognize it as a symptom of his/her health condition

      He/she had a symptom and I recognized it as a symptom of his/her health condition (Circle one)

o   Not Quickly���

o   Fairly Quickly

o   Somewhat Quickly

o   Moderately Quickly

o   Very Quickly

 

SECTION C

Listed below are behaviors that people with chronic illness use to control their symptoms. When the person you care for has symptoms, how likely are you to recommend performing m the following behaviors (or you perform these behaviors if the person you care for is unable to do so?

 

(circle one number for each behavior)

 

Not Likely

Somewhat Likely

Moderately Likely

Likely

Very Likely

14. Change what the person you care for eats or drinks to make the symptom decrease or go away?

1

2

3

4

5

15. Recommend the person you care for to change the activity level (e.g., slow down, rest)?

1

2

3

4

5

16. Recommend the person you care for to take a medicine to make the symptom decrease or go away?

1

2

3

4

5

17. Tell about the symptom to the healthcare provider of the person you care for at the next office visit?

1

2

3

4

5

18. Call the healthcare provider of the person you care for to get guidance?

1

2

3

4

5

 
 

 

 

 

(circle one number)

 

 

I did not do anything

Not Sure

Somewhat sure

Moderately Sure

Sure

Very Sure

19. Think of a treatment you used the last time the person you care for had symptoms. Did the treatment you used make him/her feel better?

0

1

2

3

4

5

 

 


The following instrument, the Self-Care Self-Efficacy Scale, is not a measure of self-care but an instrument used to measure a factor strongly related to success in contributing to self-care. We encourage you to use this instrument along with the instrument above.


SELF-CARE SELF-EFFICACY SCALE

In reference to the person you care for, in general, how confident are you that you can:

(Circle one number for each statement)

 

Not Confident

Somewhat confident

Moderately Confident

Confident

Very Confident

1.     Keep the person you care for stable and free of symptoms?

1

2

3

4

5

2.     Follow the treatment advice have been given to the person you care for?

1

2

3

4

5

3.     Persist in following the treatment for the person you care for even when difficult?

1

2

3

4

5

4.     Monitor the health condition of the person you care for routinely?

1

2

3

4

5

5.     Persist in routinely monitoring the health condition of the person you care for even when difficult?

1

2

3

4

5

6.     Recognize changes in health of the person you care for if they occur?

1

2

3

4

5

7.     Evaluate the importance of the symptoms of the person you care for?

1

2

3

4

5

8.     Do something to relieve the symptoms?

1

2

3

4

5

9.     Persist in finding a remedy for the symptoms even when difficult?

1

2

3

4

5

10. Evaluate how well a remedy works?

1

2

3

4

5

 

THANK YOU FOR COMPLETING THIS SURVEY!