Falls Efficacy Scale International (7 & 16-items)

1. Abstract

The Falls Efficacy Scale International (FES-I) and its shortened variant, the Short FES-I, represent gold-standard psychometric instruments designed to evaluate fear of falling—operationalized primarily as self-reported fall-related concern—across a diverse continuum of activities of daily living (ADL), instrumental activities of daily living (IADL), and social participation contexts. Developed under the auspices of the Prevention of Falls Network Europe (ProFaNE), the FES-I expands the original 10-item Falls Efficacy Scale developed by Tinetti and colleagues in 1990 by incorporating 6 additional challenging mobility and outdoor social tasks, yielding a 16-item self-report questionnaire. A psychometrically optimized 7-item nested version (Short FES-I) was subsequently extracted to facilitate rapid clinical screening. Each item is scored on a standardized 4-point Likert scale ranging from 1 (“Not at all concerned”) to 4 (“Very concerned”), generating aggregate scores from 16 to 64 for the full instrument, and 7 to 28 for the short version. Higher total scores denote heightened levels of fall-related concern. Psychometric evaluations across broad cross-cultural, community-dwelling, and clinical populations (such as Parkinson’s disease, stroke, vestibular disorders, and frailty) indicate excellent internal consistency (Cronbach’s alpha routinely ranging from 0.92 to 0.96 for the 16-item version, and 0.88 to 0.92 for the 7-item version), robust test-retest reliability (intraclass correlation coefficients generally exceeding 0.80), and solid construct, convergent, and discriminant validity. Structural analyses reveal a predominantly unidimensional construct, though secondary analyses sometimes identify two closely correlated sub-factors reflecting basic physiological mobility versus complex or outdoor social activities. This article details the structural, theoretical, and clinical properties of the FES-I and Short FES-I, articulating their role in gerontology, physical rehabilitation, and epidemiological research.

2. Keywords

Falls Efficacy Scale International, FES-I, Short FES-I, fear of falling, fall-related concern, balance confidence, geriatrics, psychometrics, activities of daily living, ProFaNE, accidental falls

3. Authors

The conceptual foundation of the original Falls Efficacy Scale (FES) was established by Mary E. Tinetti, M.D. (Yale School of Medicine), Dorothy Richman, PT, and Lewis Powell, Ph.D. in 1990. Recognizing the cross-cultural and operational limitations of the original scale, the Prevention of Falls Network Europe (ProFaNE) consensus group—led prominently by Gertrudis I. J. M. Kempen, Ph.D. (Maastricht University, The Netherlands), Chris J. Todd, Ph.D. (University of Manchester, United Kingdom), Karin Delbaere, Ph.D. (Neuroscience Research Australia / University of New South Wales), Clemens Becker, M.D. (Robert Bosch Hospital, Germany), and colleagues—developed and validated the 16-item Falls Efficacy Scale International (FES-I) in 2007, followed by the validation of the 7-item Short FES-I led by Kempen, Delbaere, and the ProFaNE consortium in 2008.

Corresponding academic institutional leads include:

• Prof. Dr. Gertrudis I. J. M. Kempen, Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
• Prof. Chris J. Todd, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.
• Prof. Karin Delbaere, Falls, Balance and Injury Research Centre, Neuroscience Research Australia (NeuRA), Sydney, Australia.

4. Purpose

The primary clinical and epidemiological purpose of the Falls Efficacy Scale International (FES-I) is the systematic quantification of fall-related concern (fear of falling) across a wide range of daily living activities, spanning basic self-care to demanding physical and outdoor social interactions. Fear of falling is a major public health concern affecting between 20% and 85% of older adults, observed both in individuals with a history of falls and in individuals who have never experienced a fall event. Left unaddressed, excessive fear of falling triggers a debilitating trajectory characterized by voluntary restriction of activity, muscle deconditioning, loss of functional independence, increased risk of institutionalization, social isolation, depressive symptoms, and paradoxically, a heightened prospective risk of recurrent falling due to physical deterioration.

While the original 1990 Tinetti FES effectively captured perceived confidence in performing basic indoor personal care tasks (such as dressing, bathing, and preparing meals), it suffered from substantial ceiling effects when administered to relatively high-functioning, community-dwelling older adults. Many active older adults reported maximum confidence on basic indoor tasks despite harboring significant apprehension when navigating uneven terrain, carrying out dual-task activities, or attending social events in crowded public environments. The ProFaNE consortium purposefully engineered the FES-I to remedy these limitations by introducing items measuring advanced mobility and social engagement (e.g., walking on slippery or uneven surfaces, walking up or down a slope, visiting friends or relatives, attending social events). As a consequence, the 16-item FES-I exhibits a markedly broader measurement continuum without floor or ceiling distortions across diverse functional strata.

In clinical practice, the FES-I and Short FES-I serve as critical diagnostic screening instruments to identify individuals requiring targeted psychological, physical therapy, or occupational therapy interventions. The instruments allow clinicians to differentiate between realistic caution proportional to physiological balance impairment and maladaptive, disproportionate fear that impedes rehabilitation engagement. In prospective clinical trials, the scale serves as a standardized primary or secondary outcome measure to assess the efficacy of balance training, cognitive behavioral therapy (CBT), tai chi programs, and multi-component fall-prevention regimens.

5. Psychological Construct

The central construct quantified by the FES-I is fall-related self-efficacy, clinically manifested and measured as concern about falling. In psychological literature, the terminology surrounding fear of falling has evolved across three related constructs: fear of falling (an emotional and phobic reaction), balance confidence (a task-specific confidence belief), and fall efficacy (an individual’s perceived capability to perform functional tasks without falling). Although the instrument retains “efficacy” in its historical name, the ProFaNE consensus group deliberately substituted the operative phrasing of the questionnaire items from “How confident are you…” to “How concerned are you that you might fall…”. This modification was adopted because “concern” translates more reliably across diverse European languages and cultural contexts than “confidence” or “efficacy”, reducing linguistic ambiguities and avoiding the overtly emotional or stigmatizing connotations associated with the term “fear”.

The construct encompasses several distinct functional and environmental operational domains:

• Basic Indoor Activities of Daily Living (ADL): Encompasses foundational personal management tasks characterized by familiar, controlled indoor environments with minimal dynamic perturbations (e.g., getting dressed or undressed, preparing simple meals, getting in or out of a chair).
• High-Demand Personal Hygiene & Postural Adjustments: Reflects intermediate postural challenge within wet or confined domestic settings, including stepping over thresholds and reaching outside the base of support (e.g., taking a bath or shower, reaching for something above the head or on the ground).
• Dynamic Dual-Task / Urgent Reactivity: Captures cognitive-motor interference and hasty motor planning, such as answering the telephone before it stops ringing, which requires rapid movement transitions under cognitive distraction.
• Outdoor Environmental Challenges & Locomotion: Encompasses navigation across unpredictable physical surfaces (e.g., walking on slippery surfaces, uneven ground, walking up or down slopes, walking around the neighborhood), where environmental friction, incline, and visual feedback vary continuously.
• Social and Instrumental Participation: Measures complex, ecologically valid integration into the community (e.g., visiting friends or relatives, walking in crowded environments, attending religious or community social gatherings). This domain uniquely addresses the social withdrawal and isolation secondary to fall apprehension.

The Short FES-I (7 items) preserves the breadth of this construct by selectively retaining sentinel items across low, medium, and high difficulty levels (Items 2, 4, 6, 7, 9, 15, and 16), ensuring representative assessment of both basic domestic transitions and challenging community participation.

6. Theoretical Framework

The theoretical architecture of the FES-I is grounded in Albert Bandura‘s Social Cognitive Theory, specifically the construct of perceived self-efficacy. Bandura defines self-efficacy as an individual’s belief in their capability to organize and execute the courses of action required to produce given attainments. In the context of postural control and geriatric mobility, self-efficacy does not assess an individual’s motor capacity per se, but rather their cognitive appraisal of capability within specific situational demands.

Bandura posited four foundational sources of self-efficacy expectations: enactive mastery experiences (prior personal performance successes or failures, such as past fall events), vicarious experiences (observing peers fall or navigate challenges), verbal persuasion (encouragement or cautionary warnings from family members and healthcare providers), and physiological/affective states (somatosensory cues, autonomic arousal, dizziness, or tremor associated with postural instability). When an older adult experiences an initial fall or near-fall, the resulting negative physiological arousal and cognitive appraisal can diminish balance self-efficacy. According to the fear-avoidance model adapted to falls (Vlaeyen & Linton framework), low self-efficacy fosters catastrophic misinterpretations of normal postural sway, instigating protective avoidance behaviors. This behavioral avoidance initiates a downward spiral: physical disuse induces muscle atrophy, vestibular degradation, and gait instability, which in turn reinforces low self-efficacy and elevates actual physiological fall risk.

The FES-I operates as a standardized operationalization of this appraisal mechanism. By indexing the exact degree of concern across an escalating continuum of environmental threats, the scale maps an individual’s cognitive appraisal threshold, identifying the precise inflection point where perceived postural capability dissociates from actual physical capacity.

7. Validity

The psychometric validity of the FES-I and Short FES-I has been evaluated extensively across numerous international cohorts, clinical sub-types, and linguistic adaptations.

Construct and Convergent Validity

Construct validity is evidenced by strong, statistically significant correlations with validated instruments measuring related psychological and physical parameters. The FES-I exhibits high convergent validity with the Activities-specific Balance Confidence (ABC) Scale, with negative correlation coefficients typically ranging between $r = -0.75$ and $r = -0.86$ (the negative sign reflects opposing scoring vectors, as higher ABC scores denote greater confidence). Furthermore, FES-I scores correlate moderately to strongly with objective physical performance metrics:

• Timed Up and Go (TUG) Test: Pearson/Spearman coefficients consistently range from $r = 0.42$ to $r = 0.60$, demonstrating that prolonged completion times align with heightened fall concern.
• Gait Speed: Habitual and maximal walking velocities demonstrate inverse correlations with FES-I scores ($r = -0.40$ to $-0.55$).
• Short Physical Performance Battery (SPPB): Total SPPB scores negatively correlate with FES-I ($r = -0.45$ to $-0.58$), confirming that lower physical capacity corresponds to higher fear of falling.

Discriminant and Known-Groups Validity

The instrument demonstrates exceptional known-groups validity. In validation trials across Germany, the UK, the Netherlands, and Scandinavia, the FES-I discriminated unambiguously between recurrent fallers ($ge 2$ falls in the past 12 months), single fallers, and non-fallers ($p < 0.001$). Mean FES-I scores are systematically higher among individuals utilizing walking aids, individuals with diagnosed neurological disorders (e.g., Parkinson's disease, multiple sclerosis), and those with self-reported fair-to-poor health status. Cut-off scores established by Delbaere et al. (2010) identify three distinct clinical risk bands: low concern (16–19), moderate concern (20–27), and high concern (28–64). For the Short FES-I, the corresponding bands are low concern (7–8), moderate concern (9–13), and high concern (14–28).

Predictive Validity

Longitudinal prospective cohort studies demonstrate that baseline FES-I scores independently predict future prospective falls, recurrent falls, functional decline in basic ADLs, and nursing home admission over 12- and 24-month follow-up horizons, even after statistically controlling for age, sex, medication count, and baseline physiological fall risk metrics.

8. Reliability

The reliability profile of the FES-I and Short FES-I is among the most robust recorded for geriatric self-report instruments.

Internal Consistency

Across the primary validation studies conducted by Kempen et al. (2007, 2008), the 16-item FES-I demonstrated exceptional internal consistency, with Cronbach’s alpha ($lpha$) ranging from $0.92$ to $0.96$ across general older population samples in the United Kingdom, Germany, the Netherlands, and Spain. Corrected item-total correlations across all 16 items remain well above the standard psychometric threshold of $0.40$, typically spanning $0.55$ to $0.82$. The 7-item Short FES-I similarly demonstrates high internal consistency, with Cronbach’s alpha values consistently situated between $0.88$ and $0.92$, demonstrating that item reduction does not compromise scale coherence.

Test-Retest Reliability and Stability

Test-retest reliability evaluated across intervals ranging from 1 to 4 weeks yields outstanding stability. The Intraclass Correlation Coefficient ($ICC$) for the full 16-item scale ranges between $0.79$ and $0.96$ (typically $ICC ge 0.88$ in stable community cohorts). For the Short FES-I, test-retest reliability yields $ICC$ values between $0.80$ and $0.93$. Weighted kappa coefficients ($\kappa_w$) for individual items range from $0.50$ to $0.75$, reflecting moderate to substantial individual item stability.

Measurement Error and Responsiveness

The Standard Error of Measurement ($SEM$) for the 16-item FES-I is approximately $2.5$ to $3.2$ points, and the Smallest Detectable Change ($SDC$ or Minimal Detectable Change, $MDC_{95}$) is established between $6.9$ and $8.8$ points on the 16–64 scale. For the Short FES-I, the $MDC_{95}$ approximates $3.5$ to $4.2$ points. Changes exceeding these thresholds can be inferred with 95% statistical confidence to represent true functional changes rather than measurement artifact.

9. Factor Analysis

The latent structural dimensionality of the FES-I has been rigorously analyzed via both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA), complemented by Item Response Theory (IRT) and Mokken scale analysis.

Dimensionality

Initial principal components and confirmatory analyses conducted by the ProFaNE group supported a single dominant general factor accounting for over $55%$ to $65%$ of total variance, supporting the computation of a single unidimensional composite sum score. However, several subsequent structural investigations identify a robust two-factor oblique solution:

• Factor 1: Less demanding / Basic Indoor ADL: Comprising items 1 through 6, and item 9 (cleaning, dressing, preparing meals, bathing, getting in/out of a chair, reaching). Factor loadings for this dimension typically range from $0.68$ to $0.88$.
• Factor 2: Highly demanding / Outdoor & Social Mobility: Comprising items 7, 8, 10, 11, 12, 13, 14, 15, and 16 (stairs, walking in neighborhood, rushing to phone, slippery surfaces, crowds, uneven surfaces, slopes, social events). Factor loadings for this outdoor/complex dimension typically range from $0.62$ to $0.85$.

Because these two latent factors correlate highly ($r > 0.70$), hierarchical and bifactor models confirm that a single overarching general factor (“general fall-related concern”) accounts for the vast majority of common variance, justifying clinical reliance on the total composite score.

Model Fit Indices

Confirmatory factor analytic models specifying either the single-factor model with correlated residuals or the two-factor oblique structure exhibit satisfactory to excellent goodness-of-fit indices across published literature:

• Comparative Fit Index (CFI): Values routinely exceed $0.94$ (frequently $ge 0.96$).
• Tucker-Lewis Index (TLI): Values consistently range between $0.93$ and $0.96$.
• Root Mean Square Error of Approximation (RMSEA): Values typically range between $0.052$ and $0.078$, falling within standard acceptable bounds.
• Standardized Root Mean Square Residual (SRMR): Values generally remain $le 0.05$.

Item Response Theory & Differential Item Functioning (DIF)

Rasch and graded response model (GRM) analyses confirm an ordered item difficulty hierarchy. Items such as Item 2 (“Getting dressed or undressed”) and Item 3 (“Preparing simple meals”) anchor the lower severity/difficulty end of the latent trait ($ heta$), functioning as indicators of severe impairment. Conversely, Item 11 (“Walking on a slippery surface”) and Item 14 (“Walking on an uneven surface”) anchor the high severity end, detecting mild concern among highly functioning older adults. Evaluation of Differential Item Functioning across age groups and biological sexes shows minimal bias, confirming scale invariance across demographic segments.

10. Instrument / Measurement Tool

The operational specifications of the Falls Efficacy Scale International instruments are structured as follows:

• Tool Name: Falls Efficacy Scale International (FES-I) and Short Falls Efficacy Scale International (Short FES-I).
• Construct Assessed: Level of concern regarding falling during physical, domestic, and social activities of daily living.
• Respondent Target Population: Community-dwelling older adults, geriatric clinical inpatients, outpatients undergoing physical rehabilitation, and individuals diagnosed with chronic neurological or musculoskeletal pathologies (e.g., Parkinson’s disease, vestibular failure, post-stroke hemiparesis, severe osteoarthritis).
• Administration Format: Self-administered paper-and-pencil questionnaire, face-to-face clinical interview, or standardized telephone interview. Proxy administration is discouraged due to systematically higher proxy ratings of concern compared to patient self-appraisal.
• Completion Time:
  • 16-item FES-I: Approximately 3 to 5 minutes.
  • 7-item Short FES-I: Approximately 1 to 2 minutes.
• Item Composition:
  • Full FES-I: 16 items encompassing indoor self-care, dual-task physical transitions, hazardous surfaces, and social/community mobility.
  • Short FES-I: 7 nested items extracted from the 16-item version (Items 2, 4, 6, 7, 9, 15, and 16).
• Authentic Response Scale: 4-point ordinal Likert scale presented uniformly across all items:
  • 1 = Not at all concerned
  • 2 = Somewhat concerned
  • 3 = Fairly concerned
  • 4 = Very concerned
• Scoring Algorithm & Range:
  • Full 16-item FES-I: Sum of all 16 items. Theoretical score range: 16 to 64. No reverse-scored items.
  • Short 7-item FES-I: Sum of the 7 selected items (2, 4, 6, 7, 9, 15, 16). Theoretical score range: 7 to 28. No reverse-scored items.
  • Missing Data Imputation: If up to 4 items are missing on the 16-item scale, calculate the mean of the remaining completed items and multiply by 16 to estimate total score. If more than 4 items are missing, the assessment is invalid. On the Short FES-I, if more than 1 item is missing, the questionnaire is voided.
• Validated Clinical Cut-Off Thresholds (Delbaere et al., 2010):
  • 16-item FES-I:
    • 16–19: Low fall-related concern
    • 20–27: Moderate fall-related concern
    • 28–64: High fall-related concern
  • 7-item Short FES-I:
    • 7–8: Low fall-related concern
    • 9–13: Moderate fall-related concern
    • 14–28: High fall-related concern

11. Permissions & Fee and Test Year

The original Falls Efficacy Scale was developed in 1990 by Tinetti, Richman, and Powell. The 16-item Falls Efficacy Scale International (FES-I) was developed and standardized in 2005–2007 by the Prevention of Falls Network Europe (ProFaNE). The 7-item Short FES-I was formally published in 2008.

Licensing and Accessibility: The FES-I and Short FES-I are open-access instruments available free of charge for non-commercial clinical, educational, and research use. The instruments, comprehensive administration manuals, scoring protocols, and validated linguistic translations into over 25 languages (including Dutch, German, French, Spanish, Italian, Swedish, Chinese, and Portuguese) are coordinated and hosted via the official FES-I Coordination Website maintained through the University of Manchester and ProFaNE network. Commercial entities or pharmaceutical clinical trials incorporating the instrument within proprietary digital platforms or commercial trial packages should contact the FES-I steering committee / University of Manchester for formal licensing protocols. Modifications of scale wording or response categories are strictly prohibited to maintain standardized cross-study comparability.

12. References

• Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191–215. https://doi.org/10.1037/0033-295X.84.2.191
• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman and Company.
• Delbaere, K., Close, J. C., Mikolaizak, A. S., Sachdev, P. S., Brodaty, H., & Lord, S. R. (2010). The Falls Efficacy Scale International (FES-I). A comprehensive longitudinal validation study. Age and Ageing, 39(2), 210–216. https://doi.org/10.1093/ageing/afp225
• Kempen, G. I. J. M., Todd, C. J., Van Haastregt, J. C. M., Zijlstra, G. A. R., Beyer, N., Freiberger, E., Hauer, K. A., Piot-Ziegler, C., & Yardley, L. (2007). 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, 29(2), 155–162. https://doi.org/10.1080/09638280600747637
• Kempen, G. I. J. M., Yardley, L., Van Haastregt, J. C. M., Zijlstra, G. A. R., Beyer, N., Hauer, K., & Todd, C. (2008). The Short FES-I: A shortened version of the Falls Efficacy Scale-International to assess fear of falling. Age and Ageing, 37(1), 45–50. https://doi.org/10.1093/ageing/afm157
• Tinetti, M. E., Richman, D., & Powell, L. (1990). Falls efficacy as a measure of fear of falling. Journal of Gerontology, 45(6), P239–P243. https://doi.org/10.1093/geronj/45.6.p239
• Yardley, L., Beyer, N., Andersson, K., Burlet, F., Djonne, B., Kempen, G., Piot-Ziegler, C., & Todd, C. (2005). Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age and Ageing, 34(6), 614–619. https://doi.org/10.1093/ageing/afi196

13. Items of the Scale (Questionnaire)