The Enforced Social Dependency Scale (ESDS)

Background:

Chronically ill-patients, such as those suffering from cancer, can become dependent on close friends, relatives, or care-givers as their illness progresses. This is known to be very detrimental to patients’ quality of life and well-being among other things. The term ‘enforced social dependency’ refers to the type of dependency which is both necessary and related to behaviours which might ordinarily be taken for granted. An important role of health care for such patients is to enable them to regain as mush of their pre-illness functionality as possible. This kind of training requires tools for measuring levels of functionality and this is why the Enforced Social Dependency Scale (ESDS) was developed and evaluated.

Psychometrics:

The psychometric properties of the Enforced Social Dependency Scale (ESDS) are discussed extensively in the manual attached below. The Instrument itself is in the appendix of this manual.

Author of Tool:

Mc Corkle, R. & Tzuh Tang, S.

Key references:

Benoliel, J. Q., McCorkle, R., Young, K. (1980). Development of a social dependency scale. Res Nurs Health, 3(1), 3-10.

McCorkle, R., & Benoliel, J.Q. (1981). Cancer patient responses to psychosocial variables. Final Report of project supported by Grant No. NU00730, DHHS, University of Washington.

Primary use / Purpose:

The Enforced Social Dependency Scale (ESDS) is a 10-item inventory with questions scored on a Likert scale of between 3 and 6 points. Its purpose is to measure the level of functioning in patients. Specifically, the scale aims to measure patients’ dependence on external sources in order to carry out duties which are ordinarily taken for granted such as eating, walking, and bathing.

Files:

USER’S MANUAL FOR THE ENFORCED SOCIAL DEPENDENCY SCALE

 

The Enforced Social Dependency Scale (ESDS)

Appendix A. Enforced Social Dependency Scale—Initial Interview Guide (Form I)

The Enforced Social Dependency Scale (ESDS) is recommended to be used with people who have recently experienced an illness, such as cancer, stroke, or heart attack. Form I is to be used to evaluate the patient’s function initially after illness. If the scale is administered beyond the initial illness, the questions need to be asked within the last week.

Instructions:

The Enforced Social Dependency Scale was developed to determine the extent to which the patient’s dependence on external sources of support has changed during illness. Dependence is defined in terms of a number of specific functional items, such as bathing and eating. Based on the questions asked in the interview, the interviewers should be able to rate how the patient is faring with respect to these functional activities on the Enforced Social Dependency Scale. To aid you in this effort, verbal descriptions of the levels of the items have been provided along with explicit definitions of how defining terms are being used. You should familiarize yourself with the levels of the Enforced Social Dependency Scale before beginning your interview.

In order to determine the appropriate location on the item codes for a particular person, a set of suggested interview questions has been provided for each scale item (with the exception of the consciousness item). The first question is general and open-ended. It may be that the patient will give enough information in response to this question that no further questions are necessary for that particular item. If this is so, simply record the information and move on to the next item. If more information is needed to make the proper determination, continue with the more detailed questions (marked “e.g.”) are given for some of the items. The general principle is this: Ask as many of the questions as necessary to determine where a patient belongs on a particular code for that item. Then record this information and move on to the next item.

In general, you should notaccept a quick answer that “everything is normal (usual).” The patient may not understand how you are using your terms. This is one reason for using the more specific questions. Consider an example: In response to your general question, a patient says that his bathing is normal (usual). After further probing, however, he reveals that he recently requires grab rails to get in and out of the tub. This might seem perfectly normal (usual) to him. This item would be coded a “3”, bathes with use of equipment, rather than a “1”, usual bathing activity, no change.

On the other hand, it may quickly become apparent to you that a particular aspect of the patient’s behavior is normal (usual). A patient who has already told you he plays tennis every day will probably not require assistance in walking (to take an extreme example). Once you have acquired a little experience with the items and codes, observation and inference may be used to reduce the number of questions asked for each item.

TO THE PATIENT:

In general, I would like to know how your present activities differ from your usual patterns prior to your illness. I’m interested in what effects your illness has had on your day-to-day living. To make sure I find out as much about this as I can, I’m going to ask you a number of specific questions about what a typical day is like for you.

(Eating)

  1. What about eating, for example? How do your present eating habits differ from what was usually for you before your illness?
    1. Does it take you more time to eat?
    2. Do you eat at the same times as you used to? Do you eat in the same place (e.g., at the table)?
    3. Do people bring food to you more often?
    4. Are you able to cut your own food?
    5. Is pouring milk or coffee a problem for you?

(OPTIONAL)

Are there any special eating utensils, such as enlarged fork handles or non skid plates, that you use and find helpful?

(Dressing)

  1. Do you have problems dressing yourself now that you didn’t have before your illness (e.g., bending to put on shoes, stretching to pull something over your head); has illness made it harder to get dressed?
    1. Does it take more time to get dressed?
    2. Do you need help in putting on some of your clothes—fastening buttons, for example, or lacing your shoes?
    3. Do you wear special clothes, or use special equipment, to make dressing easier?
    4. Are there days you don/t get dressed, but wear your bed clothes? About how many days a week, would you say?

(Walking)

  1. Do you walk and get about in the same way you did before your illness?
    1. Does it take more time to walk somewhere? Is your walking more deliberate (i.e., cautious or careful)?
    2. Are you ever assisted in getting about?

Has the doctor restricted your walking in any way? (e.g., do you need to be accompanied when you go on walks)?

  1. Do you use special equipment to help you walk? g., Do you use a cane or a crutch? Do you wear braces or special shoes?

Do you take elevators more than you used to?

  1. How do your present travel and transportation patterns differ from what was usual for you before your illness?
    1. How do you get to the doctor for your medical appointments?
    2. Do you drive a car or take a bus as often as you used to?
    3. What kinds of places do you drive to (or go to)?
    4. Are there places you used to drive to (or ride to), you don’t go to as often now (non-essential trips, g., going out for dinner, shopping, etc.)?

(Bathing)

  1. How do your present bathing patterns differ from what was usual for you before your illness?
    1. About how often—how many times a week—do you bathe now?
    2. How do you usually bathe? Of the times a week you bathe, how many are tub baths? Showers? Sponge baths?      (g., washing yourself down with a close or sponge)?
    3. Does it take you more time to bathe?
    4. Are you assisted in bathing by other people?
    5. Are there special devices or equipment that you use and find helpful?
    6. What about shaving? Do you shave as often? Or have you changed how you shave (e.g., manual razor to electric)?
    7. How do you care for you hair? Number of times washed? (e.g., barber shop or beauty shop)?

(Toileting)

  1. Are you able to get to the bathroom and use it in the same way as you did before your illness?
    1. Have your habits changed? g., are you having trouble with constipation or diarrhea?
    2. Do you need to get up more often at night?
    3. Do you need help to get up more often at night?

e.g. Does someone assist you in walking to the bathroom or in the bathroom?

  1. Do you need special equipment, such as grab-rails or a raised toilet seat, portable commode, bedpan or urinal?

(Role in the Home)

  1. Can you describe what your primary responsibilities have been in your home? Has this changed since your illness? If yes, in what ways?
    1. Who prepares the meals? If the patient does, ask if the illness has affected this
    2. Who does the shopping? If the patient does, ask if the illness has affected this
    3. Who does the laundry? If the patient does, ask if the illness has affected this
    4. Who cleans the house? If the patient does, ask if the illness has affected this
    5. Who does repairs around the house? If the patient does, ask if the illness has affected this
    6. Who does the yardwork? If the patient does, ask if the illness has affected this
    7. Who runs errands? If the patient does, ask if the illness has affected this

  1. (Work Role) Complete a, b, or c
    1. Do you work? That is , do you receive pay for the work you do? If yes:
      1. Are you presently working? What kind of work are you doing?
      2. Are there some things at work you used to do that you aren’t doing now?
    2. If you don’t work, did you stop working for pay because of your current illness? If yes:
      1. What kind of things do you do now that you think of as work (that is, things you are responsible for, such as chores around the house, volunteer or club duties)?
      2. Are there some things you used to do that you aren’t doing now?
    3. If you have never worked for pay or have not worked for pay for a considerable period of time unrelated to current illness:
      1. What kind of things have you done that you consider work (that is, things you are responsible for, such as chores—yardwork, repairs, cooking, cleaning, shopping— or volunteer work)?
      2. Are there some things you used to do that you aren’t doing now?

9.      (Recreational and Social Role)

  1. What kinds of things do you do for recreation or just for fun? What about TV
  2. Has this changed in any way since your illness?
  3. How much contact do you have with people not a part of your family and where does this occur?
  4. Do you keep in touch with your friends like you used to?
  5. Are there things you’d like to do in the way of recreation or entertainment that you aren’t doing right now?
  6. What do you do (do you plan to do) on the most recent (upcoming) major holiday?
  7. Have there been any changes in your sexual activity/ability?

  1. (Communication—Consciousness scale): Interviewer makes a judgment for this item
    1. Patient responds to interviewer in normal, coherent
    2. Patient responds to interviewer’s questions but adds much tangential or irrelevant
    3. Patient does not respond directly to interviewer; requires much prompting to elicit any answer or maintain attention.

Appendix B. Enforced Social Dependency Scale—Initial Interview Guide (Form II)

The Enforced Social Dependency Scale (ESDS) is recommended to be used with people who have recently experienced an illness, such as cancer, stroke, or heart attack. Form I should be used to evaluate the patient’s function initially after illness. If the scale is administered beyond the initial illness, Forum II should be used to evaluate the patient’s function over time. The questions need to be asked during the last week.

Instructions:

The Enforced Social Dependency Scale was developed to determine the extent to which the patient’s dependence on external sources of support has changed during illness. Dependence is defined in terms of a number of specific functional items, such as bathing and eating. Based on the questions asked in the interview, the interviewer should be able to rate how the patient is faring with respect to these functional activities on the Enforced Social Dependency Scale. To aid you in this effort, verbal descriptions of the levels of the items have been provided along with explicit definitions of how defining terms are being used. You should familiarize yourself with the levels of the Enforced Social Dependency Scale before beginning your interview.

In order to determine the appropriate location on the item codes for a particular person, a set of suggested interview questions has been provided for each scale item (with the exception of the consciousness item). The first question is general and open-ended. It may be that the patient will give enough information in response to this question that no further questions are necessary for that particular item. If this is so, simply record the information and move on to the next item. If more information is needed to make the proper determination, continue with the more detailed questions (marked “e.g.”) are given for some of the items. The general principle is this: Ask as many of the questions as necessary to determine where a patient belongs on a particular code for that item. Then record this information and move on to the next item.

In general, you should notaccept a quick answer that “everything is normal (usual).” The patient may not understand how you are using your terms. This is one reason for using the more specific questions. Consider an example: In response to your general question, a patient says that his bathing is normal (usual). After further probing, however, he reveals that he recently requires grab rails to get in and out of the tub. This might seem perfectly normal (usual) to him. This item would be coded a “3”, bathes with use of equipment, rather than a “1”, usual bathing activity, no change.

On the other hand, it may quickly become apparent to you that a particular aspect of the patient’s behavior is normal (usual). A patient who has already told you he plays tennis every day will probably not require assistance in walking (to take an extreme example). Once you have acquired a little experience with the items and codes, observation and inference may be used to reduce the number of questions asked for each item.

TO THE PATIENT:

In general, I would like to know how your present activities differ from your usual patterns prior to your illness. I’m interested in what effects your illness has had on your day-to-day living. To make sure I find out as much about this as I can, I’m going to ask you a number of specific questions about what a typical day is like for you.

(Eating)

  1. What about eating, for example? How are your present eating habits?
    1. Does it take you more time to eat during the last week?
    2. Do you eat at the same times as you used to? Do you eat in the same place (e.g., at the table)?
    3. Do people bring food to you more often?
    4. Are you able to cut your own food?
    5. Is pouring milk or coffee a problem for you?

(OPTIONAL)

Are there any special eating utensils, such as enlarged fork handles or non skid plates, that you use and find helpful?

(Dressing)

  1. What about dressing (e.g., bending to put on shoes, stretching to pull something over your head).
    1. Does it take more time to get dressed within the last week?
    2. Do you need help in putting on some of your clothes—fastening buttons, for example, or lacing your shoes?
    3. Do you wear special clothes, or use special equipment, to make dressing easier?
    4. Are there days you don/t get dressed, but wear your bed clothes? About how many days a week, would you say?

(Walking)

  1. Do you walk and get about?
    1. Does it take more time to walk somewhere? Is your walking more deliberate (i.e., cautious or careful)?
    2. Are you ever assisted in getting about?

Has the doctor restricted your walking in any way? (e.g., do you need to be accompanied when you go on walks)?

  1. Do you use special equipment to help you walk? g., Do you use a cane or a crutch?

Do you wear braces or special shoes?

Do you take elevators more than you used to?

  1. What about your travel and transportation patterns within the last week?
    1. How do you presently get to the doctor for your medical appointments?
    2. Do you drive a car or take a bus as often as you used to?
    3. What kinds of places do you drive to (or go to)?
    4. Are there places you used to drive to (or ride to), you don’t go to as often now (non- essential trips, g., going out for dinner, shopping, etc.)? within the last week?

(Bathing)

  1. How about your present bathing patterns within the last week?
    1. About how often—how many times a week—do you bathe now?
    2. How do you bathe? Of the times a week you bathe, how many are tub baths? Showers? Sponge baths?    (g., washing yourself down with a close or sponge)?
    3. Does it take you more time to bathe?
    4. Are you assisted in bathing by other people? g., Are water and equipment brought to you? Do you need help in getting in and out of the tube or shower?

Do you need help in washing hard-to-reach areas, such as your back?

  1. Are there special devices or equipment that you use and find helpful?
  2. What about shaving? Do you shave as often? Or have you changed how you shave (e.g., manual razor to electric)?
  3. How do you care for you hair? Number of times washed? (e.g., barber shop or beauty shop)?

(Toileting)

  1. What about your present bath room habits?
    1. Have your habits changed within the last week? e.g., are you having trouble with constipation or diarrhea?
    2. Do you need to get up more often at night?
    3. Do you need help to get up more often at night?

e.g. Does someone assist you in walking to the bathroom or in the bathroom?

  1. Do you need special equipment, such as grab-rails or a raised toilet seat, portable commode, bedpan or urinal?

(Role in the Home)

  1. Can you describe what your primary responsibilities have been in your home now?
    1. Who prepares the meals? If the patient does, ask if within the last
    2. Who does the shopping? If the patient does, ask if within the last
    3. Who does the laundry? If the patient does, ask if within the last
    4. Who cleans the house? If the patient does, ask if within the last

Who does repairs around the house? If the patient does, ask if within the last week.

  1. Who does the yardwork? If the patient does, ask if within the last
  2. Who runs errands? If the patient does, ask if within the last
  3. Are there some things you used to do that you are not doing now?

  1. (Work Role) Complete a, b, or c
    1. Do you work? That is, do you receive pay for the work you do? If yes:
      1. Are you presently working? What kind of work are you doing?
      2. Are there some things at work you used to do that you aren’t doing now?
    2. If you don’t work, did you stop working for pay because of your current illness? If yes:
      1. What kind of things do you do now that you think of as work (that is, things you are responsible for, such as chores around the house, volunteer or club duties)?
      2. Are there some things you used to do that you aren’t doing now?
    3. If you have never worked for pay or have not worked for pay for a considerable period of time unrelated to current illness:
      1. What kind of things have you done that you consider work (that is, things you are responsible for, such as chores—yardwork, repairs, cooking, cleaning, shopping— or volunteer work)?
      2. Are there some things you used to do that you aren’t doing now?

9.      (Recreational and Social Role)

  1. What kinds of things do you do for recreation or just for fun? What about TV
  2. What have you done within the last week?
  3. How much contact do you have with people not a part of your family within the last week, and where does this occur?
  4. Do you keep in touch with your friends?
  5. Are there things you’d like to do in the way of recreation or entertainment that you aren’t doing right now?
  6. What do you do (do you plan to do) on the most recent (upcoming) major holiday?

  1. (Communication—Consciousness scale): Interviewer makes a judgment for this item
    1. Patient responds to interviewer in normal, coherent
    2. Patient responds to interviewer’s questions but adds much tangential or irrelevant
    3. Patient does not respond directly to interviewer; requires much prompting to elicit any answer or maintain attention.

Appendix C. Coding Instructions for Enforced Social Dependency Scale (ESDS)

1. Eating/Feeding

         1           Feeds self without help of any kind—No restrictions.

         2           Feeding involves some minor pre-existing restriction (not severe enough to be coded 3-6) or some minor change since illness (also not severe enough to be coded 3-6).

         3           Feeds self with help of a device or equipment.

         4           Feeds self with help of another person or major changes in pattern of eating.

         5           Spoon fed (unable to participate).

         6           Does not eat or is tube fed.

2.  Dressing

         1           Dresses regularly in street clothes without help of any kind or use of special equipment.

         2           Dressing involves some minor pre-existing restriction (not severe enough to be coded 3-6) or some minor change since illness (also not severe enough to be coded 3-6).

         3           Dresses with help of equipment or device; loose clothing.

         4           Dresses with help of another person in street clothes or by self, but with major changes in the pattern of dressing, designed to maintain some degree of independence.

         5           Is regularly dressed in street clothes only by the help of another person, is unable to participate in dressing.

         6           Is usually not dressed in street clothes.

3.  Walking

         1           Walks without help of any kind—No restrictions.

         2           Walking involves some minor pre-existing restriction (not severe enough to be coded 3-6) or some minor change since illness (also not severe enough to be coded 3-6).

         3           Walks with help of equipment or device.

         4           Walks by self or with help of another person (s) (may include equipment or device); walking is definitely limited, e.g. only to bathroom, room to room, or to car.

         5           Does not walk, can take a few steps with help (also using equipment or person).

         6           Unable to take any steps at all (when this activity disrupts comfort).

4.  Travel

         1           Travel freely without help, drives car or takes bus—No restrictions.

         2           Travel involves some minor pre-existing restriction (not severe enough to be coded 3-6) or some minor change since illness (also not severe enough to be coded 3-6).

         3           Travel freely with help from another person. Takes a taxi, but not a bus.

         4           Takes occasional non-essential trips out of home, relies on self or requires help from another person. Major change from driving patterns.

         5           Take only necessary trips ( medically-related; grocery shopping) away from the home; relies on self or requires the help of another person.

         6           Confined to home.

5.  Bathing

         1           Bathes without any help—No restrictions.

         2           Bathes involves some minor pre-existing restriction (not severe enough to be coded 3-6) or some minor change since illness (also not severe enough to be coded 3-6).

         3           Bathes with help of equipment.

         4           Bathes with help of another person, or by self but with major changes in the pattern of bathing, designed to maintain some degree of independence.

         5           Is bathed (unable to participate except for face and hands).

         6           Is not bathed (when this activity disrupts comfort).

6.  Toileting

         1           Use toilet room without help of any kind—No restrictions.

         2           Use of toilet involves some minor pre-existing restriction (not severe enough to be coded 3-6) or some minor change since illness (also not severe enough to be coded 3-6).

         3           Use toilet room with help of another person (may include use of special equipment).

         4           Uses portable commode by self or with help of another person.

         5           Use bedpan or urinal by self or with help of another person.

         6           Incontinent, uses catheter, or uncontrolled, frequent urination (colostomy not under control).

7.  Activities in the Home

         1           Usual activities—no change in quantity or quality of activities characterizing usual household role performance.

         2           Modified activity—all activities continue as before but with some limitations in degree.

         3           Restricted activity—some activities characterizing usual household role can no longer be performed.

         4           No activity—major activities defining role are no longer being performed.

  1. Activities in the Work

8A. Work Activities for Person Employed Outside Home

         1           Usual activities—no change in quantity or quality of activities characterizing work role; continues to work.

         2           Modified activity—all activities continue as before but with some limitations in degree;

continues to work.

         3           Restricted activity—some activities characterizing work role can no longer be performed; work half as much time as before or less.

         4           No activity—major activities defining role are no longer being performed.

Note: Taking occasional time off or one to two days off each month is coded as two if work is still being done. Coded as 4 even if person continues to be paid

8B. Work-Type Activities if Forced to Retire Because of Illness

         1           Usual activities—no change in quantity or quality of activities characterizing work role.

         2           Modified activity—all activities continue as before but with some limitations in degree.

         3           Restricted activity—some activities characterizing work role can no longer be performed; work half as much time as before or less.

         4           No activity—major activities defining role are no longer being performed.

8C. Work-Type Activities for Retired Person (before illness) or Homemaker

         1           Usual activities—no change in quantity or quality of activities characterizing work role.

         2           Modified activity—all activities continue as before but with some limitations in degree.

         3           Restricted activity—some activities characterizing work role can no longer be performed; work half as much time as before or less.

         4           No activity—major activities defining role are no longer being performed.

9.  Recreational and Social Activities

         1           Usual activities—no change in quantity or quality of recreation and socializing.

         2           Modified activity—all recreational and social activities continue as before but with some limitations in degree.

         3           Restricted activity—some recreational and social activities have ceased altogether.

         4           No activity—no recreational or social activities at all.

10.  Communication

         1           Responds to interviewer in normal, coherent fashion.

         2           Responds to interviewer’s questions but adds much tangential or irrelevant information; has occasional lapses of attention or memory.

         3           Does not respond directly to interviewer, requires much prompting to elicit any answer or

maintain attention.