PDF | On Sep 1, , Ysabel Izquierdo-Vicario and others published Epworth Sleepiness Scale in a Sample of the Spanish Population. A Spanish version of the Epworth Sleepiness Scale (ESS-Sp) was developed by translation, back-translation, formal discussion, and a meeting of researchers. Participants completed English and Spanish versions of the Sleep Habits Questionnaire, the Epworth Sleepiness Scale, and the Acculturation Rating Scale for.

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Psychometric properties were assessed, including internal consistency, convergent validity, scale equivalence, language version intercorrelations, epwprth exploratory factor analysis using PASW Seepiness software.

Grade level readability of the sleep measure was evaluated. The Epworth correlated significantly with snoring, apnea, sleep symptoms, restless legs, and sleep disruptors on both versions, supporting convergent validity.

The Spanish-language Sleep Habits Questionnaire demonstrates conceptual and content equivalency. It has appropriate measurement properties and should be useful for assessing sleep health in community-based clinics and intervention studies among Spanish-speaking Mexican Americans. Both language versions showed readability at the fifth grade level.

Further testing is needed with larger samples. Spanish translation and cross-language validation of a Sleep Habits Questionnaire for use in clinical and research settings. J Clin Sleep Med ;8 2: Sleep research over the past two decades has shown spanizh between sleep disorders and chronic disease, 1 — 7 poorer health-related quality of life, 89 increased health spqnish work-related costs, and travel and work-related accidents. Hispanics experience the following: Limited knowledge of sleep and health epworty Hispanics of Mexican descent, the largest Hispanic group in the United States, is partly due to the need for precisely translated and validated sleep measures to assess Spanish-speaking Mexican Americans in clinical and research settings.

This Spanish-language version of the Sleep Habits Questionnaire may be applied in clinical and research settings as a first step toward addressing sleep health disparities of Spanish-speaking Mexican Americans. A major issue in the adequate and appropriate assessment of sleep disorders of Hispanics is that of language.

Participants completed demographic and health history data in English. English sleepineess Spanish versions of the Sleep Habits Questionnaire, apanish Epworth and an acculturation rating sdale were completed 7 to 10 days apart in counterbalanced randomized order. Scalr facets of this study were reviewed and approved by the university institutional review board. The questionnaire addresses several categories of sleep disorders examined in this study: There is an additional category that assesses potential sleep disruptors, including sinusitis, room noise, temperature, pain, and frequent toileting 9 items.

The questionnaire can be used in its entirety for a comprehensive overview of subjective reports of sleep disorders, or in categories e. The Epworth Sleepiness Scale is a validated self-completion tool that asks subjects to rate the likelihood of falling asleep in several common situations and was included with the sleep habits items. The Scape measure, translated for this study in the same manner as the Sleep Habits Questionnaire, also demonstrated high reliability for the English 0.

Language serves as a general indicator of level of acculturation. It has an internal reliability of 0.

This English to Spanish translation of the Sleep Habits Questionnaire was guided by the adaptation of Brislin’s Translation Model to address cultural and functional equivalence, to make the translation and validation process more efficient and to ensure the integrity of the process.

The translation and validation model is displayed in Figure 1. In Step 13 independent translations were made simultaneously in a blinded fashion from source English to target Spanish language by 3 bilingual health providers of Mexican heritage with Spanish as their first language.

During Step 2each target language version of the questionnaire was back-translated in a blinded fashion to the source language by 3 new volunteer bilingual health providers of Mexican heritage with Spanish as their slepiness language.

In Step 3a team member whose first language was Spanish completed a content analysis of the translations and back-translations to aid in assuring credibility, trustworthiness, and transferability of translation. Dpanish differences in meanings were identified in the back-translations, the principal investigator and bilingual team members met with the translators and back-translators involved in Steps 1 and 2 to review differences and adapt the target language version Spanish in order to achieve the most accurate culturally equivalent meanings.

In Step 4two additional native Spanish speakers independently back-translated the version of sleepinexs questionnaire revised in Step 3.

Epworth Sleepiness Scale (ESS)

Because bilingual speakers and certified translators may introduce bias due to using and understanding languages differently than the population to be tested, the back-translators in Step 4 were lay people from local clinics who were more representative of the population under study.

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Blinded data were reviewed by lay bilingual experts to determine the need for linguistic adjustments based on early comments in this step.

Step 5 consisted of a second meeting of the bilingual experts, who reviewed and compared the back-translations of the expert and lay translators. At this point, the team agreed seepiness culturally equivalent meanings in both the English and Spanish language versions of the Sleep Habits Questionnaire.

Step 6 assisted in assuring that both linguistic and cultural equivalence of translation was achieved cross-language validation. These data were examined for psychometric properties of the rigorously translated instrument.

The Spanish translated instrument was assessed for grade level readability using the Huerta Reading Ease Score. Scores from 90 to indicate very easy reading at an estimated 5 th grade level; scores from 80 to 90 suggest easy reading at an estimated 6 th grade level; while scores from 0 to 30 rpworth very difficult epworhh at an estimated graduate college level. Intraclass coefficients are used for test-retest reliability to determine the stability between English and Spanish versions when sample size is small.

Spearman-Brown and intraclass coefficients of 0. Spanieh among sleep variables were conducted using correlation coefficients to determine convergent validity with the Epworth Spanidh Scale.

Exploratory factor analysis utilized principal component analysis without rotation to reduce skeepiness number of items to validate item consistency between the 2 language versions. All 6 translators were of Mexican American heritage with Spanish as their first language. Two men and one woman translated the Sleep Habits Questionnaire from English to Spanish; then 2 other women and one other man reverse-translated the questionnaire from Spanish back to English.

Translators and back-translators were 19 to 55 years of age. Their current occupations included physician, nurse, clinic staff members who work with Spanish-speaking patients, and 2 certified hospital translators one translator and one back-translator. The bilingual experts and lay translators who reviewed the final translated version were no-cost volunteers of Mexican descent with Spanish as their first language.

ESS – Officially distributed by Mapi Research Trust

Characteristics of the cross-language validation participants are displayed in Table 1. The mean education level was The range of 6 to 22 years for education suggests a broad sampling for educational achievement. Given the higher levels of education seen in this predominantly Mexican American sample, education as a proxy for socioeconomic status and acculturation were stratified epwortth sleep disorder categories duration, snoring, apnea, insomnia symptoms, other sleep symptoms, restless legs, and sleep disruptors.

Neither education nor acculturation differed significantly for any sleep category for either language version. Figure 2 portrays the number of participants in each acculturation category for English and Spanish. The acculturation differences between slepeiness were not significant. Participants were also assessed for English and Spanish language fluency, including speaking, reading, writing, and comprehension Table 2. The ratings ranged from 1 poor to 5 excellent.

Internal consistency and correlation results for the Sleep Habits Questionnaire are displayed in Table 3. Table 4 displays the proportion of cross-language validation participants with and without sleep disorders by categories. The means and standard deviations for the Epworth were 7.

Correlations for both language versions are displayed in Table 5. Correlations for the English language version are shown below the diagonal.

Intercorrelations among sleep variables and comparisons with Epworth for sleepinesw validity. Bolded are scwle between the Epworth and items from the Sleep Habits Questionnaire for construct validity.

Correlations for the Spanish language version are shown above the diagonal in Table 5. Differences noted showed snoring to be negatively English and positively Spanish associated with weekend sleep duration; however, neither finding was significant.

Exploratory factor epwotth was conducted using principal components analysis without rotation that resulted in 4 factors. The factor loadings for items in the questionnaire are displayed in Table 6. Based on these factor loadings, the structure of the Spanish version of the Sleep Habits Questionnaire is similar to the structure of the English version which supports construct validity across eepworth.

Categories included in Factors 2, 3, and 4 also correlated strongly with the Epworth Sleepiness Scale, which provided convergent validity. The Epworth was significantly negatively correlated with sleep duration on the English version, but not the Spanish version, or for weekend sleep duration on both language versions. The Spanish-translated instrument was assessed in sections of sleep categories. Readability scores for the instrument were These categories, arranged with Likert-type scales for frequency of symptoms, do not provide enough words or sentences with punctuation marks to allow for readability calculations.


Overall, the Spanish-translated version of the Sleep Habits Questionnaire demonstrated acceptable psychometric characteristics. Both language versions showed high levels of content validity and conceptual equivalency.

The rigorous translation process and review of the Spanish version slepeiness experts found the sleepinesss and content to be conceptually similar to the English version. The Spearman-Brown and intraclass correlation coefficients, which measure the homogeneity of the scales, indicated strong correlation and agreement between language versions.

The Epworth provided convergent validity for a majority of sleep sleepinness on both language versions, and exploratory factor analyses provided construct validity across language. Thus, the Sleep Habits Questionnaire is suitable for use with clinic patients and in community-based studies that examine various categories of self-identified sleep disorders. All Sleep Habits Questionnaire categories except for sleep quality demonstrated strong internal consistency reliability for both language versions, ranging from 0.

The 3-item sleep quality category that assessed perception of length, depth, and satisfaction with sleep showed only moderate internal consistency for the English 0. This scaling feature may not provide enough definition or information for persons whose first language is not English to respond adequately to these items. Future studies will need to examine these items with additional bilingual and Spanish-only speakers to determine if the psychometrics for the sleep quality items remain consistent or fluctuate with other groups.

Nevertheless, the coefficients between language versions are robust, suggesting good correlation and agreement. Furthermore, the readability scores 45 suggest that each of the sleep categories, as well as the Epworth, are suitable to a fifth- to sixth-grade reading level. Translation issues selepiness years of schooling have been posited as barriers to adequate health assessment of Spanish-speaking Hispanics in the United States. Proportions of participants with the presence of sleep disorders by categories showed consistency in reporting between language versions.

Percentages of participants who report sleep disorders provide a foundation for prevalence rates among Spanish-speaking Mexican Americans.

A majority of these rates are consistent with population studies undertaken in the United States, including the rates for insomnia symptoms, weekday short sleep duration, and, in particular, the high rates for snoring among the Hispanics in this study with Hispanics in other studies.

Future studies will need to determine if these and other socioeconomic status variables, including naturalization or U.

Intercorrelations for both language versions show similar and consistent relationships and directions among variables that support what might be expected in clinical and research settings for persons with sleep disturbances, suggesting good criterion validity. For example, persons who snore would be more likely to have apnea and report daytime sleepiness positive correlations.

Persons who experience more sleep disruption due to noisy nighttime environment, pain, or the need for frequent toileting would be more likely to report shorter weekday and weekend sleep durations and poor sleep quality negative correlations and greater reports of insomnia symptoms, other sleep symptoms, and daytime somnolence positive correlations.

Likewise, significant correlations between the Epworth with the sleep symptoms, sleep disruptors, restless legs, and, in particular, the snoring and apnea categories on both language versions support the convergent validity of the Spanish-translated measure.

American Thoracic Society – Epworth Sleepines Scale (ESS)

Notably, the comprehensiveness of this questionnaire relevant to the number and type of sleep categories have identified variables and their direction for both English and Spanish speakers that can be examined in future clinical and research studies.

These covariates include insomnia symptoms, other sleep symptoms e. Reasons for the limited number of English and Spanish variables 6 of 45 that did not significantly correlate are not known, but the lack of power due to the small sample size may have contributed to the lack of significance. In addition, there may have been unexpected circumstances that could have affected these few correlations.