Validation of Malay Version of Insomnia

Severity Index (ISI) among University

Student Population in Klang Valley,
Malaysia

See Cai Yin

GS 1707-8106

Research Presentation
Introduction
 Insomnia
 The presence of an individual’s report with difficulty in sleep
(Roth, 2007).

 Impacts = daytime impairments (Doghramji, 2006)

 Primary insomnia vs Secondary insomnia
 Insomnia as a symptom or associated with other disorder
 Depression; Major risk factor for suicide (McCall & Black, 2013; Nutt, Wilson, & Paterson, 2008;
Paterson, Nutt & Wilson, 2009; Pigeon, Pinquart, & Conner, 2012; Susánszky, Hajnal & Kopp, 2011 )

 Anxiety (McLaughlin & Hatzenbuehler, 2009; Schneiderman, Ironson, & Siegel, 2005)

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Introduction
 Prevalence (Bixler, Vgontzas, Lin, Vela-Bueno & Kales, 2002; Chong, Fryer & Gu, 2013; Ohayon, 2002)
 40% in general population in United State
 4% used sleeping pills as a regular basis
 In Malaysia (Zailinawati, Ariff, Nurjahan, & Teng, 2008; Zailinawati, Mazza, & Teng, 2012)
 33.8% in general population = insomnia symptoms
 12.2% = chronic insomnia
 Systematic review (Jiang et al., 2015)
 University students = 18.5% more likely to have insomnia
 Studies from Hong Kong, China and Malaysia
 University students, especially medical students typically reported higher
number of sleep problems (Huen, Chan, Yu, & Wing, 2007; Luo, Feng & Li, 2013; Zailinawati et al., 2009)

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Problem Statement
 Structured and semi-structured clinical interviews
 Time consuming and may not be practical for routine clinical
use (Bastien, Vallières, & Morin, 2001)

 Insomnia Severity Index (ISI)

 Useful in detecting cases of insomnia and its sensitive to
treatment response in clinical patients (Morin et al., 2011)
 Assess the severity of both nighttime and daytime components
of insomnia (Morin et al., 2011)
 It has been translated and validated in many languages (Morin et al.,
2011)

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Significance of Study
 Enable more opportunities to use it as a validated tool to assess
insomnia in Malaysia
 Prevalence studies of insomnia mostly focus on teens/adolescents,
pregnant woman, working adults and older population.
 University students have different responsibilities and other
stressors, which do not make them less vulnerable to other
populations.
 Studies showed that up to 30% of the university students are
at risk of at least one sleep problem.
 To use it as the initial screening to assess insomnia symptoms
 Further allow better treatment and management planning.

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Research Objectives
1. To validate the Malay version of ISI among university
students population in Malaysia
2. To establish psychometric properties of Malay version
of ISI

6
 Literature Review

7
Literature Review
 Insomnia Severity Index (ISI)
 Assess the nature, severity, and impact of insomnia
 Internal consistency reliability (Morin et al., 2011)
 .90 for community sample and .91 for clinical sample
 Convergent validity
 Supported by significant correlation between total ISI score and
measures of fatigue (Multidimensional Fatigue Inventory MFI),
quality of life (SF-12 Health Survey SF-12), anxiety (Beck Anxiety
Inventory BAI), and depression (Beck Depression Inventory BDI)
(Morin et al., 2011)

 Sensitivity = 87.7% (Morin et al., 2011)

 Specificity = 86.1% (Morin et al., 2011)

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Literature Review
 ISI has been translated and validated into different
language and countries, including Arabic, Hindi, Spanish,
Mandarin, Persian, German, Korean and Italian.
(Baghyahi, Gao, Taghanaki & Aval, 2012; Castronovo et al., 2016; Cho, Song & Morin, 2014; Chung, Kan & Yeung, 2011;
Fernandez-Mendoza et al., 2012; Gerber et al., 2016; Lahan & Gupta, 2011; Sadeghniiat-Haghighi, Montazeri, Khajeh-Mehrizi,
Nedjat, & Aminian, 2014; Suleiman & Yates, 2011; Yazdi, Sadeghniiat-Haghighi, Zohal & Elmizadeh, 2012; Yu, 2010)

 Internal Consistency reliability = adequate to excellent (.72

- .92)
 Good test-retest reliability and concurrent validity.

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Literature Review
 Only a few establish construct validity using EFA or CFA
 Useful in exploring the fundamental construct of ISI
 Most of them establish concurrent validity, mostly with PSQI
 Inconsistent sample size (some as low as 35/65)
 Only German and Spanish language recruited university
student population
 Insomnia condition in university students tend to be
overlooked
✔ Might provide an overview of the suitability of Malay version
of ISI in Malaysian university student population

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 Methodology

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Methodology
 Study Design
 Cross-sectional survey study

 Participants
 Sample size calculation = Rule of thumb
 Pilot study = 35 participants
 Main study = 100 participants each for exploratory factor
analysis (EFA) confirmatory factor analysis (CFA)

 Sampling Method
 Convenience sampling

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Inclusion Criteria and Exclusion Criteria
Inclusion Criteria Exclusion Criteria
• Adults (males and females) who • Participants who are pregnant
aged 18 years old and above
who are currently studying in
university
• Able to provide informed • Diagnosed with mental
consent disorders
• Able to read and understand • Unable to provide consent
Malay and English

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Instruments
ISI
• Self-report
• 7 items
• 5-point Likert scale
• Dimension evaluated
• severity of sleep onset
• sleep maintenance
• early morning awakening
problems
• sleep dissatisfaction
• interference of sleep difficulties
with daytime functioning
• noticeability of sleep problems
by others
• distress caused by the sleep
difficulties
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Pittsburgh Sleep Quality Index (PSQI)
• Self-report
• 19-items
• 4-point Likert scale
• Dimension evaluated
• subjective sleep quality
• sleep latency
• sleep duration
• habitual sleep efficiency
• sleep disturbances
• use of sleep medication
• daytime dysfunction over the last
month
Procedure
Translate questionnaire

Questionnaires distributed through hard copy and online.

Consent form and e-consent Forward
form wastranslation
shown to the participants before they
agree
Experttopanel
participate.
review
Back-translation

Validation Process Exploratory factor analysis (EFA)

Confirmatory factor analysis (CFA)

Reliability Correlation with Validity

- Internal consistency PSQI - Construct validity
- Test-retest reliability - Concurrent validity

Malay ISI translation and validation process of current study.

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Ethical Consideration
 Approved by Cyberjaya University College of Medical
Sciences (CUCMS) Research Ethics Review Committee
(CRERC)
 Consent form was given before participants fill in the questionnaire,
while for online participation, e-consent was shown on the first page
of the link.
 Participation was based on a voluntary basis and the informed
consent stated that they are free to withdraw from the study anytime.
 Information and details were kept confidential

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 Results: Pilot Study

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Demographic Details
    No. (N) Percentage
(%)
Gender Male 8 22.9
Female 27 77.1
Age 18 years old – 28 years old 28 80.0
29 year old – 38 years old 5 14.3
39 years old – 48 years old 2 5.7
48 years old and above 0 0.0
Ethnicity Malay 15 42.9
Chinese 14 40.0
Indian 3 8.6
Others 3 8.6
Education Level Diploma/Foundation 2 5.7
Degree 13 37.1
Master 19 54.3
PhD 1 2.9

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Demographic Details
University Frequency Percentage (%)
CUCMS 10 28.6
UKM 2 5.7
UPM 9 25.7
IIUM 5 14.3
Monash 2 5.7
IMU 1 2.9
BAC 1 2.9
SEGi 3 8.6
UM 1 2.9
KDU 1 2.9
Total 35 100

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Reliability and Validity
 Internal Consistency
Reliability Statistics
Cronbach Alpha N of Items
.825 7

 Concurrent Validity with PSQI

 PSQI Total
ISI Total Pearson Correlation .721**
Sig. .000
N 35
**. Correlation is significant at the 0.01 level.

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Validity: EFA

Kaiser-Meyer-Olkin Measure of .723

Sampling Adequacy

Factor 1 Factor 2
ISI1 .80
ISI2 .78
ISI3 .76
ISI4 .87
ISI5 .82
ISI6 .89
ISI7 .84

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 Results: Main Study

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Demographic Details
    No. (N) Mean (M) Standard
Deviation (SD)
Gender Male 51 1.10 .30
Female 149 1.05 .42
Age 18 years old – 28 years old 189 1.76 .43
29 year old – 38 years old 10 1.50 .53
39 years old – 48 years old 1 2.00 .00
48 years old and above 0 0.00 .00
Ethnicity Malay 131 1.76 .43
Chinese 39 1.67 .48
Indian 21 1.86 .36
Others 9 1.56 .53
Education Diploma/Foundation 21 1.81 .40
Level
Degree 149 1.71 .46
Master 29 1.86 .35
PhD 1 2.00 .00

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Demographic Details

    No. (N) Mean Standard

(M) Deviation
(SD)
University Cyberjaya University College of 151 1.79 .41
Medical Sciences (CUCMS)
  City University 11 1.64 .50
  University Kebangsaan Malaysia 8 1.50 .54
(UKM)
  University Putra Malaysia (UPM) 9 1.89 .33

  International Medical University (IMU) 7 1.86 .38

  Sunway University 12 1.25 .45

  University Islam Malaysia 2 2.00 .00

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Reliability
 Internal Consistency of the Malay ISI
 Scale Cronbach’s Alpha No. of item
Malay ISI .852 7

 Two-week test-retest (N = 98)

   Pearson No. of item
Correlation
Two-week test-retest Malay ISI .857** 7

Note. ** p < .001

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Validity: EFA
 KMO = .83
 Barlett’s test of sphericity was significant (χ2 (21) = 304.83, p < .001)
 Communalities = all > .30
 Thus, factor analysis was suitable for all 7 items

Items Factor 1 Factor 2

ISI1 Sukar untuk mula tidur .61  
ISI2 Sukar untuk terus kekal tidur .81  
ISI3 Bangun terlalu awal pada waktu pagi .84  
ISI4 Sejauh mana anda berpuas hati/tidak puas hati dengan corak tidur .62  
anda sekarang?
ISI5 Sejauh mana anda mempertimbangkan masalah tidur sebagai   .87
mengganggu fungsi seharian anda (Contohnya keletihan pada siang
hari, kebolehan untuk berfungsi di tempat kerja/melakukan kerja-kerja
rumah, menumpukan perhatian, daya ingatan, mood)?
ISI6 Sejauh mana keketaraan masalah tidur anda dilihat sebagai   .72
mengganggu kualiti hidup anda pada mata orang lain?
ISI7 Adakah anda risau/bimbang tentang masalah tidur anda sekarang?   .70

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Validity: CFA
 Acceptable fit for two-factor model

Two-factor model
df 13
χ2 20.62
CFI 0.97
GFI 0.94
AGFI 0.88
RMSE 0.08
A

 No items were deleted

 Loadings for each item were acceptable
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Concurrent Validity
 Concurrent Validity with Malay PSQI
    Malay PSQI
Malay ISI Pearson Correlation .74**
Note. ** p < .001

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 Discussion

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Discussion
 Good internal consistency reliability (α = .85), suggesting it’s
reliable tool.
 Consistent with all the past studies (Baghyahi et al., 2013; Castronovo et al., 2016; Cho
et al., 2014; Chung et al., 2011; Fernandez-Mendoza et al., 2012; Gerber et al., 2016; Lahan & Gupta, 2011;
Sadeghniiat-Haghighi et al., 2014; Suleiman & Yates, 2011; Yazdi et al., 2012; Yu, 2010)
 Adequate to excellent internal consistency reliability
 Good test-retest reliability (r = .86), suggesting adequate
stability.
 Consistent with past studies (Baghyahi et al., 2013; Cho et al., 2014; Yazdi et al., 2012)
 Strong to very strong stability across a two to four-week test-retest
reliability
 Good correlation with Malay PSQI (r = .74)
 Consistent with past researches (Baghyahi et al., 2013; Cho et al., 2014; Gerber et al.,
2016; Sadeghniiat-Haghighi et al., 2014; Suleiman & Yates, 2011; Yazdi et al., 2012; Yu, 2010)

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Discussion
 EFA suggested two-factor model, CFA further confirmed
two-factor model was a satisfactory fit
 Item 1 to 4 – severity of symptoms and satisfaction domain
 Item 5 to 7 – impacts domain
 Past studies
Two-factor model Three-factor model
Item 4 loaded on symptoms domain Item 4 loaded on a third factor itself
(Yu, 2010) and cross loaded on the other two
Item 4 loaded on impacts domain factor (Castronovo et al., 2016)
(Chung et al., 2011; Sadeghniiat-Haghighi et al., 2014)

 Probably due to item 4 (measurement of satisfaction) was a

double-ended point scale (ranging from very satisfied to very
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dissatisfied) (Savard, Savard, Simard & Ivers, 2005)
Implication
 Provide an overview of the suitability of usage of the
Malay version of ISI within Malaysian culture
 By translating and validating could potentially increase
the reliability and validity to ease the screening procedure
 Current study explored more on factor structure
 Test-retest reliability and concurrent validity was also
established

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Limitations and Future Direction
 Only recruited university students population around Klang
Valley area.
 Results may not be able to generate to other population in
Malaysia.
 Future direction: validation in other population shall be done if
intended to apply Malay ISI to a particular population
 Did not recruit patients with insomnia
 Specificity, sensitivity and the cut-off score could not be
established
 Future direction: further derive the norm and cut off score to
achieve a clinically relevant measurement

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Conclusion
 Malay ISI showed:
 Good psychometric properties
 A fit model structure with two-factor model correspond to
symptoms and impact subdomains
 Good concurrent validity with Malay PSQI
 Appropriate to use as brief screening tool to screen insomnia
symptoms in university students population in Malaysia

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