RESEARCH ARTICLE

Validity and reliability of the Traditional

Chinese version of the Multidimensional
Fatigue Inventory in general population
Li-Ling Chuang1,2,3, Yu-Fen Chuang1,2,3, Miao-Ju Hsu4,5, Ying-Zu Huang6,7,8,9, Alice M.
K. Wong3, Ya-Ju Chang1,2,9*
1 School of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, and
Healthy Ageing Research Center, Chang Gung University, Taoyuan, Taiwan, 2 Healthy Ageing Research
Center, Chang Gung University, Taoyuan, Taiwan, 3 Department of Physical Medicine and Rehabilitation,
a1111111111 Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan, 4 Department of Physical Therapy, College of
a1111111111 Health Science, Kaohsiung Medical University, Kaohsiung, Taiwan, 5 Department of Physical Medicine and
a1111111111 Rehabilitation, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, 6 Department of Neurology,
a1111111111 Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan, 7 Institute of Cognitive Neuroscience, National
a1111111111 Central University, Taoyuan, Taiwan, 8 School of Medicine, College of Medicine, Chang Gung University,
Taoyuan, Taiwan, 9 Neuroscience Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan,
Taiwan

* [email protected]

OPEN ACCESS

Citation: Chuang L-L, Chuang Y-F, Hsu M-J, Abstract

Huang Y-Z, Wong AMK, Chang Y-J (2018) Validity
and reliability of the Traditional Chinese version of
the Multidimensional Fatigue Inventory in general
Background
population. PLoS ONE 13(5): e0189850. https://
doi.org/10.1371/journal.pone.0189850 Fatigue is a common symptom in the general population and has a substantial effect on indi-
Editor: Renee Hoch, PLoS, UNITED STATES viduals’ quality of life. The Multidimensional Fatigue Inventory (MFI) has been widely used
to quantify the impact of fatigue, but no Traditional Chinese translation has yet been vali-
Received: January 19, 2017
dated. The goal of this study was to translate the MFI from English into Traditional Chinese
Accepted: April 13, 2018
(‘the MFI-TC’) and subsequently to examine its validity and reliability.
Published: May 10, 2018

Copyright: © 2018 Chuang et al. This is an open Methods

access article distributed under the terms of the
The study recruited a convenience sample of 123 people from various age groups in Taiwan.
Creative Commons Attribution License, which
permits unrestricted use, distribution, and The MFI was examined using a two-step process: (1) translation and back-translation of the
reproduction in any medium, provided the original instrument; and (2) examination of construct validity, convergent validity, internal consiste-
author and source are credited. ncy, test-retest reliability, and measurement error. The validity and reliability of the MFI-TC
Data Availability Statement: All relevant data are were assessed by factor analysis, Spearman rho correlation coefficient, Cronbach’s alpha
within the paper and its Supporting Information coefficient, intraclass correlation coefficient (ICC), minimal detectable change (MDC), and
files.
Bland-Altman analysis. All participants completed the Short-Form-36 Health Survey Taiwan
Funding: This research was supported by grants Form (SF-36-T) and the Chinese version of the Pittsburgh Sleep Quality Index (PSQI) con-
MOST-104-2314-B-182-035-MY3, 104-2314-B-
currently to test the convergent validity of the MFI-TC. Test-retest reliability was assessed by
182-007-MY3, and 106-2218-E-182-003 from the
Ministry of Science and Technology, Taiwan; grant readministration of the MFI-TC after a 1-week interval.
EMRPD1G0241 from Healthy Ageing Research
Center at Chang Gung University, and grants Results
CMRPD1G0621, CMRPD1C0301, CMRPD1D0241,
CMRPD1E0371 and CMRPD3E0113 from Chang Factor analysis confirmed the four dimensions of fatigue: general/physical fatigue, reduced
Gung Memorial Hospital, Linkou, Taiwan. The activity, reduced motivation, and mental fatigue. A four-factor model was extracted, combining

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 Validity and reliability of Multidimensional Fatigue Inventory in general population

funders had no role in study design, data collection general fatigue and physical fatigue as one factor. The results demonstrated moderate con-
and analysis, decision to publish, or preparation of vergent validity when correlating fatigue (MFI-TC) with quality of life (SF-36-T) and sleep dis-
the manuscript.
turbances (PSQI) (Spearman’s rho = 0.68 and 0.47, respectively). Cronbach’s alpha for the
Competing interests: The authors have declared MFI-TC total scale and subscales ranged from 0.73 (mental fatigue subscale) to 0.92 (MFI-TC
that no competing interests exist.
total scale). ICCs ranged from 0.85 (reduced motivation) to 0.94 (MFI-TC total scale), and the
MDC ranged from 2.33 points (mental fatigue) to 9.5 points (MFI-TC total scale). The Bland-
Altman analyses showed no significant systematic bias between the repeated assessments.

Conclusions
The results support the use of the Traditional Chinese version of the MFI as a comprehen-
sive instrument for measuring specific aspects of fatigue. Clinicians and researchers should
consider interpreting general fatigue and physical fatigue as one subscale when measuring
fatigue in Traditional Chinese-speaking populations.

Introduction
Fatigue is a common and frequently distressing symptom in the general population [1–3] and
among patient populations such as cancer, rheumatoid arthritis, and stroke [4–7]. It has been
shown to have a substantial impact on individuals’ quality of life [8]. Fatigue in healthy people
is usually temporary and is conceptualized as a consequence of physical or mental exertion
[7,9]. Most individuals experience fatigue after inadequate sleep or rest, after the exertion of
physical activity, after mental effort, or when they lack the motivation to initiate activities.
Defining fatigue is difficult because it is a complex and multidimensional concept, compris-
ing physiological, emotional, and mental aspects [10]. Aaronson and colleagues [11] defined
fatigue as “the awareness of a decreased capacity for physical and/or mental activity due to an
imbalance in the availability, utilization, and/or restoration of resources needed to perform
activity.” Physiological fatigue is generally caused by excessive energy consumption, depletion
of essential substrates of physiological functioning, and/or a diminished ability to contract
muscles. Psychological fatigue is defined as “a state of weariness related to reduced motivation,
prolonged mental activity, or boredom that occurs in situations such as chronic stress, anxiety
or depression [12].”
Comparisons between fatigue and similar concepts from well-known questionnaires have
not been done in empirical studies. However, the content of the vitality subscale of the Short
Form-36 Health Survey (SF-36) is closely related to general fatigue [13]. Sleep disturbances
have also been shown to induce self-reported fatigue in patients with rheumatoid arthritis [14]
and traumatic brain injury [15] and in spouse caregivers of cancer patients [16]. Fatigue due to
sleep deprivation may place individuals at increased risk for injuries, degraded health, and
impaired physical and mental performance [17].
Because of its high prevalence and increasingly acknowledged negative effect on individu-
als’ well-being, fatigue has become an important topic of research. Such research is important
for the development of cultural adaptations of measures of fatigue, for early detection of fatigue
severity, and for the interpretation of the levels of fatigue found in general and patient popula-
tions. A comprehensive instrument with good psychometric properties for measuring specific
aspects of fatigue is needed to identify individuals with fatigue.
Instruments available to assess fatigue can be divided into one-dimensional instruments
and multidimensional instruments. Clinicians usually evaluate fatigue severity of the patients
based on a self-reporting scale, such as the Numerical Rating Scale [18], Visual Analogue Scale

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 Validity and reliability of Multidimensional Fatigue Inventory in general population

[19], and the Brief Fatigue Inventory [20]. However, these scales take a one-dimensional app-
roach to the concept of fatigue. In so doing, they cannot comprehensively represent the multi-
dimensional nature of fatigue in the general population, and they impose several limitations
on research results and subsequent interpretations [21]. In contrast, multidimensional mea-
sures of fatigue allow a comprehensive assessment of subjects’ perceptions and a detailed pic-
ture of subjects’ fatigue in both physical and mental dimensions. Multidimensional
instruments permit the exploration of the structure of a patient’s perception of fatigue [21].
A good example of the multidimensional approach of fatigue instrument is the Multidimen-
sional Fatigue Inventory (MFI). The MFI is based on the definition of fatigue given above and is
an easy-to-administer scale [22]. The original MFI assesses 5 dimensions of fatigue: general
fatigue, physical fatigue, mental fatigue, reduced activity, and reduced motivation [23]. The MFI
has been widely used to measure fatigue, not only in the general population [24–26], but also in
cancer patients [22,27,28], individuals with chronic fatigue syndrome [22], fibromyalgia patients
[29], and patients with Parkinson’s disease [30]. A previous study evaluated the internal consis-
tency of the MFI and found that the Cronbach’s α coefficient of the subscales of the MFI ranged
from 0.53–0.93. Construct and convergent validity was established via correlations with a Visual
Analogue Scale measuring fatigue (r ranges = 0.22–0.78) [22]. The MFI is a psychometrically
appropriate instrument for the evaluation of fatigue in patient populations, with high internal
consistency and high validity [22,31]. Despite the wide acceptance of the MFI worldwide, trans-
lation and cross-cultural adaptation to a Traditional Chinese version has not previously been
reported. Given the high prevalence rate of fatigue in Taiwan [32] and the importance of having
questionnaires in the native language of the subjects, there is an urgent need to generate a cul-
tural adaptation of fatigue measure that is appropriate for the general population of Taiwan.
Development of a Traditional Chinese version of the MFI will allow better standardizing of clin-
ical practice for early detection of fatigue severity and allow health professionals treating specific
aspects of fatigue symptom with a globally accepted outcome measure. It is important to investi-
gate the reliability and validity of the Traditional Chinese version of the MFI (MFI-TC) in Tai-
wanese population to assess whether the MFI-TC could be a complementary screening tool in
population with fatigue symptom.
Factors that may influence individuals’ perception of fatigue such as ethics and values result
in the challenges of fatigue measure [21]. In addition, cultural issues and language peculiarities
can affect the process of fatigue assessment. The MFI has been translated into French, Hindi,
Polish, Simple Chinese, Swedish, and Spanish [27–29,33–36] to quantify fatigue severity, but
no Traditional Chinese translation has yet been validated to evaluate fatigue status in the gen-
eral population of Taiwan. In addition, although the reliability and validity of the MFI in can-
cer patients were described in previous studies by Smets [22,31], no psychometric evaluation
of the MFI in a general population has been reported. The need for reference data from the
general population of Taiwan and for psychometric testing of the MFI-TC was the main rea-
son for this study. Therefore, the aims of this study were (a) to translate the English version of
the MFI into Traditional Chinese, (b) to examine the psychometric properties (construct valid-
ity, convergent validity, internal consistency, test-retest reliability, and measurement error) of
the MFI-TC to establish its utility in Taiwanese clinical and research practice.

Materials and methods

Participants
The required sample size was estimated to be at least 100 by the G-Power program, with an
alpha of 0.05, a power of 0.80 and a moderate correlation of 0.5. A preferable sample of more
than 100 observations is required for factor analysis [37].With a desired ratio of 5 observations

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 Validity and reliability of Multidimensional Fatigue Inventory in general population

per variable, a sample of more than 100 observations is required for the 20 items of the MFI-TC.
This study adopted a cross-sectional research method with convenient sampling. Some princi-
ples for sampling were as follows: First, our survey targeted relevant people in one university and
one association. Second, institutions willing to cooperate with the researchers were eligible for
this study. Furthermore, all potential subjects were requested to complete a self-reported ques-
tionnaire to assess their general health conditions, including physical and psychological health
for eligible screening. Perceived physical and mental health was measured by the following single
question, respectively: “How would you rate your overall physical/mental health at the present
time?” The answer was a dichotomous “healthy” or “unhealthy.” Among the eligible healthy sub-
jects, 150 citizens agreed to take part voluntarily in the study and 123 of the participants (resp-
onse rate = 82%) completed all of the questionnaires on both occasions, which were usable for
analysis. The participants included students, faculty, staff, and family members from Chang
Gung University (CGU) and Young Women’s Christian Association of Taiwan (YWCA) in two
metropolitan cities in Taiwan (one in Taiyuan, one in Taipei). The inclusion criteria for partici-
pants were: (1) aged 20 years or above; (2) volunteers in good physical, cognitive and mental
health, per self-report; and (3) capable of speaking and reading Chinese. The exclusion criteria
were: (1) participation in any experimental or drug studies during the study period; (2) treat-
ment of fatigue; and (3) severe cognitive deficits. The study was conducted according to the
Declaration of Helsinki and was approved by the Institutional Review Board of Chang Gung
Memorial Hospital (IRB serial number: 104-0704B). All participants provided written informed
consent and were informed of the study’s purpose, the process, and their right to withdraw from
the study at any time.

Procedures
The study was carried out from March 2015 to August 2015. The number of clinical trial regis-
tration is NCT02596139. The development of a Traditional Chinese version of the MFI was fol-
lowed the internationally accepted guideline for the cultural adaptation of a self-reporting
questionnaire by Beaton et al [38]. The MFI was examined in a two-step process: (1) translation
and back translation; and (2) testing for validity and reliability of the formal MFI-TC. The
English version of the MFI was initially translated into the first Traditional Chinese version by
one bilingual translator after obtaining approval from the original developer. Eight experts in
the areas of physical therapy, sports medicine, questionnaire design, and fatigue were asked to
rate the 20 items’ translation accuracy, relevance, and expression fluency on a 5 point-Likert
scale (1 = very inappropriate, 5 = very appropriate). This process ensured that the words used in
the Traditional Chinese translation meant the same thing as the words used in English to des-
cribe aspects of fatigue. The content validity index was used to estimate the validity of the items
[39] and quantify the extent of agreement between the experts [40]. The terminology and con-
tent of the first MFI-TC were revised based on the experts’ opinions and cultural concerns. An
authorized native US-English-speaking translator was asked to blindly back-translate from the
modified Traditional Chinese version into the English version to check its equivalence to the
original English version. The use of bilinguals and pretesting was a complement to the back-
translation technique for assessing and validating a translation [41]. The administration of the
questionnaire instrument in both the original English and the modified MFI-TC version to
bilingual participants was used to compare their responses to the two versions. Sixty-six bilin-
gual adults were recruited to complete the original English MFI first and the modified MFI-TC
version 30 minutes later to test the reliability and concurrent validity of the translation. The
translation reliability and concurrent validity of the modified MFI-TC version were assessed by
intra-class correlation coefficient (ICC) and Spearman correlation coefficient between the

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 Validity and reliability of Multidimensional Fatigue Inventory in general population

scores of the original English MFI and the modified MFI-TC. The results showed that there
were good reliability and concurrent validity of the translation with the value of ICC for total
fatigue score: 0.91; and Spearman correlation coefficient (ρ): 0.86 (S1 Table). This ensured that
a consistency in the content between the source and target versions of the MFI. The possible
limitation of short time intervals (having the same participants complete the two versions 30
minutes apart from one another) is a greater potential for carry-over or recall effects, which will
likely overestimate the reliability of the instrument. Based on the results of reliability, validity,
and the back translation, the formal Traditional Chinese version of the MFI (MFI-TC) was gen-
erated. It should be noted that it does not address the construct validity and test-retest reliability
that are critical to describe a successful cross-cultural adaptation.
For determining test-retest reliability, the MFI-TC was assessed twice with a 1-week interval
to reduce the memory effect of the first assessment, and at the same time of day to minimize
diurnal variation in fatigue. The participants were asked to complete the questionnaires on 2
separate occasions. The initial questionnaires were completed at the time of recruitment and
the second set of the MFI-TC was provided in a reply-paid envelope, and participants were
asked to complete questionnaire at home and return it with a week apart. Convergent validity
of the fatigue measures with the Short-Form-36 Health Survey Taiwan Form (SF-36-T) [21,42]
and with the Chinese version of the PSQI [43] was commonly tested in previous validation of
the fatigue study. We visited participants in classrooms and offices at CGU and YWCA, exp-
lained the study purpose and procedure, and received informed consent from them. Those
who agreed to participate in the study completed the MFI-TC, SF-36-T, and the Chinese ver-
sion of the Pittsburgh Sleep Quality Index (PSQI) questionnaires at that time and received
retest of the MFI-TC 1 week later.

Outcome measures
The MFI-TC. Fatigue was measured by the MFI-TC, consisting of a 20-item self-report
scale originally designed to evaluate 5 dimensions of fatigue (general fatigue, physical fatigue,
reduced activity, reduced motivation, and mental fatigue) [22]. Subjects used a Likert scale
ranging from 1 (strongly agree) to 5 (strongly disagree) to indicate how aptly certain state-
ments regarding fatigue represented their experiences. Ten positively phrased items (item 2, 5,
9, 10, 13, 14, 16, 17, 18, 19) were reverse-scored before adding up scores. The total score obt-
ained simply by adding 20-item scores together (i.e., 20–100), with higher scores indicating
more fatigue.
The SF-36-T. We used the well-validated, self-administered SF-36-T questionnaire to
document health-related quality of life. The SF-36-T has 36 questions examining 8 dimensions
of the participant’s general health, including physical functioning, physical roles, bodily pain,
general health, vitality, social functioning, emotional roles, and mental health. Its creators have
also developed algorithms to calculate two psychometrically based summary measures: a phys-
ical and a mental component summary score [44]. A high total score means a good quality of
life. The Cronbach’s alpha of the SF-36-T is between 0.84–0.88 [45]. It also has good construct
validity and content validity [46,47].
The Chinese version of the PSQI. The severity of sleep disturbance was evaluated by the
Chinese version of the PSQI, a widely used, self-report questionnaire that assesses sleep quality
during the previous month [48,49]. The Chinese version of the PSQI consists of 19 self-rated
questions and 5 questions rated by the bed partner or roommate. The 19 items are grouped
into 7 component scores, each weighted equally on a 0–3 scale. The 7 components are subjec-
tive sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use
of sleeping medications, and daytime dysfunction. The component scores are summed to yield

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 Validity and reliability of Multidimensional Fatigue Inventory in general population

a global PSQI score, which has a range of 0–21. Higher scores indicate worse sleep quality [48].
The validity of the Chinese version of the PSQI has been supported in cancer patients [50].

Data analysis
All data of the MFI-TC, SF-36, and PSQI are provided in the supplementary materials (S1 Data-
set). The construct validity, criterion validity, internal consistency, test-retest reliability, and
measurement error of the formal MFI-TC were computed. The construct validity of the
MFI-TC was tested by factor analysis (exploratory factor analysis) (IBM SPSS Statistics version
20, IBM Corp, Armonk, NY). A Principal Components Analysis (PCA) was used to extract fac-
tors. As correlations between factors were expected, the obtained factors were rotated obliquely
using the direct oblimin procedure. A minimal eigenvalue of 1 was specified as an extraction
criterion and the criterion for factor loading was set at >0.40. The existing names of the MFI
subscales were used to label the extracted factors [22]. Data from the first measurement were
used for analysis.
The convergent validity of the MFI-TC was examined by calculating the Spearman correla-
tion coefficients between the scores of the MFI-TC and the SF-36-T and between the scores of
the MFI-TC and the PSQI. To offset the effect of multiple correlations and avoid the increased
chance of a type I error, the statistical significance level of correlation coefficients was adjusted
by Bonferroni’s correction [51]. The significance level of coefficients is indicated only when
they reach the 0.001 criterion. The following cutoffs were used to define the magnitude of the
correlation coefficients: <0.25, low correlation; 0.25 to 0.5, fair correlation; 0.5 to 0.75, moder-
ate-to-good correlation; and >0.75, good-to-excellent correlation [51].
The examination of reliability of the MFI-TC included tests for internal consistency, test-
retest reliability, and measurement error. Internal consistency is the degree of the interrelated-
ness among scale items measuring a homogeneous construct or characteristic. Internal consis-
tency of the MFI-TC was assessed by calculating Cronbach’s alpha coefficient for the total
scale and for all subscales separately at the first measurement. A Cronbach’s alpha coefficient
>0.7 implies good internal consistency of a scale [51]. Test-retest reliability over a 1-week
interval was determined by computing the intra-class correlation coefficient (ICC) for both
the total and subscale scores on the MFI-TC at the initial and subsequent administrations
using a 2-way mixed-effect model with an agreement coefficient [52]. ICCs that exceed 0.75
indicate good reliability [51]. We used the standard error of measurement (SEM), the minimal
detectable change (MDC), and Bland-Altman analyses to quantify measurement error. The
SEM indicates within-subject variability in repeated measures for a group of individuals [53].
The MDC95 is the smallest change necessary to exceed the measurement error of repeated
measures that indicates a real change at the 95% confidence interval (CI) level for a single indi-
vidual [53,54]. Bland-Altman analyses were used to indicate systematic bias between repeated
measurements. The Bland-Altman plot illustrates the agreement between the 2 test occasions
(time 1 and time 2) and identifies possible outliers. The 95% CI of the mean difference was
used to determine systematic bias. If zero is included within the 95% CI, no significant system-
atic bias between measurements can be inferred. The 95% limit of agreement (LOA) was used
to examine the natural variation over time, with a narrow LOA indicating higher stability
[55,56].

Results
A total of 123 subjects (43 males and 80 females) were enrolled in this study (Table 1). The
average age was 46.12 years (range 20–87) for 121subjects due to 2 missing age information.
The average total score of the MFI-TC at the first and second assessment was 47.28 and 46.85,

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 Validity and reliability of Multidimensional Fatigue Inventory in general population

Table 1. Characteristics of the participants (n = 123).

Characteristic All participants (n = 123) Males (n = 43) Females (n = 80) p-value
Age a 46.12 (18.40) 43.02 (16.99) 47.82 (19.02) 0.17
Gender
Male 43 (35%) 43 (35%)
Female 80 (65%) 80 (65%)
Level of education a 0.29
1–6 years 5 (4%) 1 (2%) 4 (5%)
7–9 years 6 (5%) 0 (0%) 6 (8%)
10–12 years 19 (15%) 6 (14%) 13 (18%)
13–16 years 61 (50%) 25 (58%) 36 (49%)
17 years or more 26 (21%) 11 (26%) 15 (20%)
First assessment of the MFI-TC
Total score 47.28 (13.65) 44.02 (13.92) 49.03 (13.26) 0.052
Subscales
General/Physical Fatigue 18.10 (6.35) 16.67 (6.16) 18.86 (6.35) 0.07
Reduced Activity 12.33 (3.96) 11.47 (4.58) 12.79 (3.52) 0.08
Reduced Motivation 10.31 (3.76) 9.72 (3.74) 10.63 (3.76) 0.21
Mental Fatigue 6.54 (2.43) 6.16 (2.63) 6.75 (2.30) 0.20
Second assessment of the MFI-TC
Total score 46.85 (14.41) 43.88 (14.09) 48.49 (14.25) 0.09
Subscales
General/Physical Fatigue 17.58 (6.45) 16.42 (6.34) 18.20 (6.47) 0.15
Reduced Activity 12.12 (3.94) 11.37 (4.26) 12.53 (3.73) 0.12
Reduced Motivation 10.46 (3.82) 10.07 (4.00) 10.68 (3.73) 0.40
Mental Fatigue 6.68 (2.44) 6.09 (2.23) 7.00 (2.51) 0.049
SF-36-T total score 597.86 (139.66) 635.62 (124.85) 577.57 (143.67) 0.03
PSQI total score 5.81 (2.96) 5.30 (2.78) 6.09 (3.03) 0.16

Data are reported as number of participants (%), mean (SD). Abbreviation: SD, standard deviation; MFI-TC: Traditional Chinese version of the Multidimensional
Fatigue Inventory; SF-36-T: Short-Form-36 Health Survey Taiwan Form (SF-36-T); PSQI: Pittsburgh Sleep Quality Index.
a
: 2 subjects did not provide age information and 6 subjects did not provide education information.

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respectively. The average total score of the SF-36-T was 597.86 and that of the PSQI was 5.81.
The gender issue has been addressed in previous studies of the MFI [24,42] and showed pri-
marily female participants. In this study, roughly twice as many females as males were included
due to more female volunteers and more uncompleted questionnaire response by males. We
compared the data of male and female participants and showed that there was no significant
difference in age, education level, total score of the PSQI, and total score and subscales of the
MFI-TC between male and female participants (p >0.05) except for the mental fatigue subscale
score at retest (p = 0.049).

Construct validity of the formal MFI-TC

The results of the PCA are presented in Table 2. Four factors were extracted. The first factor
was interpreted as a combination of the general fatigue and physical fatigue dimensions and
the other 3 factors as the reduced activity, reduced motivation, and mental fatigue dimensions.
All 20 items had a unique loading of >0.40 on 1 of the 4 factors in the pattern matrix. The Kai-
ser-Meyer-Olikin (KMO) value and Bartlett’s test of sphericity were used to gain an under-
standing of the appropriateness of factor extraction. Factor extraction was done by PCA,

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 Validity and reliability of Multidimensional Fatigue Inventory in general population

Table 2. Factor analysis of the MFI-TC.

Item Traditional Chinese version Factor loading Variance (%) Eigenvalue
Factor 1. General Fatigue/Physical Fatigue 41.99 8.40
1 我覺得我的體能很好。 0.68
2 體力上我覺得我只能做一點點事情。 0.43
5 我覺得我疲倦。 0.75
12 我的休息是充分的。 0.76
14 在體能上,我覺得我處在一個很糟的狀態。 0.56
16 我很容易感到疲倦。 0.73
20 在體能上,我覺得我處在一個很好的狀態。 0.65
Factor 2. Reduced Activity 11.16 2.23
3 我覺得我很活躍。 0.71
4 我覺得我想去做所有美好的事情。 0.54
6 我認為我一天能做許多事情。 0.64
8 我的體力可以讓我從事許多事情。 0.66
15 我有許多的計畫。 0.75
Factor 3. Reduced Motivation 7.00 1.40
9 我對要去處理事情感到畏懼。 0.68
10 我認為我一天只能做一點點事情。 0.63
17 我只能完成一點事情。 0.64
18 我不喜歡做任何事情。 0.77
19 我很容易恍神。 0.61
Factor 4. Mental Fatigue 5.43 1.09
7 當我在做事情時,我能專心於那件事情上。 0.82
11 我可以很專心。 0.70
13 我需要很努力才能專心在事情上。 0.70
Total variance (%) 65.58
Kaiser-Meyer-Olkin (Bartlett’s Test of 0.89 (p < 0.001)
Sphericity)

MFI-TC: Traditional Chinese version of the Multidimensional Fatigue Inventory. MFI: MULTIDIMENSIONAL FATIGUE INVENTORY. Refer to Smets et al. (1995)
and Elbers et al. (2012) for the original/ English text

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which involves varimax rotation and an eigenvalue larger than 1. The results showed that the
KMO value was 0.89 (>0.80), and the result of Bartlett’s test was 1420.30 (p<0.001), which
was suitable for factor analysis [57].
Four factors were extracted, and the total variance explained was 65.58% (Table 2). This
result was confirmed by a scree plot that demonstrated marked discontinuity after the fourth
factor (S1 Fig). The 4 factors were: (1) general/physical fatigue, including 7 items that exp-
lained 41.99% of the variance; (2) reduced activity, which included 5 items that explained
11.16% of the variance; (3) reduced motivation, which included 5 items that explained 7.00%
of the variance; and (4) mental fatigue, which included 3 items that explained 5.43% of the var-
iance (Table 2).
Six items loaded on other factors compared to the original MFI subscales [22]. Item 8 (“Phys-
ically I can take on a lot”) loaded on factor 2 (reduced activity) instead of the physical fatigue
subscale. Item 4 (“I feel like doing all sorts of nice things”) and item 15 (“I have a lot of plans”)
loaded on factor 2 (reduced activity) instead of the reduced motivation subscale. Item 10 (“I
think I do very little in a day”) and item 17 (“I get little done”) loaded on factor 3 (reduced moti-
vation) instead of the reduced activity subscale. Item 19 (“My thoughts easily wander”) loaded
on factor 3 (reduced motivation) instead of the mental fatigue subscale.

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 Validity and reliability of Multidimensional Fatigue Inventory in general population

The factor loadings ranged from 0.43 to 0.82, representing the actual correlation between
each item and the factor scores (Table 2). The factor correlation matrix shows fair to good cor-
relations between factors (ρ = 0.36 to 0.68). Factor correlations between general/physical
fatigue, reduced activity, reduced motivation, and mental fatigue and the MFI-TC total scores
were 0.91, 0.81, 0.86, and 0.68, respectively (Table 3).

Convergent validity of the formal MFI-TC

The convergent validity of the MFI-TC was evaluated by calculating Spearman correlation
coefficients between the SF-36-T and the MFI-TC and between the PSQI and the MFI-TC.
The results showed that all the subscales and the total fatigue score of the MFI-TC were signifi-
cantly and negatively correlated with the total score of the SF-36-T, ranging from -0.42 to -0.69
(Table 4). The correlation coefficients between the subscales of the MFI-TC and the 8 dimen-
sions of the SF-36-T are shown in Table 4. The MFI-TC was significantly correlated with all 8
dimensions of the global quality-of-life scale of the SF-36-T. The MFI-TC total score correlated
to a higher degree with the general health, vitality, and mental health domains than with the
other domains of the SF-36-T (Spearman’s rho = -0.67 for general health, Spearman’s rho =
-0.75 for vitality, and Spearman’s rho = -0.71 for mental health). It can be seen from Table 4
that general/physical fatigue of the MFI-TC, as well as reduced activity, also had significantly
higher correlations with the general health, vitality, and mental health dimensions of the SF-
36-T (Spearman’s rho = -0.72, -0.75, and -0.69, respectively, for general/physical fatigue; Spear-
man’s rho = -0.57, -0.62, and -0.53, respectively, for reduced activity). In addition, the reduced
motivation and mental fatigue domains of the MFI-TC were significantly correlated with each
domain of the mental component of the SF-36-T (respectively, Spearman’s rho = -0.55 and
-0.40 for vitality, -0.44 and -0.37 for social functioning, -0.37 and -0.45 for emotional roles,
and -0.57 and -0.48 for mental health). All p-values are less than 0.0001 except for absolute cor-
relations coefficient of less than 0.30.
The MFI-TC total score and subscale scores were also significantly positively correlated
with the PSQI, ranging from 0.26 to 0.47. All p-values are less than 0.0001 except for correla-
tion between Mental Fatigue and PSQI Total score (Spearman’s rho = 0.004).

Reliability of the MFI-TC

The Cronbach’s alpha coefficient was 0.92 for the total scale score of the MFI-TC, 0.89 for gen-
eral/physical fatigue, 0.80 for reduced activity, 0.83 for reduced motivation, and 0.73 for men-
tal fatigue (Table 5). Cronbach’s alpha coefficients indicated that the MFI-TC has a satisfactory
internal consistency. The ICC rating was 0.94 for the total fatigue score, 0.93 for the general/

Table 3. Correlations between subscales and the total score of the MFI-TC.
General/Physical Fatigue Reduced Activity Reduced Motivation Mental Fatigue
MFI-TC Total score 0.91 0.81 0.86 0.68
MFI-TC subscales
General/Physical Fatigue - 0.68 0.62 0.51
Reduced Activity 0.68 - 0.54 0.36
Reduced Motivation 0.62 0.54 - 0.63
Mental Fatigue 0.51 0.36 0.63 -

Expressed as Spearman rho correlation coefficient. Absolute correlation coefficients of 0.5 to 0.75 are considered moderate-to-good correlation, in bold; > 0.75 are
good-to-excellent correlation [43], in bold. MFI-TC: Traditional Chinese version of the Multidimensional Fatigue Inventory. All p-values are less than 0.0001.

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 Validity and reliability of Multidimensional Fatigue Inventory in general population

Table 4. Correlations between fatigue, quality of life, and quality of sleep.

MFI-TC SF-36-T PSQI
Physical component Mental component Total Total
Physical Physical Bodily General Vitality Social Emotional Mental score score
functioning roles pain health functioning roles health
Total Fatigue Score -0.33 -0.39 -0.26 -0.67 -0.75 -0.55 -0.45 -0.71 -0.68 0.47
General/Physical -0.37 -0.36 -0.28 -0.72 -0.75 -0.55 -0.42 -0.69 -0.69 0.46
Fatigue
Reduced Activity -0.31 -0.29 -0.14 -0.57 -0.62 -0.38 -0.25 -0.53 -0.52 0.36
Reduced -0.22 -0.29 -0.17 -0.47 -0.55 -0.44 -0.37 -0.57 -0.50 0.36
Motivation
Mental Fatigue -0.07 -0.30 -0.19 -0.33 -0.40 -0.37 -0.45 -0.48 -0.42 0.26

Expressed as Spearman rho correlation coefficient. Absolute correlation coefficients of <0.25 are considered low correlation; 0.25 to 0.5 are fair correlation; 0.5 to 0.75
are moderate-to-good correlation, in bold; > 0.75 are good-to-excellent correlation [43]. All p-values are less than 0.0001 except for absolute correlations coefficient of
less than 0.30.

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physical fatigue subscale, 0.87 for the reduced activity subscale, 0.85 for the reduced motivation
subscale, and 0.88 for the mental fatigue subscale. The SEM and MDC95 for the total fatigue
score and subscales of the MFI-TC were within acceptable ranges (Total score: 3.43 and 9.50
points; general/physical fatigue: 1.69 and 4.68 points; reduced activity: 1.42 and 3.93 points;
reduced motivation: 1.47 and 4.07 points; mental fatigue: 0.84 and 2.33 points). The Bland-Alt-
man analyses showed no significant systematic bias between the repeated measurements. The
four outliers were out of the 95% limits of agreement for the mean difference. A narrow range
of the LOA was shown on the Bland-Altman plot, indicating the MFI-TC had high stability
and low variation between the 2 test occasions (Fig 1).

Discussion
This study provides evidence of the validity and test-retest reliability of the MFI-TC in quanti-
fying fatigue in the general population. Factor analysis demonstrated that MFI-TC comprises
4 major factors, and the convergent validity of the MFI-TC was good. The reliability of the
MFI-TC showed good test-retest reliability, with high agreement, small measurement error,

Table 5. Reliability (internal consistency, test-retest, and measurement error) of the total score and four subscales of the MFI-TC in healthy adults (n = 123).
Reliability Measurement error
MFI-TC Internal consistency (Cronbach’s alpha) Test-retest reliability SEM MDC95 LOA
ICC (95% CI)
Total Fatigue Score 0.92 0.94 (0.91–0.95) 3.43 9.50 -14.05 to 13.19
General/Physical Fatigue 0.89 0.93 (0.90–0.95) 1.69 4.68 -7.01 to 5.97
Reduced Activity 0.80 0.87 (0.82–0.91) 1.42 3.93 -5.45 to 5.05
Reduced Motivation 0.83 0.85 (0.79–0.90) 1.47 4.07 -5.54 to 5.24
Mental Fatigue 0.73 0.88 (0.82–0.91) 0.84 2.33 -3.32 to 3.04

MFI, Multidimensional Fatigue Inventory; 95% CI, 95% confidence interval; ICC, intraclass correlation coefficient; SEM, standard error of measurement = SDpooled ×
p
(1 − ICC)], where SDpooled is the standard deviation for all observations from test occasions 1 and 2; MDC95, minimal detectable change at the 95% CI level = 1.96 ×
p p p p
2 × SEM = 1.96 × 2 × SDpooled × (1 − ICC)], where 1.96 is the 2-tailed tabled z value for the 95% CI and 2 represents the variance of 2 measures; LOA, limits of
agreement = d ± 1.96 SDdiff, where d is the mean difference between the two test sessions (test session 2 minus test session 1) and SDdiff is the standard deviation of the
mean difference.

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 Validity and reliability of Multidimensional Fatigue Inventory in general population

Fig 1. Bland-Altman plot of the total fatigue score of the MFI-TC. The plot illustrates the agreement between time 1 and
time 2 and identifies possible outliers. Each subject is represented on the graph by conveying the mean value of the 2
assessments (x-axis) and the difference between the 2 assessments (y-axis). The mean difference was the estimated bias, and
the standard deviation (SD) of the differences measured the fluctuations around this mean (outliers being above 1.96 SDdiff).
The reference lines show the mean difference between time 1 and time 2 (solid line), and the 95% limits of agreement for the
mean difference (broken lines).
https://doi.org/10.1371/journal.pone.0189850.g001

and no systematic bias for the assessment of adult populations. These findings suggest that the
results of the MFI-TC are valid and reliable for assessing fatigue in the general population.
With respect to construct validity, the results of factor analysis of the MFI-TC in the general
population demonstrated the four-factor structure. General fatigue and physical fatigue could
not be distinguished in the Traditional Chinese version of the MFI as one subscale measuring
physical aspects of fatigue. A scree plot of the MFI-TC data from the general population showed
that the Traditional Chinese version of the MFI retrieved 4 factors, the same as reported in pa-
tients with idiopathic Parkinson’s disease [58], but different from the 5 factors reported in a US
adult population [42] and the 3 factors reported in Chinese patients with cancer [27] and Polish-
speaking patients with cancer [35]. The five-factor structure of the original MFI showed that fac-
tors were highly correlated and some items might have loaded on more than one factor [22]. The
different number of factors found in this study was possibly related to differences in the transla-
tion of the items, study sample, and cultural experience. The translation of the items of general
fatigue subscale loaded physical fatigue factor due to related physical fitness. General and physical
aspects of fatigue have likewise not been separated. Therefore, when subjects rated their physical
fitness on fatigue, people with low level of physical fitness were more associated with increased
fatigue. That is why the items of general fatigue subscale had a significant tendency to assess

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 Validity and reliability of Multidimensional Fatigue Inventory in general population

physical fatigue in a Taiwanese population. The 5 factors in the study by Lin et al. were physical
fatigue, mental fatigue, reduced activity, general fatigue, and reduced motivation [42]. These 5
factors explained 20.10%, 15.18%, 14.10%, 13.40%, and 6.87%, respectively, of the variance in the
20 items of the MFI. The PCA of the current study showed that the combined general/physical
fatigue factor extracted 41.99% of the variance, which was more than 33.50% reported for the
combined physical and general fatigue factors in the study by Lin et al. [42]. This finding may
indicate that the MFI-TC has higher construct validity in a Taiwanese adult population than in a
US adult population. The study participants in Lin et al. included not only well people, but also
people with chronic fatigue syndrome-like illness with severe fatigue lasting more than 6 months
and people with chronic unwellness with or without fatigue. This may explain the increased fac-
torial complexity in the US adult population sample. Moreover, compared with the 4 factors in
this study, only 3 factors of spiritual fatigue, mental fatigue, and physical fatigue were observed
for the Simple Chinese version of the MFI [27] and 3 dimensions of physical fatigue, mental
fatigue, and reduced motivation were found in the Polish version of the MFI [35]. Probable rea-
sons for the divergent responses might be that some items focus on the experience of fatigue and
other items are concerned with the consequences of fatigue. Fatigue items are not only related to
tiredness, weakness, exhaustion of strength after physical exercise and activities, but also to wea-
riness and perceived lack of energy. The adult Taiwanese population and patients with cancer
seemed to interpret the questions differently. Patients with cancer may experience more psycho-
logical and mental fatigue than physical fatigue; while physical fatigue appears to have greater
influence in the daily activities of the adult Taiwanese population.
Previous studies used SF-36 and PSQI as comparators to test correlation with fatigue mea-
sures [42,59,60]. Poor health-related quality of life is associated with greater fatigue in US adult
populations with or without fatigue [42] and patients with coronary artery disease [60]. Fatigue
is also associated with poor sleep in patients with multiple sclerosis [59], rheumatoid arthritis
[14], and traumatic brain injury [15], and in spouse caregivers of cancer patients [16]. Our
results found that convergent validity supported the theoretically anticipated relationship
between fatigue (MFI-TC), quality of life (SF-36-T), and sleep disturbances (PSQI). The corre-
lation coefficients of the MFI-TC subscales and the SF-36-T likewise supported convergent
validity, which is consistent with results from previous studies [42,60].
In accordance with our expectations, total fatigue score of the MFI-TC, the PSQI, and total
score of the SF-36-T were moderately correlated, indicating that fatigue, quality of life, and
sleep disturbances are theoretically related concepts. Sleep disturbances were positively corre-
lated with all 4 subscales of the MFI-TC. Quality of life was negatively correlated with all 4 sub-
scales, especially the general/physical fatigue subscale. Although previous studies did suggest
that fatigue was related to these variables, few studies have explored which dimension of fat-
igue is specifically associated with these variables [24,27,42]. The total fatigue score, the gen-
eral/physical fatigue subscale, and the reduced activity subscale of the MFI-TC each had a
significant correlation with the general health, vitality, and mental health dimensions in the
SF-36-T. This confirms that the general/physical fatigue and reduced activity subscales repre-
sent both physical and psychological aspects of fatigue. Both reduced motivation and mental
fatigue subscales of the MFI-TC were significantly correlated with mental component of the
SF-36-T, which reflects the mental health concept of fatigue. Therefore, the findings from the
current study add to our understanding of the relationship between specific dimensions of
fatigue and related factors. In comparison with the SF-36-T and the PSQI, the MFI-TC was
able to achieve good convergent validity.
Several potential physiological mechanisms might contribute to fatigue. Research has shown
that sleep disturbance, depression, and inactive lifestyles contribute to fatigue [59,61,62]. In peo-
ple with Parkinson’s disease, fatigue, mainly mental fatigue, had been characterized as one of

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 Validity and reliability of Multidimensional Fatigue Inventory in general population

the non-motor symptoms [63]. However, the results of factor analysis of our current study and
previous studies [22,31,58] showed that physical fatigue was also an important component. A
previous study using lab testing techniques revealed that physical fatigue had both peripheral
and central fatigue components [64–66]. These findings suggest that, while the MFI is a broad
tool for assessing the severity of fatigue, the physiological mechanisms of general/physical
fatigue are still unclear. Future studies should seek to elucidate these mechanisms.
Among the 20 items of the MFI-TC, 10 items are stated positively and the other 10 items are
stated negatively, which does not allow a set response and can be used to examine whether the
respondents are carefully reading the questions or not. The high Cronbach’s alpha might there-
fore be the result of a tendency of respondents to agree with the given negative statements in the
MFI-TC and disagree with the positive statements in the MFI-TC, which is taken to be indica-
tive of much fatigue. In this study, the MFI-TC subscales exhibited adequate internal consis-
tency, with Cronbach’s alpha coefficients ranging from 0.73 to 0.92, which agrees with results
from previous studies [10,22,24,28,34,42,58]. Cronbach’s alpha for the subscales of the MFI-TC
from a sample of Taiwanese adults in this study are in the same range as those reported for the
adult German population [24] and for patients suffering from Chronic Fatigue Syndrome while
receiving radiotherapy [22]. Compared with the results of a study by Smets et al. (1995) [22],
our results showed that the alpha coefficients for the total score and the 4 subscales of the
MFI-TC were greater than 0.70, indicating that the Traditional Chinese version of the MFI has
good internal consistency. Thus, the MFI-TC is a tool that can be used to accurately assess the
dimensions and severity of fatigue within a Chinese-speaking population and its level of inter-
ference with their daily activities.
Furthermore, the MFI is easy to administer. It has been used in many patient populations
with satisfactory scalability and few missing responses. In this study, the MFI-TC showed high
test-retest reliability over a 1-week interval, with ICCs ranging from 0.85 to 0.94 for the total
fatigue score and the subscales, which is consistent with results from a previous study [58].
The readministration of the instrument after 1 week was a way to track the status of the subject
on different dimensions of fatigue through time. The stability of the MFI-TC can be affected
by the variation in the amount of change among participants’ fatigue level. Our findings dem-
onstrate stable perceptions of fatigue among participants over a 1-week interval. This might be
because at the beginning of the study, participants were asked not to change their physical sta-
tus during the period of test and retest. A change in the subject’s condition may have resulted
in changes in the perceived fatigue levels. Therefore, our findings demonstrated that the
MFI-TC possesses high stability and low variation between the 2 test occasions.
Test-retest reliability is a measure of consistency of responses over time. A basic concept
regarding test-retest reliability is the need to retest a stable population (i.e., retested participants
must be in a stable condition over time) [67]. However, there is no evidence available to provide
a better time period between questionnaire administrations for evaluating test-retest reliability of
fatigue instruments. Studies of test-retest reliability for fatigue instruments have used varying
intervals between test administrations. The interval has ranged from one week to six weeks
[21,43,58,68]. To ensure fatigue measure without too many variables influencing the trait that
naturally happen, we chose one-week interval for retesting. The time between the two test
administrations may affect the test-retest reliability. An insufficient time period between test
administrations might allow participants to remember their first answers, and the longer the
interval the more change of variation of the construct to occur [69]. It is possible that the rela-
tively short, one-week time interval of re-evaluation used in this study resulted in a potential for
recall or carry-over effects to overestimate the test-retest reliability of the MFI-TC. Conversely,
longer test-retest time period used in the previous study combined with the change status of the
participants over time, which may have underestimated the reliability of the fatigue measure

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 Validity and reliability of Multidimensional Fatigue Inventory in general population

[68]. It was speculated that approximately 2 weeks might be an appropriate time interval for
retesting [68,70]. However, the appropriate time interval should depend on the construct to be
measured and the target population.
There are some limitations to interpreting the results of this study. The first is the represen-
tativeness of the sample used for the development of the MFI-TC. More females were included
in this study and this might impact the generalizability of the results. However, due to the rela-
tive small number of sample size in the present study, further research will need to validate the
gender issue.
The test-retest reliability of this study was based on a general population whose fatigue status
was generally stable within 1 week. While applying this scale in populations with progressive
diseases such as patients with Parkinson’s disease, the 1-week test-retest reliability might not be
identical. Fatigue assessments using the MFI-TC in a sample of patient populations are needed.
Another limitation was no other fatigue scales for convergent validity were used in this study.
We chose quality of life (measured by SF-36-T) and sleep quality (measured by PSQI) as con-
ceptual criteria to validate fatigue measures. The measures were correlated lowly with measures
designed to quantify different but associated concepts and highly with measures of the same
construct. Fair to moderate correlations between the total fatigue score of the MFI-TC and the
total score of the SF-36-T and the PSQI as these scales may not be strongly related with fatigue
assessment. Moreover, in this study, no cutoff point is defined for fatigue. Since there are no
generally accepted cutoff scores in the literature, the prevalence of fatigue requires further
investigation.
In conclusion, our study demonstrated that the Traditional Chinese version of the MFI has
an appropriate construct validity, reasonable convergent validity, adequate internal consis-
tency, high test-retest reliability, and low measurement error. Factor analysis found moderate
subscale-total correlations, and high factor loadings also helped to clarify the psychometric
meaning. Therefore, the MFI-TC is a reliable and valid instrument for comprehensively mea-
suring fatigue in adult populations. The MFI-TC provides a unique set of subscales (general/
physical fatigue, reduced activity, reduced motivation, and mental fatigue) designed to assess
specific aspects of fatigue in the general population. It also offers an assessment tool for health
professionals that can be used in patient populations. Evaluation of its psychometric properties
in clinical populations is warranted before the MFI-TC can be used in clinical trials of fatigue.

Supporting information
S1 Fig. The scree plot of the MFI-TC data from the general population. The Traditional
Chinese version of the MFI retrieved 4 factors.
(PDF)
S1 Table. Reliability and concurrent validity of translation between original English MFI
and modified MFI-TC version (n = 66).
(PDF)
S1 Dataset. All data of the MFI-TC, SF-36, and PSQI questionnaires (n = 123).
(XLS)

Acknowledgments
We thank Prof. EMA Smets for her permission for translation of the MFI into Traditional Chi-
nese, Melissa Stauffer for editing the manuscript, and Min-Ping Lin for coordination of expert
meeting.

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 Validity and reliability of Multidimensional Fatigue Inventory in general population

Author Contributions
Conceptualization: Li-Ling Chuang, Yu-Fen Chuang, Miao-Ju Hsu, Ya-Ju Chang.
Formal analysis: Li-Ling Chuang.
Funding acquisition: Li-Ling Chuang, Yu-Fen Chuang, Ya-Ju Chang.
Investigation: Li-Ling Chuang, Yu-Fen Chuang, Miao-Ju Hsu, Ying-Zu Huang, Alice M. K.
Wong.
Methodology: Li-Ling Chuang, Yu-Fen Chuang, Miao-Ju Hsu, Ying-Zu Huang, Alice M. K.
Wong.
Project administration: Li-Ling Chuang.
Resources: Ya-Ju Chang.
Supervision: Li-Ling Chuang, Yu-Fen Chuang, Ya-Ju Chang.
Validation: Li-Ling Chuang, Ya-Ju Chang.
Writing – original draft: Li-Ling Chuang.
Writing – review & editing: Li-Ling Chuang, Ya-Ju Chang.

References
1. Norrelund N, Hollnagel H. [Fatigue among 40-year-olds]. Ugeskr Laeger. 1979; 141: 1425–1429.
PMID: 442274
2. Ingham JG, Miller PM. Symptom prevalence and severity in a general practice population. J Epidemiol
Community Health. 1979; 33: 191–198. PMID: 508998
3. Wong WS, Fielding R. Prevalence of chronic fatigue among Chinese adults in Hong Kong: a population-
based study. J Affect Disord. 2010; 127: 248–256. https://doi.org/10.1016/j.jad.2010.04.029 PMID:
20580826
4. Dittner AJ, Wessely SC, Brown RG. The assessment of fatigue: a practical guide for clinicians and
researchers. J Psychosom Res. 2004; 56: 157–170. https://doi.org/10.1016/S0022-3999(03)00371-4
PMID: 15016573
5. Crosby GA, Munshi S, Karat AS, Worthington E, Lincoln NB. Fatigue after stroke: frequency and effect
on daily life. Disabil Rehabil. 2012; 34: 633–637. https://doi.org/10.3109/09638288.2011.613517
PMID: 21978259
6. Nicklin J, Cramp F, Kirwan J, Greenwood R, Urban M, Hewlett S. Measuring fatigue in rheumatoid
arthritis: a cross-sectional study to evaluate the Bristol Rheumatoid Arthritis Fatigue Multi-Dimensional
questionnaire, visual analog scales, and numerical rating scales. Arthritis Care Res (Hoboken). 2010;
62: 1559–1568.
7. Glaus A, Crow R, Hammond S. A qualitative study to explore the concept of fatigue/tiredness in cancer
patients and in healthy individuals. Eur J Cancer Care (Engl). 1996; 5: 8–23.
8. Pettersson S, Bostrom C, Eriksson K, Svenungsson E, Gunnarsson I, Henriksson EW. Lifestyle habits
and fatigue among people with systemic lupus erythematosus and matched population controls. Lupus.
2015.
9. Ream E, Richardson A. Fatigue: a concept analysis. Int J Nurs Stud. 1996; 33: 519–529. PMID:
8886902
10. Stein KD, Jacobsen PB, Blanchard CM, Thors C. Further validation of the multidimensional fatigue
symptom inventory-short form. J Pain Symptom Manage. 2004; 27: 14–23. https://doi.org/10.1016/j.
jpainsymman.2003.06.003 PMID: 14711465
11. Aaronson LS, Teel CS, Cassmeyer V, Neuberger GB, Pallikkathayil L, Pierce J, et al. Defining and mea-
suring fatigue. Image J Nurs Sch. 1999; 31: 45–50. PMID: 10081212
12. Lee KA, Hicks G, Nino-Murcia G. Validity and reliability of a scale to assess fatigue. Psychiatry Res.
1991; 36: 291–298. PMID: 2062970
13. Appels A, Mulder P. Excess fatigue as a precursor of myocardial infarction. Eur Heart J. 1988; 9:
758–764. PMID: 3169045

PLOS ONE | https://doi.org/10.1371/journal.pone.0189850 May 10, 2018 15 / 18

 Validity and reliability of Multidimensional Fatigue Inventory in general population

14. Irwin MR, Olmstead R, Carrillo C, Sadeghi N, Fitzgerald JD, Ranganath VK, et al. Sleep loss exacer-
bates fatigue, depression, and pain in rheumatoid arthritis. Sleep. 2012; 35: 537–543. https://doi.org/
10.5665/sleep.1742 PMID: 22467992
15. Ponsford JL, Ziino C, Parcell DL, Shekleton JA, Roper M, Redman JR, et al. Fatigue and sleep distur-
bance following traumatic brain injury—their nature, causes, and potential treatments. J Head Trauma
Rehabil. 2012; 27: 224–233. https://doi.org/10.1097/HTR.0b013e31824ee1a8 PMID: 22573041
16. Zhang Q, Yao D, Yang J, Zhou Y. Factors influencing sleep disturbances among spouse caregivers of
cancer patients in Northeast China. PLoS One. 2014; 9: e108614. https://doi.org/10.1371/journal.
pone.0108614 PMID: 25275619
17. Heaton KJ, Maule AL, Maruta J, Kryskow EM, Ghajar J. Attention and visual tracking degradation during
acute sleep deprivation in a military sample. Aviat Space Environ Med. 2014; 85: 497–503. PMID:
24834562
18. Metta V, Logishetty K, Martinez-Martin P, Gage HM, Schartau PE, Kaluarachchi TK, et al. The possible
clinical predictors of fatigue in Parkinson’s disease: a study of 135 patients as part of international non-
motor scale validation project. Parkinsons Dis. 2011; 2011: 125271. https://doi.org/10.4061/2011/
125271 PMID: 22191065
19. Tseng BY, Gajewski BJ, Kluding PM. Reliability, responsiveness, and validity of the visual analog
fatigue scale to measure exertion fatigue in people with chronic stroke: a preliminary study. Stroke Res
Treat. 2010; 2010: 412964. https://doi.org/10.4061/2010/412964 PMID: 20700421
20. Mendoza TR, Wang XS, Cleeland CS, Morrissey M, Johnson BA, Wendt JK, et al. The rapid assessment
of fatigue severity in cancer patients: use of the Brief Fatigue Inventory. Cancer. 1999; 85: 1186–1196.
PMID: 10091805
21. Pien LC, Chu H, Chen WC, Chang YS, Liao YM, Chen CH, et al. Reliability and validity of a Chinese ver-
sion of the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF-C). J Clin Nurs. 2011;
20: 2224–2232. https://doi.org/10.1111/j.1365-2702.2010.03691.x PMID: 21615574
22. Smets EM, Garssen B, Bonke B, De Haes JC. The Multidimensional Fatigue Inventory (MFI) psycho-
metric qualities of an instrument to assess fatigue. J Psychosom Res. 1995; 39: 315–325. PMID:
7636775
23. Smets EM, Visser MR, Willems-Groot AF, Garssen B, Oldenburger F, van Tienhoven G, et al. Fatigue
and radiotherapy: (A) experience in patients undergoing treatment. Br J Cancer. 1998; 78: 899–906.
PMID: 9764581
24. Schwarz R, Krauss O, Hinz A. Fatigue in the general population. Onkologie. 2003; 26: 140–144.
https://doi.org/10.1159/000069834 PMID: 12771522
25. Hinz A, Barboza CF, Barradas S, Korner A, Beierlein V, Singer S. Fatigue in the general population of
Colombia—normative values for the multidimensional fatigue inventory MFI-20. Onkologie. 2013; 36:
403–407. https://doi.org/10.1159/000353606 PMID: 23921758
26. Watt T, Groenvold M, Bjorner JB, Noerholm V, Rasmussen NA, Bech P. Fatigue in the Danish general
population. Influence of sociodemographic factors and disease. J Epidemiol Community Health. 2000;
54: 827–833. https://doi.org/10.1136/jech.54.11.827 PMID: 11027196
27. Tian J, Hong JS. Validation of the Chinese version of Multidimensional Fatigue Inventory-20 in Chinese
patients with cancer. Support Care Cancer. 2012; 20: 2379–2383. https://doi.org/10.1007/s00520-011-
1357-8 PMID: 22198167
28. Hagelin CL, Wengstrom Y, Runesdotter S, Furst CJ. The psychometric properties of the Swedish Multi-
dimensional Fatigue Inventory MFI-20 in four different populations. Acta Oncol. 2007; 46: 97–104.
PMID: 17438711
29. Munguia-Izquierdo D, Segura-Jimenez V, Camiletti-Moiron D, Pulido-Martos M, Alvarez-Gallardo IC,
Romero A, et al. Multidimensional Fatigue Inventory: Spanish adaptation and psychometric properties
for fibromyalgia patients. The Al-Andalus study. Clin Exp Rheumatol. 2012; 30: 94–102. PMID:
23261007
30. Friedman JH, Alves G, Hagell P, Marinus J, Marsh L, Martinez-Martin P, et al. Fatigue rating scales cri-
tique and recommendations by the Movement Disorders Society task force on rating scales for Parkin-
son’s disease. Mov Disord. 2010; 25: 805–822. https://doi.org/10.1002/mds.22989 PMID: 20461797
31. Smets EM, Garssen B, Cull A, de Haes JC. Application of the multidimensional fatigue inventory (MFI-
20) in cancer patients receiving radiotherapy. Br J Cancer. 1996; 73: 241–245. PMID: 8546913
32. Lee YC, Chien KL, Chen HH. Lifestyle risk factors associated with fatigue in graduate students. J For-
mos Med Assoc. 2007; 106: 565–572. https://doi.org/10.1016/S0929-6646(07)60007-2 PMID:
17660146
33. Gentile S, Delaroziere JC, Favre F, Sambuc R, San Marco JL. Validation of the French ’multidimen-
sional fatigue inventory’ (MFI 20). Eur J Cancer Care (Engl). 2003; 12: 58–64.

PLOS ONE | https://doi.org/10.1371/journal.pone.0189850 May 10, 2018 16 / 18

 Validity and reliability of Multidimensional Fatigue Inventory in general population

34. Chandel P, Sultan A, Khan KA, Choudhary V, Parganiha A. Validation of the Hindi version of the Multidi-
mensional Fatigue Inventory-20 (MFI-20) in Indian cancer patients. Support Care Cancer. 2015; 23:
2957–2964. https://doi.org/10.1007/s00520-015-2661-5 PMID: 25744285
35. Buss T, Kruk A, Wisniewski P, Modlinska A, Janiszewska J, Lichodziejewska-Niemierko M. Psychomet-
ric properties of the Polish version of the Multidimensional Fatigue Inventory-20 in cancer patients.
J Pain Symptom Manage. 2014; 48: 730–737. https://doi.org/10.1016/j.jpainsymman.2013.11.015
PMID: 24681111
36. Chung KF, Yu BY, Yung KP, Yeung WF, Ng TH, Ho FY. Assessment of fatigue using the Multidimen-
sional Fatigue Inventory in patients with major depressive disorder. Compr Psychiatry. 2014; 55:
1671–1678. https://doi.org/10.1016/j.comppsych.2014.06.006 PMID: 25035160
37. Hair J, Black WC, Babin BJ, Anderson RE (2010) Multivarite Data Analysis. Upper Saddle River, NJ
Prentice Hall.
38. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adapta-
tion of self-report measures. Spine (Phila Pa 1976). 2000; 25: 3186–3191.
39. Lynn MR. Determination and quantification of content validity. Nurs Res. 1986; 35: 382–385. PMID:
3640358
40. Wynd CA, Schmidt B, Schaefer MA. Two quantitative approaches for estimating content validity. West
J Nurs Res. 2003; 25: 508–518. https://doi.org/10.1177/0193945903252998 PMID: 12955968
41. Cha ES, Kim KH, Erlen JA. Translation of scales in cross-cultural research: issues and techniques.
J Adv Nurs. 2007; 58: 386–395. https://doi.org/10.1111/j.1365-2648.2007.04242.x PMID: 17442038
42. Lin JM, Brimmer DJ, Maloney EM, Nyarko E, Belue R, Reeves WC. Further validation of the Multidi-
mensional Fatigue Inventory in a US adult population sample. Popul Health Metr. 2009; 7: 18. https://
doi.org/10.1186/1478-7954-7-18 PMID: 20003524
43. Kim HJ, Abraham I. Measurement of fatigue: Comparison of the reliability and validity of single-item and
short measures to a comprehensive measure. Int J Nurs Stud. 2017; 65: 35–43. https://doi.org/10.
1016/j.ijnurstu.2016.10.012 PMID: 27821285
44. Ware JE Jr., Kosinski M, Bayliss MS, McHorney CA, Rogers WH, Raczek A Comparison of methods for
the scoring and statistical analysis of SF-36 health profile and summary measures: summary of results
from the Medical Outcomes Study.Med Care. 1995; 33: AS264–279.
45. Freeman JA, Hobart JC, Thompson AJ. Does adding MS-specific items to a generic measure (the SF-
36) improve measurement? Neurology. 2001; 57: 68–74. PMID: 11445630
46. Lu JF, Tseng HM, Tsai YJ. Assessment of health-related quality of life in Taiwan (I): development and
psychometric testing of SF-36 Taiwan version. Taiwan Journal of Public Health. 2003; 22: 501–511.
47. Tseng HM, Lu JF, Tsai YJ. Assessment of health-related quality of life in Taiwan (II): norming and vali-
dation of SF-36 Taiwan version. Taiwan Journal of Public Health. 2003; 22: 512–518.
48. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a
new instrument for psychiatric practice and research. Psychiatry Res. 1989; 28: 193–213. PMID:
2748771
49. Cole JC, Motivala SJ, Buysse DJ, Oxman MN, Levin MJ, Irwin MR. Validation of a 3-factor scoring
model for the Pittsburgh sleep quality index in older adults. Sleep. 2006; 29: 112–116. PMID: 16453989
50. Ho RT, Fong TC. Factor structure of the Chinese version of the Pittsburgh sleep quality index in breast
cancer patients. Sleep Med. 2014; 15: 565–569. https://doi.org/10.1016/j.sleep.2013.10.019 PMID:
24759325
51. Portney LG, Watkins MP (2009) Foundations of clinical research: Applications to practice. Upper Sad-
dle River, NJ: Pearson/Prentice Hall.
52. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979; 86:
420–428. PMID: 18839484
53. Haley SM, Fragala-Pinkham MA. Interpreting change scores of tests and measures used in physical
therapy. Phys Ther. 2006; 86: 735–743. PMID: 16649896
54. Schuck P, Zwingmann C. The ’smallest real difference’ as a measure of sensitivity to change: a critical
analysis. Int J Rehabil Res. 2003; 26: 85–91. https://doi.org/10.1097/01.mrr.0000070759.63544.65
PMID: 12799601
55. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical
measurement. Lancet. 1986; 1: 307–310. PMID: 2868172
56. Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res.
1999; 8: 135–160. https://doi.org/10.1177/096228029900800204 PMID: 10501650
57. Kaiser HFR, Jiffy J. Little, Mark IV. Educational and Psychological Measurement 1974; 34: 111–117.

PLOS ONE | https://doi.org/10.1371/journal.pone.0189850 May 10, 2018 17 / 18

 Validity and reliability of Multidimensional Fatigue Inventory in general population

58. Elbers RG, van Wegen EE, Verhoef J, Kwakkel G. Reliability and structural validity of the Multidimen-
sional Fatigue Inventory (MFI) in patients with idiopathic Parkinson’s disease. Parkinsonism Relat Dis-
ord. 2012; 18: 532–536. https://doi.org/10.1016/j.parkreldis.2012.01.024 PMID: 22361576
59. Ghajarzadeh M, Sahraian MA, Fateh R, Daneshmand A. Fatigue, depression and sleep disturbances in
Iranian patients with multiple sclerosis. Acta Med Iran. 2012; 50: 244–249. PMID: 22592574
60. Staniute M, Bunevicius A, Brozaitiene J, Bunevicius R. Relationship of health-related quality of life with
fatigue and exercise capacity in patients with coronary artery disease. Eur J Cardiovasc Nurs. 2014;
13: 338–344. https://doi.org/10.1177/1474515113496942 PMID: 23818215
61. Huang YT, Chi LK. The effects of moderate acute exercise on RPE and affects among different objec-
tive and subjective fitness level. Physical Education Journal. 1998; 25: 239–248.
62. Chen HL, Fang CL, Chuang HY, Chu YC. A Comparative Study of the Level of Fatigue, Exercise Behav-
ior and Cardiopulmonary Fitness of Female Primary School Teachers. Physical Education journal.
2013; 46: 329–338.
63. Bonnet AM, Jutras MF, Czernecki V, Corvol JC, Vidailhet M. Nonmotor symptoms in Parkinson’s dis-
ease in 2012: relevant clinical aspects. Parkinsons Dis. 2012; 2012: 198316. https://doi.org/10.1155/
2012/198316 PMID: 22888466
64. Chang YJ, Hsu MJ, Chen SM, Lin CH, Wong AM. Decreased central fatigue in multiple sclerosis patients
after 8 weeks of surface functional electrical stimulation. J Rehabil Res Dev. 2011; 48: 555–564. PMID:
21674405
65. Lin KH, Chen YC, Luh JJ, Wang CH, Chang YJ. H-reflex, muscle voluntary activation level, and fatigue
index of flexor carpi radialis in individuals with incomplete cervical cord injury. Neurorehabil Neural
Repair. 2012; 26: 68–75. https://doi.org/10.1177/1545968311418785 PMID: 21952197
66. Chen SW, Liaw JW, Chang YJ, Chan HL, Chiu LY. A Cycling Movement Based System for Real-Time
Muscle Fatigue and Cardiac Stress Monitoring and Analysis. PLoS One. 2015; 10: e0130798. https://
doi.org/10.1371/journal.pone.0130798 PMID: 26115515
67. Aaronson N, Alonso J, Burnam A, Lohr KN, Patrick DL, Perrin E, et al. Assessing health status and qual-
ity-of-life instruments: attributes and review criteria. Qual Life Res. 2002; 11: 193–205. PMID:
12074258
68. Mathiowetz V. Test-retest reliability and convergent validity of the Fatigue Impact Scale for persons with
multiple sclerosis. Am J Occup Ther. 2003; 57: 389–395. PMID: 12911080
69. Allen MJ, Yen WM (1979) Introduction to measurement theory. Monterey, CA: Brook/Cole.
70. Streiner DL, Norman GR (2008) Health measurement scales. A practical guide to their development
and use. New York: Oxford University Press.

PLOS ONE | https://doi.org/10.1371/journal.pone.0189850 May 10, 2018 18 / 18