FES-I

• FES-I: minimum 16 (no concern about falling) to maximum 64 (severe concern about falling)
• Short FES-I: minimum 7 (no concern about falling) to maximum 28 (severe concern about falling)

Scoring with missing items

If responses are missing on more than four items on FES-I (i.e.≥5), or more than two items (i.e.≥3) for Short-FES-I then the questionnaire scores cannot be used. If responses are missing on four or less for FES-I, or 2 or less on Short FES-I then it is possible to calculate a FES-I/Short FES-I score. To do this first calculate the total score of the items which have been completed. Divide that score by the number of items completed and then multiply by 16 (FES-I) or 7 (Short FES-I). The new total score should be rounded up to the nearest whole number to give the score for an individual. For example, if scores on Short FES-I were: Item 1=2 Item 2=3 Item 3=missing Item 4=3 Item 5=2 Item 6=4 Item 7=missing Then 2+3+3+2+4=14/5 = 2.8×7= 19.6 which is rounded up to 20.

10 step FES-I translation protocol prepared by researchers participating in ProFaNE Workpackage 4 2005. The following 10 steps need to be used for the translation of the FES-I into a local language:

1. The English version of the FES-I is always point of departure. Translate the full 16 item FES-I. Once these 16 items are translated the seven items that make up Short FES-I can simply be selected from this text. However, ensure that the instructions for Short FES-I are also translated as they are slightly different from FES-I instructions.
2. Make use of the translator/interviewer notes for interpretations of different items.
3. The English version of the FES-I will be translated from English into the local language by at least two translators independently. These translators need to be (a) native speakers of the local language, and (b) familiar with the concept fear of falling.
4. A first consensus meeting of the translators is held which has to result in a provisional local version.
5. Each of the translators will select two older persons for a try-out of the FES-I in written form. The questionnaire needs to be filled in by each older person separately without any disruption of the translator. Afterwards, the 16 items are discussed between the translator and the older person (Were all items clear? Is it necessary to reformulate items?).
6. Each of the translators may adjust the wording of items.
7. A second consensus meeting is held to create consensus about a next preliminary local version of the FES-I.
8. A back translation from the local language into English is done by a professional translator whose native language is English.
9. A third consensus meeting of the translators is held to review the back translation. Important for the reviewing is the intentional meaning of the back translation, not the literal meaning. The objective is a valid translation of the local version of the FES-I, not a new English one. If necessary, the professional back translator will be consulted for additional information.
10. We always need to be informed about the final local version. Email fes-i@manchester.ac.uk

For further information about translation and validation see:

• WHO guidelines on translation of instruments
• Acquadro C, Conway K, Giroudet C, Mear I. Linguistic validation manual for health outcome assessments. Lyon: Mapi Institute, 2012.

It became clear during the process of translation from English to other European languages that there was no wording of the questionnaire that would translate easily into every European language using exactly the same words and phrases. Consequently, these notes are intended to assist translators of the FES-I to express the same meaning of items, even if they cannot use quite the same words in their language. They may also assist interviewers who are asked for clarification of the meaning of items when the FES-I is administered by interview.

Participants should answer items thinking about how they usually do the activity. For example, if they usually walk with an aid they should answer items about walking to show how concerned they would be about falling when using that aid. Some translators may find it helpful to clarify in the instructions (after the sentence on circling an opinion) “The opinions you can choose from are: 1 = not at all concerned 2 = somewhat concerned 3 = fairly concerned 4 = very concerned”. In some languages it is better to translate the word ‘opinion’ as ‘statement’.

The word ‘concerned’ expresses a cognitive or rational disquiet about the possibility of falling, but does not express the emotional distress that would be expressed by terms such as ‘worried’, ‘anxious’ or ‘fearful’. It is important to use a similar unemotional term, as respondents may be less willing to admit to emotions, which might be viewed as signs of weakness.

• Item 3: In some languages, ‘simple’ meals are best translated as ‘everyday’ meals, but the intention is to refer to a meal that does not require complex preparation, rather than one that is prepared every day.
• Item 5: This item is intended to refer to shopping that is not extensive or recreational. In some languages, the best translation is ‘shopping for groceries’.
• Item 7: This item refers to any stairs, not necessarily the flight of stairs in one’s own house. (FES-I Item 7 = Short FES-I Item 4)
• Item 8: In some languages, ‘neighbourhood’ may be difficult to translate, and so ‘walking around outside’ can be used instead.

• Item 12: In some languages, it is necessary to add the term ‘acquaintances’ to friends and relatives, since this is a more common and casual category of relationship than friends (see also last comment on items 12, 13 and 16 below).

• Item 13: ‘Crowds’ can be translated as ‘many people’ if necessary (see also last comment on items 12,13 and 16 below).

• Item 14: It was found to be necessary to give examples of what is meant by uneven ground, but no examples could be found that were appropriate for all countries. Consequently, translators should choose any two examples from the following: cobblestones; poorly maintained pavement; rocky ground; unpaved surface.

• Items 12, 13, 16: These items contain a greater element of ambiguity than many of the items assessing functional capabilities, because the physical activities involved in these social events may differ greatly for different respondents. However, it was decided that this ambiguity was acceptable because it is important to assess effects of fear of falling on social activities. (FES-I Item 16 = Short FES-I Item 7)

• Jørstad EC, Hauer K, Becker C, Lamb SE on behalf of the ProFaNE group. Measuring the psychological outcomes of falling: a systematic review. Journal of the America Geriatrics Society 2004; 5: 501-510.
• Yardley L, Beyer N, Hauer K, Kempen G, Piot-Ziegler C, Todd C. Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age and Ageing 2005; 34(6): 614-619.
• Dias N, Kempen GIJM, Todd CJ, Beyer N, Freiberger E, Piot-Ziegler C, Yardley L, Hauer K. The German version of the Falls Efficacy Scale – International Version (FES-I). Zeitschrift für Geriatrie und Gerontologie 2006; 39: 297-300.
• Kempen GI, Todd CJ, Van Haastregt JC, Zijlstra GA, Beyer N, Freiberger E, Hauer KA, Piot-Ziegler C, Yardley L. Cross-cultural validation of the Falls Efficacy Scale International (FES-I) in older people: results from Germany, the Netherlands and the UK were satisfactory. Disability and Rehabilitation 2007; 29(2): 155-162.
• Kempen GIJM, Yardley L, van Haastregt JCM, Zijlstra GAR, Beyer N, Hauer K, Todd C. The Short FES-I: a shortened version of the falls efficacy scale-international to assess fear of falling. Age and Ageing 2008; 37(1): 45-50.
• Hauer K, Yardley L, Beyer N, Kempen G, Dias N, Campbell M, Becker C, Todd C. Validation of the Falls Efficacy Scale and Falls Efficacy Scale International in geriatric patients with and without cognitive impairment: results of self-report and interview-based questionnaires. Gerontology 2010; 56(2): 190-199.
• Helbostad JL, Taraldsen K, Granbo R, Yardley L, Todd CJ, Sletvold O. Validation of the Falls Efficacy Scale-International in fall-prone older persons. Age and Ageing 2010: 39(2): 256-259.
• Hauer KA, Kempen GIJM, Schwenk M, Yardley L, Beyer N, Todd C, Oster P, Zijlstra GAR. Validity and sensitivity-to-change of the Falls Efficacy Scales International to assess fear of falling in older adults with and without cognitive impairment. Gerontology 2011; 57(5): 462-472

The original FES

• Tinetti ME, Mendes de Leon CF, Doucette JT, Baker DI. Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. Journal of Gerontology 1994; 49(3): M140-147.

Please find below links to citations for the original FES-I and Short FES-I publications.

• Yardley L, Beyer N, Hauer K, Kempen G, Piot-Ziegler C, Todd C. Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age and Ageing 2005; 34(6): 614-619.
• Kempen GI, Todd CJ, Van Haastregt JC, Zijlstra GA, Beyer N, Freiberger E, Hauer KA, Piot-Ziegler C, Yardley L. Cross-cultural validation of the Falls Efficacy Scale International (FES-I) in older people: results from Germany, the Netherlands and the UK were satisfactory. Disability and Rehabilitation 2007; 29(2): 155-162.
• Kempen GIJM, Yardley L, van Haastregt JCM, Zijlstra GAR, Beyer N, Hauer K, Todd C. The Short FES-I: a shortened version of the falls efficacy scale-international to assess fear of falling. Age and Ageing 2008; 37(1): 45-50.

In addition to the original publications, there are many hundreds of papers reporting on or using the FES-I and Short FES-I in different populations.  We suggest you also search for publications within your local countries and languages. You may also want to get in touch with the local contact listed by the translated versions, as they may be able to inform you of papers and reviews within your local countries.

1. Yardley L, Beyer N, Hauer K, Kempen G, Piot-Ziegler C, Todd C. Development and initial validation of the Falls Efficacy Scale International (FES-I). Age and Ageing 2005; 34: 614-619. doi:10.1093/ageing/afi196
2. Kempen GIJM, Yardley L, van Haastregt JCM, Zijlstra GAR, Beyer N, Hauer K, Todd C. The Short FES-I: a shortened version of the Falls Efficacy Scale-International to assess fear of falling. Age and Ageing 2008; 37: 45-50. doi:10.1093/ageing/afm157
3. Kempen GIJM, Todd CJ, van Haastregt JCM, Zijlstra GAR, Beyer N, Freiberger E, Hauer KA, Piot-Ziegler C, Yardley L. Cross-cultural validation of the Falls Efficacy Scale International (FES-I) in older people: Results from Germany, the Netherlands and the United Kingdom were satisfactory. Disability and Rehabilitation 2007; 29: 155-162. doi:10.1080/09638280600747637
4. Hauer K, Yardley L, Beyer, N, Kempen G, Dias N, Campbell M, Becker C, Todd C. Validation of the Falls Efficacy Scale and Falls Efficacy Scale International in geriatric patients with and without cognitive impairment: Results of self-report and interview-based questionnaires.  Gerontology 2010; 56: 190-199. doi:0.1159/000236027
5. Delbaere K, Close JCT, Mikolaizak AS, Sachdev PS, Brodaty H, Lord SR. The Falls Efficacy Scale International (FES-I). A comprehensive longitudinal validation study. Age and Ageing 2010; 39: 210-216. doi:10.1093/ageing/afp225