1.

Given information in primary source, do you think the title of the press article is
appropriate? Explain why it is, or suggest alternatives with justifications.
The title may not be appropriate given the information in the primary source. The primary
source states that those reporting sleep durations of more than 9 hours per night had a
greater risk of total stroke. This would mean that sleeping any duration more than 9 hours
per night may increase the risk of stroke. However, the title of the press article implies that
sleeping specifically 9 hours a night may increase the risk of stroke. The title is thus
misleading as it specifies 9 hours as the duration that will increase the risk of stroke.
Readers may thus think that 9 hours, but not 10 or 11 hours, will increase the risk of stroke.
The conclusion drawn by readers of the press article will contradict that of the primary
source. Therefore, the title of the press article should be “Sleeping more than 9 hours a
night may raise stroke risk” instead.

2. State up to two pieces of misrepresentation in the newspaper article and explain why.
Suggest corrections.
The article states that “sleeping less than six hours a night had no effect on stroke
incidence”. Since previous studies suggested that 7 to <8 hours of sleep were beneficial, it is
allocated a hazard ratio (HR) of 1.00. From the primary source, HR of sleeping less than six
hours a day is 1.10. This means that sleeping less than six hours a night will increase the risk
of stroke, albeit less significantly relative to other durations. If sleeping less than six hours a
day has no effect on stroke incidence, HR for it should be the same as that of sleeping 7 to
<8 hours, which is 1.00. The increase in HR when sleeping less than 6 hours thus means that
sleeping less than 6 hours increases the stroke incidence. It is thus wrong to say that it has
no effect on stroke incidence. The correct representation would be “sleeping less than six
hours a night increased stroke incidence, albeit to a smaller extent compared to other
durations”.
The article states that “midday napping for more than 90 minutes a day was associated with
a 25 percent increased risk for stroke compared with napping 30 minutes or less”. Based on
Table 2 in the primary source, 25% was found by comparing the adjusted HR of midday
napping of 1-30 minutes and that of midday napping of more than 90 minutes. “Napping 30
minutes or less” includes napping for 0 minutes, which was not taken into account during
the calculation. Therefore, the correct representation would be “midday napping for more
than 90 minutes a day was associated with a 25 percent increased risk for stroke compared
with napping between 1 to 30 minutes”.

3. If you could add a short paragraph to the newspaper article to give more information
from the study, what would you say?
I would include information about the joint effects of sleep duration and midday napping,
and sleep duration and sleep quality on the risk of incidental total stroke. The paragraph
may go:
“The study found that compared with moderate sleep duration of 7 to <8 hours a night and
midday napping of 1-30 minutes, longer sleep duration more >9 hours a night and midday
napping of >90 minutes increased relative risk for stroke by 85%. Furthermore, sleeping ≥9
hours a night with poor sleep quality and sleeping <7 hours a day with poor sleep quality
increased risk for stroke by 82% and 84% respectively compared with sleeping 7 to <8 hours
a night with good sleep quality.”
4. If the main finding involves a test of hypothesis, what is the null hypothesis for that
test? Do they have sufficient evidence to reject that null hypothesis?
5. Can you think of any potential confounder that the researchers did not control for in
the study? If yes, briefly explain why it might be a confounder.
A confounder is a third variable associated with both the dependent and independent
variable. A potential confounder can be the consumption of caffeine. Increased
consumption in caffeine can lead to shorter durations of sleep and midday naps by crossing
the blood-brain barrier and binding to adenosine receptors, thus affecting the independent
variable in the study. Increased consumption can also lead to a decrease in risks of stroke,
according to a study by Korean J Fam Med, thus affecting the dependent variable in the
study.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3526718/

6. Are there sources of potential bias or imprecision in this study? Have these been
acknowledged by the researchers?
The recommended duration of sleep for elderly is 7 to 8 hours. Elderly who chooses to sleep
7 to 8 hours may be more health conscious compared to those who sleep more or less than
the recommended amount. As a result, they may have a lower risk of stroke due to their
general heightened sense of health. The study may thus be biased towards 7 to 8 hours of
sleep per day, thus driving down HR for 7 to <8 hours a night to the lowest in all categories
of duration of sleep. This bias has not been acknowledged by the researchers.

7. In view of questions 5 and 6, to what extent can the findings be generalised to the
population of interest?
The population of interest is middle-aged and older Chinese adults. The 31,750 participants
of the study are mostly Chinese adults aged 61.7 years on average. Since the study excludes
participants with coronary heart disease, stroke and cancer, the findings should be able to
be extended to middle-aged and older Chinese adults with no history of coronary heart
disease, stroke and cancer. However, due to the presence of confounders such as caffeine
consumption and potential bias such as the health-consciousness of the different groups of
people in each sleep durations, the generalisation of findings may be limited.

8. In addition to the questions above, feel free to add anything else which might
demonstrate you learning in this project.