RESEARCH ARTICLE

Sleep and Academic Performance

in Hong Kong Adolescents
KWOK-KEI MAK, PhDa SO-LUN LEE, MBBSb SAI-YIN HO, PhDc WING-SZE LO, PhDd TAI-HING LAM, MDe

ABSTRACT
BACKGROUND: Sleep problems may have different inuences on students academic performance. We investigated the
prevalence of sleep patterns, naps, and sleep disorders, and their associations with academic performance in Hong Kong
adolescents.
METHODS: In 2007-2008, 22,678 students aged 12-18 (41.6% boys) completed a questionnaire on sociodemographic
characteristics, sleep patterns and problems, and lifestyle factors including exercise, smoking, alcohol drinking, and academic
performance.
RESULTS: The prevalence of having >8 hours of sleep was higher on holiday nights (86.4%) than on school-day nights
(27.4%). Sleeping after midnight was more common before holidays (49.3%) than before school days (19.9%). Symptoms of
insomnia and obstructive sleep apnea (OSA) were reported by 21.5% and 34.4% of students. Having >2 hours of weekend sleep
delay was associated with poor academic performance with an odds ratio (OR) (95% condence interval) of 1.46 (1.29-1.65).
However, having 1-2 hours and >2 hours of weekend wake-up delay were both associated with less likelihood of poor academic
performance with ORs of 0.64 (0.56-0.73) and 0.69 (0.59-0.80). Other factors associated with poor academic performance
included >2 hours of sleep debt, OR of 1.17 (1.03-1.33); having any insomnia symptoms in the past 30 days, OR of 1.27 (1.17-1.37);
and having any OSA symptoms at least weekly, OR of 1.23 (1.14-1.32). Napping in the past 5 school days was only marginally
associated with poor school performance with an OR of 1.08 (1.00-1.16).
CONCLUSION: Poorer academic performance was associated with sleep debt, and symptoms of insomnia and OSA. Sleep
compensation but not naps may be a protective factor of poor academic performance.
Keywords: sleep patterns; insomnia; obstructive sleep apnea; academic performance; adolescents.
Citation: Mak K-K, Lee S-L, Ho S-Y, Lo W-S, Lam T-H. Sleep and academic performance in Hong Kong adolescents. J Sch
Health. 2012; 82: 522-527.

Received on May 4, 2011

Accepted on May 2, 2012

R egular sleep is fundamental to health and

growth of adolescents. Insufficient sleep and sleep
disturbance are associated with adverse physical and
psychological consequences in adolescents,1,2 as well
as poorer academic performance.3,4 Knowledge of
sleep characteristics, such as sleep duration and sleep-
wake schedule, is important to the assessments of
health problems and provision of preventive advice at
both individual and population levels.5 Investigation
of daytime naps may provide a good indication of
insufficient nocturnal sleep. In Mainland China, it
is widely perceived that taking an afternoon nap is
a healthy complement to normal sleep. Thus, nap
time is commonly provided in schools and workplaces,
especially in rural areas. Whereas short naps may be
beneficial to memory performance,6-8 frequent late
naps may delay bedtime and shorten the length of
nighttime sleep.9 One study also reported that napping
was associated with diabetes and impaired fasting
glucose in older Chinese.10 Epidemiological studies

a
Assistant Professor, (kkmak@graduate.hku.hk), Department of Community Medicine and School of Public Health, Faculty of Medicine, University of Hong Kong, 21 Sassoon Road,
Pokfulam, Hong Kong.
bAssistant Professor, (slleem@hku.hk), Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong.
c Assistant Professor, (syho@hku.hk), Department of Community Medicine and School of Public Health, Faculty of Medicine, University of Hong Kong, 21 Sassoon Road, Pokfulam,

Hong Kong.
d(tracia@hku.hk), Department of Community Medicine and School of Public Health, Faculty of Medicine, University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong.
e (hrmrlth@hku.hk), Department of Community Medicine and School of Public Health, Faculty of Medicine, University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong.

Address correspondence to: Sai-Yin Ho, (syho@hku.hk), Department of Community Medicine and School of Public Health, Faculty of Medicine, University of Hong Kong, 21
Sassoon Road, Pokfulam, Hong Kong.
This study was supported by the University Research Committee, Strategic Research Theme on Public Health, University of Hong Kong.

522 Journal of School Health November 2012, Vol. 82, No. 11 2012, American School Health Association
have shown a high prevalence of sleep problems in
Chinese adolescents in Taiwan,11 Mainland China,12,13
and Hong Kong.14,15 Indeed, a recent systematic
review also indicated that Asian adolescents generally
have later bedtimes than those from North America
and Europe.16
Insomnia and obstructive sleep apnea (OSA)
are closely related sleep disorders common in
adolescents.17,18 Insomnia symptoms include difficulty
initiating sleep, difficulty maintaining sleep, and early
morning awakening. OSA symptoms include snoring,
sleepiness, tiredness during the day, nocturia, memory
loss, and hypertension. Information of the association
between sleep behaviors and academic performance in
adolescents is scarce. We investigated the prevalence
of sleep patterns, daytime naps, and sleep disorders,
and their associations with academic performance in
Chinese adolescents.
METHODS
Participants
The present findings were based on data col-
lected from the 2007-2008 Hong Kong Student Obe-
sity Surveillance (HKSOS) project. A total of 42
schools participated in the baseline study (2006-
2007) and the present sample was the 28 schools
included in the second wave (2007-2008) of the
study. They represented all Hong Kong mainstream
non-international secondary schools in the school
district by funding source, language of instruc-
tion, religion, and mixed-/single-sex education. More
details of the project were described in previous
publications.19,20
Instruments
The questionnaire collected information about
sociodemographic characteristics, general health prob-
lems, lifestyle factors including exercise, smoking, alco-
hol, and sleep, and academic performance. Academic
performance was self-reported and assessed with the
question How is your academic performance? and
the responses included very good, good, average, poor,
and very poor. Similar questions have been used in
other local studies.14,21
Individual questions were used to assess the usual
sleeping time and wake time during school days and
holidays. The original categorical responses for bedtime
(weekday/weekend: 9:00 PM or before, 9:30 PM to
10:30 PM, 11:00 PM to 12:00 AM, after 12:00 AM) and
wake time (weekday: 6:00 AM or before, 6:30 AM to
7:30 AM, 8:00 AM to 9:00 AM, after 9:00 AM; weekend:
7:00 AM or before, 7:30 AM to 8:30 AM, 9:00 AM to 10:00
AM, after 10:00 AM) were transformed into continuous
variables to calculate the sleep duration.
Weekend sleep delay was estimated by the
difference in bedtime between holiday nights and
Journal of School Health November 2012, Vol. 82, No. 11
school-day nights. Weekend wake-up delay was esti-
mated by the difference in wake time between holidays
and school days. Sleep debt was estimated by the
difference in sleep duration between holiday nights
and school-day nights. Daytime nap after schools in
the preceding 5 school days was also assessed with
response options from 0 to 5 days. The same scales
for assessing sleep patterns have been used in Chinese
adolescents.14
Additionally, symptoms of 2 common sleep disor-
ders, insomnia and OSA, were also assessed. Insomnia
was defined as the presence of one or more symp-
toms of difficulty initiating sleep, difficulty maintaining
sleep, and early morning awakening over the past
30 days. OSA symptoms were assessed with the ques-
tions How often do you breathe via mouth, but not
nose during sleep? (breath via mouth), How often
does bedwetting occur? (nocturnal enuresis), and
How often do you feel asleep during sedentary activ-
ities, such as TV watching and reading? (sleepiness).
The options provided for each question were always,
usually (at least weekly), from time to time (at least
monthly), and seldom (yearly) or never. Similar
questions have been used in studies in children.22,23 In
another adolescent study, the 4-week test-retest relia-
bility was fair for insomnia (kappa = 0.26) and snoring
(kappa = 0.25), and moderate for disordered breath-
ing (kappa = 0.48). Furthermore, the same reported
symptoms were found valid with significant associa-
tions with smoking status in the baseline study.24
Procedures
In the present analyses, 22,678 (98.4% of 23,055),
form 1 to 7 (equivalent to grade 7-12 in the
United States), Chinese adolescents (41.6% boys)
providing complete information in the questionnaires
were included. Student participation was totally
voluntary.
Data Analysis
Body mass index was calculated from the reported
height and weight. The distributions of sleep-wake
variables including total sleep duration (before school
day, before holiday), weekend oversleep, and weekend
sleep delay were described. In logistic regression,
academic performance was dichotomized as poor
(poor/very poor) and good (very good/good/average).
The relation of poor academic performance with
weekend sleep delay, weekend wake-up delay, day-
time naps, insomnia, and OSA was assessed using
multiple logistic regression, with adjustment for sex,
age, smoking (past 30 days), drinking (past 30 days),
and exercise (continuously for 30 minutes) in the basic
models. The final models mutually adjusted for other
sleep problems. Potential clustering effects of school
were also adjusted for in the models.
2012, American School Health Association 523
RESULTS Table 2. Basic Characteristics, Academic Performance, and
Perceived Health of Participants
Table 1 shows that the participating schools were
representative of all mainstream schools with small N (%)
effect sizes of the differences in school characteris- Sex
tics. Table 2 shows that 20.8% of students reported Boys 9433 (41.6)
poor or very poor academic performance. Table 3 Girls 13,245 (58.4)
shows that at school-day nights, only 27.4% reported Age (years)
having slept for >8 hours. The prevalence of hav- 12 or below 2707 (11.9)
13 3857 (17.0)
ing >8 hours of sleep was higher (86.4%) at holiday
14 4097 (18.1)
nights. For insomnia symptoms, the prevalence was 15 3940 (17.4)
the highest for difficulty initiating sleep (12.3%), 16 3477 (15.3)
followed by difficulty maintaining sleep (8.8%) and 17 2303 (10.2)
early morning awakening (7.2%). The prevalence of 18 or above 2297 (10.1)
OSA symptoms was breathing via mouth (21.0%), Family afuence
Wealthy/above average 12,387 (54.6)
sleepiness (17.8%), and nocturnal enuresis (2.5%). Average 7557 (33.3)
Overall, 21.5% of the students had at least 1 insom- Below average/poor 2734 (12.1)
nia symptom while 34.4% had at least 1 OSA Academic performance
symptom. Very good/good 4114 (18.1)
Table 4 shows that >2 hours of weekend sleep Average 13,841 (61.0)
Poor/very poor 4723 (20.8)
delay was significantly associated with poor academic
Exercise (at least 30 minutes/week) 11,729 (51.7)
performance with an odds ratio (OR) (95% confidence Drinking (past 30 days) 5355 (23.6)
interval [CI]) of 1.46 (1.29-1.65). On the other hand, Smoking (past 30 days) 1788 (7.9)
wake-up delay for 1-2 hours and >2 hours were Body mass index (kg/m2) (mean [SD]) 21.99 (0.65)
both significantly associated with less likelihoods of
poor academic performance with ORs (95% CI) of
0.64 (0.56-0.73) and 0.69 (0.59-0.80). Greater than DISCUSSION
2 hours of sleep debt was also significantly associated Just over one fourth (27.4%) of our sample slept
with poor academic performance [OR (95% CI) of 8 hours or more on school nights which is slightly
1.17 (1.03-1.33)]. Napping in the past 5 school lower than that among US high school students, as
days was marginally associated with poor academic reported by the 2009 Youth Risk Behavior Surveillance
performance with an OR (95% CI) of 1.08 (1.00-1.16). System (30.9% slept 8 hours or more at school
Furthermore, having any insomnia symptoms in the nights).25 The World Health Organization does not
past 30 days and any OSA symptoms at least weekly provide a guideline of sleeping hours in the recent
were related to poor academic performance with ORs technical meeting of sleep and health.26 Nevertheless,
(95% CI) of 1.27 (1.17-1.37) and 1.23 (1.14-1.32), 8 to 9 sleeping hours are commonly suggested for
respectively. adolescents.27,28 The literature shows mixed results
on the associations between sleep duration and
academic performance. Some studies showed the
Table 1. Characteristics of the Participating Schools and adverse effects of insufficient sleep and sleepiness on
Hong Kong Schools school functioning.4,29 However, other studies showed
that total sleep duration was neither associated with
Hong Kong Participating executive function30 nor academic performance in
Schools Schools Effect Size* adolescents.31 Therefore, we chose the sleep debt
2007-2008 2007-2008 (Cohens d) rather than total sleep duration as the predictor so
N (%) N (%)
as to reflect individuals sleep deprivation better.
School district Sleep delay over weekends was associated with
Hong Kong Island 95 (18.2) 2 (7.1) 0.14 poor academic performance, yet wake-up delay over
Kowloon 154 (29.6) 10 (35.7)
the weekend had an opposite effect. Consistent with
New Territories 272 (52.2) 16 (57.1)
Funding source findings of many other studies, a sleep delay was
Government/aided 407 (78.1) 24 (85.7) 0.11 observed in our adolescents with 66% sleeping at
Others (Caput/Direct 114 (21.9) 4 (14.2) or after 11:00 PM during weekdays, although most
Subsidy/Private) woke up at 6:30-7:00 AM, depending on school hours.
Coeducational The prevalence of late bedtime increased on the
Yes (boys and girls) 442 (84.8) 25 (89.3) 0.06
weekend and nearly 50% did not begin sleeping until
No (boys or girls only) 79 (15.2) 3 (10.7)
after midnight. These results are consistent with a
Effect size: 0.2 is indicative of a small effect, 0.5 a medium, and 0.8 a large effect.
recent meta-analysis reporting a general later bed

524 Journal of School Health November 2012, Vol. 82, No. 11 2012, American School Health Association
Table 3. Sleep Patterns and Problems of Participants although sleep extension did not have significant effect
on morning alertness32 or improvement in vigilance.33
N (%)
These studies were carried out in normal healthy adults
Sleep hours (school-day nights) who did not complain of any daytime sleepiness and
<7 5446 (24.0) may not be generalized to our adolescent population
7-8 11,017 (48.6) with different physiological responses and daytime
>8 6215 (27.4)
Sleep hours (holiday nights)
activity patterns. In adolescents, Eliasson and Lettieri34
<7 825 (3.6) suggested that sleep time and wake time, but not
7-8 2267 (10.0) total sleep time, were associated with poorer academic
>8 19,586 (86.4) performance. We further suggest that the effects of
Bedtime (weekday) sleep time and wake time (sleep debt) may be even
9:00 PM or before 1742 (7.7) more closely related to poorer academic performance
9:30 PM to 10:30 PM 5657 (24.9)
11:00 PM to 12:00 AM 10,762 (47.5)
than the effect of sleep time and wake time
After 12:00 AM 4517 (19.9) alone.
Bedtime (weekend) Most of our adolescents attended all-day school.
9:00 PM or before 1328 (5.9) Despite the tight school-day schedule and the preva-
9:30 PM to 10:30 PM 1923 (8.5) lence of after-school tutorials in Hong Kong,35 38.7%
11:00 PM to 12:00 AM 8244 (36.4) of our participants reported napping in the past 5
After 12:00 AM 11,183 (49.3)
Wake time (weekday)
school days. Our prevalence is similar to the self-
6:00 AM or before 2352 (10.4) reported prevalence of evening naps (more than 30%)
6:30 AM to 7:30 AM 19,212 (84.7) in Japanese adolescents,36 but much higher than the
8:00 AM to 9:00 AM 372 (1.6) self-reported prevalence of habitual daytime naps (less
After 9:00 AM 742 (3.3) than 10%) in Austrian adolescents.37 Furthermore,
Wake time (weekend) having a nap was associated with poor academic
7:00 AM or before 1437 (6.3)
7:30 AM to 8:30 AM 3356 (14.8)
performance after adjustment for insomnia or OSA
9:00 AM to 10:00 AM 7492 (33.0) symptoms. Our results seemed to contradict other
After 10:00 AM 10,393 (45.8) daytime nap studies that supported that napping could
Weekend sleep delay (hours) improve memories38,39 and motor memory tasks.40 It
<1 10,007 (44.1) is important to note that most of these studies did not
1-2 10,005 (44.1) adjust for participants intelligence which might affect
>2 2666 (11.8)
Weekend wake-up delay (hours)
task acquisition. To our knowledge, no other study has
<1 2297 (10.1) examined the relation between academic performance
1-2 4473 (29.9) and daytime napping. Therefore, further studies are
>2 15,908 (70.1) warranted.
Sleep debt (hours) Evidence suggests that OSA symptoms in children
<1 6800 (30.0) affect neurocognitive and behavioral domains, espe-
1-2 4643 (20.5)
>2 11,235 (49.5)
cially in the interrelated areas of attention capacity,
Naps in past 5 school days 8770 (38.7) memory, intelligence, and learning but only 1 recent
Insomnia symptoms (past 30 days) study to our knowledge has directly examined the
Difculty in initiating sleep 2789 (12.3) relation between academic performance and OSA
Difculty in maintaining sleep 1985 (8.8) symptoms.41 We assessed the presence of OSA symp-
Early morning awakening 1642 (7.2) toms in our participants with a validated questionnaire
Any one 4868 (21.5)
OSA symptoms (at least weekly)
that has been shown to have fairly good positive pre-
Breathe via mouth at night 4763 (21.0) dictive value for clinically significant OSA.22 Our study
Nocturnal enuresis 564 (2.5) also concurred with Perez-Chada et al41 that the pres-
Sleepiness 4046 (17.8) ence of OSA symptoms is associated with self-reported
Any one 7798 (34.4) poor academic performance.
Sleep disturbance underlying insomnia has been
well described. However, the extent to which disturbed
time in Asian than North American adolescents.16 sleep can result in daytime impairment remains
In addition to homework requirements, energizing unclear and such impairment appears to be more
effects of after-school activities may contribute to the subtle than other sleep disorders.42 Despite substantial
delay. Other pronounced factors were having fewer limitations of various studies, attention tasks and
parental constraints and wide access to electronic working memory appear to be frequently affected
devices. in insomnia patients,42 which supports our finding
Wake-up delay on weekends appeared to have that insomnia symptoms was associated with poor
an advantageous effect on academic performance, academic performance in adolescents.

Journal of School Health November 2012, Vol. 82, No. 11 2012, American School Health Association 525
Table 4. Prevalence and Adjusted ORs of Poor Academic Performance for Sleep Problems

Model 1 Model 2
% OR (95% CI) p OR (95% CI) p
Weekend sleep delay
<1 hour 20.5 1 1
1-2 hours 19.8 1.00 (0.93-1.07) .97 1.06 (0.98-1.15) .16
>2 hours 26.0 1.34 (0.93-1.07) <.001 1.46 (1.29-1.65) <.001
Trend <.001 <.001
Weekend wake-up delay
<1 hour 29.0 1 1
1-2 hours 17.2 0.61 (0.53-0.69) <.001 0.64 (0.56-0.73) <.001
>2 hours 20.6 0.75 (0.68-0.84) <.001 0.69 (0.59-0.80) <.001
Trend .042 <.001
Sleep debt
<1 hour 22.2 1 1
1-2 hours 18.0 0.85 (0.77-0.94) .001 1.00 (0.89-1.13) .97
>2 hours 21.2 1.00 (0.92-1.08) .94 1.17 (1.03-1.33) .02
Trend .71 <.001
Naps (past 5 school days)
No 19.4 1 1
Yes 23.1 1.13 (1.05-1.21) .001 1.08 (1.00-1.16) .04
Insomnia symptoms (past 30 days)
No 19.7 1 1
Yes 24.8 1.29 (1.20-1.40) <.001 1.27 (1.17-1.37) <.001
OSA symptoms (at least weekly)
No 19.0 1 1
Yes 24.4 1.27 (1.19-1.37) <.001 1.23 (1.14-1.32) <.001
Model 1: Adjusted for sex, age, family affluence, exercise, smoking, drinking, body mass index, and school effect.
Model 2: Mutually adjusted for sleep patterns and problems in addition to the covariates in Model 1.

Limitations performance. Our study supports and supplements

The studys cross-sectional design precludes causal
inference on the relation between the different sleep
variables and academic performance. A previous
study suggested that academic stress could be a
cause of sleep problems in college students.43 Second,
self-reports of sleep duration, sleep-awake patterns,
insomnia, and OSA symptoms were used instead of
24-hour diary data, actigraph, or polysomnography. It
is not clear whether the errors from self-reporting
were random or systematic. Similar questions for
insomnia and OSA symptoms have been used in our
previous publication.24 Third, academic performance
was based on self-report as school records were
considered sensitive information. Students in Hong
Kong usually have good knowledge of their academic
performance relative to others, and any random
misreporting would have biased our results toward
null. Nevertheless, quantitative indices for assessing
academic performance would be useful in this context.
CONCLUSIONS
We found that having sleep delay on the night
before holidays, sleep debt, and after-school naps
were associated with poor academic performance.
However, wake-up delay in the morning of holidays
had a protective effect on poor academic performance.
For sleep disorders, having insomnia symptoms or
OSA symptoms were associated with poor academic
the existing information about the associations of
academic performance with sleep disturbance, as well
as sleep-wake pattern and naps.
IMPLICATIONS FOR SCHOOL HEALTH
Napping is still scheduled daily in many schools
in Mainland China but more empirical findings are
needed to understand its possible effects on students
academic performance and physical development.
Moreover, school-based health programs on sleep
patterns are warranted to raise the awareness of
students to different types of sleep problems. More
in-depth studies to explore the fundamental causes
for sleep problems in adolescents and their relations
with other health problems are warranted to provide
further advice to parents, educators, and health
policy makers in other Chinese communities. Students
with problems of academic performance should seek
medical advice for maintaining a better health-related
lifestyle including sufficient rest time. Sleep quality
assessments may also be included in annual student
health examinations as a holistic approach.
Human Subjects Approval Statement
Ethical approval was granted by the Institutional
Review Board of the University of Hong Kong/Hospital
Authority Hong Kong West Cluster.

526 Journal of School Health November 2012, Vol. 82, No. 11 2012, American School Health Association
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