Psychometric Evaluation of the Traditional Chinese Multidimensional Fatigue Inventory in Patients With Heart Failure

"General fatigue" is widely regarded in both clinical and general population research as a multidimensional symptom experience centered on subjective perception, rather than a phenomenon that can be defined by a single physiological indicator. Multiple review studies have indicated that, regardless of disease type, patients' descriptions of fatigue commonly encompass physical, cognitive, and emotional/motivational dimensions. Therefore, multidimensionality has become a widely accepted characteristic of the fatigue construct. These studies emphasize that fatigue should not be simply reduced to "muscle weakness" or "sleepiness." Rather, it represents a persistent or recurrent sense of energy depletion accompanied by reduced tolerance for activity, and is closely associated with limitations in activities of daily living and health-related quality of life.

In patients with heart failure, fatigue is not merely a feeling of being "tired" or experiencing reduced physical strength. Instead, it is a complex symptom involving physiological, psychological, and behavioral dimensions. It is commonly manifested as persistent or abnormally severe energy depletion, reduced motivation to engage in activities, and restricted participation in physical functioning. Importantly, such fatigue may not be completely relieved even after adequate rest.

The Multidimensional Fatigue Inventory (MFI) is a widely used self-reported instrument for assessing fatigue. It consists of 20 items and evaluates five dimensions: General Fatigue, Physical Fatigue, Mental Fatigue, Reduced Motivation, and Reduced Activity. These dimensions reflect the multidimensional characteristics of fatigue across perceived energy levels, physical functioning, cognitive burden, and behavioral participation.

In Taiwan, researchers have translated the MFI into Traditional Chinese and evaluated the reliability and validity of the Taiwan Traditional Chinese version of the MFI (MFI-TC) in a general adult population. The study followed a standardized cross-cultural adaptation process. The findings demonstrated that the MFI-TC had good content validity, an appropriate factor structure, and acceptable to excellent Cronbach's alpha coefficients across its subscales. In addition, the MFI-TC showed theoretically meaningful associations with related constructs, including self-perceived health status, sleep, and quality of life, supporting its feasibility and stability for use among generally healthy adults in Taiwan.

Nevertheless, existing studies of the MFI-TC have primarily focused on healthy adult populations. Its psychometric properties and clinical applicability have not yet been systematically evaluated in patients with heart failure, a population characterized by a high burden of fatigue and distinctive pathophysiological mechanisms.

• Questionnaire investigate (Other): investigate patient with heart failure fatigue codition

Primary outcomes

• Multidimensional Fatigue Inventory [Inpatients: at baseline (prior to hospital discharge) and 1 day after baseline (test-retest). outpatients: at baseline and 1 week after baseline (test-retest).]: The MFI-TC is a 20-item self-report questionnaire assessing fatigue across five subscales: General Fatigue, Physical Fatigue, Mental Fatigue, Reduced Motivation, and Reduced Activity (4 items per subscale). Each item is rated on a 5-point Likert scale (1-5). Subscale scores range from 4 to 20 and the total score ranges from 20 to 100, with higher scores indicating greater fatigue. MFI-TC scores will be used to evaluate psychometric properties in patients with heart failure, including test-retest reliability (intraclass correlation coefficient, ICC), construct validity (confirmatory factor analysis), and convergent validity (correlations with the SF-8a, WHOQOL-BREF, PSQI, and Barthel Index).

Secondary outcomes

• World Health Organization Quality of Life-BREF, Taiwan Version (WHOQOL-BREF) [Assessed once at baseline (Day 1): prior to hospital discharge for inpatients, and at the first assessment for community-dwelling patients.]: The WHOQOL-BREF Taiwan version is a self-report questionnaire developed by the WHOQOL Group and culturally adapted for use in Taiwan to assess quality of life. It consists of 28 items, including the 26 standard items and two Taiwan-specific items. The items cover four domains: Physical Health, Psychological Health, Social Relationships, and Environment, plus two general items on overall quality of life and general health. Each item is rated on a 5-point Likert scale with reference to the past two weeks. Domain scores range from 4 to 20, with higher scores indicating better quality of life. Negatively worded items are reverse-scored. In this study, the WHOQOL-BREF is used to examine the convergent validity of the MFI-TC; higher fatigue is expected to be associated with poorer quality of life.
• PROMIS Fatigue Short Form 8a (SF-8a) [Assessed once at baseline (Day 1): prior to hospital discharge for inpatients, and at the first assessment for community-dwelling patients.]: The PROMIS Fatigue Short Form 8a is a self-report questionnaire developed by the Patient-Reported Outcomes Measurement Information System (PROMIS) initiative to assess fatigue. It consists of 8 items that evaluate the experience of fatigue, such as feelings of tiredness and lack of energy, and its impact on daily activities and physical, mental, and social functioning. Each item is rated on a 5-point Likert scale with reference to the past 7 days. Raw scores range from 8 to 40 and can be converted to standardized T-scores (mean = 50, SD = 10), with higher scores indicating greater fatigue. In this study, the SF-8a is used as a comparison fatigue measure to examine the convergent validity of the MFI-TC; a positive correlation between the two measures is expected.
• Pittsburgh Sleep Quality Index (PSQI) [Assessed once at baseline (Day 1): prior to hospital discharge for inpatients, and at the first assessment for community-dwelling patients.]: The Pittsburgh Sleep Quality Index (PSQI) is a self-report questionnaire developed by Buysse and colleagues to assess sleep quality and disturbances. It consists of 19 self-rated items grouped into seven components: Subjective Sleep Quality, Sleep Latency, Sleep Duration, Habitual Sleep Efficiency, Sleep Disturbances, Use of Sleeping Medication, and Daytime Dysfunction. The questionnaire refers to the past month. Each component is scored from 0 to 3, and the component scores are summed to give a global score ranging from 0 to 21, with higher scores indicating poorer sleep quality. A global score greater than 5 indicates poor sleep. In this study, the PSQI is used to examine the convergent validity of the MFI-TC; poorer sleep quality is expected to be associated with greater fatigue.
• Barthel Index (BI) [Assessed once at baseline (Day 1): prior to hospital discharge for inpatients, and at the first assessment for community-dwelling patients.]: The Barthel Index (BI) is a widely used measure developed by Mahoney and Barthel to assess independence in basic activities of daily living. It consists of 10 items: feeding, bathing, grooming, dressing, bowel control, bladder control, toilet use, transfers, mobility on level surfaces, and stair climbing. In this study, the BI is administered by a trained research team member through interview. Items are weighted according to the level of assistance required, and the total score ranges from 0 to 100, with higher scores indicating greater independence in daily living. The BI is used to examine the convergent validity of the MFI-TC; greater fatigue is expected to be associated with lower functional independence.

Sex: All, ages: 20 Years to any

Inclusion Criteria:

* \### Inclusion Criteria

**Hospitalized patients with heart failure:**

1. Aged 20 years or older.
2. Diagnosed with heart failure by a physician and admitted to a general ward.
3. Normal cognitive function, defined as a Mini-Mental State Examination (MMSE) score of ≥24, or meeting the education-adjusted cutoff criteria.
4. Able to read Chinese and understand the questionnaire content.
5. Willing to participate in the study and provide written informed consent.

**Community-dwelling patients with heart failure:**

1. Aged 20 years or older.
2. Diagnosed with heart failure.
3. Normal cognitive function, defined as a Mini-Mental State Examination (MMSE) score of ≥24, or meeting the education-adjusted cutoff criteria.
4. Able to read Chinese and understand the questionnaire content.
5. Willing to participate in the study and provide written informed consent.

Exclusion Criteria:

* Hospitalized patients with heart failure:

Presence of other major neurological or psychiatric disorders, such as dementia or severe depression.

Clinical deterioration requiring transfer to an intensive care unit. Terminal-stage cancer.

Community-dwelling patients with heart failure:

Presence of other major neurological or psychiatric disorders, such as dementia or severe depression.

A history of acute heart failure exacerbation within the past month, or hospitalization due to other medical conditions during the same period.

Terminal-stage cancer.