Assessment of Fatigue (MAF)
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 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.
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.
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
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
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.
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
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.
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
GFI Scores Across Samples
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
McNair, D., Lorr, M., & Droppleman, L. (1971). Profile
of Mood States. San Diego: Education and Industrial Testing
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
Tack (Belza), B. (1991). Dimensions and correlates of fatigue
in older adults with rheumatoid arthritis. Unpublished
doctoral dissertation, School of Nursing, University of California,
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
B. (1995). Comparison of self-reported fatigue in rheumatoid
arthritis and controls. Journal of Rheumatology, 22, 639-643.
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
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
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
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
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
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
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
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
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
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
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
KA. (1998). Maternal fatigue in breastfeeding primiparae during
the first nine weeks postpartum. Journal of Human Lactation,
14 (3), 219-229. - View
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
P. (1998). Psychometric assessment of four fatigue scales
with a sample of rural cancer patients. Journal of Nursing
Measurement, 6 (2), 111-122. - View
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.