Asia-Pacific Journal Of

Public Health
Volume 20 Number 3

Epidemiology of Insomnia July 2008 224-233

© 2008 APJPH
10.1177/1010539508316975
in Malaysian Adults: http://aph.sagepub.com
hosted at

A Community-Based Survey in http://online.sagepub.com

4 Urban Areas
AH Zailinawati, FRACGP, GradDip FamMed (Monash), KM Ariff,
FRACGP, MFamMed (Monash), MI Nurjahan, FRACGP, and
CL Teng, FRACGP, MMed (FamMed UM).

This study aimed to determine the prevalence and pattern of insomnia in a Malaysian population
aged 30 to 70 years. The sample consisted of 1611 subjects, recruited by stratified random sampling
and interviewed using a semistructured questionnaire conducted in 2004. This was a community-
based survey in 4 Malaysian states. The prevalence of insomnia symptom was 33.8%, and 12.2% of
the subjects had chronic insomnia. Insomnia was more common among elderly; those who were
separated, divorced, or widowed; and those who smoked at bedtime. Subjects with insomnia had a
higher prevalence of feeling depressed (12.7), loss of concentration (19.1%), exhaustion (17.2%),
poor memory (9.2%), decreased work productivity (6.4%), and perceived poor health status (40.9%;
all, P < .05). A total of 22.2% of those with insomnia had excessive daytime sleepiness based on
their Epworth Sleepiness Score (P = <.001). Those with insomnia used more sedatives (9.9%)
compared with those without insomnia (2.6%; P < .001). About one-third of the population had
insomnia associated with impaired daily function. This study concluded that insomnia is common
in Malaysian adult population, and it has significant impact on psychological well being and daily
functioning.

Keywords: community; insomnia; Malaysia; prevalence

I
nsomnia is a common complaint with significant medical, social, and psychological con-
sequences. The National Center for Sleep Disorders Research (NCSDR)1 defines insom-
nia as an experience of inadequate or poor quality sleep characterized by 1 or more of
the following: difficulty falling asleep, difficulty maintaining sleep, waking up too early in
the morning, and unrefreshing sleep. In addition, the presence of 1 or more of these symp-
toms is also associated with a significant impairment of social, occupational, or other areas
of functioning.

From the International Medical University, Jalan, Kuala Lumpur, Malaysia (AHZ, MIN, CLT), and KMA (deceased).

Address correspondence to: Dr Zailinawati Abu Hassan, International Medical University, Jalan Rasah, 70300, Seremban,
Negeri Sembilan, Malaysia; e-mail: zailina@nasioncom.net.

224
 Epidemiology of Insomnia in Malaysian Adults / Zailinawati et al 225

Reported prevalence estimates for insomnia of any duration or severity range from 30%
to 50% for the general population.2-5 The Asian Sleep Research Society (ASRS)6 reported
that insomnia is also highly prevalent in 3 Asian countries (Thailand, Taiwan, and
Philippines) with overall prevalence of 52%.
Many studies showed that there are many risk factors associated with insomnia, includ-
ing older age, female sex, low educational level, low socioeconomic status, and psychologi-
cal status.5,6 The results were not consistent because it seems that social and cultural factors
may affect prevalence of insomnia.5,7
It has been implicated of causing a significant burden to the society medically, psycho-
logically, and socially.2-4,8,9 Population-based strategies are needed to enhance recognition
and management of insomnia and prevention of its complication. To date, no documented
study has been carried out on insomnia or its impact in the Peninsular Malaysia. Therefore,
this study was undertaken to determine the prevalence and pattern of insomnia, associated
factors, and its impact on daytime function.

Method

Study Design
This is a cross-sectional epidemiological survey on community-dwelling adults aged 30 to 70
years using an interviewer-administered semistructured questionnaire. This is part of a
larger study, “The study on snoring and breathing pauses in the Malaysian population”.10

Setting and Sampling

The study was conducted in the following 4 Malaysian towns: (a) Kangar, the state capital
of Perlis, (b) Georgetown, in Penang, (c) Kuala Lumpur, the capital of Malaysia, and (d)
Kota Bharu, in Kelantan. These areas were selected based on their varied geographical loca-
tions in the north, west, central, and east of Peninsular Malaysia, respectively, and multi-
ethnic populations. The sample was collected using a stratified random sampling, based on
age, sex, and ethnicity, representative of the Malaysian population.11 The ethical approval
was given by the ethics committee of University Malaysia Sarawak.

Data Collection
For a 1-year period in 2004, 1611 subjects were interviewed in their homes by trained
research assistants after seeking informed consent. The questionnaire was in English and
Malay language, and the respondents were interviewed in English or Malay. The subjects
who had impaired hearing or were too ill to be interviewed were excluded from the study.

Questionnaire and Definition

The questionnaire sought information on (a) socio-demographic characteristics (b) current
sleep pattern (c) daytime consequence of sleep problems, morning headaches, napping, and
perceived quality of sleep. Daytime sleepiness was measured using the Epworth Sleepiness
Scale (ESS), a score of 11 or more was considered as excessive daytime sleepiness.12 Other
information sought included current and past consumption of alcohol, tobacco and coffee;
and current mood changes (irritability, feeling anxious, and depressed). Sleep efficiency was
calculated by dividing total sleep time by total time spent in bed.
226 Asia-Pacific Journal of Public Health / Vol. 20, No. 3, July 2008

On the basis of NCSDR1 and Diagnostic and Statistical Manual of Mental Disorders
(Fourth Edition) criteria,13 the presence of insomnia symptoms in an individual is defined as
any 1 of the following; occurring at least 3 times a week:

• Difficulty falling asleep (>30 minutes to fall asleep)

• Difficulty maintaining sleep (>3 night-time awakenings)
• Early morning awakening (waking between 2 am to 5 am)
• Waking unrefreshed in the morning

Chronic insomnia is considered when symptoms are experienced more than 4 weeks.
Insomnia with daytime consequences is assumed when the respondent has insomnia symp-
toms associated with daytime impairment. Daytime impairment is considered if any of the
following are present.14

• Self-reports of trouble functioning during the day because of sleepiness

• Irritability
• Anxiety
• Depressed
• Loss of concentration
• Exhaustion
• Decreased work productivity
• Poor memory and
• if the Epworth Scale is ≥11.

Statistical Analysis
Data were analyzed using the SPSS version 11.0 SPSS, Inc, Chicago, Ill. Statistical com-
parison of categorical variables and continuous data were done using χ2 test and t test,
respectively. Statistical significance was set at P < .05. Univariate analysis was used to assess
the association between the likelihood of experiencing insomnia (outcome variable) with
factors such as sex, age group, employment status, and lifestyle habits (smoking at bedtime
and sedative use). Variables found to be significant in univariate analyses (P < .05) were sub-
jected to multivariate logistic regression analysis.

Results

Demographic Characteristics
Out of the 1764 invited participants, a total of 1611 people consented to be interviewed;
thus, the response rate was 91.3%. Table 1 shows the socio-demographic characteristics of
the respondents. The mean age of the subjects was 49 years (SD ± 10.9, 30-70). Majority
of the participants, 85.9%, were married, and 9.4% participants were divorced or widowed.
The age, sex, and ethnic breakdown of the participants in the sample population were
almost comparable with the adult Malaysian population aged 30 to 69 years.10

Prevalence of Insomnia and Sleep Pattern

Thirty-four percent of the study population experienced at least 1 of the 4 insomnia symp-
toms, and 12.2% of the study population had chronic insomnia. (Figure 1) More specifically,
7.3% of the sample reported only 1 symptom; 21% reported 2 symptoms; 4.7% reported 3
 Epidemiology of Insomnia in Malaysian Adults / Zailinawati et al 227

Table 1. Socio-Demographic Characteristic of the Study Subjects

n (%) Sex

Sex
Male 853 52.9
Female 758 47.1
Age group
30-39 401 24.9
40-49 445 27.6
50-59 432 26.8
≥ 60 333 20.7
Ethnic group
Malay 759 47.1
Chinese 590 36.6
Indian 182 11.3
Others 80 5
Marital status
Single 65 4
Married 1356 84.2
Separated/divorced 91 5.6
Widowed 67 4.2
Employment status
Employed 756 47.4
Unemployed 670 42
Pensioner 169 10.6

symptoms; and 0.8% reported 4 symptoms. The 2 most common symptoms of insomnia
experienced were feeling unrefreshed after waking up (15.8%) and difficulty in maintaining
sleep (15.1%). Twelve percent (12.2%) had difficulty falling asleep and 11.2% had early
awakening.
Table 2 shows that sleep pattern is rather consistent among the age group; however,
respondents aged more than 60 experienced more early awakening compared with the
younger age group.

Factors Associated With Insomnia Symptoms

Table 3 presents prevalence rates of insomnia symptoms as a function of demographic and
clinical variables. There were significant differences in those experiencing insomnia symp-
toms according to the marital status, age group, employment status, smoking habits, seda-
tive use, and emotional changes. However, sex and ethnicity were not associated with
insomnia prevalence rates.

Sleep Duration
The total sleep time reported by respondents was in the range of 1 to 10 hours per night
with the average total sleep time being 7.11 hours (SD = 1.07). Time spent in bed was
in the range from 5.5 to 11 hours per night with the average time in bed being 7.7 hours
(SD = 1.07).
Respondents with insomnia symptoms experienced significantly less sleep than those
without insomnia (mean 6.7 vs 7.2 hours; t = 4.2; P < .001), with the range of sleep between
3 to 10 hours of sleep per night. However, they spent about the same amount of time in
bed (mean total amount of time spent in bed for those reporting insomnia and those not
228 Asia-Pacific Journal of Public Health / Vol. 20, No. 3, July 2008

No Insomnia Insomnia Chronic Insomnia

1066 (66.2) (Insomnia symptoms (Insomnia symptoms
more than 3 times per more than 4 weeks)
week 197 (12.2%)
545 (33.8%)

Insomnia with daytime consequence Chronic insomnia

389 (24.1%) with daytime
consequence
155 (9.6%)

Figure 1. Distribution of prevalence insomnia symptoms in the study population. Total Sample: 1611 (100%)

Table 2. Sleep Pattern in the Different Age Group Category

Among Those With Insomnia Symptom

Sleep Pattern 30-39, n (%) 40-49, n (%) 50-59, n (%) >60 n (%) P valuea

Difficulty falling asleep 36 (34.6) 48 (32.4) 49 (34.3) 64 (42.7) .264

Difficulty maintaining asleep 45 (43.3) 65 (43.9) 64 (44.8) 70 (46.7) .949
Early awakening 24 (23.1) 50 (33.8) 44 (30.8) 63 (42.0) .015
Waking up unrefreshed 91 (87.5) 112(75.7) 127 (88.8) 122(81.3) .013
a
P < .05 is statistically significant

reporting insomnia were 7.7 and 7.8 hours, respectively, P = .279). There was also signifi-
cant difference in sleep efficiency between the 2 groups, insomnia versus noninsomnia was
0.89 and 0.93 (t = 11.9; P <.001).

Drugs and Substances Affecting Sleep

Table 3 shows the association between drugs and substance use with insomnia symptoms.
A total of 23.7% of respondents who smoked at bedtime had insomnia compared with 17.9%
who did not smoke at bedtime (P < .05). Respondents who consumed alcohol on 3 days per
week experienced feeling unrefreshed on waking in the morning compared with those who
did not (12.4% vs 8.9%; P < .05). Subjects with insomnia had a tendency to use more seda-
tives than those without insomnia (9.9% vs 2.6%), and approximately 5% of those with
insomnia used sedatives on 2 or more nights in a week (odds ratio [OR] = 7.89).

Multivariate Analysis
All factors analyzed, which were clearly associated with insomnia (P < .05), were entered
into multivariate model. Logistic regression analysis indicated that the likelihood of some-
one having insomnia was independently associated with the age 60 or above, (OR = 1.73;
CI = 1.19-2.51), unemployed (OR = 1.33; CI = 1.04-1.70), pensioner (OR = 1.52;
 Epidemiology of Insomnia in Malaysian Adults / Zailinawati et al 229

Table 3. Socio-Demographic Characteristics and Other Clinical Variables of

Respondents With and Without Insomniaa

Insomnia No Insomnia
Characteristics (n = 559; %)a (n = 1052; %) P valueb OR 95% CI

Gender
Male 271 (31.8) 582 (68.2)
Female 274 (36.1) 484 (63.9) .064
Ethnic Group
Malay 236 (31.1) 523 (68.9)
Chinese 206 (34.9) 384 (65.1)
Indian 73 (40.1) 109 (59.9)
Others 30 (37.5) 50 (62.5) .088
Age Group (y)
30-39 104 (25.9) 297 (74.1) Reference group
40-49 148 (33.3) 297 (66.7) 1.42 (1.06-1.92)
50-59 143 (33.1) 289 (66.9) 1.41 (1.05-1.91)
≥60 150 (45.0) 183 (55.0) <.001b 2.34 (1.72-3.19)
Occupational status
Employed 213 (28.2) 543 (71.8) Reference group
Unemployed 247 (36.9) 423 (63.1) 1.49 (1.20-1.86)
Pensioner 76 (45.0) 93 (55.0) <.001b 2.08 (1.48-2.93)
Marital Status
Single 17 (26.2) 48 (73.8) Reference group
Married 432 (31.9) 924 (68.1) 1.32 (0.75-2.32)
Separated/divorce 40 (44.0) 51 (56.0) 2.22 (1.11-4.42)
Widowed 39 (58.2) 28 (41.8) <.001b 3.93 (1.88-8.21)
Drugs and substances use
Smoking at bedtime 129 (23.7) 191 (17.9) .006b 1.42 (1.10-1.83)
Sedative use 54 (9.9) 28 (2.6) <.001b 4.08 (2.55-6.52)
Sedative use 2 night per wk 27 (5.0) 7 (0.7) <.001b 7.89 (3.41-18.23)
Consequences of insomnia
Morning headache 88 (16.1) 98 (9.2) <.001b 1.9 (1.39-2.59)
Excessive daytime sleepiness 121 (22.2) 118 (11.1) <.001b 2.29 (1.79-3.03)
Trouble functioning 166 (34.7) 143 (14.9) <.001b 3.04 (2.35-3.94)
Naps 268 (49.3) 418 (39.3) <.001b 1.50 (1.22-1.85)
Loss of concentration 104 (19.1) 88 (8.3) <.001b 2.62 (1.93-3.56)
Poor memory 50 (9.2) 52 (4.9) .001b 1.97 (1.32-2.95)
Decreased productivity 35 (6.4) 33 (3.1) .002b 2.15 (1.32-3.50)
Mood change
Personality change 263 (48.3) 365 (34.2) <.001b 1.79 (1.45-2.21)
Irritable 96 (17.6) 143 (13.4) .025b 1.38 (1.04-1.83)
Depressed 69 (12.7) 76 (7.1) <.001b 1.88 (1.34-2.66)
Exhausted 94 (17.2) 128 (12.0) .004b 1.53 (1.14-2.04)
a
n refers to actual numbers of respondents
b
p < .05 is statistically significant
230 Asia-Pacific Journal of Public Health / Vol. 20, No. 3, July 2008

Insomnia Chronic
33.8% Insomnia
12.2%

**Insomnia with
Daytime
Consequences
24.1%

*ESS
14.8%

Figure 2. Prevalence of insomnia, chronic insomnia, excessive daytime sleepiness, and daytime consequences in
the study population. A total of 71.4% of those with insomnia and 78.7% of those with chronic insomnia have
daytime consequences. *Excessive daytime sleepiness: it is based on Epworth Sleepiness Scale score 11 and more.
** Insomnia with daytime consequences: it is defined as subjects reporting of morning headache, daytime sleepiness,
unable to function, personality changed noted by others, irritability, feeling anxious, exhausted, perceived reduced
productivity, and poor memory.14

CI = 1.01-2.28), those who smoked at bedtime (OR = 1.38; CI = 1.05-1.81), and those who
used more sedatives (OR = 4.47; CI = 2.72-7.34).

Consequences of Insomnia
Figure 2 shows the overall percentage of daytime consequences secondary to insomnia.
Undesirable daytime symptoms were significantly higher among those experiencing insom-
nia, as shown in Table 3. A total of 16% of those with insomnia symptoms experienced
morning headaches. Forty-five percent of those with insomnia symptoms reported experi-
encing daytime sleepiness. However, only 22.2% of them scored 11 or more on the ESS.
Approximately 34.7% of those with insomnia reported that they had trouble functioning dur-
ing the day, 1 in 5 was unable to concentrate in their work, and 6.4% of them reported
reduced work productivity.
Insomnia subjects also perceived that they had poor quality of sleep compared with
those without insomnia (37% vs 6.9%; P < .001).

Discussion

To our knowledge, this is the first large interviewer administered survey in the general pop-
ulation of West Malaysia attempting to assess the prevalence of insomnia symptoms.

Comparison With Other Studies With the Same Definition

This study showed that the prevalence and demographic pattern of those with insomnia is
comparable with studies carried out in the west and neighboring countries. 5-7,15,16 In our
study, 1 in 3 adults has insomnia and 1 in 10 has chronic insomnia.
 Epidemiology of Insomnia in Malaysian Adults / Zailinawati et al 231

The prevalence rate of patients with insomnia in this study may be lower compared with
the recent studies carried out using the same definition.6,17,18 The Sleep in America Poll in
2002,17 a nationwide survey of 1010 adults using telephone interviews, reported that 58% of
those interviewed had at least 1 of the 4 symptoms of insomnia. A British study 18 reported that
55% of the 1997 respondents had insomnia during the previous week. However, a local study
conducted by Hassan Syed et al19 in Sarawak in East Malaysia, in which a self-administered
questionnaire method was used, reported a lower prevalence rate of 21.1% amongst 1677
respondents. The varying prevalence is because of the difference in the research methodology.

Age-Sex Distribution
This study showed that the prevalence of insomnia symptoms, such as problems with sleep
maintenance and early awakening, increased with age and that there was an age-related
decline in total sleep duration, and perceived poor sleep quality is congruent with the find-
ings of other researchers.5,17,18,20 Insomnia in elderly has potentially serious effects, such as
poor quality of life and slowed response, resulting in falls and unable to sustain attention.1,21
This in turn may be interpreted as early dementia.21
Most of the studies show that women were more likely to report insomnia symptoms
and daytime consequences than men.5 Although this study showed that more women had
insomnia symptoms, we did not find any statistically significant sex difference even in the
older age groups; the reason for this is unclear.

Drugs and Substance Affecting Sleep

The findings of this study conforms to the findings of other studies that cigarette smokers
(especially smoking at bedtime) were more likely, than nonsmokers, to report difficulties in
initiating sleep, maintaining sleep, and daytime sleepiness.22,23
Although a third of the respondents in this study reported insomnia, only about 1 in 10
had taken sleeping pills, a figure much lower than that is reported in western studies where
almost one-third of those with sleep disturbances took sleep medications.5 The lower usage
of sleeping pills in this study is unknown. We could only postulate that it could be because
of the difficulty in finding sleeping pills, the fear of being addicted, the subjects took their
sleep problems for granted, or they were probably able to cope with insomnia symptoms
without the need for sleeping pills. We also noted that 2.6% of those without insomnia took
sedatives, which is probably taken as anxiolytics.

Impact on Daytime Functioning

Daytime Sleepiness
Sleep researchers in the mid and late 1990s have emphasized the importance of sleep diffi-
culties on daytime functioning.3 One in every 2 of the respondents with insomnia in this
study reported daytime sleepiness, although only 1 in 5 had excessive daytime sleepiness
based on ESS scores. This study shows that daytime sleepiness was twice as common in men
as in women.
Those who reported both insomnia symptoms and daytime sleepiness tended to take
naps (55%), perceived their sleep quality as poor (30%), and had trouble functioning during
the day (64%).
232 Asia-Pacific Journal of Public Health / Vol. 20, No. 3, July 2008

Work Productivity and Psychological Symptoms

Our findings show that majority of subjects with insomnia had daytime consequences, more
so among those with chronic insomnia (Figure 2). They were unable to concentrate in their
work and perceived that they had reduced work productivity.
They also reported negative mood changes, such as being irritable, feeling depressed,
exhausted, and perceived poor memory. These results correspond with that of other epi-
demiological studies.2-5,7,15 Insomnia has been identified as a risk factor for new onset of psy-
chiatric disorders, including mood disorders such as major depression and anxiety disorder
like panic disorder.23,24 Early identification and treatment of insomnia may therefore prevent
the occurrence of these disabling psychiatric manifestations.4
In view of high prevalence in the community, with impaired daytime function and
potential long-term morbidity, we suggest a comprehensive population-based preventive
program to create awareness among health care personnel and population. Clinicians may
need to be aware that insomnia is common and has various causes; therefore, the rational
for treatment offered also varies.

Limitations of the Study

The study population in this survey was limited among those aged 30 to 70 years and only
those from the 4 selected urban areas; therefore, it is unable to extrapolate to the general
population.
Even though insomnia is defined as subjective complaints by the respondent, to iden-
tify insomnia symptoms based on self-report, data may have its limitation due to recall and
self-report bias. However, this bias may reduce with the presence of the sleeping partner.
This is a cross-sectional study, which may only explore the associations of the variables and
could not show causal relationship. Furthermore, this is a prevalence study; it is difficult to
determine whether the respondents with insomnia can be considered as a clinical problem.
Further studies are needed to provide a better understanding of recognition and the natural
course of insomnia and long-term impact to the sufferers and the health care system. This
would help the health care professionals to understand the problem better.

Conclusion

The findings of this study show that insomnia is a common symptom in the general popu-
lation, and it is associated with impaired social function and psychological symptoms. The
associated demography may assist the clinicians to identify individuals who are at higher risk
of insomnia symptoms.

Acknowledgments

The authors thank Dr Chirk-Jenn Ng and Dr Nik-Sherina Hanafi of University Malaya

Medical Centre, Kuala Lumpur, for their comments in the preparation of the manuscript.
This article was presented at the 6th Ministry of Health and the Academy of Medicine of
Malaysia Conference, in September 2005.
 Epidemiology of Insomnia in Malaysian Adults / Zailinawati et al 233

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