Received: 17 October 2018 Revised: 1 August 2019 Accepted: 2 May 2020

DOI: 10.1111/ijn.12856

ORIGINAL RESEARCH PAPER

Validity and reliability of the Indonesian version of the

Pittsburgh Sleep Quality Index in adolescents

Anggi Setyowati Ners, MSc, Doctoral Student1,2 | Min-Huey Chung RN, PhD, Professor2,3

1
Public Health Faculty, Universitas Airlangga,
Surabaya, Indonesia Abstract
2
School of Nursing, College of Nursing, Taipei Aim: The study aims to examine the psychometric properties of the Pittsburgh Sleep
Medical University, Taipei, Taiwan, ROC
Quality Index-Indonesian version.
3
Department of Nursing, Shuang Ho Hospital,
Taipei Medical University, New Taipei City, Background: The Pittsburgh Sleep Quality Index has never been translated into
Taiwan, ROC Bahasa.
Correspondence Design: This study employs a cross-sectional and correlational study.
Min-Huey Chung, School of Nursing, College Methods: Data were collected from 528 adolescents of junior high school age (13–-
of Nursing, Taipei Medical University,
250 Wu-Xing Street, Taipei 110, Taiwan, ROC. 16 years) during August to September 2014. All participants agreed on the Indone-
Email: minhuey300@tmu.edu.tw sian version of Pittsburgh Sleep Quality Index and Beck Depression Inventory-II.
Psychometric properties were examined including internal consistency, construct
validity and known group validity, and the receiver operating characteristic curve was
used to measure the cut-off point.
Results: The Cronbach's alpha for the Pittsburgh Sleep Quality Index-Indonesian ver-
sion was adequate. There were positive correlations between the total score and
seven component scores. Construct validity revealed that the total score of the
Pittsburgh Sleep Quality Index-Indonesian version was correlated with the total
score of the Indonesian version of the Beck Depression Inventory-II. Known group
validity indicated that adolescents without depression risk had better sleep quality.
According to receiver operating characteristic curve analysis, the cut-off point at a
score of 6.5 indicated the best possible relationship of sensitivity and specificity.
Conclusion: The Pittsburgh Sleep Quality Index-Indonesian version has high reliabil-
ity and validity for screening sleep quality among adolescents.

KEYWORDS

adolescent, questionnaire, sleep disturbances, sleep quality, validation

S U M M A R Y ST A T E M E N T What this paper adds?

What is already known about this topic? •

The results support the validity and reliability of the Pittsburgh
• The original Pittsburgh Sleep Quality Index has adequate internal Sleep Quality Index-Indonesia in screening sleep quality among
consistency and favourable reliability. adolescents.
• It is easy for patients and health-care providers to use for inter- • The cutoff score for the Pittsburgh Sleep Quality Index-Indonesian
preting sleep disturbances. version for adolescents was 6.5.

Int J Nurs Pract. 2020;e12856. wileyonlinelibrary.com/journal/ijn © 2020 John Wiley & Sons Australia, Ltd 1 of 7
https://doi.org/10.1111/ijn.12856
2 of 7 SETYOWATI AND CHUNG

The implications of this paper: psychometric efficiency of the PSQI-I, including translation, validation,
reliability and cut-off point, in assessing Indonesian adolescents.
• The cut-off point could detect poor sleep quality among Indone-
sian adolescents.
• This simple tool is capable of quickly assessing sleep quality for 2.2 | Participants and settings
health-care providers.
This study employed a cross-sectional and correlational design, using
self-reported questionnaires. Data were collected from adolescents
who lived at a junior high school, Darul Ulum Islamic Boarding School.
1 | I N T RO D UC TI O N The inclusion criteria were junior high school students who lived in a
dormitory and had no history of psychiatric or neurological disorders.
Sleep disturbance in adolescents is not rare (Danielsson, Harvey, The exclusion criteria were students whose parents disapproved of
MacDonald, Jansson-Fröjmark, & Linton, 2013) and has been their participation in this study and students who did not provide
associated with sleep quality (LeBourgeois, Giannotti, Cortesi, informed consent. Previous study recommended that 60% response
Wolfson, & Harsh, 2005). Adolescents in Europe, Asia and the rate (Dong & Peng, 2013). The final sample has a total of 528 adoles-
United States have multiple behaviours that influence sleep quality, cents, with a 75% response rate.
such as difficulty going to bed, falling asleep, getting undisturbed
sleep and waking up in the morning (LeBourgeois, Giannotti, Cor-
tesi, Wolfson, & Harsh, 2004). Haryono et al. (2016) observed that 2.3 | Instruments
62.9% of adolescents aged 12–15 years who live in Indonesia,
especially in East Jakarta, have sleep disorders and 72.9% have dif- 2.3.1 | Beck Depression Inventory-II
ferences in their awake and sleep times between weekdays and
weekends. The Beck Depression Inventory (BDI)-II was created by Aaron T. Beck
Poor sleep quality can affect adolescents' concentration, atten- (Beck, Steer, & Brown, 1996). Each adolescent was assessed using the
tion, memory and physical and mental health (Suen, Tam, & Indonesian version of the BDI-II (Indo BDI-II; Ginting, Näring, van der
Hon, 2010). Furthermore, among adolescents, poor sleep is associated Veld, Srisayekti, & Becker, 2013). The BDI-II is a valid measure of
with emotional disturbance (Roberts, Roberts, & Chen, 2002), nega- depression in the Indonesian general population. The BDI-II has
tive mood (Lund, Reider, Whiting, & Prichard, 2010) and depression 21 items, each scored from 0 to 3. The total score of the BDI-II ranges
(Owens & Adolescent Sleep Working Group, 2014). Adolescents are from 0 to 63, and the cut-off point of for the Indo BDI-II is 17. It has a
often unaware that sleep disturbances influence their health. There- high coefficient alpha (0.90). For validity, the BDI is more closely asso-
fore, an appropriate tool to measure the sleep quality among adoles- ciated with the diagnostic criteria for depression (Beck et al., 1996).
cents is relevant to conduct rapid screening inthe clinical settings to The convergent validity of the Indo BDI-II is acceptable (Ginting
improve sleep quality (Tzeng, Fu, & Lin, 2012). et al., 2013). BDI-II had three dimensions: Items 1–3, 5–9 and 14 rep-
Sleep quality is a crucial factor related to sleep (Buysse, Reynolds, resenting cognitive; Items 4, 10, 12 and 13 representing affective; and
Monk, Berman, & Kupfer, 1989). The quantitative aspects of sleep Items 11 and 15–21 representing somatic (Titov et al., 2011). In this
comprise various domains such as sleep duration, sleep latency and study, Item 21 was excluded based on suggestion made by the ethics
number of arousals, and the purely subjective aspects include the committee and the head of the boarding school. They considered age,
depth or restfulness of sleep (Krystal & Edinger, 2008). In this study, religion and culture that prohibited to conduct sexual activity before
the Pittsburgh Sleep Quality Index (PSQI) was used to determine self- marriage. The Cronbach's alpha for the Indo BDI-II was 0.82 (Items
reported sleep quality and sleep disturbances for the preceding 1–20) in this study.
month. The original PSQI has adequate internal consistency and
favourable test–retest reliability (Buysse et al., 1989). It is a consistent
and easy for patients and health-care providers in interpreting the 2.3.2 | Pittsburgh Sleep Quality Index
indicators of sleep quality (Buysse et al., 1989; Mollayeva et al., 2016).
The PSQI was designed by Daniel J. Buysse (Buysse et al., 1989). The
PSQI is used to measure self-reported sleep quality and sleep distur-
2 | METHODS bances during the preceding month. It is a 19-item test and consists
of seven components: (1) subjective sleep quality, (2) sleep latency, (3)
2.1 | Aim sleep duration, (4) sleep efficiency, (5) sleep disturbance, (6) sleeping
medication use and (7) daytime dysfunction. Each component is
The PSQI has never been translated into Bahasa, and no study has scored from 0 to 3, and the total score ranges from 0 to 21, with a lower
been conducted to evaluate the psychometric efficiency of the PSQI- score (<5) indicating favourable sleep quality. The PSQI has adequate
Indonesian version (PSQI-I). The aim of this study was to develop the internal consistency (Cronbach alpha = 0.73) (Buysse et al., 1989).
SETYOWATI AND CHUNG 3 of 7

2.4 | Ethical considerations correlated with sleep quality (Borbély & Wirz-Justice, 1982). Known
group validity was assessed by comparing each component scores of
This study was approved by the ethics committee of Universitas samples (Kotronoulas, Papadopoulou, Papapetrou, & Patiraki, 2011;
Airlangga, Indonesia (number: 1190/UN3.14/LT/2014). Tzeng et al., 2012) between boys and girls and between the depres-
sion risk (Indo BDI-II > 17) and normal groups (Indo BDI-II ≤ 17) using
independent sample t test. We hypothesized that adolescents with a
2.5 | Procedures high score for depression have poor sleep quality. In addition, we used
receiver operating characteristic (ROC) (de la Vega et al., 2015) analy-
Data were collected from August to September 2014. Permission to sis to establish the cut-off point of the PSQI-I among adolescents
use the PSQI was granted by the original inventors. The final English with and without sleep disturbance. Previous study noted that
version of the PSQI was translated into Bahasa based on the World sleep disturbance can be assessed by sleep quality (Buysse
Health Organization guidelines (World Health Organization, 2014). et al., 1989; Lund et al., 2010; Tzeng et al., 2012). Thus, ROC was also
The guidelines were implemented as follows: used to measure sleep disturbance with PSQI-I. Sleep disturbance
was defined as >30 min of sleep onset latency (Berger &
1. Forward translation: One expert translator who was familiar with Higginbotham, 2000; Espie, Inglis, & Harvey, 2001), total sleep time of
the terminology of this instrument and knew English but whose ≤6.5 h (Lacks & Morin, 1992) or ≤85% sleep efficiency (Berger &
mother tongue was Bahasa translated the PSQI into Bahasa. Higginbotham, 2000).
2. Expert panel: Two experts, namely, a mental health nurse and com-
munity nurse, reviewed the PSQI after translation into Bahasa.
3. Back translation: The instrument was translated back to English by 3 | RESULTS
a professional translator.
4. Pretesting and cognitive interviewing: A pilot study was conducted 3.1 | Description of the sample
in which 10 adolescents were recruited to examine whether the
Indonesian questionnaire was easily understood by adolescents. The characteristics of the respondents are listed in Table 1. Most
5. Final version. respondents were aged 13–14 years (87.9%). The proportion of male
(53.2%) and female (46.8%) participants was almost equal. In terms of
After finalizing the questionnaire, the researcher requested the residence, most of the respondents were from East Indonesia (88.8%).
Islamic boarding school for permission to conduct the research. After On the basis of the Indo BDI-II, the majority of the respondents did
obtaining permission from the leader and headmaster of the school, not have depression (70.5%), with 29.5% of the respondents having
the researcher introduced and explained the study to the participants. depression. The total scores of the PSQI-I ranged from 2 to 16, with a
Next, informed consent forms were distributed to the participants to mean total score of 7.25 and a standard deviation (SD) of 2.50. The
be given to their parents or guardians for approval to participate in mean score of seven component of the PSQI-I ranged from 0.24 to
the study. The next day, participants who were granted permission by 1.50 (SD = 0.58–0.89) (Table 1).
their parents or guardians were given the research questionnaire in
sealed envelopes. The participants were allowed to withdraw from
the study at any time even after reading the questionnaire. After a 3.2 | Reliability
stipulated time, the participants were asked to return their question-
naires in the envelopes provided. These envelopes ensured answer Further analyses were conducted to determine internal consistency
confidentiality. for the PSQI-I. Cronbach's alpha for the PSQI-I was 0.72, and that for
each item ranged from 0.69 to 0.72. There were statistically signifi-
cant and positive correlations between the total score of the PSQI-I
2.6 | Statistical analyses and seven component scores of the PSQI-I. The range of correlation
between each domain was r = 0.36–0.56, P < 0.05.
All analyses were conducted using SPSS (Version 22) for Windows. A
P < 0.05 was considered statistically significant. Descriptive statistics
were used to evaluate all variables. The Cronbach's alpha for each 3.3 | Validity
item of the PSQI-I and the item-total correlations, which were calcu-
lated using the Pearson-moment correlation coefficient between 3.3.1 | Construct validity
seven component score and a total score of the PSQI-I (Kline, 1986),
were used to measure internal consistency. Testing hypothesized rela- The total score of the PSQI-I was significantly correlated with the
tionships based on a theory or previous research can be used to eval- total score of the Indo BDI-II (r = 0.22, P < 0.05). The somatic, affec-
uate construct validity (DeVellis, 2003; Pedhazur & Schmelkin, 1991). tive and cognitive component in BDI-II showed significant correlation
In this study, we hypothesized that depression would be negatively with the total score of PSQI-I (r = 0.17–0.19, P < 0.05). Among seven
4 of 7 SETYOWATI AND CHUNG

TABLE 1 Demographic characteristics of the participants component of PSQI-I, sleep quality, sleep disturbances, sleep medica-
(n = 528) tion use and daytime dysfunction were significantly correlated with
Variables n % the total score of Indo BDI-II (r = 0.11–0.25, P < 0.05) (Table 4). This

Age (years) supported our hypothesis that there is a correlation between depres-
sion and sleep quality.
13 211 40.0
14 253 47.9
15 63 11.9
3.3.2 | Known group validity
16 1 0.2
Gender
We hypothesized that a low score of depression indicates favourable
Female 247 46.8
sleep quality. An independent sample t test was employed to compare
Male 281 53.2 normal and depression risk adolescents in order to develop known
Residence group validity. The total score of the PSQI-I in adolescents with
East Indonesia 469 88.8 depression risk (Indo BDI-II > 17, n = 139; mean = 8.08, SD = 2.89)
Central Indonesia 51 9.7
West Indonesia 8 1.5 T A B L E 3 Sensitivity and specificity values of the PSQI-I total
BDI score using ROC curve analysis
Normal 372 70.5 Sensitivity
Depression 156 29.5 Total Sensitivity 1 − specificity Specificity + specificity
Sleep disturbance 438 83.0 1 1.00 1.00 0.00 1.00
Sleep onset latency, >30 min 84 15.9 2.5 1.00 0.98 0.02 1.01
Total sleep time, ≤6.5 h 429 81.3 3.5 0.97 0.84 0.16 1.13
Sleep efficiency, ≤85% 55 10.4 4.5 0.91 0.63 0.37 1.27
Mean SD 5.5 0.79 0.39 0.61 1.40
Total score of the PSQI-I 7.25 2.50 6.5 0.66 0.26 0.74 1.41
Total sleep time (min) 320.89 82.24 7.5 0.49 0.21 0.79 1.28
Sleep efficiency (%) 93.06 6.51 8.5 0.32 0.12 0.88 1.20
Sleep quality 1.10 0.67 9.5 0.16 0.02 0.98 1.14
Sleep latency 1.06 0.73 10.5 0.09 0.02 0.98 1.07
Sleep duration 1.49 0.89 11.5 0.05 0.00 1.00 1.05
Sleep efficiency 0.24 0.68 12.5 0.02 0.00 1.00 1.02
Sleep disturbances 1.50 0.58 13.5 0.01 0.00 1.00 1.01
Sleep medication use 0.38 0.78 14.5 0.01 0.00 1.00 1.01
Daytime dysfunction 1.47 0.88 15.5 0.00 0.00 1.00 1.00
Total score of the BDI-II 14.30 8.73 17 0.00 0.00 1.00 1.00

Abbreviations: BDI-II, Beck Depression Inventory-II; PSQI-I, Pittsburgh Abbreviations: PSQI-I, Pittsburgh Sleep Quality Index-Indonesian version;
Sleep Quality Index-Indonesian version; SD, standard deviation. ROC, receiver operating characteristic.

TABLE 2 Correlation coefficients of the component of PSQI-I and BDI-II

Somatic Affective Cognitive Total score of the BDI-II

Variables γ P γ P γ P γ P
Sleep quality 0.102 <0.05 0.136 >0.05 0.126 <0.05 0.141 <0.05
Sleep latency 0.11 >0.05 0.067 >0.05 0.003 >0.05 0.024 >0.05
Sleep duration 0.71 >0.05 0.084 >0.05 0.051 >0.05 0.078 >0.05
Sleep efficiency 0.87 <0.05 0.039 >0.05 0.035 >0.05 0.064 >0.05
Sleep disturbances 0.227 <0.05 0.206 <0.05 0.209 <0.05 0.253 <0.05
Sleep medication use 0.070 >0.05 0.071 >0.05 0.130 <0.05 0.112 <0.05
Daytime dysfunction 0.108 <0.05 0.081 >0.05 0.158 <0.05 0.144 <0.05
Total score of the PSQI-I 0.174 <0.05 0.192 <0.05 0.194 <0.05 0.219 <0.05

Abbreviations: BDI-II, Beck Depression Inventory-II; PSQI-I, Pittsburgh Sleep Quality Index-Indonesian version.
SETYOWATI AND CHUNG 5 of 7

was significantly higher than that in normal adolescents (Indo BDI- 4 | DISCUSSION
II ≤ 17, n = 317; mean = 6.89, SD = 2.22), with P < 0.05 (Table 2).
Regarding gender, there was no statistically significant difference To the best of our knowledge, this is the first study to examine the
between the total score of PSQI-I in boys (mean = 7.36, SD = 2.56) psychometric efficiency of the PSQI among Indonesian adolescents.
and girls (mean = 7.11, SD = 2.43). The results were consistent with a previous study of psychometric
analysis in a youth population (de la Vega et al., 2015). Our findings
revealed that the PSQI-I has adequate reliability and validity. Reliabil-
3.4 | Cut-off point determination ity was supported by internal consistency, with a Cronbach's alpha of
0.72 and item-total correlations of 0.36–0.56. This finding was similar
ROC curves were employed to measure the cut-off point of the PSQI- to those of previous studies (Beck, Schwartz, Towsley, Dudley, &
I (Figure 1). The area below the ROC curve was 0.74, which means Barsevick, 2004; Sohn, Kim, Lee, & Cho, 2012; Tzeng et al., 2012;
that the PSQI was acceptable for differentiating between adolescents Zheng, Li, Wang, & Lv, 2016). Studies have noted that considered cut-
with and without sleep disturbance. The result showed that 6.5 of the off for Cronbach's alpha (>0.7) (Cho & Kim, 2015; Morera &
total score of PSQI-I represented the best possible relationship of sen- Stokes, 2016; Nunally, 1978) and item-total correlations (>0.4)
sitivity and specificity for measuring sleep quality among adolescents (Kline, 1986) indicated acceptable reliability of PSQI-I.
with and without sleep disturbance (Table 3). The PSQI-I was supported by construct validity and known group
validity. Based on the theory, depression leads to reduced sleep qual-
ity (Borbély & Wirz-Justice, 1982). Therefore, construct validity was
established using Pearson correlation between the total and each
component scores of the PSQI-I and Indo BDI-II. As Table 4 showed,
the total score of the PSQI-I not only significantly correlated with
total score of Indo BDI-II (r = 0.22) but also with score of somatic,
affective and cognitive component of the Indo BDI-II. The results is
consisted with previous studies (Isaac & Greenwood, 2011; Skouteris,
Wertheim, Germano, Paxton, & Milgrom, 2009). A correlation of >0.2
between each domain was considered satisfactory (Kline, 1986).
Therefore, the construct validity of PSQI-I was confirmed satisfactory.
In contrast to a previous study (Tsai & Li, 2004), our study found
that the total score of the PSQI-I was not statistically different
between boys and girls. Many factors can contribute to sleep distur-
bance among adolescents, for example, the presence of a bed partner
(Beninati, Harris, Herold, & Shepard, 1999). These adolescents lived at
a dormitory, and they have partner in their room; therefore, both girls
F I G U R E 1 Receiver operating characteristic (ROC) curve of the
and boys had a similar environment. However, our study still retained
Pittsburgh Sleep Quality Index-Indonesian version (PSQI-I). Area
favourable known group validity. The total score of the PSQI-I in the
below the ROC curve: 0.74; SE: 0.03; asymptotic sig. <0.001; lower
bound: 0.69; and upper bound: 0.80 normal group of adolescents was found to be significantly lower than
that of the adolescents with depression risk. This supports our

TABLE 4 Mean difference between adolescents of the normal and depression-risk groups

Boys Girls Adolescents normal group Adolescents depression risk group

Mean SD Mean SD t value Mean SD Mean SD t value

Sleep quality 1.07 0.67 1.12 0.66 0.80 1.02 0.60 1.27 0.77 −4.03*
Sleep latency 1.10 0.73 1.00 0.72 −1.60 1.04 0.70 1.08 0.79 −0.49
Sleep duration 1.51 0.89 1.46 0.88 −0.60 1.45 0.85 1.59 0.94 −1.71
Sleep efficiency 0.23 0.69 0.24 0.67 0.14 0.20 0.63 0.32 0.78 −1.70
Sleep disturbances 1.50 0.57 1.49 0.59 −0.22 1.41 0.56 1.69 0.58 −5.03*
Sleep medication use 0.44 0.86 0.315 0.66 −1.89 0.34 0.74 0.47 0.86 −1.71
Daytime dysfunction 1.48 0.87 1.46 0.88 −0.19 1.40 0.87 1.64 0.87 −2.97*
Total score of PSQI-I 7.36 2.56 7.11 2.43 −1.14 6.89 2.22 8.08 2.89 −5.11*

Abbreviations: PSQI-I, Pittsburgh Sleep Quality Index-Indonesian version; SD, standard deviation.
*
P < 0.05.
6 of 7 SETYOWATI AND CHUNG

hypothesis that there is a positive correlation between depression CONFLIC T OF INT ER E ST

and sleep quality and is consistent with the findings of previous stud- The authors declare that they have no conflicts of interest.
ies (Lund et al., 2010; Tsai et al., 2013). These results indicate that the
PSQI-I is valid for use in assessing sleep quality among Indonesian AUT HOR SHIP S TAT EME NT
adolescents. AS and MHC designed the study. AS collected the data and prepared
Scores of three components (sleep quality, sleep disturbance the manuscript. All authors analysed the data and approved the final
and daytime dysfunction) of the PSQI-I were significantly different version for submission.
between the depression risk and normal adolescents. This might
reflect the different sleep patterns of these two groups. That is, the RE FE RE NCE S
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