Journal of Psychosomatic Research 59 (2005) 11 – 19

Factors associated with objective (actigraphic) and subjective sleep quality

in young adult women
Shelley S. Tworogera,T, Scott Davisb,c, Michael V. Vitiellod,
Martha J. Lentze, Anne McTiernanb,c,f
a
Channing Laboratory, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115, United States
b
Division of Public Health Sciences, The Fred Hutchinson Cancer Research Center, Seattle, WA 98109, United States
c
Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle, WA 98195, United States
d
Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA 98195, United States
e
School of Nursing, University of Washington, Seattle, WA 98195, United States
f
Department of Medicine, School of Medicine, University of Washington, Seattle, WA 98195, United States
Received 24 July 2004; accepted 18 March 2005

Abstract
Objective: The aim of this study was to describe factors
associated with actigraphic and subjective sleep quality in young
women. Methods: Participants were 73 regularly menstruating
women, 20 – 40 years old, who were not taking oral contra-
ceptives, pregnant, or shift workers. Women contributed an
average of 7 nights of actigraphy data during the luteal menstrual
cycle phase, resulting in a total of 595 nights of data. Results:
One night of actigraphy data was unreliable for measuring total
sleep time, sleep onset, and time in bed (intraclass correlation
V.15) but was acceptable for measuring sleep efficiency and total
wake time (intraclass correlation [ICC]=.52). Going to bed late,
medication use, employment, increased daylight hours, longer
menstrual cycle length, and higher body mass index (BMI) were
associated with poorer actigraphic sleep measures. Employment,
age, and perceived stress were associated with subjective sleep
quality. Conclusion: Multiple factors were associated with sleep
quality in these young women who were sleeping at home.
However, the associations differed for subjectively versus acti-
graphically assessed sleep quality. Actigraphy is feasible for
measuring sleep, but multiple recording nights may be needed to
obtain reliable estimates.
D 2005 Elsevier Inc. All rights reserved.

Keywords: Sleep; Actigraphy; Women; Employment; Day of week; Daylight hours; Menstrual cycle length; Alcohol consumption; Perceived stress

Introduction ments of sleep quality should be considered because the

Chronically disturbed sleep is associated with a number
of deleterious effects, including reduced memory and
learning ability, compromised immune function, and an
increased risk of cardiovascular disease [1–3]. Thus, it is
important to understand factors that are associated with
poor sleep quality in a natural environment. In assessing
such relationships, both subjective and objective assess-
Abbreviations: LH, Luteinizing hormone; CI, Confidence interval.
T Corresponding author. Tel.: +1 617 525 2087; fax: +1 617 525 2008.
E-mail address: nhsst@channing.harvard.edu (S.S. Tworoger).
two are only modestly correlated [4 –6], suggesting that
each modality assesses different aspects of an individual’s
sleep experience [5– 7].
Actigraphy is a validated, objective method to monitor
sleep and other activity patterns (and their variability), over
long periods in the home [8–10], and has been successfully
used to assess sleep quality among children and adolescents
[9,10] and the elderly [11]. All three studies reported
considerable within-subject variability in sleep patterns
[9–11]. However, little actigraphically assessed sleep quality
information is available for young adult, menstruating
women [12]. Two small actigraphy studies (nV 20)
of young and middle-aged men and women reported

0022-3999/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpsychores.2005.03.008
12 S.S. Tworoger et al. / Journal of Psychosomatic Research 59 (2005) 11–19
consistently high Pearson correlations between two consec-
utive nights for sleep efficiency ( Pz.70) and awakenings
z3 minutes ( Pz.69), but not for total sleep time ( P=.60 and
P=.05, respectively; [13,14]).
The purpose of this study was to examine objectively
assessed sleep patterns across multiple nights (range=2 –10),
using actigraphy, in a large sample of 20- to 40-year-old
women. Women were assessed while sleeping at home,
where they were unrestricted in their behavior. Specifically,
we assessed the within- and between-subject variability and
the reliability of actigraphic sleep assessments. We also
examined potential risk factors for poor sleep quality for
both actigraphic and subjective sleep assessments and
determined whether patterns of association differed between
the two types of measures. Participants from this study were
drawn from an intervention trial examining the effect of
magnetic field exposure on hormone levels and sleep
patterns; the current study represents a cross-sectional
analysis of these data.
Methods
Participants
Participants were identified from women in a randomized
crossover trial investigating the effect of a nighttime
magnetic field on melatonin and reproductive hormone
levels in premenopausal women, specifically during the
luteal phase of the menstrual cycle. This menstrual phase
was chosen to due to the high concentrations of estrogens,
the primary hormone of interest, during this part of the
cycle. Eligibility criteria included being 20 to 40 years old,
not taking oral contraceptives or other hormones in the past
6 months, having a body mass index (BMI) V30.0 kg/m2,
having regular menstrual cycles, not pregnant or breast
feeding during the previous year, not a shift worker, and not
taking melatonin supplements. Participants lived in the
greater Seattle, WA area.
Participants who contacted the study telephone line in
response to posted advertisements for the parent study,
which did not mention sleep in any way, completed an
initial screening interview and, if eligible, were scheduled
for a home visit. Between March and September 2001, 85
women from the primary study were asked to participate in
an additional component to assess sleep. We did not screen
participants for sleep disturbances.
At the first home visit, a technician obtained written
consent, approved by the Institutional Review Board at the
Fred Hutchinson Cancer Research Center, and taught
participants to determine their ovulation date using a
menstruation calendar and a commercial ovulation kit
(Assure LH Ovulation Predictor, Conception Technologies,
San Diego, CA), which detects the luteinizing hormone
(LH) surge 24 to 48 h before ovulation. Participants tracked
one complete menstrual cycle, including detecting an LH
surge, before proceeding to the intervention phase. After the
next two detectable LH surges, the participant was
scheduled for the two measurement periods in which the
study intervention was applied and sleep assessed via
actigraphy (see below). Both measurement periods were 5
nights long and started approximately 2 days after the LH
surge. Half the women were randomly assigned to the
intervention and half to ambient exposure (no intervention)
during the first measurement period; exposure status was
switched at the second period.
The intervention consisted of a continuous, 60-Hz
magnetic field, 0.5 to 1.0 AT above the ambient levels, at
the participant’s normal head location on the bed. The
exposure was administered by placing a common household
appliance underneath the bed, which was plugged into a
power strip that was either off or on. Participants were
blinded to exposure status.
Sleep data
Participants wore an actigraph (Actiwatch-16, Mini
Mitter, Bend, OR) on their nondominant wrist [15] from
bedtime to rise time all nights of both measurement
periods. Because the parent study protocol was compli-
cated, participants were not asked to wear the actigraph
during the day to minimize the burden of participating in
the additional sleep component. Written and oral instruc-
tions for using the actigraph were provided at each
measurement period.
The actigraph is designed for long-term monitoring of
gross motor activity in humans and has an accelerometer
capable of sensing motion with a minimal resultant force of
0.01
g [16]. We used 1-min sampling intervals. All but
eight participants used the same actigraph at both measure-
ment periods.
Actigraph data were downloaded onto a personal
computer and analyzed via a FORTRAN program using
the method of Cole et al. [17]. Using polysomnographic
validation data provided by Mini Mitter [16], the sleep/wake
status of each minute of the night was assessed as follows:
D ¼ 0:025ð0:04A2 þ 0:20A1 þ 1:0A0 þ 0:20Aþ1
þ 0:04Aþ2 Þ
where A x is the number of detectable motions in that minute.
If D z1, then the participant was considered to be awake
during minute A 0, otherwise, the participant was considered
to be asleep. To increase accuracy, we applied the five
rescoring rules outlined by Cole et al. [17], which corrected
for the problem that participants falling asleep after waking
up during the night tend to stop moving a few minutes
before polysomnography indicates sleep onset. Initial sleep
onset was considered to be at the beginning of the first
20-min interval in which no more than 1 min was scored
as wake; this criterion had the highest correlation with
polysomnography [17].
 S.S. Tworoger et al. / Journal of Psychosomatic Research 59 (2005) 11–19
Other data collection
Information about age and self-reported menstrual
cycle length were collected during the screening inter-
view. On the first day of each measurement period, a
technician measured height to the nearest 0.1 cm; weight
to the nearest pound; administered a structured interview
collecting demographic information, job status, exercise
habits, and the Perceived Stress Scale [18]; and asked
participants to complete a truncated version of the
Pittsburgh Sleep Quality Index (PSQI; [19]). Participants
were not asked to have their bed partners complete that
portion of the PSQI due to the already large burden of
the parent study. Usual bedtime and rise time were
abstracted from the PSQI, and the global index assessing
sleep quality was calculated. Participants also completed a
nightly diary during both measurement periods, recording
their bedtime, rise time, medication use, and alcohol
consumption. Hours of daylight were determined via
sunrise/sunset tables calculated by the National Research
Council (Herzberg Institute of Astrophysics, Victoria,
BC). On the last night of the measurement period,
participants collected all urine excreted during the night
after sleep onset plus the first morning void. To determine
whether the cycle was ovulatory, pregnanediol-3-glucur-
onide was measured in the urine by enzyme immunoassay
[20] at the University of Southern California under the
direction of Dr. Frank Z. Stanczyk.
Statistical methods
We considered seven actigraphic sleep measures (total
sleep time, sleep efficiency, total wake time, minutes awake
after sleep onset, the number of awakenings, number of
awakenings z3 minutes, and sleep onset latency) and three
measures abstracted from the sleep diary (time in bed,
bedtime, and rise time). Sleep efficiency was calculated as
(total sleep time/time in bed)
100. The within- and
between-subject standard deviations of each measure were
determined using a random effects model, controlling for
exposure status, exposure order, and measurement period as
fixed effects [21]. We also considered whether the within-
subject variance differed for participants who had different
actigraphs at the two measurement periods. The intraclass
correlation (ICC) is an estimate of the reliability of a specific
sleep measure with 1 night of data collection and provides an
indication of within-subject stability across nights. We
calculated the ICC by dividing the between-subject variance
by the total variance [22]; we considered all nights, week-
nights only (Sunday through Thursday), and weekend nights
only (Friday and Saturday). The Spearman–Brown formula
[22] was used to estimate how many nights of aggregated
sleep data were needed to obtain a representative sample of a
participant’s sleep patterns; a reliability z.70 was used based
on previous literature [9]. We used data from both the
intervention and nonintervention measurement periods
13
because the intervention was not associated with sleep
patterns [23].
Using linear regression, we assessed whether sleep
outcomes with an ICC N0.30 were associated with various
potential risk factors. This ICC was chosen because, based
on the Spearman–Brown formula, we needed five or less
days of sleep assessment to achieve a reliability z.70; about
83% of the participants had at least 5 nights of data. The risk
factors considered include (1) bedtime differed from usual
bedtime on the PSQI (within 1 h, z1 h later, and z1 h
earlier); (2) rise time differed from usual rise time on the
PSQI (within 1 h, z1 h later, and z1 h earlier); (3) alcohol
servings (none, one, and two or more); (4) min/week of
exercise during the previous month (linear); (5) took a
prescription or over-the-counter medication other than a
sedative (no vs. yes); (6) job status (employed vs. unem-
ployed); (7) perceived Stress Scale in quartiles (V12, 13 –18,
19 –24, and z25); (8) day of week (weeknight vs. weekend);
(9) daylight hours (linear); (10) age (linear); (11) menstrual
cycle length (linear); and (12) BMI (linear). Categorical
exposures were included as indicator variables in the model.
All variables were included in one model, adjusting for
intervention status (exposed, not-exposed), exposure order
(exposed/not-exposed, not-exposed/exposed), measurement
period (1, 2), night (1, 2, 3, 4, 5), and external sleep
disruptions (yes, no). For this last covariate, we used the
question about botherQ sleep disturbances on the PSQI as a
surrogate for disruptions due to bed partners, children, and
pets. We also considered whether these associations differed
on weeknights versus weekend nights and was similar
between the intervention and nonintervention periods. We
did not consider sedative use due to the small number of
women (n=2) using them. For this analysis, we excluded six
records with extreme bed (N03:00) or rise times (N14:00).
Using logistic regression, we determined whether self-
reported poor sleep quality (global PSQI score N5) was
associated with the following exposures measured before or
at the same time as the PSQI: age (20 –24, 25 –29, 30 –34, and
35 – 40), min/week of exercise during previous month (V139,
140 –249 250 –359, and z360), menstrual cycle length, BMI,
employment status, and Perceived Stress Scale, adjusting for
measurement period and external sleep disruptions. Age and
minutes of exercise were categorized for this analysis because
their association with self-reported sleep quality was not
linear. Due to the correlated nature of the data, we used
generalized estimating equations with an independent work-
ing correlation matrix for all regression models [24]. All
statistical tests were two sided, and analyses were conducted
using Stata Version 8.0 (College Station, TX).
Of the 85 eligible women from the parent trial, 77 (91%)
consented to participate in the sleep component. Nineteen
participants completed one measurement period (16 became
ineligible or dropped the study and for 3 no actigraph was
available) and 58 completed both. We excluded measure-
ment periods in which the participant was anovulatory
(pregnanediol-3-glucuronide b1.25 Ag/mg creatinine) or
14 S.S. Tworoger et al. / Journal of Psychosomatic Research 59 (2005) 11–19

Table 1 diary data. Some participants did not wear the actigraph for
Characteristics of 73 women who provided 595 nights of data collection
the entire night, put it on N30 min after bedtime, or took it
Mean (S.D.a) off N30 min before rise time, resulting in at least partially
Age (years) 30.6 (5.3) missing data for 82 (14%) of 595 nights. Removing the
Body mass index (kg/m2) 23.8 (3.7) actigraph early was associated with significantly worse
Menstrual cycle length (days) 28.8 (2.1)
sleep outcomes compared with nights that had complete
Daylight (h) 14.3 (1.1)
Exercise in past month (min/wk) 276.5 (199.0) data (data not shown).
Perceived Stress Scaleb 18.8 (8.1)
Usual bedtimec (min) 22:50 (56.6)
Usual rise timec (min) 06:53 (71.0) Results
Number of participants n (%)
Self-reported poor sleepd 22 (30.1) On average, participants were 31 years old and had a
Exposed to magnetic field during 36 (49.3) normal BMI (Table 1). The usual bed and rise times reported
first measurement period on the PSQI were about 22:50 and 06:53, respectively, and
Employed 65 (89.0) nearly a third of women had a global score N5 on the PSQI,
indicating poor sleep. Some type of nonsedative medication
Number of nights in which participants
Took a sedative 7 (1.2) was used on 21.5% of the nights; however, sedatives were
Took another medicatione 128 (21.5) used by only two participants on a total of 7 nights. Alcohol
Weekend day 173 (29.1) was consumed on about 27% of nights; on half of these
Consumed nights, one drink was consumed. Bed and rise times differed
One alcoholic drink 78 (13.1)
by over an hour from the usual times reported on the PSQI
Two or more alcoholic drinks 82 (13.8)
Bedtimec for over a third of the nights.
z1 h later than usual 176 (29.6) The mean total sleep time was almost 7 h per night, but
z1 h earlier than usual 52 (8.8) ranged from about 2.9 to 11.5 h (Table 2). Similarly, mean
Rise timec sleep efficiency was 88.4%, but varied from 62.6% to
z1 h later than usual 141 (23.7)
98.7%. The mean number of awakenings was 22.1 per night,
z1 h earlier than usual 70 (11.8)
a
with an average of 4.1 awakenings being z3 min long. The
Standard deviation.
b
Scale ranges from 0 to 56.
median sleep onset was 7 min. Bed and rise times spanned a
c
Usual bed and rise times were abstracted from the PSQI. wide range. For all sleep measures, the within-subject
d
Poor sleep was defined as having a global score N5 on the PSQI. standard deviation was nearly the same as or larger than
e
Any nonsedative prescription or over-the-counter medication. the between-subject standard deviation. In general, the
within-subject standard deviations were slightly lower when
menstruating (n=10), or if sleep data for 4 or 5 nights were excluding the eight participants with different actigraphs at
missing (n=6). No significant differences existed between their measurement periods (data not shown).
participants who contributed data for two (n=46) versus one The overall ICC was low for total sleep time ( ICC=.15),
measurement period (n=27). We had 119 measurement sleep onset ( ICC=.09), and time in bed ( ICC=.13); the
periods from 73 participants available for analysis, with an Spearman–Brown formula estimates that N5 nights of data
average of 7 nights of actigraphic data and 8 nights of sleep collection are needed to obtain a reliability z.70 (Table 3).

Table 2
Mean, median, between- and within-subject standard deviations, and range for sleep parameters measured via actigraphy or abstracted from the sleep diary
Standard deviation
na Mean Median Between subject Within subject Range
Total sleep time (min)b 513 419.5 419 27.2 64.5 175–689
Sleep efficiency (%)b 513 88.4 89.3 3.4 3.3 62.6–98.7
Total wake time (min)b 513 55.0 51 17.5 16.8 7–163
Wake after sleep onset (min)b 513 39.9 37 13.2 13.8 4–118
Awakeningsb 513 22.1 22 5.0 6.1 3–51
Awakenings z3 minutesb 513 4.1 4 2.0 2.2 0–15
Sleep onset (min)b 532 12.7 7 4.6 14.3 1–89
Time in bed (min)c 594 480.9 481 28.2 74.4 201–751
Bedtime (min)d 594 23:18 23:00 47.2 63.7 19:00–07:00
Rise time (min)d 594 07:18 07:07 50.5 71.5 03:57–16:00
a
Number of nights with nonmissing data.
b
Assessed via actigraphy.
c
Calculated using information from the sleep diary.
d
Obtained from the sleep diary.
 S.S. Tworoger et al. / Journal of Psychosomatic Research 59 (2005) 11–19 15

Table 3
Intraclass correlation coefficientsa (ICC) for the reliability of sleep measures, for all nights and by day of weekb
All nights Weeknights Weekend nights
nc ICC Nightsd nc ICC Nightsd nc ICC Nightsd
Total sleep time (min) 513 0.15 N5 370 0.24 N5 143 0.13 N5
Sleep efficiency (%) 513 0.52 3 370 0.50 3 143 0.49 3
Total wake time (min) 513 0.52 3 370 0.52 3 143 0.39 4
Wake after sleep onset (min) 513 0.48 3 370 0.51 3 143 0.23 N5
Awakenings 513 0.40 4 370 0.40 4 143 0.29 N5
Awakenings z3 minutes 513 0.45 3 370 0.45 3 143 0.43 3
Sleep onset (min) 532 0.09 N5 383 0.08 N5 149 0.16 N5
Time in bed (min) 594 0.13 N5 422 0.20 N5 172 0.08 N5
Bedtime (min) 594 0.35 5 422 0.45 3 172 0.27 N5
Rise time (min) 594 0.33 5 422 0.55 2 172 0.25 N5
a
The intraclass correlation is equivalent to the reliability for 1 night of data collection.
b
Weeknights are Sunday through Thursday nights and weekend nights are Friday and Saturday nights.
c
Number of nights with nonmissing data.
d
Estimated number of nights of data collection needed to have a reliability of N.70, based on the Spearman–Brown formula.

All other sleep outcomes had an ICC z.30; sleep efficiency
and total wake time had the highest ICCs and needed an
estimated 3 to 4 days of data collection to obtain reliable
estimates. The ICCs were substantially higher on week-
nights versus weekend nights for all actigraphic sleep
measures, except sleep efficiency, awakenings z3 minutes,
and sleep onset.
No difference in sleep efficiency was detected for nights in
which the participant’s bed or rise time was more than an hour
different versus within an hour of usual (Table 4). However,
going to bed z1 h later than usual was associated with
decreased total wake time, wake after sleep onset, and
awakenings. Going to bed z1 h earlier or rising z1 h later
than usual was associated with increased total wake time,
wake after sleep onset, and awakenings. Using any non-
sedative medication was associated with 1.9% lower sleep
efficiency [95% confidence interval (CI): 3.8, 0.2] and 11.3
more min of total wake time (95% CI: 0.5, 22.1). Compared
with employed women, unemployed women had 1.9% higher
sleep efficiency (95% CI: 0.7, 3.2), 10.6 min less total wake
time (95% CI: 17.0, 4.2), and 1.2 fewer awakenings
z3 minutes (95% CI: 2.1, 0.3). On weekend nights,
participants had 1.7 more awakenings (95% CI: 0.0, 3.3)
than on weeknights. Increasing daylight hours, menstrual
cycle length, and BMI were associated with significantly
lower sleep efficiency and more total wake time. Alcohol,

Table 4
Averagea difference (95% CIb) in selected sleep outcomes by various exposures that may affect sleep
Sleep efficiency Total wake time Wake after sleep onset Awakenings Awakenings z3
(%) (min) (min) minutes
Bedtime z1 h later than 0.5 (0.5, 1.5) 8.9TT(14.0, 3.7) 5.7** (9.9, 1.5) 3.7** (5.0, 2.3) 0.3 (1.0, 0.4)
usualc
Bedtime z1 h earlier than 0.3 (2.2, 1.5) 10.5** (1.5, 19.4) 8.6** (1.0, 16.3) 4.7** (1.3, 8.0) 1.1 (0.5, 2.8)
usualc
Rise time z1 h later than 0.1 (1.6, 1.4) 6.6T (0.6, 13.8) 4.3* (0.2, 8.8) 2.6** (0.3, 4.8) 0.4 (1.3, 1.2)
usualc
Rise time z1 h earlier than 0.8 (2.6, 1.1) 5.2 (13.9, 3.5) 4.7 (11.1, 1.7) 2.8* (5.8, 0.2) 0.2 (1.3, 1.0)
usualc
Used a medication vs. notd 1.9* (3.9, 0.2) 11.3** (0.5, 22.1) 7.0* (0.9, 14.9) 2.0 (1.1, 5.1) 0.7 (0.5, 2.0)
Unemployed vs. employed 1.9** (0.7, 3.2) 10.6** (17.0, 4.2) 6.2** (11.9, 0.6) 2.8** (5.6, 0.0) 1.2** (2.1, 0.3)
Weekend vs. weekday 0.1 (0.9, 1.1) 0.8 (4.0, 5.6) 2.5 (0.9, 6.0) 1.7** (0.0, 3.3) 0.3 (0.2, 0.9)
Daylight hourse 0.6** (1.2, 0.1) 3.4** (0.5, 6.3) 2.0* (0.3, 4.2) 0.7 (0.2, 1.5) 0.2 (0.2, 0.5)
Menstrual cycle lengthe 0.4** (0.6, 0.1) 1.7** (0.2, 3.2) 1.3** (0.0, 2.6) 0.4 (0.2, 1.1) 0.2 (0.05, 0.4)
(day)
Body mass indexe (kg/m2) 0.2* (0.4, 0.05) 1.0** (0.05, 2.0) 0.8** (0.0, 1.6) 0.1 (0.2, 0.4) 0.1 (0.05, 0.2)
a
All exposures were modeled simultaneously and were adjusted for intervention status, exposure order, measurement period, night, external sleep
disruptions, exercise in the previous month, age, alcohol servings, and perceived stress. Sleep measures were not associated with exercise, age, alcohol, or stress.
b
95% confidence interval.
c
Usual bed and rise times were abstracted from the PSQI; reference groups are nights in which bed or rise times are within 1 h of usual.
d
Any nonsedative prescription or over-the-counter medication.
e
Included as a linear variable, such that the coefficient is the change in the sleep parameter for a (1) 1-h increase in daylight, (2) 1-day increase in
menstrual cycle length, or (3) 1 kg/m2 increase in BMI.
T PV.10.
TT PV.05.
16 S.S. Tworoger et al. / Journal of Psychosomatic Research 59 (2005) 11–19
exercise over the previous month, perceived stress, and age
were not associated with actigraphic sleep measures (data not
shown). Associations were not substantially different on
weekend versus weeknights (data not shown). Overall, the
results were similar when only considering nonintervention
nights, although the association between medication use and
sleep outcomes was weaker (data not shown).
On average, participants went to bed 14.7 min later (95%
CI: 2.7, 32.0) and rose 48.3 min later (95% CI: 30.1, 66.5)
on weekend versus weeknights. Unemployed participants
had significantly later bedtimes and rise times than did the
employed participants only on weeknights, and older age
was associated with earlier bedtimes on all nights and earlier
rise times on weekdays (data not shown).
Self-reported poor sleep (global PSQI score N5) was not
significantly associated with menstrual cycle length, BMI,
or exercise during the previous month (data not shown).
However, 25- to 29- and 30- to 34-year-olds had a modestly
increased risk of reporting poor sleep compared with 20- to
24-year olds [odds ratio (OR): 5.3, 95% CI: 0.8, 33.6 and
OR: 7.4, 95% CI: 1.2, 46.0, respectively]; the oldest women
were not significantly different from the youngest. Unem-
ployed versus employed women had a modestly increased
risk (OR: 5.1, 95% CI: 1.0, 25.7) of reporting poor sleep.
Score on the Perceived Stress Scale was positively
associated with risk of reporting poor sleep ( P trend=.04).
Discussion
This is the first large study to examine sleep quality and
the factors associated with it among young women using
both actigraphic and subjective assessment methods while
sleeping at home, where they were unrestricted in their
behavior. A unique aspect of this study is that women were
assessed during the luteal phase of the menstrual cycle;
sleep during this phase may be more variable than other
menstrual phases due to its hormonal complexity. Overall,
actigraphy was an acceptable modality for measuring sleep
in this population, as over 90% of participants consented to
participate. We observed a wide range of sleep patterns in
this young adult female sample, with low ICCs for total
sleep time, sleep onset, and time in bed, but higher ICCs for
sleep efficiency and total wake time. Unusual bed or rise
times, medication use, employment, day of week, daylight
hours, menstrual cycle length, and BMI were associated
with actigraphic sleep measures, while age, alcohol con-
sumption, exercise over the previous month, and perceived
stress were not. Employment, age, and perceived stress were
associated with subjective sleep quality.
About 30% of the participants had a score N5 on the
PSQI, indicating a perception of poor sleep quality; only
two participants (2.4%) reported taking a sedative. This is
consistent with surveys of sleep problems in this age group
among different populations [25–28]. Thus, although young
people have fewer sleep problems than the elderly do [27],
there is a substantial proportion with at least some sleep
disturbances, indicating that it is important to study sleep in
this population.
We observed a wide range of sleep patterns, although we
excluded women who did shift work, had irregular
menstrual cycles, or had recently had or breastfed a child.
This suggests that the stringent eligibility criteria did not
lead to the exclusion of all women with poor sleep patterns.
We also found that the within- and between-subject
variabilities were similar and the ICCs were moderate to
low, signifying that sleep measures in a natural environment
may not be stable across nights, necessitating multiple
nights of data collection. Pair-wise, consecutive-night
correlations for all sleep measures were similar to the ICCs
(data not shown). Studies in both children [9,10] and the
elderly [11] also reported large within-subject variabilities
and low ICCs for sleep in a natural environment. However,
two small studies collecting two consecutive nights of sleep
data reported higher correlations for sleep efficiency and
awakenings z3 minutes than our study [13,14]. This
discrepancy could be explained by the healthy population
used or the inclusion of men in these latter studies.
Furthermore, we found that, for most sleep measures, the
ICC was lower on weekend nights than on weeknights,
suggesting that sleep is more variable on weekends. In our
study, sleep efficiency was the most stable sleep parameter
on both weekends and weeknights.
We also examined potential risk factors for poor sleep
and found multiple associations. Medication use, but not
alcohol consumption or exercise over the past month, was
associated with worse sleep patterns. Taking a medication
may reflect the presence of an underlying chronic disease,
such as asthma or gastrointestinal problems, that could
affect sleep [29,30]. Although we did not find that alcohol
was associated with sleep patterns, other studies suggest that
it may initially improve sleep but then disrupt sleep during
the second half of the night [31,32]. We may not have
observed an association with alcohol because we considered
sleep across the entire night. Other research suggests that
exercise may moderately improve sleep [33,34], however,
our assessment of exercise may not have been sensitive
enough to observe an association because we only asked
about exercise over the previous month.
Sleep hygiene recommendations suggest that it is
important to establish a routine bed and rise time [35]. In
our study, nearly 40% of bedtimes and over a third of rise
times were more than 1 h different than the usual reported
times, suggesting that fluctuations in bed and rise times are
common. While such fluctuations were associated with total
wake time and awakenings, there were no associations with
sleep efficiency. This discrepancy is likely explained by the
fact that total wake time and the number of awakenings are
not adjusted for the amount of time spent in bed.
We also observed that an increasing number of daylight
hours was associated with lower sleep efficiency and more
total wake time, despite the fact that data collection occurred
 S.S. Tworoger et al. / Journal of Psychosomatic Research 59 (2005) 11–19
between March and September. To our knowledge, no other
studies have directly assessed the association between the
number of daylight hours and sleep quality. However,
several studies have suggested that sleep patterns and
circadian rhythms can vary by season in men [36 –38];
although one study of 190 men and women (ages 40 –59)
found no effect of season on subjective sleep quality [39].
These data suggest that studies measuring participants at
multiple time points should either ensure similar hours of
daylight between measurement periods or adjust for this
factor during the analytic phase.
In addition, we found that increased BMI and longer
menstrual cycle length were associated with slightly worse
sleep efficiency, despite the limited range of these exposures
in our study. Obesity (BMI N30 kg/m2) is associated with
sleep apnea and other sleep disorders [40]. Our data suggest
that even women who are overweight (BMI between 25 and
30) may experience reductions in sleep quality. To our
knowledge, no other studies have examined menstrual cycle
length and sleep; however, previous research suggests that
sleep patterns change across the menstrual cycle [41– 43]
and by ovulation status [44].
As expected, we found that participants went to bed and
got up later on weekends versus weeknights. This is
consistent with a study of 266 healthy participants, aged
20 to 50 years, which reported a 26-min later bedtime and a
53-min later wake time on weekends [45]. We also found
that the relationships of employment status and age with bed
and rise times differed by the day of week. This suggests
that the sleep experience on weekend days may differ from
that on weekdays; thus, sleep on both types of days should
be collected.
We also observed that patterns of association of
perceived stress, age, and employment status differed for
actigraphic versus subjective sleep assessments. For exam-
ple, perceived stress was not associated with actigraphic
sleep measures, but was positively associated with poor
subjective sleep. This is consistent with two studies that
reported no difference in perceived stress between good and
poor sleepers and that perceived stress was associated with
subjective, but not objective (actigraph), sleep [46,47].
Similarly, we found that unemployment was associated with
better actigraphic sleep measures but worse subjective sleep
quality. Likewise, age was not associated with actigraphic
sleep measures, but some age groups (25–35 years) were
more likely to report poor subjective sleep. This age group
likely includes women with young children, as our study
protocol did not allow us to collect this information;
however, this potential relationship remains conjectural.
Our results suggest that subjective sleep reports may partly
reflect an individual’s perspective or state of mind in
addition to some component of their objective sleep
patterns. Thus, it is important to assess both the subjective
and objective aspects of sleep, if possible.
The current study has several strengths. We examined
young women, a group for which there is little objective
17
sleep data in a natural environment. Another unique aspect
of the study is that we did not place restrictions on
participants with respect to various parameters that may
affect sleep, such as medication use and alcohol consump-
tion. This allowed us to consider the variability of sleep
patterns in a natural environment and look at multiple
exposures that may affect sleep. In addition, measurement
periods were conducted during the same menstrual phase,
thus eliminating the possibility that observed associations
were due to differing sleep patterns across the menstrual
cycle [41– 43]. We also had an average of 7 nights of
actigraphic sleep assessment from each woman, therefore,
our data are relatively reliable with respect to the analyses
exploring the association between sleep and other factors.
Finally, our analytic technique accounted for the correlated
nature of the data, which has the benefit of providing valid
standard error estimates.
The present study, however, has several weaknesses.
First, because the parent trial was not designed specifically
to assess sleep patterns, we did not collect information on
some important exposures, such as caffeine consumption,
pets in bed, the presence of small children in the home, or
bed partners. Although this does not affect the validity of the
reliability analysis, these exposures could potentially con-
found the observed associations between other exposures
and sleep; we did adjust our analyses for external sleep
disruptions, primarily bed partner snoring, pets, and small
children. Second, we had some exclusion criteria (e.g., no
shift work) that may have excluded women with the worst
sleep. Thus, our results may not be generalizeable to all
women in this age group. Third, although actigraphy is an
objective assessment of sleep, it overestimates total sleep
time compared with polysomnography because it cannot
detect wake time in which no movement occurs [17,48,49].
This overestimation may be larger among those with poor
sleep quality [17,50,51], possibly causing an attenuation of
the observed associations.
Another limitation was that 14% of the nights had some
missing data, which may limit the generalizability of our
results. We hypothesize that most missing data were due to
the participant forgetting to put on the actigraph when going
to bed. However, for about 25% of the missing nights, the
participant took off the actigraph early, i.e., before getting
out of bed. Sleep measures on these nights were signifi-
cantly worse than nights with complete data, even when
delineating all missing minutes as sleep. This suggests that
if a participant is sleeping poorly, she may remove the
actigraph in an effort to improve sleep. Thus, it is important
to query participants about whether they removed the
actigraph during the night.
In conclusion, we found that sleep measures during the
luteal phase of the menstrual cycle vary widely in women
ages 20 to 40 years sleeping at home, where they were
unrestricted in their behavior. Multiple nights of data
collection, including weekend and weeknights, may be
necessary to obtain reliable estimates of an individual’s
18 S.S. Tworoger et al. / Journal of Psychosomatic Research 59 (2005) 11–19
sleep patterns. Unusual bed or rise times, medication use,
employment, day of week, daylight hours, menstrual cycle
length, and BMI were associated with actigraphically
assessed sleep in this population. Associations of per-
ceived stress, employment, and age with objective and
subjective sleep patterns differed, suggesting that these two
modalities may assess different aspects of the sleep
experience. Due to the preliminary nature of these
findings, these results need to be confirmed by other
studies. Future studies also should examine the relation-
ships between these factors and sleep quality during other
phases of the menstrual cycle and among young adult
women on oral contraceptives.
Acknowledgments
This research was performed at the Fred Hutchinson
Cancer Research Center in Seattle, WA, and was supported
by Research Grant RO1CA80346 from the National Cancer
Institute. Dr. Tworoger was supported, in part, by a National
Institutes of Environmental Health Sciences Training Grant
(T32EF07262) and by a National Cancer Institute Cancer
Epidemiology Training Grant (T32CA090001). Dr. Vitiello
was supported by an NIMH Independent Scientist Award
(K02-MH01158).
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