Article published online: 2024-04-09

THIEME
Original Article

Test-Retest Reliability of a Bilingual Arabic-English

Pittsburgh Sleep Quality Index among Adolescents and
Young Adults with Good or Poor Sleep Quality
Ashokan Arumugam1,2,3,4 Shima A. Mohammad Zadeh1,2 Hanan Youssef Alkalih1
Zina Anwar Zabin Tamara Mohd. Emad Hawarneh1 Hejab Iftikhar Ahmed1 Fatema Shabbir Jauhari1
1

Alham Al-Sharman1,2

1 Department of Physiotherapy, College of Health Sciences, University Address for correspondence Ashokan Arumugam
of Sharjah, Sharjah, United Arab Emirates (email: ashokanpt@gmail.com; aarumugam@sharjah.ac.ae).
2 Neuromusculoskeletal Rehabilitation Research Group, Research
Institute of Medical and Health Sciences (RIMHS), University of
Sharjah, Sharjah, United Arab Emirates
3 Sustainable Engineering Asset Management Research Group, 4 Department of Physiotherapy, Manipal College of Health
Research Institute of Sciences and Engineering (RISE), University of Professions, Manipal Academy of Higher Education, Manipal,
Sharjah, Sharjah, United Arab Emirates Karnataka, India

Sleep Sci

Abstract Introduction The Pittsburg Sleep Quality Index (PSQI) is widely used in different
population groups to assess self-reported sleep quality over the previous month. As the
Arabic language is spoken by more than 400 million people, the PSQI has been
translated into Arabic for its optimal application to Arabic-speaking individuals.
However, the test-retest reliability of the Arabic version of the PSQI has not been
reported yet.
Objective To examine the reliability and agreement of a bilingual Arabic-English
version of the PSQI (AE-PSQI) among bilingual Arabic-English-speaking adolescents and
young adults of the United Arab Emirates (UAE) with good or poor sleep quality.
Materials and Methods We included 50 bilingual Arabic-English-speaking adoles-
cents and young adults (mean age of 20.82
2.7 years; 30/50 subjects classified as
poor sleepers [PSQI > 5] at baseline) who filled put the AE-PSQI twice, 7 days apart. The
internal consistency of the AE-PSQI was assessed through the Cronbach’s alpha. The
intraclass correlation coefficient (ICC[3,1]) was used to assess the test-retest reliability.
The standard error of measurement (SEM), the smallest real difference (SRD), and the
Keywords Bland-Altman plots were used to report agreement measures.
► PSQI Results The global score on the AE-PQSI showed an acceptable level of internal
► reliability consistency with a Cronbach’s alpha value of 0.65, and no floor and ceiling effects were
► sleep quality observed. The 95% confidence intervals (95%CI: 0.63-0.87) of the ICC(3,1) revealed
► young adults moderate to strong reliability estimates for overall AE-PSQI scores. The SEM and SRD
► psychometric were of 1.6 and 4.5 respectively, and the Bland-Altman plots revealed a moderate
property agreement between the baseline and retest global AE-PQSI scores.

received DOI https://doi.org/ © 2024. Brazilian Sleep Association. All rights reserved.
June 22, 2023 10.1055/s-0044-1782170. This is an open access article published by Thieme under the terms of the
accepted ISSN 1984-0659. Creative Commons Attribution-NonDerivative-NonCommercial-License,
November 16, 2023 permitting copying and reproduction so long as the original work is given
appropriate credit. Contents may not be used for commercial purposes, or
adapted, remixed, transformed or built upon. (https://creativecommons.org/
licenses/by-nc-nd/4.0/)
Thieme Revinter Publicações Ltda., Rua do Matoso 170, Rio de
Janeiro, RJ, CEP 20270-135, Brazil
Test-Retest Reliability of a Bilingual Arabic-English PSQI Arumugam et al.

Conclusion The AE-PSQI is a reliable instrument to assess sleep quality in bilingual

Arabic-English-speaking adolescents and young adults with good or poor sleep quality.
Further studies on the validity and responsiveness of the AE-PSQI are warranted in
individuals with and without sleep disorders.

Highlights used and found to have adequate psychometric properties

and sensitivity of 89.6% and specificity of 86.5% (kappa
The internal consistency of the AE-PSQI was minimally ¼ 0.75; p < 0.001) in differentiating good from poor
acceptable for bilingual Arabic-English-speaking adolescents sleepers.22
and young adults with good or poor sleep quality. The PSQI has been translated into 51 languages.23 A
No floor and ceiling effects were observed for the AE-PSQI. systematic review revealed an acceptable internal consisten-
There was a moderate-to-strong (test-retest) reliability cy and construct validity24 for the English,25 Chinese,11
for almost all components and the overall score on the Korean,26 and Portuguese27 versions of the PSQI. The original
AE-PSQI. PSQI has been validated among different populations, such as
healthy individuals,28–30 and patients with sleep disorders,31
psychiatric disorders,32 neurological diseases, and chronic
Introduction
conditions.33,34 The internal consistency of the original PSQI
Good sleep quality in all age groups is essential for physical, has been found to be fair to good, with a Cronbach alpha
mental, and cognitive functioning, which could impact qual- coefficient ranging from 0.64 to 0.83.22,24 The original PSQI
ity of life1. Poor sleep quality has become a public health total score test-retest reliability estimates have been found to
concern that has been associated with several serious medi- be moderate (r ¼ 0.56) in pregnant women,35 and strong
cal conditions.1 This problem is becoming increasingly rec- (r ¼ 0.87) in individuals with primary insomnia.36
ognized for adolescents and young adults,2,3 and it is linked In 2010, the PSQI was translated into Arabic, and was
to obesity,4 depression, musculoskeletal pain,5–8 cognitive tested by Suleiman et al.37 (2010) on 35 healthy bilingual
impairments and increased risk-taking medications.1,9–11 Arabic-English-speaking individuals. It has correlated
Consequently, a reduction in physical functioning, psycho- strongly with the Insomnia Severity Index (ISI; r ¼ 0.76),
logical well-being, self-care, activities of daily living, ability and moderately with the vitality subscale of the Medical
to work, and interpersonal relationships has been reported Outcome Study Short Form-36 (r ¼ -0.33).37 However, the
to be associated with reduced sleep quality in adolescents Arabic translation of the PSQI has demonstrated
and young adults.3–7,10,12–17 Emphasizing the importance of borderline/minimal acceptability (Cronbach alpha ¼ 0.65).37
sleep quality and including sleep assessment as a major part Another study38 examined the internal consistency of the
of the routine clinical practice are necessary. Therefore, a Arabic PSQI in cancer patients and found a Cronbach alpha
better understanding of sleep quality assessment tools can coefficient of 0.77, demonstrating very good acceptability.
help in the identification and management of sleep problems According to a systematic review by Al Maqbali et al.23
before the patients suffer the long-term consequences asso- (2020), the Arabic PSQI meets the quality assessment criteria
ciated with poor sleep. for content, construct validity and internal consistency;
Sleep quality can be assessed objectively and subjectively. however, criterion validity agreement, reliability, respon-
Self-reported questionnaires were found to be one of the siveness, floor and ceiling effects, and interpretation have not
most used methods to assess subjective sleep quality among been reported. No study has specifically investigated the
different populations, including adolescents and young test-retest reliability of the Arabic version of the PSQI yet.39
adults. They are also known to be the most cost-effective Moreover, (self-administered) bilingual versions of
measurement method.18 The Pittsburgh Sleep Quality Index questionnaires/tests may be more useful and applicable
(PSQI), the Epworth Sleepiness Scale (ESS), and the Function- than the monolingual one for bilingual individuals.40–42
al Outcomes of Sleep Questionnaire (FOSQ) are often used to Therefore, in the present study we have examined the test-
assess an individual’s subjective sleep quality.19,20 The PSQI retest reliability of a bilingual Arabic-English PSQI (AE-PSQI)
contains 19 self-reported items and 5 questions covering 7 among healthy bilingual Arabic-English-speaking adoles-
domains of subjective sleep quality (including sleep dura- cents and young adults of the United Arab Emirates (UAE).
tion, disturbances, latency, daytime dysfunction, habitual
sleep efficiency, sleep quality, and use of sleeping medica-
Materials and Methods
tions) during the previous month. This tool has been
designed to identify and differentiate good and poor Participants
sleepers.21 The global PSQI score ranges from 0 to 21, and In the present cross-sectional study, 50 participants of both
higher scores are indicative of worse quality of sleep (scores sexes, aged between 14 and 26 years, with either poor or
> 5 indicate poorer sleep quality). The PSQI has been widely good sleep quality at the baseline assessment, were recruited

Sleep Science © 2024. Brazilian Sleep Association. All rights reserved.

 Test-Retest Reliability of a Bilingual Arabic-English PSQI Arumugam et al.

from schools and universities in the UAE. Participants were distribution was considered nearly normal if the number of
excluded if they had a medical condition or had recently participants is considered large enough ( > 30).47 There-
undergone surgeries that affected their sleep. The ethical fore, we used parametric tests for the statistical analysis. The
approval for this study was approved by the Research Ethics McNemar test was used to compare the proportion of
Committee of the University of Sharjah (REC-22-02-23-01-S). participants with good and poor sleep quality regarding
the baseline and retest global scores on the AE-PSQI. The
Procedure IBM SPSS Statistics for Windows (IBM Corp., Armonk, NY,
Body weight was measured to the nearest 100 g using a United States) software, version 28.0, was used for the
standard portable digital weighing scale. Height was mea- statistical analysis, and values of p < 0.05 were set as the
sured to the nearest 1 cm using a portable stadiometer. The threshold for statistical significance.
Body Mass Index (BMI) was calculated for each participant as
body weight (kg) divided by height in meters squared. Floor and Ceiling Effects
The floor and ceiling effects were assessed with the percent-
Pittsburgh Sleep Quality Index (PSQI) age of participants who scored the lowest (0) and highest
The overall sleep quality over the preceding month22 in (21) respectively. If more than 15% participants scored lowest
adolescents and young adults was assessed using the or highest scores, then floor or ceiling effects were consid-
PSQI,33 considering that this questionnaire is used among ered to exist.48
adolescents and young adults as a reliable and valid tool.43,44
It consists of 19 items divided into 7 sleep-related variables: Internal Consistency
1) sleep quality; 2) sleep latency; 3) sleep duration; 4) sleep Internal consistency refers to the degree of consistency
efficiency; 5) sleep disturbance; 6) medication use; among all internal items of the questionnaire. The internal
and 7) daytime dysfunction. Every item is rated on a 4-point consistency of the AE-PSQI was assessed using the Cronbach
Likert scale in terms of frequency or severity. The sum of the alpha; in addition, the item-to-total correlation was assessed
component scores yields a global PSQI score ranging from 0 using the Pearson correlation coefficient and the alpha values
to 21, with higher scores indicating poor sleep quality. for the tool, if each item was deleted, were reported. The
Scores > 5 indicate poor sleep quality, while those  5 item-to-total correlation refers to the correlation between
indicate good sleep quality.45 each item/component and the global score on the PSQI. The
alpha score was interpreted according to the following
Sample Size Estimation criteria: lower than 0.60: “unacceptable”; 0.60 to 0.65:
Considering a minimum acceptable reliability (intraclass “undesirable”; 0.65 to 0.70: “minimally acceptable”; 0.70
correlation coefficient, ICC) of 0.60, an expected reliability to 0.80 “respectable”; 0.80 to 0.90 “very good”; and much
(ICC) of 0.80, a significance level of 0.05, and a power higher than 0.90: “consider shortening the scale”.49
of 0.80, the number of participants required is 49 for
2 measurements (test [baseline] versus retest [after Test-Retest Reliability
7 days]).46 Therefore, 50 participants were recruited for We compared the Pearson correlation coefficient, the Spear-
the present study. man correlation coefficient, and the ICC ([3,1]; two-way mixed
effects, consistency, single measurements, agreement) for the
Procedure test-rest reliability analysis of the baseline PSQI global and
The subjects were invited to participate in the study through component scores and seven-day retest scores. As the reliabil-
social media adverts, university/school notice boards, and ity estimates were almost the same for all three analyses for all
word of mouth. The study procedures were explained to the comparisons, and there were 50 participants, the ICC(3,1) was
interested participants. Prior to being enrolled in the study, used for further interpretation; ICC values > 0.75 are consid-
participants and/or their parents read the information sheet ered strong, those from 0.40 to 0.75 are moderate, and those
and informed consent was provided by them (in the case of < 0.40 are considered poor to estimate reliability.50 The stan-
adults) or by their parents/guardians (in the case of adoles- dard error of measurement (SEM), as a measure of agreement,
cents). We provided both English and the corresponding was calculated using the following equation: Sp √(1- r), in
Arabic translations of each item of the PSQI together to all which Sp is the pooled standard deviation of test-retest
participants. The participants were asked to fill the AE-PSQI measures and r is the reliability coefficient (ICC).51,52 Addi-
twice, seven days apart. tionally, the smallest real difference (SRD), the threshold to
detect a “real” change beyond the measurement error, was
Statistical Analysis analyzed using the formula 1.96  SEM  √2.52
Descriptive characteristics of the participants were pre-
sented as mean and standard deviation (SD) values. Data Bland-Altman Plots
were tested for normal distribution using the Shapiro-Wilk To further explore the agreement of test-retest AE-PSQI
test and histograms. As the data were not normally distrib- scores, the Bland-Altman plot was used. The plots with
uted, log and square-root transformation were applied, but mean values against differences of global PSQI scores be-
the transformed data did not meet the required assumption tween baseline (1) and retest (2) with 95% limits of agree-
of normality. The distribution of means from any skewed ment (mean bias
[1.96  SD]) were used. Here, mean bias

Sleep Science © 2024. Brazilian Sleep Association. All rights reserved.

Test-Retest Reliability of a Bilingual Arabic-English PSQI Arumugam et al.

and SD are the mean
SD values of differences respectively. Table 2 Item-to-total correlation.
A significance level < 0.050 was set for all analyses. While
assessing the test-retest agreement in the plot, the differ- Items Item-to-total Alpha if item
ences between the tests were arbitrarily considered high if correlation was deleted
they were  1.5 SDs, moderate if the differences ranged from Subjective sleep quality 0.71 0.56
1.0 to 1.49 SDs, and low if the differences were < 1.0 SD.53 Sleep latency 0.74 0.54
Sleep duration 0.70 0.58
Results Sleep efficiency 0.46 0.68
Participant Characteristics Sleep disturbances 0.44 0.64
This study included 50 participants. The mean age of the Use of sleeping medicine 0.31 0.66
sample was of 20.82
2.7 years, and it included 34 female Daytime dysfunction 0.55 0.63
(68%) and 16 male (32%) subjects. Participants character-


istics are shown in ►Table 1. The proportion of poor sleepers Note: Pearson correlation coefficient.
(PSQI > 5) at baseline was of 60% (n ¼ 30/50), which was
significantly different (p ¼ 0.039) from that of the retest
(46%; n ¼ 23/50).

Floor and Ceiling Effects

None of the included participants showed floor or ceiling
effects based on the AE-PSQI global score calculated with
test-retest responses.

Internal Consistency
A Cronbach alpha score of 0.65 was obtained, which met “the
minimally acceptable” criterion for the internal consistency
of the AE-PSQI. The alpha scores were nearly the same for
both the baseline and retest scores. The item-to-total corre-
lation coefficients ranged from 0.31 to 0.74, and the smallest Fig. 1 Bland-Altman plot showing agreement between baseline (T1)
component-total correlation coefficient was found for the and retest (T2) global PSQI scores.

use of sleep medications, while the largest was found for

sleep latency (►Tables 2). both tests because nearly all differences were falling within
1.0 to 1.49 SDs. Only one outlier was present in the plot.
Test-retest Reliability Nevertheless, this interpretation is based on arbitrary
The ICC(3,1) values revealed strong relative reliability for the thresholds suggested by Jensen et al.53 (2016).
global PSQI score. Except for the sleep efficiency component
(ICC ¼ 0.26), all other subcomponents showed moderate to
Discussion
strong reliability estimates. There were no statistically sig-
nificant differences in paired t-tests comparing the test- In the present study, healthy bilingual Arabic-English-speak-
retest scores (p > 0.05), and there was no statistically signifi- ing adolescents and young adults were recruited to assess the
cant systematic bias in the data (3). The SEM for the global test-retest reliability of AE-PSQI. Even though previous stud-
AE-PSQI score was of 1.6 and the SRD was found to be of 4.5. ies54,55 have used the Arabic version of the PSQI for data
collection in young healthy individuals, none of them have
Bland-Altman Plot assessed the test-retest reliability of the Arabic version or of
The Bland-Altman plot depicting the test (1) versus retest (2) the AE-PSQI.
mean global AE-PSQI scores is shown in ►Figure 1. An The global AE-PSQI score did not show either floor or ceiling
analysis of the plot revealed a moderate agreement between effects, which indicates that the item analysis supported the
quality of the content validity of the AE-PSQI. In the present
Table 1 Characteristics of the study participants (n ¼ 50).
study, < 15% of the participants scored lowest or highest
scores. The internal consistency of the AE-PQSI was minimally
Characteristics Mean
SD
acceptable (Cronbach alpha ¼ 0.65) among our healthy ado-
Age (in years) 20.82
2.7 lescent and young adult participants. Our results are compa-
Sex: n (female/male) 50 (34/16) rable with those of previous studies validating the Italian PSQI
Body mass (in kg) 59.28
15.9 in healthy children56 and the Arabic PSQI in healthy Arab
Americans.37 The Italian and Brazilian version of the PSQI
Height (in cm) 164.58
7.7
presented good internal consistency values, of 0.72 and 0.71
BMI (in kg/m2) 21.80
5.3
respectively; however, both versions were focused on one age
Abbreviations: BMI, Body Mass Index; SD, standard deviation. group: either children or adolescents.56,57 The Arabic PSQI has

Sleep Science © 2024. Brazilian Sleep Association. All rights reserved.

 Test-Retest Reliability of a Bilingual Arabic-English PSQI Arumugam et al.

Table 3 PSQI item characteristics, paired t-test (test 1 versus test 2) p-values, and intraclass correlation coefficients (ICC[3,1]) with
95% confidence intervals and p-values.

PSQI Items Test 1: Test 1: Test 2: Test 2: Paired ICC(3,1) 95%CI p-value
mean standard mean standard t-test:
Lower Upper
deviation deviation p-value
bound bound
Subjective sleep quality 1.16
0.91 1.16
0.79 1.000 0.66 0.48 0.79 < 0.001
Sleep 0.78
0.86 0.80
0.86 0.785 0.82 0.70 0.89 < 0.001
latency
Sleep duration 1.28
1.03 1.36
1.05 0.552 0.59 0.37 0.74 < 0.001
Sleep efficiency 0.56
0.97 0.52
0.84 0.799 0.26 0 0.50 0.034
Sleep disturbance 1.04
0.53 0.94
0.62 0.168 0.62 0.41 0.76 < 0.001
Use of sleep medication 0.12
0.39 0.08
0.34 0.322 0.70 0.52 0.82 < 0.001
Daytime dysfunction 1.22
0.84 1.10
0.79 0.182 0.70 0.53 0.82 < 0.001
Global PSQI 6.16
3.27 5.96
3.11 0.510 0.77 0.63 0.87 < 0.001
score

Abbreviations: 95%CI, 95% confidence interval; ICC, intraclass correlation coefficient; PSQI, Pittsburg Sleep Quality Index.

been reported to meet the quality assessment criteria for Future Recommendation
internal consistency.23 The internal consistency of the original Future research is essential to explore various population
PSQI was found to be fair to good, with a Cronbach alpha value groups, as a valid and reliable AE-PSQI is needed to support
ranging from 0.64 to 0.83.22,24 clinical decision-making for interventions that can improve
Overall, the test-retest reliability estimate for the AE-PSQI sleep quality. This is particularly relevant for bilingual indi-
global score was strong (ICC ¼ 0.77), while the reliability viduals who speak both Arabic and English and present
estimates of other subcomponents, except the sleep efficiency, issues such as insomnia, sleep disorders, chronic pain, fibro-
ranged from moderate to strong. Previous studies have found myalgia, multiple sclerosis etc. Moreover, other psychomet-
test-retest reliability estimates to be moderate (r ¼ 0.65) for ric properties (such as validity and responsiveness) of the AE-
the Brazilian PSQI version in healthy adolescents57 and strong PSQI should be investigated further.
(r ¼ 0.83) for the Italian PSQI version in healthy children.56
Furthermore, two other studies including both healthy and
Conclusion
symptomatic participants (with sleep problems) revealed a
high internal consistency (Cronbach α ¼ 0.84) and moderate The AE-PSQI was found to be a reliable instrument to assess
reliability (r ¼ 0.65) for the Korean PSQI,26 and good internal sleep quality in bilingual Arabic-English-speaking adoles-
consistency (Cronbach α ¼ 0.70) and strong reliability cents and young adults with good or poor sleep quality.
(r ¼ 0.83) for the Kurdish PSQI.58 Therefore, the PSQI has The AE-PSQI demonstrated no floor or ceiling effects, mini-
been found to have acceptable internal consistency and reli- mally acceptable internal consistency, and moderate to
ability, irrespective of the language used. strong test-retest reliability estimates.
The SEM of the AE-PSQI global score was of 1.6. Moreover,
the SEM of the Brazilian PSQI has been reported to be of 1.1 Authors Contributions
for healthy adolescents.57 As the previous study37 investi- AA: conceptualization, design, supervision, data curation,
gating the psychometric properties of the Arabic PSQI in data analysis, interpretation, drafting, and revision; SAM,
healthy adults has not reported agreement measures, com- HYA, ZAZ, TMEH, HIA, and FSJ: data collection, data
parisons of SEM/SRD values of the AE-PSQI with that of the curation, interpretation, drafting, and revision; SAM:
Arabic PSQI were not possible. data analysis; AAS: interpretation, drafting, and critical
revision; AA led the writing of the paper; all authors read
Strengths and Limitations of the Study and approved the final manuscript.
To our knowledge, the present study is the first of its kind
investigating the floor and ceiling effects, internal consisten- Funding
cy, and test-retest reliability of the AE-PSQI, and positive The authors declare that they have received no specific
findings were observed for the AE-PQSI using multiple grants from funding agencies in the public, private, or not-
reliability and agreement estimates. As only healthy adoles- for-profit sectors for the conduction of the present study.
cents and young adults with good or poor sleep quality were
included, the results cannot be generalized to individuals Conflict of Interests
with clinical conditions affecting sleep. The authors have no conflict of interests to declare.

Sleep Science © 2024. Brazilian Sleep Association. All rights reserved.

Test-Retest Reliability of a Bilingual Arabic-English PSQI Arumugam et al.

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