Journal of Clinical Epidemiology 56 (2003) 436–440

Reliability of the Wisconsin Sleep Questionnaire: A French

contribution to international validation
Dan Teculescua,*, Francis Guilleminb,e, Jean-Marc Virionc, Catherine Aubryd,
Bernard Hannharta, Jean-Pierre Michaelya, René Gueguend
a
INSERM Unité 420, BP 184, 54505 Vandœuvre, France
b
EA 3444, School of Public Health, Faculty of Medicine, University H. Poincaré, 3 Avenue de la Foret de Haye, 54500 Vandœuvre, France
c
Centre of Clinical Investigations, INSERM and Department of Clinical Epidemiology and Evaluation, Nancy University Hospital,
5 Avenue de Lattre de Tassigny, 54000 Nancy, France
d
Centre of Preventive Medicine, 7 rue du Doyen Parisot, 54501 Vandœuvre, France
e
Department of Clinical Epidemiology and Evaluation, Nancy University Hospital, 5 Avenue de Lattre de Tassigny, 54000 Nancy, France
Received 10 December 2002; received in revised form 16 December 2002; accepted 6 January 2003

Abstract
We evaluated the reliability of a French version of the Wisconsin Sleep Questionnaire designed to investigate snoring, obstructive
apnoeas, and sleeping problems. The assessment of reliability included the study of internal consistency and the 3 months repeatability of
the questionnaire. The questionnaire was first completed at a Center of Preventive Medicine by a random sample of 122 subjects from the
community. Three months later the same form was mailed and 82 questionnaires were returned (67.2%). No significant differences existed
between responders and nonresponders for anthropometric data or life habits. The internal consistency in each domain was good or
satisfactory (Cronbach’s alpha ⫽ 0.67 to 0.81). The concordance between the answers at a 3-month interval was excellent for questions
on ever snoring, frequency of snoring, gasping/choking during sleep, and breathing stops during sleep (Cohen kappa ⬎ 0.60). The questions on
snoring loudness, a history of sleep apnoea, and excessive daytime sleepiness were fairly reproducible (kappa 0.28 to 0.60). We found no
difference in reproducibility by gender or age. In conclusion, this reliability assessment in a sample of middle-aged subjects from the
community in northeastern France showed satisfactory internal consistency and 3-months reproducibility of the main questions of a French
translation of the Wisconsin Sleep Questionnaire. 쑖 2003 Elsevier Inc. All rights reserved.
Keywords: Sleep questionnaire; Three-month repeatability; Internal consistency; General population

1. Introduction to French again (the Wisconsin University form). We also

At the time (1996) an epidemiologic study on sleep-
disordered breathing (SDB) was planned in our area, no
validated French sleep questionnaire was available. For the
sake of comparability, we wished to utilize a form largely
applied in previous studies. Comparing several such instru-
ments [1–4], we opted for the questionnaire utilized in the
Wisconsin Sleep Cohort Study [3], which seemed com-
plete although not too long to fill in. Its validity has been
documented, and the content has been shown to target sleep
disorders and consequences appropriately. This content
should be preserved when using it in a different cultural
context [5].
Knowing that transcultural adaptation of a field survey
questionnaire implies a complex work of adaptation to the
second language [5,6], we first translated it from English to
French, then retranslated it to English and translated it
* Corresponding author. Tel.: ⫹33-03-83-69-39-16; fax: ⫹33-03-83-
68-39-19.
E-mail address: Dan.Teculescu@nancy.inserm.fr (D. Teculescu).
0895-4356/03/$ – see front matter 쑖 2003 Elsevier Inc. All rights reserved.
doi: 10.1016/S0895-4356(03)00029-5
performed a pilot study to ensure that the subjects understood
correctly the sense of every question [7].
The reliability of the Wisconsin Sleep Questionnaire
has not been analyzed yet. Reliability is composed of internal
consistency (the degree to which items exploring various
facets of a domain are interrelated) as well as reproducibility,
the property providing the same result when measuring the
same level of the phenomenon. We explored here the internal
consistency and intraobserver test-retest repeatability [5,6].
Only a few attempts were devoted to the validation of
other sleep and breathing questionnaires [8–12]; all of these
studies were done in small groups of patients attending
diagnostic centers. As such questionnaires are increasingly
used in large field studies [13–15], including non-Anglo-
Saxon samples [16], we felt it necessary to assess the psy-
chometric property as part of the quality of the measurement
tool. This article presents the analysis of the 3-month repro-
ducibility and of the internal consistency of the translated
Wisconsin Sleep Questionnaire in a sample of subjects from
the general population of northeastern France.
 D. Teculescu et al. / Journal of Clinical Epidemiology 56 (2003) 436–440 437

2. Methods repeated on three categories, collapsing the “rarely”plus

2.1. Subject recruitment
The target population were the subjects attending between
November 1998 and March 1999, a regional Center of Pre-
ventive Medicine serving a population of about 2 million.
The subjects were approached in the order of the Center
computer-generated list; a written explanation of the study
was given, stressing the noninvasive character of the proto-
col, and the sleep questionnaire was distributed in person
for self-completion to subjects who volunteered.
“sometimes” answers on one side, the “several nights per
week” and “almost every night” on the other side, and leav-
ing the “at least once a week-pattern irregular” as a the
median (third) category.
Internal consistency was assessed by the Cronbach’s
alpha coefficient [20]. According to Nunally, an alpha over
0.7 indicated a high reliability, over 0.5 a moderate reliability,
and below 0.2 a low reliability [21]. Data processing used
the SAS software version 8.1 (1999).

2.2. Design of the study 3. Results

Couples of recruited people completed the forms side by Demographic data from subjects who returned (⫽“re-
side, so that he information concerning breathing during sleep spondents”) or did not return (⫽“nonrespondents”) the
was available both from subject and from spouse. Subjects mailed questionnaire were checked and found to be compara-
were included if living in couples, and aged 30 years or ble (Table 1); thus, the group of respondents could be consid-
more. Of 434 subjects invited, 402 (201 couples) agreed to ered representative of the sample to which the questionnaire
participate (participation rate 92.6%), completing the ques- was addressed. As we looked at the prevalence of the main
tionnaire. Three months later, the questionnaire was mailed symptoms in responders, we found habitual snoring in
with a covering letter and a stamped envelope to a random 41.7%; loud snoring in 30.2%; gasping or choking in 5.1%;
subsample of 122 subjects, and was returned by 82 of breathing pauses perceived by the bedpartner in 6.8%; dis-
them (67.2%). No reminder was send to those who did not ruptive movements during sleep in 7.6%; waking up repeat-
answer. The study was approved by the Ethics in Medical edly during the night in 20.7%; difficult to wake up in the
Research Regional Committee. morning in 19.5%; waking up with headaches in 4.9%;
excessive daytime sleepiness in 13.4%, and an obstructed/
2.3. The questionnaire running nose during the night in 12.2%.
For the sake of clarity, the repeatability of the responses
The Wisconsin University Sleep Questionnaire [3], has is presented according to the type of question, with the
been adapted from the Basic Northern Sleep Questionnaire five-category answers collapsed to three, as specified. The
elaborated by Scandinavian authors [2]. The questionnaire repeatability of main questions pertaining to breathing
was first translated to French, checked by experts for ad- during sleep was fair for two questions, good for one, and
equacy of terms, back-translated to English, and finally trans- excellent for three (Table 2), with kappa extreme values of
lated to French again. We used the form utilized in the 0.41 to 0.86. A computation including all the five possible
initial (1992) survey by T. Young et al. [3], consisting of categories would yield somewhat lower figures for kappa,
10 questions on snoring and sleep-disordered breathing, five
questions on disturbed sleep, five questions on personal and
family medical history, and 12 questions on life habits, edu- Table 1
cation, job working hours, gender, anthropometric data, Demographic variables and life habits in responders and
number of children, etc. For each question evaluating the non-responders to a repeat (3-months interval) sleep questionnaire
frequency of a phenomenon, the possible answers were: (1) Responders Nonresponders
rarely; (2) sometimes; (3) at least once a week-pattern irregu- No. subjects 82 40 P—
lar; (4) several (3 to 5) nights per week; (5) every night or Age (years) 43.4 ⫾ 10.5 a
44.2 ⫾ 8.1 .67
almost every night; and (6) do not know. A copy of the Height (cm) 167.1 ⫾ 9.3 165.2 ⫾ 9.3 .28
Weight (kg) 71.3 ⫾ 12.0 73.5 ⫾ 13.5 .39
questionnaire can be obtained from the authors on request.
BMI (kg/m2) 25.5 ⫾ 4.0 26.9 ⫾ 4.5 .08
Neck girth (cm) 36.9 ⫾ 3.7 37.6 ⫾ 4.0 .31
2.4. Statistics Waist girth (cm) 83.8 ⫾ 12.1 86.7 ⫾ 11.8 .22
Hip girth (cm) 99.1 ⫾ 13.8 100.2 ⫾ 7.3 .42
The test/retest repeatability was assessed using the Waist/hip ratio 0.84 ⫾ 0.10 0.87 ⫾ 0.10 .30
Cohen’s kappa statistic [17]; weighted kappa was used for Current smokers (%) 24.7 23.7 .91
Education (school years) 12.9 ⫾ 3.4 11.6 ⫾ 2.9 .12b
questions with multiple-point answers [18]. According to Leisure physical activity 3.6 ⫾ 6.1 5.7 ⫾ 7.7 .45b
Fleiss [19], an agreement of less than 0.40 was considered (hr/week)
as poor, between 0.41 and 0.59 as fair, between 0.60 and 0.74 a
Figures are means ⫾ standard deviations.
as good, and of 0.75 or more as excellent. The analysis was b
Mann–Whitney test; all other comparisons are based on the t
first done on the original five answers categories, and then (Student) test.
438 D. Teculescu et al. / Journal of Clinical Epidemiology 56 (2003) 436–440

Table 2 Table 3
Repeatability of answers pertaining to sleep-disordered breathing Repeatability of answers on sleep problems and daytime sleepiness
during sleep 95%
95% Confidence
Confidence Question Kappa interval
Question Kappaa interval Please check if you have one of these
Have you ever been told that you snore? 0.86 0.72 0.99 sleeping problems:
According to what others have told you, please 0.69 0.53 0.84 Difficulty getting to sleep 0.51 0.35–0.66
estimate how often you snore? Wake up, with hard time getting back to sleep 0.53 0.38–0.68
How loud have others said your snoring is? 0.41 0.17 0.65 Wake up repeatedly during the night 0.43 0.26–0.61
Have you had the feeling or awareness that you 0.45 0.24 0.66 Wake up too early in the morning 0.53 0.37–0.70
have been snoring? Not feel rested during the day 0.28 0.11–0.45
Do you gasp, choke, or make snorting 0.80 0.60 0.99 Very difficult to wake up in the morning 0.53 0.35–0.70
sounds during sleep? Nightmares, disturbing dreams 0. 35 0.14–0.55
Do you seem to have momentary periods during 0.75 0.54 0.97 “Restless legs” 0.50 0.28–0.71
sleep when you stop breathing or breathe Excessive daytime sleepiness 0.52 0.35–0.70
abnormally? Nasal obstruction or discharge at night 0.45 0.24–0.66
a
The results correspond to “simple” kappas for questions with binary Fall asleep or doze watching TV or reading 0.60 0.41–0.75
answers and “weighted” kappas for questions with multiple-point answers,
collapsed to three categories.
4. Discussion
for example, 0.57 instead of 0.69 for snoring frequency, or Crosscultural adaptation of a questionnaire is much more
0.50 instead of 0.75 for breathing pauses during sleep. We than a simple translation [6]: the novel version must reflect
addressed the problem of possible differences in reproduc- in depth the true significance of the questions in the new
ibility by sex or by age. For example, the reproducibility of language [6,22]. Adaptation of an English questionnaire to
snoring frequency yielded a kappa of 0.65 for males and one of the Latin group languages is reputed to raise difficult
of 0.69 for females (difference nonsignificant). Subjects problems [23]. In the present study, we followed the recom-
aged more than 50 years had a slightly lower reproducibility mended sequence: forward translation to French; evaluation
when compared with younger subjects (kappa 0.65 vs. 0.70), of the preliminary translation; backward translation to
but again, the difference was not significant. We also evalu- English; and final translation to French [24]. In the pilot study
ated the distribution of concordance of the extreme catego- mentioned above [7], the nonresponses were infrequent (2%
ries of response. In males, 64.3% of nonsnorers remained or less, with the exception of hypertension = 12.0%). The
nonsnorers after 3 months, while 86.7% of habitual snorers responses “do not know” were frequent for certain items,
remained habitual snorers. In females, the proportions were such as “how many years do you think you have been snor-
85.7 and 66.7%, respectively. The same analysis according to ing,” for a parental history of narcolepsy and for a parental
age yielded 78.9% concordance for nonsnoring, and 78.6% history of sleep apnoea.
concordance for habitual snoring in subjects older than 50 In studies by previous authors, the interval between two
years; in subjects less than 50 years old, concordance for administrations of the questionnaire varied between very
nonsnoring was 66.7%, and concordance for habitual snoring large limits [8,25]. We followed the recommendation of
was 85.7%. Most questions on sleep problems and excessive Bailar [26] and adopted an interval of 3 months for our
daytime sleepiness yielded fair repeatable answers (eight repeatability study; this is reputed to minimize recall bias
questions) with three exceptions: question 13e “not feel [27,28]. The questionnaire was self-completed in both
rested during the day” and question 13g “nightmares or phases of our study. The only difference was that at the
disturbing dreams” were poorly repeatable; “falling asleep first phase it was distributed in person, while at the second
watching TV” showed good repeatability (Table 3). The it was mailed. Thus, both administrations used the same
kappa values ranged between 0.28 and 0.60. technique [29].
The reproducibility of the question on current smoking For reasons alluded to in the introduction, a direct com-
was excellent (kappa 0.91). Concerning the medical family parison between our results and those of previous validation
history, our subjects obviously poorly knew two conditions: studies [8–12] is impossible for several reasons. First, it is
narcolepsy (30 and 33% missing values for the mother and very difficult to compare two different questionnaires.
the father, respectively), and sleep apnoea in parents. For the Second, previous work was done in small groups of patients
latter condition, the missing values were more frequent in attending specialized laboratories, while the present one
males (49% for both parents) compared to the females (29% involved a larger sample of (presumably) healthy subjects
for mothers, 27% for fathers). from the community. Third, any comparison is meaning-
The reliability coefficient showed good to high internal less until the test/retest interval is standardized. We under-
consistency throughout. The alpha statistic was 0.67 for took our study being aware of the fact that measures of
questions on snoring, 0.81 for questions on apnoeas, and 0.76 validity of questionnaires used in patients cannot be general-
for questions on sleep disturbance and daytime sleepiness. ized for measurement in general population, as stressed by
 D. Teculescu et al. / Journal of Clinical Epidemiology 56 (2003) 436–440
Young [30]. The subjects studied by us belonged to families
attending a Preventive Medicine Center. We were satisfied
to obtain a return rate of 67% for the mailed form and to
find no significant difference in anthropometry, smoking
habits, education, and leisure physical activities between
responders and nonresponders. We obtained excellent or
good agreement for four of the important questions on
breathing during sleep: “have you ever been told you snore”;
“please estimate how often you snore”; “do you gasp, choke,
or make snorting sounds…” and “do you seem to have periods
you stop breathing…” The agreement was fair for the two
remaining questions (“loudness of snoring” and “have you
had the feeling that you have been snoring?”).
The questions on other sleep problems were somewhat
less repeatable. The kappa values were in the fair range for
eight (out of 11 questions), poor for two questions, and good
for one question. In respect to the missing values, it should
be mentioned that we found no difference by sex, with one
notable exception: daughters seem to have a better recollec-
tion of the presence/absence of sleep apnoea in their parents,
compared to sons. If we exclude overestimation by daugh-
ters, this means that information of familial factors in sleep-
disordered breathing should preferably be obtained from
daughters, rather than sons.
Finally, the internal consistency of the principal chapters
of the questionnaire (snoring, apnoeas, and sleep distur-
bances including daytime sleepiness) was found to be satis-
factory, confirming previous results in patients [4,10,12], and
the preliminary report of Goudge et al. in a mixed group of
patients and healthy subjects [31]. A good to high Cronbach’s
alpha coefficient is the reflection of the degree of coherence
of items within one domain in exploring the concept, in our
case snoring, obstructed breathing, or sleeping problems. It
was usually interpreted as items being complementary of
each other so as to explore comprehensively all related
aspects of this domain. However, recent literature [32]
has stressed the fact that a high internal consistency could also
be the reflection of redundancy in measurement of the under-
lying phenomenon, thus leading to reject items that would
be too highly correlated to other scale items. Therefore, an
alpha value within the range of 0.7 to 0.8 can be considered
a scale balanced for reliability.
The translation of questionnaires may result in a new
questionnaire that does not exactly reflect the original mea-
sure. Indeed, a change in culture may not convey the same
meaning to words sentences or context. Although translators
may reliably obtain semantic equivalence, idioms, and other
forms of equivalence like conceptual or experiential adapta-
tion may loose the original concept intended to measure.
Thus, it is recommended to use adequate and qualified
translators, to apply forward and backward translations
successively, to submit a preliminary version to a multidisci-
plinary expert committee, and to conduct a pretest in commu-
nity or patient groups [5]. For example, we translated English
“angina” into the French “angine,” with agreement of the
experts. When, however, in the pilot study, the investigator
439
asked each subject, for each question, “what do you mean
by this?” it came out that one-third of the subjects meant
“angor pectoris,” while the other two-thirds meant “acute
pharyngitis”! A careful translation process is particularly
important for investigating subjective perceptions by the
individual of his/her health status, less so for physical symp-
toms. Most of the above-mentioned steps have been imple-
mented during the development of the French version of
the Wisconsin Sleep Questionnaire.
In conclusion, in this sample of middle-aged subjects of
both sexes from a French community, we found excellent or
good reproducibility at a 3-month interval for most questions
of a French translation of the Wisconsin University Sleep
Questionnaire, with no significant differences according to
gender or age. No valid conclusions could be reached on
the reproducibility of the familial history of narcolepsy or
sleep apnoea because of the small number of positive an-
swers. The internal consistency of the French version of the
Wisconsin Sleep Questionnaire proved to be satisfactory.
The reliability of this version should be tested in samples
with a larger age and socioeducational range. Similar
“breathing during sleep” and “sleep-quality” questionnaires
are increasingly used in large-scale field surveys [30]. En-
glish versions were utilized in the Wisconsin Sleep Cohort
Study [3], in the Nurses Health Study [14], and in the Sleep
Heart Health Study [13,15]. A translation of the Wisconsin
Sleep Questionnaire has recently been used in a large survey
in Poland [16]; it would be interesting to compare the repro-
ducibility and internal consistency of the present work
to translations of the Wisconsin Sleep Questionnaire to
other languages.
Acknowledgments
The authors are indebted to the staff of the Vandœuvre
Preventive Medicine Center for their help in subject recruit-
ment, to Mr. Bruno Phelut for his help with the computer
files, to Ms. Aline Berthelin for manuscript processing, and
to the subjects of the study for their willing participation.
They wish to acknowledge the constructive criticism of the
two anonymous reviewers whose comments substantially
improved the initial version of this article.
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