Social Support in Diabetes
Social Support in Diabetes
Social Support in Diabetes
Name _____________________
Michigan Diabetes
Research and Training Center
DCP2.0
Please answer each of the following questions by filling in the blanks with the correct answers
or by choosing the single best answer.
Note: For this survey, a Health Care Provider refers to a doctor, nurse practitioner,
or physician assistant.
Q5. What year were you first told you had diabetes? (Please enter the year) __ __ __ __
1 Never married
2 Married
3 Separated/Divorced
4 Widowed
1 White
2 Black
3 Hispanic
4 Native American
5 Asian or Pacific Islander
6 Arabic
7 Other _______________
-2-
-
-3-
-
Q8. Where do you live most of the year? (check one box)
Q9. How many people live with you? (check one box)
0 I live alone
1 1 person
2 2 people
3 3 people
4 4 people
5 5 or more
Q10. How much schooling have you had? (Years of formal schooling completed)
(check one box)
1 8 grades or less
2 Some high school
3 High school graduate or GED
4 Some college or technical school
5 College graduate (bachelor’s degree)
6 Graduate degree
-4-
-
Q11. Which of the following best describes your current employment status? (check one box)
Q12. How would you describe the insurance plan(s) you have had in the past 12 months?
(check all that apply)
-5-
-
Q13. What type(s) of insurance plans have you had in the past 12 months?
(check all that apply)
1 Indemnity or fee-for-service plan (i.e., you choose which health care provider you
see for care without financial penalty)
2 Health Maintenance Organization (HMO) (i.e., you must have a primary care
provider who must refer you to specialty care if needed)
3 Preferred Provider Organization (PPO) (i.e., you have lower co-payments when
you see a preferred provider within the network, but you can see a provider
out-of-network for a higher co-payment)
4 Point of Service (POS) (i.e., you must have a primary care provider; you have the
option to self-refer to an in-network specialist, or you can see an out-of-network
specialist with a higher co-payment)
5 Other (please specify): _________________
6 I have not had an insurance plan in the past 12 months.
-6-
-
Q14. Do you test your blood sugar? (check one box)
1 No 2 Yes Q14a. How many days a week do you test your blood
sugar?
Q14b. On days that you test, how many times do you test
your blood sugar?
-7-
-
Section II – Health Status
Q1. In general, would you say your health is: (check one box)
1 2 3 4 5
Q2. These questions ask about how you feel and how things have been with you during the
past 4 weeks. For each question, please give the one answer that comes closest to the
way you have been feeling.
How much of the time during the past 4 weeks: (circle one answer for each line)
-8-
-
Section III – Education / Advice Received
Q1. Has your health care provider or nurse ever told you to take special care of your feet?
(check one box)
Q2. Has your health care provider or nurse ever told you to follow an exercise program?
(check one box)
Q3. Has your health care provider or nurse ever told you to follow a meal plan or diet?
(check one box)
Q4. Have you ever received diabetes education? (for example: attended a series of classes or
series of meetings with a diabetes educator) (check one box)
-9-
-
Section IV - Understanding
- 10 -
-
Section V – Support
Q1. I want a lot of help and support from my family or friends in:
(circle one answer for each line)
Does
Strongly Somewhat Somewhat Strongly Not
Disagree Disagree Neutral Agree Agree Apply
a) following my meal 1 2 3 4 5 N/A
plan.
b) taking my medicine. 1 2 3 4 5 N/A
c) taking care of my feet. 1 2 3 4 5 N/A
d) getting enough 1 2 3 4 5 N/A
physical activity.
e) testing my sugar. 1 2 3 4 5 N/A
f) handling my feelings 1 2 3 4 5 N/A
about diabetes.
Does
Strongly Somewhat Somewhat Strongly Not
Disagree Disagree Neutral Agree Agree Apply
a) follow my meal plan. 1 2 3 4 5 N/A
b) take my medicine. 1 2 3 4 5 N/A
c) take care of my feet. 1 2 3 4 5 N/A
d) get enough physical 1 2 3 4 5 N/A
activity.
e) test my sugar. 1 2 3 4 5 N/A
- 11 -
-
f) handle my feelings 1 2 3 4 5 N/A
about diabetes.
- 12 -
-
Q3. My family or friends: (circle one answer for each line)
Q4. Who helps you the most in caring for your diabetes? (check only one box)
1 Spouse
2 Other family members
3 Friends
4 Paid helper
5 Doctor
6 Nurse
7 Case manager
8 Other health care professional
9 No one
- 13 -
-
DCP Appendices
Q1. How many times in the last month have you had a low blood sugar (glucose) reaction
with symptoms such as sweating, weakness, anxiety, trembling, hunger or headache?
1 0 times
2 1-3 times
3 4-6 times
4 7-12 times
5 More than 12 times
6 Don’t know
Q2. How many times in the last year have you had severe low blood sugar reactions such as
passing out or needing help to treat the reaction?
1 0 times
2 1-3 times
3 4-6 times
4 7-12 times
5 More than 12 times
6 Don’t know
- 14 -
-
Q3. How many days in the last month have you had high blood sugar with symptoms such
as thirst, dry mouth and skin, increased sugar in the urine, less appetite, nausea, or
fatigue?
1 0 days
2 1-3 days
3 4-6 days
4 7-12 days
5 More than 12 days
6 Don’t know
Q4. How many days in the last month have you had ketones in your urine?
1 0 days
2 1-3 days
3 4-6 days
4 7-12 days
5 More than 12 days
6 Don’t test
- 15 -
-
Q5. During the past year, how often did your
blood sugar become too high because: Don't
(circle one answer for each line) Never Sometimes Often Know
Don't
Never Sometimes Often Know
Q1. How often has your diabetes kept you
from doing your normal daily activities
1 2 3 4 5 DK
during the past year (e.g., couldn't: go
to work, work around the house, go to
school, visit friends)?
- 17 -
-
Strongly Strongly
Disagree Disagree Neutral Agree Agree
Strongly Strongly
Disagree Disagree Neutral Agree Agree
- 18 -
-
Section VIII - Attitudes Toward Diabetes Scales
Strongly Strongly
Disagree Disagree Neutral Agree Agree
Q1. I am afraid of my 1 2 3 4 5
diabetes.
Q2. I find it hard to believe 1 2 3 4 5
that I really have diabetes.
Q3. I feel unhappy and 1 2 3 4 5
depressed because of my
diabetes.
Q4. I feel satisfied with my 1 2 3 4 5
life.
Q5. I feel I'm not as good as 1 2 3 4 5
others because of my
diabetes.
Q6. I can do just about 1 2 3 4 5
anything I set out to do.
Q7. I find it hard to do all the 1 2 3 4 5
things I have to do for my
diabetes.
Q8. Diabetes doesn't affect my 1 2 3 4 5
life at all.
Q9. I am pretty well off, all 1 2 3 4 5
things considered.
Q10. Things are going very 1 2 3 4 5
well for me right now.
- 19 -
-
Q11. I am able to: (circle one answer Strongly Strongly
for each line) Disagree Disagree Neutral Agree Agree
a) keep my blood sugar in 1 2 3 4 5
good control.
b) keep my weight under 1 2 3 4 5
control.
c) do the things I need to do 1 2 3 4 5
for my diabetes (diet,
medicine, exercise, etc.).
d) handle my feelings (fear, 1 2 3 4 5
worry, anger) about my
diabetes.
- 20 -
-
Don't
Never Sometimes Always Know
- 21 -
-
Section IX - Diet Adherence Scale
Q1. Has any health care provider or nurse 1 No 2 Yes 3 Not sure
told you to follow a meal plan or diet?
- 22 -
-
Section X - Long-Term Care Benefits Scale
- 23 -
-
Section XI - Exercise Barriers Scale
- 24 -
-
Section XII - Monitoring Barriers and Understanding Management Practice Scales
Q1. How many days a week have you been told to test:
- 25 -
-
Q3. Have you ever received diabetes education? 1 No 2 Yes
- 26 -
-
Addition to Section I (Demographics) - Income Question
Q15. Which of the categories best describes your total annual combined household income
from all sources? (check one box)
02 $5,000 to $9,999
03 $10,000 to $14,999
04 $15,000 to $19,999
05 $20,000 to $29,999
06 $30,000 to $39,999
07 $40,000 to $49,999
08 $50,000 to $59,999
09 $60,000 to $69,999
- 27 -
-
Addition to Section I (Demographics) - Occupation Question (from NHANES III)
Q15/Q16. During the past 2 weeks, did you work at any time at a job or business,
not counting work around the house?
1 No 2 Yes
- 28 -
-
Replace Section II (Health Status) with SF-12
Q1. In general, would you say your health is: (check one box)
1 2 3 4 5
The following items are about activities you might do during a typical day. Does your health
now limit you in these activities? If so, how much? (check one box for each line)
During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of your physical health? (check one box for each line)
Yes No
Q4. Accomplished less than you would like 1 2
- 29 -
-
During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of any emotional problems (such as feeling depressed or
anxious)? (check one box for each line)
Yes No
- 30 -
-
Q8. During the past 4 weeks, how much did pain interfere with your normal work (including
both work outside the home and housework)? (check one box)
1 2 3 4 5
These questions are about how you feel and how things have been with you during the
past 4 weeks. For each question please give the one answer that comes closest to the
way you have been feeling.
How much of the time during the past 4 weeks: (circle one answer for each line)
Q12. During the past 4 weeks, how much of the time has your physical health or emotional
problems interfered with your social activities (like visiting with friends, relatives, etc.)?
(check one box)
1 2 3 4 5
All of the Most of the Some of the A little of None of the
time time time the time time
- 31 -
-
Replace Section II (Health Status) with SF-36
Q1. In general, would you say your health is: (check one box)
1 2 3 4 5
Excellent Very Good Good Fair Poor
Q2. Compared to one year ago, how would you rate your health in general now?
(check one box)
- 32 -
-
Q3. The following questions are about activities you might do during a typical day.
Does your health now limit you in these activities? If so, how much?
(circle one answer on each line)
- 33 -
-
Q4. During the past 4 weeks, have you had any of the following problems with your work or
other regular daily activities as a result of your physical health?
(circle one answer on each line)
Yes No
A. Cut down the amount of time you spent on work or other 1 2
activities
B. Accomplished less than you would like 1 2
- 34 -
-
Q5. During the past 4 weeks, have you had any of the following problems with your work or
other regular daily activities as a result of any emotional problems (such as feeling
depressed or anxious)? (circle one answer on each line)
Yes No
A. Cut down the amount of time you spent on 1 2
work or other activities
B. Accomplished less than you would like 1 2
Q6. During the past 4 weeks, to what extent has your physical health or emotional problems
interfered with your normal social activities with family, friends, neighbors, or groups?
(check one box)
1 2 3 4 5
Q7. How much bodily pain have you had during the past 4 weeks? (check one box)
1 2 3 4 5 6
Q8. During the past 4 weeks, how much did pain interfere with your normal work (including
both work outside the home and housework)? (check one box)
1 2 3 4 5
- 35 -
-
Q9. These questions are about how you feel and how things have been with you during the
past 4 weeks. For each question please give the one answer that comes closest to the
way you have been feeling.
How much of the time during the past 4 weeks: (circle one answer on each line)
- 36 -
-
Q10. During the past 4 weeks, how much of the time has your physical health or emotional
problems interfered with your social activities (like visiting with friends, relatives, etc.)?
(check one box)
Q11. Please choose the answer that best describes how true or false each of the following
statements is for you. (circle one answer on each line)
D. My health is excellent. 1 2 3 4 5
2 Female
- 37 -
-
Q12b. How old were you on your last birthday? (check one box)
1 Less than 35
2 35-44
3 45-54
4 55-64
5 65-74
6 75-84
7 85 and older
Q13. Have you ever filled out this form before? (check one box)
1 Yes
2 No
3 Don’t remember
- 38 -
-
DCP Questions Needed for Cost Effectiveness Analysis
Essential:
1. Employment Question (Section I - Q11)
2. Age, Date of DM Diagnosis, and Race Questions (Section I - Q1, Q5, Q7)
Often Needed:
1. Occupation Question (appendix)
2. Health Insurance Questions (Section I - Q12 and Q13)
3. Income Question (appendix)
- 39 -
-
DCP Summary
Core Questions:
Section I – Demographics (Q1 – Q14)
Section II – Health Status (Q1 – Q2)
Section III – Education / Advice Received (Q1 – Q4)
Section IV – Understanding (Q1)
Section V – Support (Q1 – Q4)
Appendices:
Section VI – Control Problems Scale
Section VII – Social and Personal Factors Scale
Section VIII – Attitudes Toward Diabetes Scales
Section IX – Diet Adherence Scales
Section X – Long-term care benefits Scale
Section XI – Exercise Barriers Scale
Section XII – Monitoring Barriers and Understanding Management Practice Subscales
(add understanding subscale to the end of Section IV)
- 40 -
-