CC-SCODI (English)
Authored By
Davide Ausili, RN, MSc, PhD
Assistant Professor
Università degliStudi di Milano –Bicocca,
Via Cadore 48, Monza –Italy
Phone: +390264488032
Email: davide.ausili@unimib.it
Dr. Barbara Riegel, PhD, RN, FAHA, FAAN
Professor
University of Pennsylvania, School of Nursing
Claire M. Fagin Hall, 418 Curie Boulevard
Philadelphia, PA 19104-4217
briegel@nursing.upenn.edu
215-898-9927 Phone
240-282-7707 eFax
Co-Director, International Center for Self-Care Research www.selfcareresearch.org
Claire M. Fagin Hall, 418 Curie Boulevard
Philadelphia, PA 19104-4217
briegel@nursing.upenn.edu
215-898-9927 Phone
240-282-7707 eFax
Co-Director, International Center for Self-Care Research www.selfcareresearch.org
Confidenal material subject to authorizaon for every use. Developed by Ausili D. and Fabrizi D., School of Medicine and
Surgery, University of Milano-Bicocca. Useful contacts: davide.ausili@unimib.it ; dilea.fabrizi@unimib.it
Caregiver Contribuon to Self-Care of Diabetes Index (CC-SCODI)
Please think about what you did in the last month.
SECTION A
Below are listed some behaviors that a person with diabetes could perform to
maintain health and wellness. How oſten do you recommend the following things to
the person you care for? Or, how oſten do you do these acvies because the person
you care for is not able to do them?
(circle one number)
NEVER ALWAYS
1.
Maintain an acve lifestyle (e.g., walking, going out, doing acvies)
1 2 3 4 5
2.
Perform physical exercise for 2 hours and 30 minutes each week (e.g.,
swimming, going to the gym, cycling, walking)
1 2 3 4 5
3.
Eat a balanced diet of carbohydrates (e.g., pasta, rice, sugars, bread), proteins
(e.g., meat, fish, legumes), fruits, and vegetables
1 2 3 4 5
4.
Avoid eang salt and fats (e.g., cheese, cured meats, sweets, red meat)
1 2 3 4 5
5.
Limit alcohol intake (no more than 1 glass of wine/day for women and 2
glasses/day for men)
1 2 3 4 5
6.
Try to avoid geng sick (example: washing hands, geng recommended
vaccinaons)
1 2 3 4 5
7.
Avoid cigarees and tobacco smoke
1 2 3 4 5
8.
Take care of feet (e.g., washing and drying the skin, applying moisture, using
correct socks)
1 2 3 4 5
9.
Maintain good oral hygiene (e.g., brushing teeth at least twice/day, using
mouthwash, using dental floss)
1 2 3 4 5
10.
Keep appointments with healthcare provider
1 2 3 4 5
11.
Have health check-ups on me (e.g., blood tests, urine tests, ultrasounds, eye
exams)
1 2 3 4 5
12.
Many people have problems taking all their prescribed medicines.
Take all medicines as prescribed to by the healthcare provider (please also
consider insulin if prescribed)
1 2 3 4 5
1
Confidenal material subject to authorizaon for every use. Developed by Ausili D. and Fabrizi D., School of Medicine and
Surgery, University of Milano-Bicocca. Useful contacts: davide.ausili@unimib.it ; dilea.fabrizi@unimib.it
SECTION B
Below are listed some behaviors that a person with diabetes could perform to
monitor their diabetes. How oſten do you recommend the following things to the
person you care for? Or, how oſten do you do these acvies because the person you
care for is not able to do them?
(circle one number)
NEVER ALWAYS
13.
Monitor blood sugar regularly
1 2 3 4 5
14.
Monitor weight
1 2 3 4 5
15.
Monitor blood pressure
1 2 3 4 5
16.
Keep a record of blood sugars in a diary or notebook
1 2 3 4 5
17.
Monitor the condion of feet daily to see if there are wounds, redness or
blisters
1 2 3 4 5
18.
Pay aenon to symptoms of high blood sugar (e.g., thirst, frequent
urinaon) and low blood sugar (e.g., weakness, perspiraon, anxiety)
1 2 3 4 5
The last me the person you care for had symptoms:
I DIDN’T
RECOGNIZE
SYMPTOMS
NOT
QUICKLY
VERY
QUICKLY
19.
How quickly did you recognize that he/she was
having symptoms?
0 1 2 3 4 5
20.
How quickly did you know that the symptoms were
due to diabetes?
0 1 2 3 4 5
2
Confidenal material subject to authorizaon for every use. Developed by Ausili D. and Fabrizi D., School of Medicine and
Surgery, University of Milano-Bicocca. Useful contacts: davide.ausili@unimib.it ; dilea.fabrizi@unimib.it
SECTION C
Below are listed some behaviors that a person with diabetes could perform to
improve their blood sugar when it’s too high or too low. How oſten do you
recommend the following things to the person you care for? Or, how oſten do you do
these acvies because the person you care for is not able to do them?
(circle one number)
NEVER ALWAYS
21.
If symptoms (e.g., thirst, frequent urinaon, weakness, perspiraon,
anxiety) occur, check blood sugar 1 2 3 4 5
22.
If abnormal blood sugar levels occur, take notes about the events that
could have caused it and acons he/she took 1 2 3 4 5
23.
If abnormal blood sugar levels occur, ask a family member or friend
for advice 1 2 3 4 5
24.
If symptoms occur and blood sugar is low , eat or drink something with
sugar to solve the problem
1 2 3 4 5
25.
If blood sugar is high , adjust the diet to fix it
1 2 3 4 5
26.
If blood sugar is high, adjust physical acvity to fix it
1 2 3 4 5
27.
Aſter taking acons adjust an abnormal blood sugar level, to re-check
blood sugar to assess if the acons were effecve
1 2 3 4 5
28.
If blood sugar is very low or very high , call the healthcare provider for
advice
1 2 3 4 5
Does the person you care for take insulin?
Yes
No
If yes, please answer the following queson.
29.
If blood sugar is too high or too low, adjust the insulin dosage in the
way the healthcare provider suggested. 1 2 3 4 5
3
Confidenal material subject to authorizaon for every use. Developed by Ausili D. and Fabrizi D., School of Medicine and
Surgery, University of Milano-Bicocca. Useful contacts: davide.ausili@unimib.it ; dilea.fabrizi@unimib.it
SECTION D
In reference to the person you care for, how much do you feel confident that you
can recommend or do these acvies?
(circle one number)
NOT
CONFIDENT
AT ALL
EXTREMELY
CONFIDENT
30.
Prevent high or low blood sugar levels and its
symptoms
1 2 3 4 5
31.
Follow advice about nutrion and physical acvity
1 2 3 4 5
32..
Take medicines in the appropriate way (including
insulin if prescribed)
1 2 3 4 5
33.
Persist in following the treatment plan even when it is
difficult
1 2 3 4 5
34.
Monitor blood sugar as oſten as the health care
provider asked that it be done
1 2 3 4 5
35.
Understand if blood sugar levels are good or not
1 2 3 4 5
36.
Recognize the symptoms of low blood sugar
1 2 3 4 5
37.
Persist in monitoring diabetes even when it is difficult
1 2 3 4 5
38.
Take acon to adjust blood sugar and relieve
symptoms
1 2 3 4 5
39.
Evaluate if the implemented acons were effecve to
change blood sugar and relieve symptoms
1 2 3 4 5
40.
Persist in carrying out acons to improve blood sugar
even when it is difficult
1 2 3 4 5
Thank you for compleng this survey!
4