Investigating the appropriateness of the Pittsburgh Sleep Quality Index (PSQI) in a

non-clinical Cypriot sample

Dr. Panayiotis Panayides

Its development was based on:

• psychiatrists’ clinical intuition • experience with sleep disorder patients • a review of other sleep quality questionnaires found in the literature and • clinical experience with the instrument during 18 months of field work.

(Buysse, Reynolds, MonK, Berman & Kupfer, 1989).

In order to:

• to provide a reliable, valid, and standardized measure of sleep quality• to discriminate between “good” and “poor” sleepers• to provide an index that is easy for subjects to use and for clinicians and researchers to interpret and • to provide a brief, clinically useful assessment of a variety of sleep disturbances that might affect sleep quality.

(Buysse, Reynolds, MonK, Berman & Kupfer, 1989, p.194)

The PSQI is a self-rated instrument used to measure sleep quality in clinical samples.

- It consists of 19 self rated questions

- Grouped into 7 components

subjective sleep quality,

sleep latency,

sleep duration,

habitual sleep efficiency,

sleep disturbances,

use of sleeping medications and

daytime dysfunction.

- Each component is scored separately, weighted equally on a 0 – 3 scale.

- The scores of the 7 components are then added to give a global PSQI score, which

has a range of 0 – 21 with higher scores indicating worse sleep quality.

- Three of the components are measured by one question, two components by 2

questions, one component by 3 and one by 9.

The PSQI Structure

1. During the past month, what time have you usually gone to bed at night? BED TIME ___________

2. During the past month, how long (in minutes) has it usually taken you to fall asleep each night?

NUMBER OF MINUTES ___________

3. During the past month, what time have you usually gotten up in the morning? GETTING UP TIME ___________

4. During the past month, how many hours of actual sleep did you get at night? (This may be different than the number of hours you spent in bed.)

HOURS OF SLEEP PER NIGHT ___________ For each of the remaining questions, check the one best response. Please answer all questions. 5. During the past month, how often have you had trouble sleeping because you . a) Cannot get to sleep within 30 minutes Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ b) Wake up in the middle of the night or early morning Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ c) Have to get up to use the bathroom Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ d) Cannot breathe comfortably Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ e) Cough or snore loudly Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ f) Feel too cold Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ g) Feel too hot Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____

The PSQI Items

h) Had bad dreams Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ i) Have pain Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ j) Other reason(s), please describe__________________________________________ How often during the past month have you had trouble sleeping because of this? Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ 6. During the past month, how would you rate your sleep quality overall? Very good _____ Fairly good ______ Fairly bad ______Very bad ______ 7. During the past month, how often have you taken medicine to help you sleep (prescribed or "over the counter")? Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ 8. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity? Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ 9. During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done? No problem at all _____Only a very slight problem _____ Somewhat of a problem _____ A very big problem __________

The seven componentsComponent 1: Subjective sleep quality = Score Q6

Q6. During the past month, how would you rate your sleep quality overall?Very good _____ Fairly good ______ Fairly bad ______Very bad ______

Component 2: Sleep latency = Score Q2 + Score Q5a

Q2. During the past month, how long (in minutes) has it usually taken you to fall asleep each night?NUMBER OF MINUTES ___________

1 <=15, 2 16 – 30, 3 31 – 60, 4 >60

Q5. During the past month, how often have you had trouble sleeping because you . . .a) Cannot get to sleep within 30 minutes

0 If sum = 0 1 If sum = 1 – 2 2 If sum = 3 – 4 3 If sum = 5 – 6

Component 3: Sleep duration = Score Q4

Q4. During the past month, how many hours of actual sleep did you get at night? (This may be different than the number of hours you spent in bed.)HOURS OF SLEEP PER NIGHT ___________

0 > 7, 1 6 – 7, 2 5 – 6, 3 < 5

Component 4: Habitual Sleep Efficiency =

0 If >= 85%, 1 75 – 84% 2 65 – 74% 3 < 65%

Component 5: Sleep Disturbances = Sum of score Q5b, …, Q5j (9 items)0 If sum = 0 1 If sum = 1 – 9 2 If sum = 10 – 18 3 If sum = 19 – 27

b) Wake up in the middle of the night or early morning Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ c) Have to get up to use the bathroom d) Cannot breathe comfortably e) Cough or snore loudly f) Feel too cold g) Feel too hot h) Had bad dreams i) Have pain j) Other reason(s), please describe__________________________________________ How often during the past month have you had trouble sleeping because of this?

.%......13

4

QScoreQScoreQScore

Component 6: Use of Sleep Medication = Score Q7

Q7. During the past month, how often have you taken medicine to help you sleep (prescribed or "over the counter")?

Component 7: Daytime Dysfunction = Score Q8 + Score Q9

Q8. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?

Q9. During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?

0 If sum = 0 1 If sum = 1 – 2 2 If sum = 3 – 4 3 If sum = 5 – 6

The original study Reliability evidence:

- Cronbach’s alpha (0.83) for the whole 19-item questionnaire and for the 7 component scores

- Test-retest correlation of 0.85 for the global scores and for the component scores

- No differences in the global scores and on the component scores from the two different applications

(stable responses across time).

Validity evidence

- Detection of differences between the 3 distinct groups

o the ‘good sleepers’ (52 healthy control subjects with no complaints about sleep),

o The ‘poor sleepers’ (34 patients with major depressive disorder) and

o another ‘poor sleepers’ group (62 patients with disorder of initiating and maintaining sleep or

disorder of excessive somnolence).

- Concurrent polysomnographic findings and

- Correlations between global score and component scores. Subjective sleep quality 0.76 and sleep

disturbances 0.35 (the 9-item component).

Another difference (between the PSQI and other instruments) is that these other questionnaires have used factor analysis to generate specific factors, while the PSQI components are empirical and clinical in origin rather than statistical

(Buysse, Reynolds, MonK, Berman & Kupfer, 1989, p.203)

Other validation studies with samples of

• elderly people (Buysse, Reynolds, Monk, Berman & Kupfer, 1991)

• patients with AIDS (Rubinstein & Selwyn, 1998)

• patients with panic disorders (Stein, Chartier, & Walker, 1993)

• cancer patients (Beck et al., 2004)

• patients with primary insomnia

(Backhaus, Junghanns, Broocks, Riemann & Hohagen, 2002)

• bone marrow transplant patients and women with breast cancer

(Carpenter & AndryKowski, 1998)

• Nigerian students (Aloba, Adewuya, Ola & Mapayi 2007).

Only in one study Chien, Hsu, Tai, Guo and Su (2008) have used Rasch analyses to validate a revised version of the PSQI (9 items instead of the original 18).

The sampleStratified sampling (By area of residence urban or rural, age and gender)

Age

18 – 24 25 – 34 35 – 44 45 – 54 55 – 64 65 +

Total

Male 42 56 57 48 39 39 281 (47%) Gender

Female 45 59 67 60 39 49 319 (53%)

Total 87 115 124 108 78 88 600

+ 15 depression patients (for validation purposes)

415 (69.2%) lived in urban areas and 185 (30.8%) in rural areas

Rasch Rating Scale Diagnostics

1. Category frequencies

2. Average measures (a.m) Average of the ability estimates for all persons who choose that particular response category on any item in the scale. (Useful for quick observation of initial problems with the rating scale)

They should increase monotonically, indicating that on average, those with higher ability / stronger attitude endorse the higher categories

3. Threshold or step calibrationsThresholds should also increase monotonically across the rating scale, otherwise they are considered disordered.Distances between threshold estimates should indicate that each step defines a distinct position on the variable. (i.e. should be neither too close together nor too far apart)Between 1.4 – 5 logits to avoid large gaps in the variable. (Linacre, 1999; Bond & Fox, 2001, p. 224)

4. Fit StatisticsOutfit > 2 indicate more misinformation than information (Linacre, 1999), meaning that the category is introducing noise into the measurement process. Those categories warrant further empirical investigation and might be good candidates for collapsing with adjacent categories.

Regular distributions (Uniform, Normal, Bimodal, slightly skewed) are preferableLow Frequencies do not provide enough observations for estimation of stablethresholds. Recommended min frequency 10 (Linacre 1999)

ANALYSES 1 – Component 5 (Sleep Disturbances, 9 items)

component STATISTICS: MISFIT ORDER-----------------------------------------------------------------------------------------|ENTRY RAW MODEL| INFIT | OUTFIT |PTMEA|EXACT MATCH| ||NUMBER SCORE COUNT MEASURE S.E. |MNSQ ZSTD|MNSQ ZSTD|CORR.| OBS% EXP%| component||------------------------------------+----------+----------+-----+-----------+----------|| 9 265 526 .29 .05|1.27 3.3|1.15 1.2|A .36| 52.7 56.3| item 5j || 4 411 526 -.06 .05|1.15 2.4|1.27 2.6|B .42| 39.9 44.6| item 5e || 5 254 526 .32 .05|1.18 2.2|1.18 1.3|C .34| 58.2 60.6| item 5f || 6 196 526 .51 .06|1.13 1.3|1.10 .7|D .32| 67.5 67.6| item 5g || 7 291 526 .22 .05| .88 -1.7|1.10 .9|E .37| 53.2 55.6| item 5h || 3 220 526 .42 .06|1.06 .7| .86 -1.0|d .39| 68.1 66.5| item 5d || 2 785 526 -.74 .04| .91 -1.9| .88 -1.8|c .63| 28.9 27.8| item 5c || 8 464 526 -.17 .04| .90 -1.8| .82 -2.1|b .54| 41.3 40.2| item 5i || 1 816 526 -.79 .04| .77 -5.2| .70 -4.9|a .70| 36.3 29.8| item 5b ||------------------------------------+----------+----------+-----+-----------+----------|| MEAN 411.3 526.0 .00 .05|1.03 -.1|1.01 -.4| | 49.6 49.9| || S.D. 223.6 .0 .45 .01| .16 2.6| .18 2.2| | 13.0 14.1| |-----------------------------------------------------------------------------------------

Table of STANDARDIZED RESIDUAL variance (in Eigenvalue units) -- Empirical -- ModeledTotal raw variance in observations = 14.1 100.0% 100.0% Raw variance explained by measures = 5.1 36.0% 35.8% Raw variance explained by persons = 2.7 19.0% 18.8% Raw Variance explained by items = 2.4 17.0% 16.9% Raw unexplained variance (total) = 9.0 64.0% 100.0% 64.2% Unexplned variance in 1st contrast = 1.6 11.5% 18.0%

STANDARDIZED RESIDUAL CONTRAST 1 PLOT -1 0 1 -+--------------------------------+--------------------------------+- COUNT .8 + | + | 1 | | 1 .7 + | + | 2 | | 1C .6 + | +O | | |N .5 + | +T | | |R .4 + | +A | | |S .3 + | +T | | | .2 + | +1 | | | .1 + | 9 + 1L | | |O .0 +---------------------------------|---------------------------------+A | | |D -.1 + | +I | | |N -.2 + 8 | 7 + 2G | | 3 | 1 -.3 + | 6 + 1 | | | -.4 + | 5 + 1 | 4 | | 1 -+--------------------------------+--------------------------------+- -1 0 1 component MEASURE COUNT: 1 1 1 1 1 1 1 1 1

During the past month, how often have you had trouble sleeping because you: b) Wake up in the middle of the night or early morning c) Have to get up to use the bathroom

ANALYSES 2 – The seven Components

Component 1: Subjective sleep quality

Component 2: Sleep latency

Component 3: Sleep durationComponent 4: Habitual Sleep Efficiency

Component 5: Sleep DisturbancesComponent 6: Use of Sleep MedicationComponent 7: Daytime Dysfunction

component STATISTICS: MISFIT ORDER----------------------------------------------------------------------------------------|ENTRY RAW MODEL| INFIT | OUTFIT |PTMEA|EXACT MATCH| ||NUMBER SCORE COUNT MEASURE S.E. |MNSQ ZSTD|MNSQ ZSTD|CORR.| OBS% EXP%| component||------------------------------------+----------+----------+-----+-----------+----------|| 6 78 585 2.53 .13|2.27 8.2|1.04 .3|A .43| 92.5 88.7| comp 6 || 7 445 585 -.09 .07|1.47 6.9|1.41 5.7|B .46| 50.6 54.8| comp 7 || 4 287 585 .68 .08|1.30 4.1| .98 -.2|C .65| 70.1 66.7| comp 4 || 2 599 585 -.69 .06|1.12 2.0|1.07 1.3|D .69| 47.9 52.3| comp 2 || 3 660 585 -.91 .06|1.11 2.0|1.11 1.9|c .59| 46.5 52.0| comp 3 || 5 666 585 -.93 .06| .54 -9.9| .64 -7.2|b .66| 66.3 51.9| comp 5 || 1 569 585 -.58 .06| .54 -9.7| .55 -9.3|a .77| 70.3 52.1| comp 1 ||------------------------------------+----------+----------+-----+-----------+----------|| MEAN 472.0 585.0 .00 .07|1.19 .5| .97 -1.1| | 63.4 59.8| || S.D. 203.1 .0 1.16 .02| .55 6.9| .27 4.9| | 15.3 12.8| |----------------------------------------------------------------------------------------

Use of Sleep Medication

5 5 21

569

0

100

200

300

400

500

600

1 2 3 4

Categories

Freq

uenc

y

15 out of the 21 3s 4 out of the 5 2s

MOST UNEXPECTED RESPONSEScomponent MEASURE |person | 21 1 254 443443511421 421 555432221114 533145 |721968 4132353292149968328751878741188764141371215 |81964380250977973701308737495940821386012204097199 high-------------------------------------------------- 5 comp 5 -.93 5|...11...1......................................... 3 comp 3 -.91 3|............00.00....0............................ 2 comp 2 -.69 2|2........00........0...........33.3...3.33......2. 1 comp 1 -.58 1|...........................................3...... 7 comp 7 -.09 7|2010...0.0............333...3.3..3..33......2222.1 4 comp 4 .68 4|...................33....3...3.....2...2.......... 6 comp 6 2.53 6|.333333.33.33223223..3....33..............1....... |----------------------------------------------low- |72196184125454434435114218421875554322211141533145 |821648 0232373292149968327751948741188764144371215 | 19 3 509 797370130873 495 082138601220 097199

1,99 - 0.19 - 1.32

Table of STANDARDIZED RESIDUAL variance (in Eigenvalue units) -- Empirical -- ModeledTotal raw variance in observations = 13.6 100.0% 100.0% Raw variance explained by measures = 6.6 48.4% 50.0% Raw variance explained by persons = 4.3 31.5% 32.6% Raw Variance explained by items = 2.3 16.9% 17.5% Raw unexplained variance (total) = 7.0 51.6% 100.0% 50.0% Unexplned variance in 1st contrast = 1.6 11.6% 22.4% Unexplned variance in 2nd contrast = 1.4 10.7% 20.7% Unexplned variance in 3rd contrast = 1.1 8.4% 16.3% Unexplned variance in 4th contrast = 1.1 7.9% 15.3% Unexplned variance in 5th contrast = 1.0 7.2% 13.9%

STANDARDIZED RESIDUAL CONTRAST 1 PLOT -1 0 1 2 3 -+---------------+---------------+---------------+---------------+- COUNT | | | .7 + | 4 + 1 | | | .6 + | + | 3 | | 1 .5 + | +C | | |O .4 + | +N | | |T .3 + | +R | | |A .2 + | +S | | |T .1 + | + | 2 | | 11 .0 +----------------|------------------------------------------------+ | 1 | | 1L -.1 + | 6 + 1O | | |A -.2 + | +D | | |I -.3 + | +N | | |G -.4 + | + | | | -.5 + 5 | + 1 | | | -.6 + | + | | | -.7 + 7| + 1 -+---------------+---------------+---------------+---------------+- -1 0 1 2 3 component MEASURE COUNT: 2 1 1 1 1 1

SUMMARY OF CATEGORY STRUCTURE. Model="R"-------------------------------------------------------------------|CATEGORY OBSERVED|OBSVD SAMPLE|INFIT OUTFIT||STRUCTURE|CATEGORY||LABEL SCORE COUNT %|AVRGE EXPECT| MNSQ MNSQ||CALIBRATN| MEASURE||-------------------+------------+------------++---------+--------|| 0 0 1845 45| -2.73 -2.66| .97 .98|| NONE |( -2.80)| 0| 1 1 1407 34| -1.10 -1.20| .85 .58|| -1.58 | -.83 | 1| 2 2 632 15| -.06 -.21| .92 .92|| .09 | .87 | 2| 3 3 211 5| .57 1.09| 1.55 2.06|| 1.49 |( 2.74)| 3-------------------------------------------------------------------

CATEGORY PROBABILITIES: MODES - Structure measures at intersectionsP -+---------+---------+---------+---------+---------+---------+-R 1.0 + +O | |B | |A | |B .8 +00 333+I | 00 33 |L | 000 33 |I | 00 33 |T .6 + 00 33 +Y | 0 33 | .5 + 00 111111111111 2222222 33 +O | 1** 111 2222 22*2 |F .4 + 111 0 2*1 33 22 + | 11 00 222 11 33 222 |R | 111 00 22 11 3 222 |E | 11 0022 1*3 222 |S .2 +111 2200 333 111 222+P | 222 000 33 11 |O | 2222 0***3 1111 |N | 2222222 333333 000000 1111111 |S .0 +*******3333333333333333 00000000000000000******+E -+---------+---------+---------+---------+---------+---------+- -3 -2 -1 0 1 2 3 person [MINUS] component MEASURE

MOST MISFITTING RESPONSE STRINGSperson OUTMNSQ |component |5321746 high------- 259 1259 9.90 A|......3 474 1474 9.90 B|......3 160 1160 8.48 C|.0....3 57 1057 5.60 D|.0....3 397 1397 5.55 E|.0....3 235 1235 5.49 F|..0.0.3 340 1340 5.38 G|......3 96 1096 5.11 H|1...0.3 221 1221 4.33 I|....0.3 439 1439 4.62 J|......3 64 1064 3.52 K|1.....3 12 1012 3.49 L|1.....3 355 1355 2.91 M|....1.3 440 1440 3.23 N|......1 542 1542 2.89 O|....3.. 119 1119 2.72 P|....1.3 423 1423 3.17 Q|.0....2

Should component 6 be removed from the PSQI ?(in the case of using it in a non-clinical sample)

ANALYSES 3 – The whole PSQI

7. During the past month, how often have you taken medicine to help you sleep (prescribed or "over the counter")?

8. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?

5e. During the past month, how often have you had trouble sleeping because you cough or snore loudly

component STATISTICS: MISFIT ORDER-----------------------------------------------------------------------------------------|ENTRY RAW MODEL| INFIT | OUTFIT |PTMEA|EXACT MATCH| ||NUMBER SCORE COUNT MEASURE S.E. |MNSQ ZSTD|MNSQ ZSTD|CORR.| OBS% EXP%| component||------------------------------------+----------+----------+-----+-----------+----------|| 15 78 585 1.30 .10|1.81 4.3| .88 -.6|A .30| 94.2 88.6| item 7 || 16 308 585 .17 .05|1.44 5.4|1.57 4.5|B .28| 51.5 58.1| item 8 || 8 411 585 -.10 .05|1.39 5.8|1.52 4.8|C .35| 43.2 48.6| item 5e || 13 265 585 .30 .06|1.51 5.6|1.18 1.5|D .35| 60.0 62.3| item 5ja || 10 196 585 .55 .07|1.41 3.9|1.34 2.3|E .27| 69.9 71.2| item 5g || 9 254 585 .33 .06|1.40 4.4|1.35 2.7|F .31| 60.3 62.7| item 5f || 7 220 585 .45 .06|1.35 3.6|1.11 .9|G .35| 69.2 67.6| item 5d || 11 291 585 .22 .05|1.03 .4|1.11 1.0|H .34| 56.6 59.9| item 5h || 3 660 585 -.60 .04| .84 -3.4|1.07 1.1|I .40| 39.8 35.2| item 4 || 12 464 585 -.22 .05|1.07 1.3| .94 -.6|h .51| 41.0 43.1| item 5i || 6 785 585 -.82 .04|1.03 .6| .99 -.1|g .57| 30.9 33.4| item 5c || 17 378 585 -.02 .05| .84 -2.6|1.00 .1|f .41| 49.9 52.0| item 9 || 2 287 585 .23 .06| .88 -1.6| .75 -2.4|e .47| 62.1 60.0| comp 4 || 4 638 585 -.56 .04| .82 -3.8| .75 -3.8|d .63| 41.4 37.4| item 5a || 5 816 585 -.87 .04| .80 -4.6| .73 -4.7|c .67| 37.4 33.9| item 5b || 1 348 585 .06 .05| .66 -5.8| .79 -2.1|b .47| 59.8 55.1| item 2 || 14 569 585 -.43 .04| .36 -9.9| .44 -9.3|a .65| 63.2 39.7| item 6 ||------------------------------------+----------+----------+-----+-----------+----------|| MEAN 409.9 585.0 .00 .05|1.10 .2|1.03 -.3| | 54.7 53.5| || S.D. 207.2 .0 .53 .01| .36 4.5| .29 3.4| | 15.0 14.8| |-----------------------------------------------------------------------------------------

Table of STANDARDIZED RESIDUAL variance (in Eigenvalue units) -- Empirical -- ModeledTotal raw variance in observations = 26.2 100.0% 100.0% Raw variance explained by measures = 9.2 35.1% 35.4% Raw variance explained by persons = 5.5 21.0% 21.2% Raw Variance explained by items = 3.7 14.1% 14.2% Raw unexplained variance (total) = 17.0 64.9% 100.0% 64.6% Unexplned variance in 1st contrast = 2.0 7.8% 12.0%

STANDARDIZED RESIDUAL CONTRAST 1 PLOT -1 0 1 2 -+---------------------+---------------------+---------------------+- COUNT | A | | 1 .6 + B | + 1 | | |C .5 + | +O | | |N .4 + |D C + 2T | | |R .3 + | +A | E | | 1S .2 + | +T | | G F | 2 .1 + H | + 11 | | | .0 +----------------------|--------------------------------------------+L | | |O -.1 + h I | + 2A | | |D -.2 + | g f + 2I | | e d | 2N -.3 + | +G | | | -.4 + c b + 2 | | | -.5 + | + | | a | 1 -+---------------------+---------------------+---------------------+- -1 0 1 2 component MEASURE COUNT: 11 11 1 1 1 11 12 2 1 1 1

SUMMARY OF CATEGORY STRUCTURE. Model="R"-------------------------------------------------------------------|CATEGORY OBSERVED|OBSVD SAMPLE|INFIT OUTFIT||STRUCTURE|CATEGORY||LABEL SCORE COUNT %|AVRGE EXPECT| MNSQ MNSQ||CALIBRATN| MEASURE||-------------------+------------+------------++---------+--------|| 0 0 6099 61| -1.36 -1.35| .98 .98|| NONE |( -1.49)| 0| 1 1 1748 18| -.73 -.79| .85 .75|| .19 | -.40 | 1| 2 2 1074 11| -.38 -.36| 1.02 1.01|| -.08 | .39 | 2| 3 3 1024 10| .00 .02| 1.05 1.27|| -.11 |( 1.51)| 3------------------------------------------------------------------- CATEGORY PROBABILITIES: MODES - Structure measures at intersectionsP -+--------------+--------------+--------------+--------------+-R 1.0 + +O | |B |00 3|A | 00000 33333 |B .8 + 000 3333 +I | 000 333 |L | 000 33 |I | 00 333 |T .6 + 00 33 +Y | 00 33 | .5 + 0 3 +O | 00 33 |F .4 + 00 33 + | 0 3 |R | 00 33 |E | 11111111111***2222222222222 |S .2 + 1111111 222** 11**1 222222 +P | 111111 2222333 0**111 2222222 |O |11111 222223333 00011111 222|N | 222222222*33333 00000**11111111 |S .0 +*****333333333 00000000******+E -+--------------+--------------+--------------+--------------+- -2 -1 0 1 2

0123

0122

CATEGORY PROBABILITIES: MODES - Structure measures at intersectionsP -+--------------+--------------+--------------+--------------+-R 1.0 + +O | |B |0000 2222|A | 0000 2222 |B .8 + 0000 2222 +I | 000 222 |L | 000 222 |I | 00 22 |T .6 + 00 22 +Y | 00 22 | .5 + 00 22 +O | 00 22 |F .4 + 00 22 + | 2*0 |R | 222 000 |E | 111**111111111**111 |S .2 + 1111111222 0001111111 +P | 1111111 222 000 1111111 |O |1111111 22222 00000 1111111|N | 222222222 000000000 |S .0 +2222 0000+E -+--------------+--------------+--------------+--------------+- -2 -1 0 1 2 person [MINUS] component MEASURE

SUMMARY OF CATEGORY STRUCTURE. Model="R"-------------------------------------------------------------------|CATEGORY OBSERVED|OBSVD SAMPLE|INFIT OUTFIT||STRUCTURE|CATEGORY||LABEL SCORE COUNT %|AVRGE EXPECT| MNSQ MNSQ||CALIBRATN| MEASURE||-------------------+------------+------------++---------+--------|| 0 0 6099 61| -1.99 -1.98| .97 .98|| NONE |( -1.89)| 0| 1 1 2822 28| -.81 -.85| .93 .84|| -.62 | .00 | 1| 2 2 1024 10| -.04 .03| 1.08 1.27|| .62 |( 1.89)| 3-------------------------------------------------------------------

0112

CATEGORY PROBABILITIES: MODES - Structure measures at intersectionsP -+--------------+--------------+--------------+--------------+-R 1.0 + +O | |B | |A | |B .8 +00 22+I | 000 222 |L | 0000 2222 |I | 00 22 |T .6 + 000 222 +Y | 000 222 | .5 + 00 1111111 22 +O | 0**11111 11111**2 |F .4 + 11111 00 22 11111 + | 1111 000 222 1111 |R | 1111 000 222 1111 |E | 1111 22*00 1111 |S .2 +111 222 000 111+P | 2222 0000 |O | 22222 00000 |N | 22222222222 00000000000 |S .0 +22222 00000+E -+--------------+--------------+--------------+--------------+- -2 -1 0 1 2 person [MINUS] component MEASURE

0 1 2 3 0 1 2 2 0 1 1 2

PCA of st. residuals

Var. explained by Measures 35.1 % 33.6 % 33.8 %

1st factor eigenvector 2.0 2.1 2.0

% of Unexplained variance 12 % 12.2 % 12.2 %

% of Total variance 7.8 % 8.1 % 8.0 %

Item fit Infit msq One (1.81) --- One (1.54)

Outfit msq Two (1.57, 1.52) One (1.53) ---

ReliabilityPerson Reliability 0.67 0.69 0.71

Person Separation 1.44 1.50 1.56

Strata 2.25 2.33 2.41

Categories Disordered Disordered Ordered

Original 4-category model 3-category models

b) Wake up in the middle of the night or early morning Not during the Less than Once or twice Three or more past month once a week a week_____ times a week c) Have to get up to use the bathroom d) Cannot breathe comfortably e) Cough or snore loudly f) Feel too cold g) Feel too hot h) Had bad dreams i) Have pain j) Other reason(s), please describe__________________________________________ How often during the past month have you had trouble sleeping because of this?

9 items

5 b) Wake up in the middle of the night or early in the morning5 c) Have to get up to use the bathroom5 de) Having breathing problems or snoring5 fg) Feeling too cold or too hot5 hij) Have any other problems (like pains, bad dreams, …. )

5 items

0 1 1 2 0 1 1 2

PCA of st. residuals

Var. explained by Measures 34.7 % 39.0 %

1st factor eigenvector 2.0 2.0

% of Unexplained variance 12 % 15.4 %

% of Total variance 7.8 % 9.4 %

Item fit Infit msq --- ---

Outfit msq --- ---

ReliabilityPerson Reliability 0.71 0.73

Person Separation 1.58 1.64

Strata 2.44 2.52

Categories Nicely ordered Nicely ordered

PSQI 17 items 13

misfitting persons13 (2.2%) removed 15 (2.5%)Outfit > 2.30

.8 +0 2+I | 0000 2222 |L | 000 222 |I | 000 222 |T .6 + 000 222 +Y | 00 22 | .5 + 000 11111111111 222 +O | **1111 1111** |F .4 + 1111 000 222 1111 + | 1111 000 222 1111 |R | 1111 00 22 1111 |E | 11111 *** 11111 |S .2 +11 2222 0000 11+P | 2222 0000 |O | 22222 00000 |N | 22222222222 00000000000 |S .0 +22222 00000+E -+--------------+--------------+--------------+--------------+- -2 -1 0 1 2

|00 22|A | 0000 2222 |B .8 + 000 222 +I | 00 22 |L | 000 222 |I | 00 22 |T .6 + 00 22 +Y | 0 111111111 2 | .5 + 00 111 111 22 +O | 1** **1 |F .4 + 111 00 22 111 + | 11 00 22 11 |R | 111 0 2 111 |E | 111 00*22 111 |S .2 + 111 22 00 111 +P | 1111 222 000 1111 |O |11 2222 0000 11|N | 2222222 0000000 |S .0 +22222222222222 00000000000000+E -+---------+---------+---------+---------+---------+---------+- -3 -2 -1 0 1 2 3

-0.66 0.661.32

-0.88 0.881.76

17 items

13 items

-6

-5

-4

-3

-2

-1

0

1

2

3

4

5

6

-6 -4 -2 0 2 4 6

measure 17

Mea

sure

13

r = 0.991

FINAL CALIBRATION

component STATISTICS: MISFIT ORDER -----------------------------------------------------------------------------------------|ENTRY RAW MODEL| INFIT | OUTFIT |PTMEA|EXACT MATCH| ||NUMBER SCORE COUNT MEASURE S.E. |MNSQ ZSTD|MNSQ ZSTD|CORR.| OBS% EXP%| component||------------------------------------+----------+----------+-----+-----------+----------|| 9 194 570 .76 .09|1.47 6.1|1.43 3.8|A .32| 67.9 72.7| item 8 || 8 38 570 2.82 .17|1.44 2.6| .48 -2.2|B .35| 95.4 93.7| item 7 || 11 325 570 -.08 .07|1.41 6.6|1.44 5.5|C .42| 53.7 62.2| item 5de || 12 256 570 .33 .08|1.30 4.6|1.22 2.5|D .43| 62.6 65.8| item 5fg || 6 512 570 -1.01 .07|1.11 2.2|1.09 1.6|E .61| 49.6 55.8| item 5c || 10 275 570 .21 .08| .96 -.7|1.08 1.0|F .43| 61.9 65.1| item 9 || 3 438 570 -.66 .07| .89 -2.2|1.07 1.3|G .37| 57.7 57.1| item 4 || 13 481 570 -.87 .07| .95 -.9| .92 -1.4|f .63| 58.6 56.9| item 5hij|| 1 259 570 .31 .08| .77 -4.1| .93 -.8|e .49| 68.9 65.6| item 2 || 4 435 570 -.64 .07| .92 -1.6| .86 -2.5|d .68| 56.5 57.1| item 5a || 2 207 570 .66 .09| .91 -1.4| .81 -2.1|c .55| 73.3 70.9| comp 4 || 5 536 570 -1.12 .07| .90 -2.0| .84 -2.9|b .72| 58.2 56.1| item 5b || 7 448 570 -.71 .07| .50 -9.9| .55 -9.1|a .65| 75.4 57.3| item 6 ||------------------------------------+----------+----------+-----+-----------+----------|| MEAN 338.8 570.0 .00 .08|1.04 -.1| .98 -.4| | 64.6 64.3| || S.D. 143.2 .0 1.02 .03| .28 4.3| .28 3.5| | 11.5 10.1| |-----------------------------------------------------------------------------------------

persons - MAP - components <more>|<rare> | item 7 | . | | . | 2 +T . | | # | | . | 1 .## T+S | item 8 .# | comp 4 .# | .## | item 2 item 5fg .#### | item 9 0 .#### +M item 5de S| .##### | ######## | .####### | item 4 item 5a item 6 ########## | item 5hij -1 ######### +S item 5c M| item 5b .########## | .########## | | .######### | -2 +T .######### | S| .######## | | | -3 .####### + | | T| .##### | | -4 ### + <less>|<frequ> EACH '#' IS 5.

Use of sleep medication

Staying awake Sleep efficiency

How long to sleep, Too cold or too hotTo keep enough enthusiasmBreathing or snoring

Hours actual sleep, Can’t sleep 30 min, Rate Quality of Sleep Other reason

Bathroom Wake up middle of night/early morning

Distinct Group Comparisons

Depression patients vs Non-clinical subjects

(Doi et al., 2000; Buysse, Reynolds, Monk, Berman and Kupfer, 1989)

Group Statistics

600 -1,3648 1,25538 ,0512515 -,0785 ,69317 ,17898

Depression Or Not1,002,00

measureN Mean Std. Deviation

Std. ErrorMean

p = 0.000

Gender, with higher rate of complaints and worse quality of sleep found in women

(Campbell, Gillin, Kripke, Erikson & Clopton, 1989; Lindberg, Janson, Gislason, Bjornsson, Hetta & Boman, 1997; Manni, Ratti, Marchioni, Castelnovo, Murelli, Sartori, Galimberti & Tartara, 1997).

Group Statistics

281 -1,6329 1,30826 ,07804319 -1,1287 1,15850 ,06486

GenderMaleFemale

measureN Mean Std. Deviation

Std. ErrorMean p = 0.000

Age, with older people having a higher sleep disorder rate (Foret, Bensimon, Benoit, & Vieux, 1981; Marquie and Foret, 1999)

Descriptives

measure

87 -1,8267 1,15633 ,12397 -4,96 ,53115 -1,6616 1,03212 ,09625 -4,96 ,74124 -1,5673 1,31490 ,11808 -4,96 1,77108 -1,3040 1,10876 ,10669 -4,96 2,1278 -1,2348 1,27582 ,14446 -4,96 1,4788 -,4249 1,19776 ,12768 -4,96 2,54

600 -1,3648 1,25538 ,05125 -4,96 2,54

18 - 2425 - 3435 - 4445 - 5455 - 6465 +Total

N Mean Std. Deviation Std. Error Minimum Maximum

ANOVA

measure

113,233 5 22,647 16,192 ,000830,780 594 1,399944,013 599

Between GroupsWithin GroupsTotal

Sum ofSquares df Mean Square F Sig.

People living in Urban areas vs Rural areas

Correlations

1 ,265**,000

615 600,265** 1,000600 600

Pearson CorrelationSig. (2-tailed)NPearson CorrelationSig. (2-tailed)N

measure

Mass Index

measure Mass Index

Correlation is significant at the 0.01 level (2-tailed).**.

Group Statistics

415 -1,4431 1,22200 ,05999185 -1,1893 1,31370 ,09659

AreaUrbanRural

measureN Mean Std. Deviation

Std. ErrorMean

p = 0.022

THANK YOU FOR YOUR ATTENTION

PSQI 13 - Invariance Plot

-2

-1

0

1

2

3

4

-2 -1 0 1 2 3 4

Item Estimates (Urban)

Item

Est

imat

es (R

ural

)