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User's Guide
Multidimensional Assessment of Fatigue (MAF) Scale

Multidimensional Assessment of Fatigue (MAF)
User's Guide

The Multidimensional Assessment of Fatigue (MAF) scale contains 16 items and measures four dimensions of fatigue: severity (#1-2), distress (#3), degree of interference in activities of daily living (#4-14), and timing (#15-16). Fourteen items contain numerical rating scales (#1-14) and two items have multiple-choice responses (#15-16). Respondents are asked to reflect on fatigue patterns for the past week. The MAF is a revision of the Piper Fatigue Scale, a 41-item measure of fatigue developed for research purposes and tested with oncology patients (Piper, Lindsey, Paul, & Weller, 1989).

Psychometric Properties
Psychometric properties of the original MAF (using visual analog scales) were tested with 133 respondents with rheumatoid arthritis (RA) (Tack, 1991; Belza et al., 1993). Cronbach's alpha was computed for the MAF to determine internal consistency. The computed value of Cronbach's alpha was 0.93, much higher than the criterion level of .70 for newly developed instruments. To determine concurrent validity of the MAF, respondents completed the Profile of Mood States (POMS). The POMS consists of 65 items measuring a broad, diverse set of mood states (McNair, Lorr, & Droppleman, 1971). Of particular interest are the two subscales of fatigue and vigor. Pearson correlations indicated that the MAF has convergent validity with the fatigue subscale and has divergent validity with the vigor subscale.

Scales on the MAF were changed to numerical rating scales and tested in 51 patients with RA and 26 age and gender matched controls (Belza, 1995). Cronbach's alpha was 0.93. The change in the response format facilitated the scoring of the MAF, did not require interpretation of unclear markings on the VAS, and did not adversely affect the instrument's reliability. Pearson correlations indicated the MAF has concurrent validity with the POMS fatigue subscale (r=0.84; p<0.01) and divergent validity with the POMS vigor subscale (r=-0.62; p<0.01). Stability of the MAF was determined by analyzing correlations of the MAF at three time points. The stability correlation ranged from a high of 0.73 for controls at time 1 to a low of 0.47 for the controls at time 3.

Since the initial testing of the MAF by Belza in healthy controls and patients with RA, the MAF has been tested in other chronic conditions such as HIV, multiple sclerosis, and cancer, and postpartum women. Refer to the list of published studies for the psychometric properties obtained in other samples.

Strengths of the MAF
The MAF scale is a good choice when selecting an instrument to measure fatigue in chronic illness as it is: easy to administer and score, relatively short in length, and assesses the subjective aspects of fatigue including quantity, degree, distress, impact, and timing. The questionnaire allows patients to omit activity items that do not apply, thus making it a more accurate assessment of the impact of fatigue on activities of daily living (ADLs).

To yield reliable and valid responses, instructions are included on page one of the three-page instrument. The instructions read: "These questions are about fatigue and the effect of fatigue on how you have been feeling during the past week." If no fatigue is reported, If respondents answer item #1 by indicating they have not had any fatigue in the past week, then they are instructed to stop.

The MAF was originally developed in US English. Several language-versions are available at the MAPI Research Institute (Lyon, France) including Spanish for Mexico, Spanish for USA, Spanish for Spain, Dutch for Belgium, Dutch for the Netherlands, French for Belgium, French for France, Mandarin for China, Croatian for Croatia, Danish for Denmark, Finnish for Finland, Czech for the Czech Republic, German for Germany, Turkish for Turkey, Swedish for Sweden, Afrikaans for South Africa, English for South Africa, Russian for Russia, Portuguese for Portugal, Portuguese for Brazil, Polish for Poland, Italian for Italy, Hungarian for Hungary, Hebrew for Israel, and Norwegian for Norway. Both forward and backward translations were used in the translation process. To gain access to and information about a translated version contact MAPI at their website at

The MAF is self-administered. Respondents are given the questionnaire and asked to complete it. It takes less than five minutes to complete. Individuals who administer the instrument should verify respondents have answered all of the items.

Permission to Use and Copyright
There is no charge for individual use of the MAF. Colleagues in industry who would like to use the MAF may be charged a nominal fee. The MAF is copyrighted by Basia Belza.

To calculate the Global Fatigue Index (GFI): Convert item #15 to a 0-10 scale by multiplying each score by 2.5 and then sum items #1, 2, 3, average #4-14, and newly scored item #15.

Scores range from 1 (no fatigue) to 50 (severe fatigue). Do not assign a score to items #4-14 if respondent indicated they "do not do any activity for reasons other than fatigue." If respondents select no fatigue on item #1, assign a zero to items #2-16. Item #16 is not included in the Global Fatigue Index.

GFI Scores Across Samples


1. Belza, B., Henke, C., Yelin, E., Epstein, W., & Gilliss, C. (1993). Correlates of fatigue in older adults with rheumatoid arthritis. Nursing Research. 42 (2), 93-99. - View Abstract

 2. McNair, D., Lorr, M., & Droppleman, L. (1971). Profile of Mood States. San Diego: Education and Industrial Testing Service.

3. Piper, B., Lindsey, A., Dodd, M., Ferketich, S., Paul, S., & Weller, S. (1989). The development of an instrument to measure the subjective dimension of fatigue. In S. Funk, E. Tornquist, M. Champagne, & R. Wiese (Eds.). Key aspects of comfort: Management of pain, fatigue, and nausea (pp. 199-207). New York: Springer.

 4. Tack (Belza), B. (1991). Dimensions and correlates of fatigue in older adults with rheumatoid arthritis. Unpublished doctoral dissertation, School of Nursing, University of California, San Francisco.

Published Articles Referring to the MAF (through 2005)

1. Belza, B., (1994). The impact of fatigue on exercise performance. Arthritis Care and Research, 7(4), 176-180. - View Abstract

2. Belza, B. (1995). Comparison of self-reported fatigue in rheumatoid arthritis and controls. Journal of Rheumatology, 22, 639-643. - View Abstract

3. Belza, B., Henke, C., Yelin, E., Epstein, W., & Gilliss, C. (1993). Correlates of fatigue in older adults with rheumatoid arthritis. Nursing Research. 42 (2), 93-99. - View Abstract

4. Belza, B., Steele, BG., Cain, K., Coppersmith, J., Howard, J., and Lakshminarayan, S. (2005). Seattle Obstructive Lung Disease Questionnaire: sensitivity to outcomes in pulmonary rehabilitation in severe pulmonary illness. Journal of Cardiopulmonary Rehabilitation, 25(2), 107-114. - View Abstract

5. Bormann, J., Shively, M., Smith, T., & Gifford, A. (2001). Measurement of fatigue in HIV-positive adults: Reliability and validity of the Global Fatigue Index. Journal of the Association of Nurses in AIDS Care, 12 (3), 75-83. - View Abstract

6. Bouzubar, FF. (2003). Self-reported fatigue in individuals with knee osteoarthritis. Unpublished doctoral dissertation, University of Pittsburgh, 126 p. - View Abstract

7. Cella, D., Yount, S., Sorensen, M., Chartash, E., Sengupta, N., and Grober, J. (2005). Validation of the Functional Assessment of Chronic Illness Therapy Fatigue Scale relative to other instrumentation in patients with rheumatoid arthritis. Journal of Rheumatology, 32(5), 811-819. - View Abstract

8. Coppersmith, J., Steele, B., Cain, K., Belza, B., and Howard J. (2004). Strength changes in patients with COPD following pulmonary rehabilitation…37 th Annual Communicating Nursing Research Conference/ 18 th Annual WIN Assembly, “Hallmarks of Quality: Generating and Using Knowledge,” held April 22-24, 2004, Portland, Oregon. Communicating Nursing Research, 37, 347. - View Abstract

9. Dittner, AJ., Wessely, SC., and Brown, RG. (2004). The assessment of fatigue: A practical guide for clinicians and researchers. Journal of Psychosomatic Research, 56, 157-170. - View Abstract

10. Dwight, MM., Kowdley, KV., Russo, JE., Ciechanowski, PS., Larson, AM., and Katon, WJ. (2000). Depression, fatigue, and functional disability in patients with chronic hepatitis C. Journal of Psychosomatic Research, 49, 311-317. - View Abstract

11. Fox, KM., Felsenthal, G., Hebel, JR., Zimmerman, SI., and Magaziner, J. (1996). A portable neuromuscular function assessment for studying recovery from hip fracture. Archives of Physical Medicine and Rehabilitation, 77(2), 171-176. - View Abstract

12. Fraser, RT., Johnson, EK., Clemmons, DC., Getter, A., Johnson, KL., and Gibbons, L. (2003). Vocational rehabilitation in multiple sclerosis (MS): a profile of clients seeking services. WORK: A Journal of Prevention, Assessment and Rehabilitation, 21(1), 69-76. - View Abstract

13. Gerber, L., El-Gabalawy, H., Arayssi., T., Furst, G., Yarboro, C., and Schumacher, HR. (2000). Polyarticular arthritis, independent of rheumatoid factor is associated with poor functional outcome in recent onset inflammatory synovitis. Journal of Back and Musculoskeletal Rehabilitation, 14(3), 105-109. - View Abstract

14. Grady, C., Anderson, R, & Chase, GA (1998). Fatigue in HIV-infected men receiving investigational interleukin-2. Nursing Research, 47 (4), 227-234. - View Abstract

15. Jump, RL., Fifield, J., Tennen, H., Reisine, S., and Giuliano, AJ. (2004). History of affective disorder and the experience of fatigue in rheumatoid arthritis. Arthritis and Rheumatism, 51(2), 239-245. - View Abstract

16. Kaltwasser, JP., Kessler, U., Gottschalk, R., Stucki, G., and Moller, B. (2001). Effect of recombinant human erythropoietin and intravenous iron on anemia and disease activity in rheumatoid arthritis. Journal of Rheumatology, 28(11), 2430-2436. - View Abstract

17. Meek, PM., and Lareau, SC. (2003). Critical outcomes in pulmonary rehabilitation: assessment and evaluation of dyspnea and fatigue. Journal of Rehabilitation Research and Development, 40(5), 13-24. - View Abstract

18. Meek, PM., Nail, LM, Barsevick, A, Schwartz, A., Stephen, S., Whitmer, K., Beck, S.L., Jones, L.S., & Walker, B.L. (2000). Psychometric testing of fatigue instruments for use with cancer patients. Nursing Research, 49 (4), 181-190. - View Abstract

19. Morrow, GR., Hickok, JT., Roscoe, JA., Raubertas, RF., Andrews, PLR., Flynn, PJ., Hynes, HE., Banerjee, TK., Kirshner, JJ., and King, DK. (2003). Differential effects of paroxetine on fatigue and depression: a randomized, double-blind trial from the University of Rochester Cancer Center Community Clinical Oncology Program . Journal of Clinical Oncology, 21(24), 4635-4641. - View Abstract

20. Neuberger, G., Press, AN, Lindsley, HB, Hinton, R., Cagle, PE, Carlson, K, Scott, S, Dahl, J. Kramer, B. (1997). Effects of exercise on fatigue, aerobic fitness, and disease activity measures in persons with rheumatoid arthritis. Research in Nursing and Health, 20(3), 195-204. - View Abstract

21. Parker, JC., Smarr, KL., Slaughter, JR., Johnston, SK., Priesmeyer, ML., Hanson, KD., Johnson, GE., Hewett, JE., Irvin, WS., Komatireddy, GR., and Walker, SE. (2003). Management of depression in rheumatoid arthritis: a combined pharmacologic and cognitive-behavioral approach. Arthritis and Rheumatism, 49(6), 766-777. - View Abstract

22. Roscoe, JA., Morrow, GR., Hickok, JT., Bushunow, P., Matteson, S., Rakita, D., and Andrews, PL. (2002). Temporal interrelationships among fatigue, circadian rhythm and depression in breast cancer patients undergoing chemotherapy treatment. Support Care Cancer, 10(4), 329-336. - View Abstract

23. Schwartz, CE, Coulthard-Morris, L., & Zeng, Q. (1996). Psychosocial correlates of fatigue in multiple sclerosis. Archives of Physical Medicine and Rehabilitation, 77 (2), 165-170. - View Abstract

24. Schwartz, CE., Sprangers, MAG., Carey, A., and Reed, G. (2004). Exploring response shift in longitudinal data. Psychology and Health, 19(1), 51-69. - View Abstract

25. Sullivan, MD, LaCroix, AZ, Spertus, JA, & Hecht, J. (2000). Five-year prospective study of the effects of anxiety and depression in patients with coronary artery disease. American Journal of Cardiology, 86 (10), 1135-1138. - View Abstract

26. Wambach, KA. (1998). Maternal fatigue in breastfeeding primiparae during the first nine weeks postpartum. Journal of Human Lactation, 14 (3), 219-229. - View Abstract

27. Williams, P.D., Press, A., Williams, A.R., Piamjariyakul, U., Keeter, L.M., Schultz, J., Hunter, K. (1999). Fatigue in mothers of infants discharged to the home on apnea monitors. Applied Nursing Research, 12 (2), 69-77. - View Abstract

28. Winstead-Fry, P. (1998). Psychometric assessment of four fatigue scales with a sample of rural cancer patients. Journal of Nursing Measurement, 6 (2), 111-122. - View Abstract

Contact Information
The distribution of the MAF is handled by MAPI Research Trust, on behalf of Basia Belza, developer and copyright owner of the MAF. Please contact MAPI Research Trust for information, translations and permission to use: MAPI Research Trust, Lyon, France.

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