Final Report ANDIAB2 2012 Quality Assurance of Patient Practices and Diabetes Centre Care - December 2012

Appendix 3 - Self Assessment of Health Status Form, Diabetes Distress Data Questionnaire

Page last updated: 16 December 2013

Self Assessment of Health Status

[1] Listed below are 2 potential problem areas that people with diabetes may experience. Consider the degree to which each of the 2 items may have distressed or bothered you during the past month and circle the appropriate number.

Please note that we are asking you to indicate the degree to which each item may be bothering you in your life, NOT whether the item is merely true for you. If you feel that a particular item is not a bother or a problem for you, you would circle "1". If it is very bothersome to you, you might circle "6".


Not a
Problem
A Slight
Problem
A
Moderate
Problem
Somewhat
Serious
Problem
A
Serious
Problem
A Very
Serious
Problem
1. Feeling
overwhelmed
by the
demands of
living with
diabetes.
123456
2. Feeling
that I am
often failing
with my
diabetes
routine.
123456

[2] We would like you to indicate on this scale, how good or bad your own health state is today, in your opinion. Please do this by drawing a line from the box on the right, to whichever point on the scale indicates how good or bad your health state is today.

Name
Date


Your Own Health State Today

Image of Health State Scale

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Appendix 3

DDS

Directions: Living with diabetes can sometimes be tough. There may be many problems and hassles concerning diabetes and they can vary greatly in severity. Problems may range from minor hassles to major life difficulties. Listed below are 17 potential problem areas that people with diabetes may experience. Consider the degree to which each of the 17 items may have distressed or bothered you during the past month and circle the appropriate number.

Please note that we are asking you to indicate the degree to which each item may be bothering you in your life, NOT whether the item is merely true for you. If you feel that a particular item is not a bother or a problem for you, you would circle "1". If it is very bothersome to you, you might circle "6".


Not a
Problem
A Slight
Problem
A
Moderate
Problem
Somewhat
Serious
Problem
A Serious
Problem
A Very
Serious
Problem
1. Feeling that my doctor doesn't
know enough about diabetes and
diabetes care.
123456
2. Feeling that diabetes is taking
up too much of my mental and
physical energy every day.
123456
3. Not feeling confident in my
day-to-day ability to manage
diabetes.
123456
4. Feeling angry, scared and/or
depressed when I think about
living with diabetes.
123456
5. Feeling that my doctor doesn't
give me clear enough directions on
how to manage my diabetes.
123456
6. Feeling that I am not testing my
blood sugars frequently enough.
123456
7. Feeling that I will end up with
serious long-term complications,
no matter what I do.
123456
8. Feeling that I am often failing
with my diabetes routine.
123456
9. Feeling that friends or family
are not supportive enough of
self-care efforts (e.g. planning
activities that conflict with my
schedule, encouraging me to
eat the "wrong" foods).
123456
10. Feeling that diabetes controls
my life.
123456
11. Feeling that my doctor doesn't
take my concerns seriously
enough.
123456
12. Feeling that I am not sticking
closely enough to a good meal
plan.
123456
13. Feeling that friends or family
don't appreciate how difficult
living with diabetes can be.
123456
14. Feeling overwhelmed by the
demands of living with diabetes.
123456
15. Feeling that I don't have a
doctor who I can see regularly
enough about my diabetes.
123456
16. Not feeling motivated to keep
up my diabetes self management.
123456
17. Feeling that friends or family
don't give me the emotional
support that I would like.
123456

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DDS17 Scoring Sheet



Instructions for Scoring

The DDS17 yields a total diabetes distress scale score plus 4 sub scale scores, each addressing a different kind of distress. To score, simply sum the patient’s responses to the appropriate items and divide by the number of items in that scale. The letter in the far right margin corresponds to that item’s subscale as listed below. We consider a mean item score of 3 or higher (moderate distress) as a level of distress worthy of clinical attention. Place a check on the line to the far right if the mean item score is ≥ 3 to highlight an above-range value.

We also suggest reviewing the patient’s responses across all items, regardless of mean item scores. It
may be helpful to inquire further or to begin a conversation about any single item scored 3 or higher.

Total DDS Score:
a. Sum of 17 item scores. ______________
b. Divide by: _____17_______
c. Mean item score: ______________ ≥ 3 ____

A. Emotional Burden:
a. Sum of 5 items (2, 4, 7, 10, 14) _______________
b. Divide by: _______5_______
c. Mean item score: ______________ ≥ 3 ____

B. Physician Distress:
a. Sum of 4 items (1, 5, 11, 15) ______________
b. Divide by: _______4______
c. Mean item score: ______________ ≥ 3 ____

C. Regimen Distress:
a. Sum of 5 items (6, 8, 3, 12, 16) ______________
b. Divide by: _______5______
c. Mean item score: ______________ ≥ 3 ____

D. Interpersonal Distress:
a. Sum of 3 items (9, 13, 17) ______________
b. Divide by: _______3______
c. Mean item score: ______________ ≥ 3 ____