Frenchay Activities Index (FAI)

Evidence Reviewed as of before: 19-08-2008
Author(s): Lisa Zeltzer, MSc OT
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Frenchay Activities Index (FAI) is a measure of instrumental activities of daily living (IADL) for use with patients recovering from stroke. The FAI assesses a broad range of activities associated with everyday life. The benefit of the FAI is that while activities of daily living scales tend to focus on issues related to self-care and mobility (Holbrook & Skilbeck, 1983), the FAI provides a broader measurement of actual activities patients have undertaken in the recent past (Wade, Legh-Smith, & Langton, 1985).

In-Depth Review

Purpose of the measure

The Frenchay Activities Index (FAI) is a measure of instrumental activities of daily living (IADL) for use with patients recovering from stroke. The FAI assesses a broad range of activities associated with everyday life. The benefit of the FAI is that while activities of daily living scales tend to focus on issues related to self-care and mobility (Holbrook & Skilbeck, 1983), the FAI provides a broader measurement of actual activities patients have undertaken in the recent past (Wade, Legh-Smith, & Langton, 1985).

Available versions

The FAI was published by Margaret Holbrook and Clive E. Skilbeck in 1983.

Features of the measure

Items

The FAI contains 15 items or activities that can be separated into 3 subscales; Domestic chores, Leisure/work and Outdoor activities.

The items of the FAI are as follows:

  1. Preparing main meals
    Must play a substantial part in organization, preparation and cooking.
  2. Washing up
    Must do all or share equally, e.g. washing or wiping and putting away.
  3. Washing clothes
    Organization of washing and drying clothes. Sharing task equally, e.g. loading, unloading, hanging, folding.
  4. Light housework
    Dusting, ironing, tidying small objects. Anything heavier is included in item 5.
  5. Heavy housework
    Changing beds, cleaning floors, windows, vacuuming, moving chairs, etc.
  6. Local shopping
    Substantial role in organizing and buying groceries. Can include collection of pension or going to the Post Office.
  7. Social outings
    Going out to clubs, cinema, theatre, drinking, dinner with friends, etc. May be transported there, provided patient takes an active part once arrived. Includes social activities at home, initiated by the patient.
  8. Walking outdoors over 15 minutes
    Sustained walking for at least 15 minutes (allowed short stops for breath).
  9. Pursuing active interest in hobby
    Must require ‘active’ participation, e.g. caring for houseplants, knitting, reading specialist magazines or window-shopping.
  10. Driving a car
    Must drive a car, or get to a bus/coach and travel on it independently.
  11. Outings/car rides
    Train, bus, or car rides to some place for pleasure, not for a routine social outing. Must involve patient organization and decision-making. Holidays within the last 6 months are divided into days/month (e.g. a 7-day holiday = 1 or 2 days/month).
  12. Gardening
    Light = occasional weeding or sweeping; Moderate = regular weeding, raking, pruning; Heavy = all necessary work including heavy digging.
  13. Household and/or car maintenance
    Light = repairing small items, replacing lightbulb or plug; Moderate = spring cleaning, hanging a picture, routine car maintenance; Heavy = painting/decorating, most necessary household/car maintenance.
  14. Reading books
    Full-length books, not magazines or newspapers. Can be talking books.
  15. Gainful work
    Paid work, not voluntary work. The time worked should be averaged out over six months (e.g., 1 month working for 18 hours/week over the 6-month period would be scored as ‘up to 10 hours/week’).

Time

The FAI takes approximately 5 minutes to complete when administered in an interview format (with or without the patient’s family) (Segal & Schall, 1994).

Scoring

The frequency with which each item or activity is undertaken over the past 3 or 6 months (depending on the nature of the activity) is assigned a score of 1 – 4 where a score of 1 = lowest level of activity. The scale provides a summed score from 15 – 60.

A modified 0-3 scoring system introduced by Wade et al. (1985) yields a score of 0 – 3 for each item, and a summed score from 0 – 45.

Note: In patients with stroke, the FAI should be used to assess pre-morbid IADL at 3 and 6 months before stroke, and subsequently to record changes in IADL following stroke, at specific intervals (Holbrook & Skilbeck, 1983). Studies typically examine change in post-stroke IADL by examining patients at 1 year after stroke, and looking retrospectively at the past 3 and 6 months.

Subscales

There are 3 subscales to the FAI:

  • Domestic (items 1-5)
  • Leisure/work (items 7, 9, 11, 13, 15)
  • Outdoors (items 6, 8, 10, 12, 14)

Equipment

Only the questionnaire and a pencil are needed to complete the FAI.

Training

No training is required to complete the FAI. The FAI is most often interview-administered.

The FAI can be used as a mailed questionnaire. Carter, Mant, Mant, Wade, and Winner (1997) reported an excellent correlation between mailed questionnaire FAI scores and face-to-face interview scores (r = 0.94).

The FAI can also be used with a proxy respondent. Proxy agreement was excellent for the FAI (intraclass correlation coefficient (ICC) = 0.85) (Segal & Schall, 1994). Holbrook and Skilbeck (1983) found that information obtained by relatives were interchangeable with information acquired from the patient. Segal and Schall (1994) reported proxy agreement for the three subscales as ranging from adequate (ICC = 0.59 for Leisure/work) to excellent (ICC = 0.77 for Domestic and Outdoors).

Alternative Forms of the FAI

  • FAI-18 (Miller, Deathe, & Harris, 2004).
    Three items (sport/recreation and visiting in the last 3 months, and banking in the last 6 months) were added to the FAI and the reliability was examined in patients with lower limb amputation. The total score of the FAI-18 ranges from 0 to 54. Support for the concurrent validity (r = -0.46), the Prosthetic Evaluation Questionnaire-Mobility Scale (r = 0.40) and the Activities-specific Balance Confidence Scale (r = 0.52). The FAI-18 was not found to offer any advantage over the original FAI and therefore use of the original FAI is recommended to ensure results are comparable between populations and studies. Further, the FAI-18 has not been examined in patients with stroke.
  • Modified FAI (Tooth, McKenna, Smith, & O’Rourke, 2003).
    A 13-item modified version has been developed based on the recommendations by Schuling, de Haan, Limburg, and Groenier (1993) to omit the items ‘reading books’ and ‘gainful work’. At 6 months post-stroke, the internal consistency of the 13 FAI items was excellent when scored by patients (alpha = 0.85) and when scored by proxies (alpha = 0.83). However, the internal consistency of each subscale examined separately varied widely.

Client suitability

Can be used with

  • Patients with stroke.
  • Can also be used with patients with cognitive impairment, using a proxy respondent. The focus of the FAI is on frequency of activity rather than quality of activity. This may reduce elements of subjectivity, which typically undermine the reliability of proxy assessment (Segal & Schall, 1994).

Should not be used with

  • When examining FAI scores, male and female scores should be considered separately as there is evidence of a gender bias in FAI scores (Holbrook & Skilbeck, 1983). Sveen, Bautz-Holter, Sodring, Wyller, and Laake (1999) reported that men had significantly higher scores in the Outdoor activities subscale, and there was a trend towards women having higher scores in the Domestic activity subscale.
  • Due to individual variability, the FAI should not be administered by interview and by mailed questionnaire, sequentially (Carter et al., 1997).
  • Use caution when examining proxy ratings at the item level, because there is less agreement than what has been observed with the total score (Wyller, Sveen, & Bautz-Holter, 1996; Tooth et al., 2003).
  • Be aware of the biases involved with proxy use. Tooth et al. (2003) reported that patients tend to score themselves as performing activities more frequently than proxy respondents especially in meal preparation, heavy housework, social outings, driving and home maintenance. In addition, male proxy respondents and respondents who are relatives (rather than spouses) tend to give higher ratings, particularly in the area of domestic activities.

In what languages is the measure available?

  • English
  • Dutch – translated (Schuling, de Haan, Limburg, & Groenier, 1993)
  • Chinese – translated and validated (Hsueh & Hsieh, 1997)

Summary

What does the tool measure? Instrumental Activities of Daily Living
What types of clients can the tool be used for? Patients with stroke
Is this a screening or assessment tool? Assessment
Time to administer Interview: 5 minutes (with or without the patient’s family)
Versions FAI-18, Modified FAI
Other Languages Chinese (translated and validated), Dutch (translated)
Measurement Properties
Reliability
  • Out of 3 studies examining internal consistency, 3 reported excellent internal consistency.
  • Out of 4 studies examining test-retest, 3 reported excellent test-retest, and one reported a range from poor to excellent depending on item examined.
  • Out of 2 studies examining inter-rater reliability, 2 studies reported excellent inter-rater reliability as measured by intraclass correlation coefficients. Using Cohen’s kappa, 1 study reported adequate to excellent reliability and 1 study reported poor to excellent reliability.
Validity

Criterion: Excellent correlation between postal and interview FAI scores, however individual differences on scores ranged widely between mailed and postal responses taken 10 days later.

Construct: Excellent correlations with Rankin Scale ; SF-36 (Physical Functioning subscale). Adequate to excellent correlations with the Sickness Impact Profile ; Barthel Index ; Functional Independence Measure (Motor subscale); Euroqol. Adequate correlations with Stroke Adapted Sickness Impact Profile ; SF-36 (Social Functioning and Vitality subscales); two-minute walk test, Timed Up and Go test ; Prosthetic Evaluation Questionnaire-Mobility; Activities-specific Balance Confidence Scale.

Known groups: The FAI has been found to distinguish stroke severity in male patients only and can discriminate between patients in a pre-stroke versus a reference group, and patients’ pre-stroke and post-stroke levels of activity.

Does the tool detect change in patients?
  • One study reported an “obvious” floor effect for individuals examined at 6 months post-stroke.
  • Out of 2 studies examined, 1 reported that the FAI had a moderate ability to detect change (in patients 6-12 months post-stroke) and 1 reported that the FAI changed in the expected direction from pre-stroke to 6 months post-stroke, to 1 year post-stroke.
Acceptability The FAI is short, simple, and encourages participation of significant others or family members. It is suitable for use with proxy respondents.
Feasibility The FAI is simple to administer and requires no training or special equipment. It has been used for longitudinal assessment.
How to obtain the tool? A copy of the original FAI provided in Holbrook, M., Skilbeck, C. E. (1983). An activities index for use with stroke patients. Age and Ageing, 12(2), 166-170.

Psychometric Properties

Overview

For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the FAI. In general, the FAI has good overall reliability, however it has considerable variability in the strength of agreement at the level of individual scale item scores (reported both for test-retest and inter-rater reliability). Further, there is little evidence regarding the responsiveness of the FAI.

Floor/Ceiling Effects

Schuling et al. (1993) examined the psychometric properties of the FAI in a group of patients with stroke and a control group of individuals from the general population aged 65 or older. No ceiling effects were reported in this study.

Similarly, Wade et al. (1985) examined the psychometric properties of the FAI using data from 976 patients with acute stroke. No ceiling effects were reported.

Pederson et al. (1997) examined the FAI in 437 patients with stroke and reported an “obvious” floor effect at 6 months post-stroke.

Walters, Morrell and Dixon (1999) examined the psychometric properties of four generic instruments in 233 patients with venous leg ulcers. The FAI demonstrated an adequate floor effect of 2.1%. No ceiling effect was observed.

Reliability

Internal consistency:

Schuling et al. (1993) examined the internal consistency of the FAI retrospectively in a group of patients with stroke and a control group of individuals from the general population aged 65 or older. They looked at the internal consistency of the FAI pre-stroke, 6 months post-stroke and in control patients. An excellent internal consistency was reported for the total score of the FAI in the control group (alpha = 0.83) and in patients post-stroke (alpha = 0.87). An adequate alpha coefficient was reported for patients pre-stroke (alpha = 0.78). When subscales were examined individually, the Domestic subscale had excellent alpha coefficients (alpha = 0.82 for control and pre-stroke; 0.88 for post-stroke). The Leisure/work subscale had poor internal consistency in all groups (control, alpha = 0.63; pre-stroke, alpha = 0.58; post-stroke, alpha = 0.61). The Outdoors subscale also had poor internal consistency in all groups (control, alpha = 0.67; pre-stroke, alpha = 0.55; post-stroke, alpha = 0.66). However, when item 14 (reading books) was deleted, alpha coefficients were adequate for control and post-stroke groups (alpha = 0.72, alpha = 0.73, respectively) and remained poor in the pre-stroke group (alpha = 0.66).

Tooth et al. (2003) examined the agreement between patients with stroke and their proxies using a modified version of the FAI (13 items). At 6 months post-stroke, the internal consistency of the 13 FAI items was excellent when scored by patients (alpha = 0.85) and when scored by proxies (alpha = 0.83). The internal consistency of each subscale examined separately varied widely. Coefficient alphas for the Domestic, Leisure, and Outdoor subscales completed by patients ranged from poor to excellent (0.83, 0.38, 0.66, respectively), as did completion by proxies (0.83, 0.59, 0.57, respectively).

Miller et al. (2004) compared the reliability of the FAI to a modified version, the FAI-18. The internal consistency of the FAI was excellent (alpha = 0.81).

Test-retest:

Wade et al. (1985) examined the test-retest reliability of the FAI and reported that the overall agreement of individual items was variable. Heavy housework, local shopping, walking outside and social outings failed to reach statistical significance, while other items demonstrated excellent agreement (r = 0.80).

Green, Forster, and Young (2001) examined the test-retest reliability of the Barthel Index (Mahoney & Barthel, 1965), the Rivermead Mobility Index (Nouri & Lincoln, 1987), the Nottingham Extended Activities of Daily Living Scale (Whiting & Lincoln, 1980), and the FAI in 22 patients > 1 year post-stroke, tested twice at an interval of 1 week. Kappa coefficients for the FAI ranged from poor (kappa = 0.25 for heavy housework) to excellent (kappa = 1.00 for preparing main meals). The results of this study indicate that basic measures of activities of daily living (as measured by the Barthel Index and Rivermead Mobility Index) may be more reliable than the measures used to assess IADL.

Turnbull, Kersten, Habib, McLellan, Mullee, and George (2000) assessed the reliability of the FAI to establish age and sex norms in people age 16 years and over. A postal questionnaire survey was sent to 1,280 people. Then 57 respondents completed a re-test questionnaire. Test-retest reliability of the postal version of the FAI was excellent, with a correlation of r = 0.96.

Miller et al. (2004) examined the reliability of the FAI in 84 individuals with lower limb amputation. Individuals completed the FAI twice, within two weeks. The ICC for the FAI was excellent (ICC = 0.79), demonstrating the test-retest reliability of the FAI.

Inter-rater:

Piercy, Carter, Mant, and Wade (2000) examined the inter-rater reliability of the FAI in 35 patients with stroke and 24 individuals who were the main caregivers for patients with stroke. Two raters evaluated each person, 15 days apart on average. Kappa statistics showed an excellent level of agreement for 3/15 items (kappas ranging from 0.77-0.80). An adequate level of agreement was found for 10/15 items (kappas ranging from 0.42-0.73). The other 2 items showed poor agreement (social outings, 0.27; pursuing active interest in hobby, 0.35). Three items showed significant differences between the two raters (light housework, outing/car rides, household and/or car maintenance). Spearman’s correlation for FAI totals of rater B verses rater A was excellent (r = 0.93). The results of this study confirm the reliability of the FAI when administered by interview.

Post and de Witte (2003) examined the inter-rater reliability of the Dutch version of the FAI in 45 patients with stroke. The FAI was administered twice, with 3-5 days in between evaluations. The total inter-rater reliability of the FAI was excellent (ICC = 0.90). At item level, kappa coefficients ranged from adequate to excellent (kappa = 0.41-0.90).

Validity

Construct

Wade et al. (1985) examined data from 976 patients with acute stroke. A factor analysis was conducted to demonstrate levels of communality among the FAI’s items. Correlations ranged from 0.44-0.77, suggesting the presence of a single underlying construct in that each item contributes to each of the three identified factors (Domestic; Leisure/work; Outdoors) to some extent.

Pedersen, Jorgensen, Nakayama, Raaschou, and Olsen (1997) examined whether the FAI was a good supplementary assessment to the Barthel Index (Mahoney & Barthel, 1965) for measuring higher order ADL functions in 437 patients with stroke. The FAI was found to be a heterogeneous scale comprised of 3 factors, two of which may represent increased item difficulties, and the third related to activities away from the home. Items from the Barthel Index and the FAI, when analyzed together, appeared on different, orthogonal factors, suggesting that the FAI supplements the Barthel Index with minimal content overlap.

Sveen et al. (1999) examined data from 65 patients with stroke to observe how motor and cognitive impairments relate to physical activities of daily living. In this study, the 3-factor structure of the FAI was confirmed. These three subscales include Domestic chores, Outdoor activities and Hobbies.

Concurrent:

Schuling et al. (1993) examined the construct validity of the FAI in patients with stroke, and in a group of unselected participants aged 65 or older. Functional status of the patients with stroke was measured at 26 weeks. Correlations between the FAI and the Sickness Impact Profile (Bergner, Bobbitt, Carter, & Gilson, 1981) subscales of Home management, Body care and movement, Mobility and Ambulation ranged from adequate to excellent (r = -0.56 to -0.73). The FAI also had an excellent correlation with the disability scores of the Barthel Index (Wade & Collin, 1988) (r = 0.66). These results provide evidence for the convergent validity of the FAI. Further, the discriminant validity of the FAI is supported by the poor correlation found between FAI scores and Emotional Behavior and Alertness Behavior scales of the Sickness Impact Profile (r = -0.15 and -0.14).

Note: Some correlations are negative because a high score on the FAI indicates a high level of functioning, where as a high score on the Sickness Impact Profile indicates less desirable health outcomes.

Sveen et al. (1999) examined data from 65 patients with stroke and found that Domestic chores and Outdoor activities (factors found in this study to make up the FAI) correlated adequately with Barthel Index (Mahoney & Barthel, 1965) scores (r = 0.58 and r = 0.50). Domestic chores was the factor most strongly related to arm motor function of the Barthel Index, and Outdoor activities was most strongly related to visuospatial ability. Hobbies, the third factor found in this study, did not correlate with Barthel Index scores (r = 0.11).

Tooth et al. (2003) examined the construct validity of the FAI in patients with stroke and their proxies using a modified version of the index (13 items). The total patient FAI score was found to correlate significantly with the Motor subscale of the Functional Independence Measure (Keith, Granger, Hamilton, & Sherwin, 1987) (r = 0.63) but not with the Cognitive subscale of the Functional Independence Measure (r = 0.09).

Cup, Scholte op Reimer, Thijssen, and van Kuyk-Minis (2003) administered a number of different standardized measures to 26 patients with stroke. The FAI had excellent correlations with the Barthel Index (Mahoney & Barthel, 1965) (r = 0.79), the Euroqol (r = 0.65) (EuroQol Group, 1990), and the Rankin Scale (r = -0.80) (de Haan, Limburg, Bossuyt, van der Meulen, & Aaronson, 1995). The FAI an adequate correlation with the Stroke Adapted Sickness Impact Profile-30 (van Straten, de Haan, Limburg, Schuling, Bossuyt, & van den Bos, 1997) (r = -0.43).

Note: Some correlations are negative because a high score on the FAI indicates a high level of functioning, where as a high score on the Stroke Adapted Sickness Impact Profile-30 and the Rankin Scale indicates less desirable health outcomes.

Segal and Schall (1994) examined the proxy agreement between 38 patients with stroke and their caregivers. Using Spearman’s rho, the FAI and the Functional Independence Measure (Keith et al., 1987) were found to have an excellent correlation (r = 0.80).

Hsueh, Lee, and Hsieh (2001) examined the psychometric properties of the Barthel Index (Mahoney & Barthel, 1965) in 121 patients with stroke. The FAI was compared to the Barthel Index at 180 days after stroke and was found to have an adequate correlation with the Barthel Index scores obtained at 14, 30, and 90 days after stroke (Pearson’s r = 0.59).

Walters et al. (1999) examined the psychometric properties of four generic instruments: Short-Form Health Survey (SF-36) (Ware & Sherbourne, 1992); EuroQol (EuroQol Group, 1990); McGill Short Form Pain Questionnaire (Melzack, 1975) and the FAI in 233 patients with venous leg ulcers. Correlations were calculated using Pearson Product Moment Correlations. The FAI had an excellent correlation with the SF-36 subscale of Physical Functioning (r = 0.72). Poor correlations between FAI and the SF-36 subscales of Role Limitations-Physical (r = 0.25), Role Limitations-Emotional (r = 0.11), Pain (r = 0.28), General Health Perceptions (r = 0.30), and Mental Health (r = 0.26) were observed. Adequate correlations were found between the FAI and the SF-36 subscales of Social Functioning (r = 0.35), and Vitality (r = 0.45). The FAI had a moderate correlation with the EuroQol Derived Single Index (r = 0.54), and a poor correlation with the McGill Pain Questionnaire Sensory (r = -0.12) and Affective (r = -0.13) subscales. Note: Some correlations are negative because a high score on the FAI indicates a high level of functioning, where as a high score on other measures indicates less desirable health outcomes.

Miller et al. (2004) examined the concurrent validity of the FAI in 84 individuals with lower limb amputation. As predicted, the FAI correlated adequately with the Two-minute walk test (r = 0.53), the Timed Up and Go test (Podsiadlo & Richardson, 1991) (r = -0.49), the Prosthetic Evaluation Questionnaire-Mobility Scale (Legro, Reiber, Smith, del Aguila, Larsen, & Boone, 1998) (r = 0.39), and the Activities-specific Balance Confidence Scale (Powell & Myers, 1995) (r = 0.51).

Note: Some correlations are negative because a high score on the FAI indicates a high level of functioning, whereas a high score on the Timed Up and Go test indicates less desirable health outcomes.

Known groups:

Holbrook and Skilbeck (1983) divided patients by stroke severity into ‘mild’ and ‘severe’ based on Rankin grade at the time of stroke. They reported that the FAI distinguished severity of stroke (by Rankin groupings) in male patients, who showed significantly poorer Domestic chores scores and Outdoor activities scores at follow up. However, stroke severity did not influence one-year follow-up for females.

Schuling et al. (1993) reported that the FAI was able to discriminate between patients in the pre-stroke group and patients in the reference group. The FAI was also discriminative of patients’ pre-stroke and post-stroke levels of activity.

Criterion

Carter et al. (1997) examined the agreement between postal and interview-administered versions of the FAI, and assessed the criterion validity of the postal version, using the interviewer method as the gold standard. An excellent Spearman’s correlation of r = 0.94 was found between mailed questionnaire FAI scores and face-to-face interview FAI scores. Individual differences on scores ranged widely between FAI responses by post and responses by interview 10 days later. At the level of individual items, kappas ranged from poor (kappa = 0.35 for travel outings/car rides) to excellent (kappa = 1.00 for gainful work). The postal version was found to be a satisfactory alternative to interview administration, however, due to poor agreement in scores for individual patients, the two approaches should not be used sequentially to monitor individual patient

Responsiveness

Schepers, Ketelaar, Visser-Meily, Dekker, and Lindeman (2006) compared the responsiveness of frequently used functional health status measures in stroke. The FAI and the Stroke Adapted Sickness Impact Profile detected the most changes and had moderate effect sizes for patients in the chronic phase (between 6 and 12 months post-stroke) of stroke rehabilitation.

Wade et al. (1985) reported that FAI scores changed in the expected direction from pre-stroke to 6 months post-stroke to 1 year post-stroke.

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  • Walters, S. J., Morrell, J., Dixon, S. (1999). Measuring health-related quality of life in patients with venous leg ulcers. Quality of Life Research, 8, 327-336.
  • Wyller, T. B., Sveen, U., Bautz-Holter, E. (1996). The Frenchay Activities Index in stroke patients: Agreement between scores by patients and by relatives. Disabil Rehabil, 18(9), 454-459.

See The Measure

How to obtain the FAI:

For a copy of the FAI with the scoring system by Wade et al. (1985), please click here.

A copy of the measure with the original scoring system is also provided in Holbrook, M., Skilbeck, C. E. (1983). An activities index for use with stroke patients. Age and Ageing, 12(2), 166-170.

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