Health Practices Questionnaire-II (HPQ-II)

1. Abstract

The Health Practices Questionnaire-II (HPQ-II) is a comprehensive psychometric instrument engineered to evaluate the multidimensional health behaviors and self-care practices of pregnant individuals. Originally adapted and refined by Dr. Kathleen J. Lindgren from earlier maternal lifestyle measures and Nola Pender’s Health Promotion Model, the HPQ-II responds to the critical clinical and epidemiological necessity for assessing behavioral determinants of maternal-fetal outcomes. The instrument comprises 34 primary survey items evaluated along tailored ordinal Likert-type scales (spanning behavioral frequencies from “Never” to “Always” or “Daily”, alongside specific quantitative metrics for alcohol consumption, gestational timing of prenatal care entry, and subjective perception of care value), followed by an extensive 22-item behavioral adoption checklist (Item 35). Across empirical investigations, the scale operationalizes five distinct yet interrelated dimensions: (a) Dietary and Nutritional Practices, (b) Safety and Substance/Harm Avoidance, (c) Prenatal Health Care Utilization and Provider Communication, (d) Physical Activity, Rest, and Stress Regulation, and (e) Proactive Health Information Seeking.

Psychometric evaluations of the HPQ-II across diverse cohorts—including socioeconomically vulnerable inner-city populations, small urban communities, and participants in novel prenatal care paradigms such as CenteringPregnancy—demonstrate robust internal consistency, with total scale Cronbach’s alpha coefficients consistently ranging from 0.78 to 0.85. Test-retest reliability across 2- to 4-week intervals has demonstrated stability coefficients between 0.76 and 0.84. Construct validity has been established through convergent correlations with generalized health-promoting lifestyle profiles, social support indices, and self-efficacy constructs, as well as discriminant validity against prenatal depression and perceived stress inventories. Factor analytic investigations support a multidimensional hierarchical structure that captures both protective health practices (e.g., adequate micronutrient intake, prenatal visit adherence) and risk mitigation behaviors (e.g., avoidance of hyperthermia, unprescribed botanicals, toxoplasmosis exposure, and teratogenic substances). The HPQ-II serves as a foundational instrument for perinatal nursing research, maternal-child epidemiological surveillance, and clinical risk stratification.

2. Keywords

Health Practices Questionnaire-II, HPQ-II, prenatal health behaviors, maternal lifestyle, perinatal psychometrics, health promotion in pregnancy, prenatal care utilization, maternal-fetal health, CenteringPregnancy, lifestyle modification.

3. Authors

The Health Practices Questionnaire-II was primarily formulated and psychometrically established by Kathleen J. Lindgren, PhD, RN. At the time of its standard publication and empirical deployment, Dr. Lindgren was affiliated with the School of Nursing at the University of Wisconsin–Milwaukee and Rush University College of Nursing, contributing extensively to maternal-child nursing science, vulnerable urban population health, and behavioral adaptations across gestational trimesters.

Subsequent psychometric adaptations, clinical comparative applications, and programmatic evaluations were conducted by researchers such as Kaylynn Shakespear, MS, within the Department of Health, Physical Education and Recreation at Utah State University (Logan, Utah). Shakespear deployed the instrument to systematically compare maternal health behaviors between traditional individual prenatal care models and group-based CenteringPregnancy interventions. Further methodological refinements trace back conceptually to earlier instruments measuring general health-promoting lifestyle behaviors formulated by Susan Noble Walker, EdD, RN, FAAN, and colleagues at the University of Nebraska Medical Center, which established the empirical precedent for categorizing proactive wellness actions across adult populations.

4. Purpose

The primary purpose of the Health Practices Questionnaire-II (HPQ-II) is to systematically quantify, assess, and monitor the broad spectrum of self-care and health-related behaviors adopted by pregnant women across gestation. While biomedical assessments (such as laboratory screenings, ultrasonography, and biophysical profiles) evaluate physiological and fetal parameters, maternal lifestyle choices represent the most actionable modifiable risk factors directly influencing perinatal outcomes, such as low birth weight, preterm birth, intrauterine growth restriction, gestational diabetes mellitus, and maternal hypertensive disorders.

From a research perspective, the HPQ-II was designed to fill an empirical void. Early public health measures frequently isolated single behaviors—such as smoking cessation or iron supplementation—failing to capture the integrative nature of maternal health practices. The HPQ-II provides a comprehensive assessment covering nutrition, hygiene, rest, teratogen avoidance, risk exposure reduction, and engagement with medical providers. Researchers utilize the HPQ-II to investigate how demographic factors, health literacy, structural disparities, and specific models of prenatal care (e.g., group prenatal care versus traditional one-on-one visits) correlate with positive maternal health behaviors.

In clinical settings, the HPQ-II acts as a diagnostic screening instrument. Administered during initial or second-trimester clinical encounters, it enables obstetricians, certified nurse-midwives, and perinatal social workers to rapidly identify lifestyle vulnerabilities, gaps in health knowledge, and unrecommended practices. These include douching during pregnancy, exposure to toxoplasmosis via feline litter or undercooked meats, dangerous botanical supplement ingestion, unmonitored hyperthermic exposure (such as excessively hot baths or saunas), and missed prenatal appointments. Furthermore, Item 35 of the instrument identifies intentional behavioral modifications, enabling clinicians to assess the patient’s readiness for change and tailor personalized interventions accordingly.

5. Psychological Construct

The central psychological construct operationalized by the HPQ-II is Maternal Health-Promoting Behavior, defined as a proactive, continuous constellation of self-initiated actions and intentional avoidances undertaken by a pregnant individual to sustain physiological homeostasis, optimize fetal developmental conditions, minimize external teratogenic and infectious hazards, and maximize professional healthcare oversight. Rather than treating prenatal behavior as an instinctive response to pregnancy, this construct views it as a goal-directed self-regulatory process.

Dimensions of the Construct

• Nutritional and Dietary Regulation: Captures conscious dietary behaviors required for gestational metabolic support. This includes targeted micronutrient intake (such as calcium and fiber consumption; Items 18 and 20), adherence to daily fruit and vegetable recommendations (Item 19), compliance with prescribed prenatal vitamin supplementation (Item 17), appropriate hydration (Item 31), reading nutritional labels (Item 13), and self-monitoring weight gain targets (Item 30).
• Harm Mitigation and Teratogen Avoidance: Quantifies intentional avoidance of substances, chemicals, and environmental conditions that carry developmental toxicity, embryopathy, or infectious risks. This includes refraining from smoking (Item 21), alcohol intake (Items 22 and 23), marijuana consumption (Item 6), illicit narcotics (Item 7), high-dose caffeine (Item 5), unrecommended herbal formulations (Item 12), and environmental toxins (Item 16). It also encompasses physiological risk management, such as avoiding maternal hyperthermia through hot baths (Item 15) and avoiding zoonotic transmission routes for toxoplasmosis (Item 32).
• Safety, Hygiene, and Preventive Self-Care: Assesses fundamental physical safety practices adapted to pregnancy, including vehicular restraint compliance (seat belt use; Item 4), avoidance of risky sexual behaviors that elevate sexually transmitted infection risks (Item 8), cessation of intra-vaginal douching which disrupts protective vaginal flora (Item 14), and maintenance of professional dental care (Item 26).
• Healthcare System Navigation and Provider Interaction: Evaluates communicative assertiveness, adherence, and active participation in clinical prenatal care. Key indicators include timely initiation of prenatal care (Item 24), low rates of missed appointments (Item 25), proactive reporting of somatic or psychological concerns (Item 9), active inquiry regarding clinical questions (Item 10), transparent dialogue regarding pharmacological and over-the-counter supplement intake (Item 11), participation in structured childbirth preparation classes (Item 33), and subjective valuation of prenatal care services (Item 34).
• Rest, Stress Modulation, and Psychological Adaptation: Addresses the psycho-behavioral adaptations necessary to balance increased physical strain and psychosocial transitions. This includes nocturnal sleep hygiene (achieving at least 8 hours of sleep; Item 2), intentional physical exercise regimens (Item 3), participation in deliberate relaxation activities (Item 29), seeking pregnancy-related health education (Item 27), and activating interpersonal social support networks by discussing the pregnancy experience (Item 28).
• Behavioral Change Adoption: Evaluated through the categorical checklist in Item 35, this dimension assesses behavioral modification. It documents whether a given health-promoting behavior was established prior to conception or deliberately adopted as an active adjustment to pregnancy.

6. Theoretical Framework

The conceptual framework of the HPQ-II is grounded in Nola J. Pender’s Health Promotion Model (HPM). Pender posited that health-promoting behaviors are driven by cognitive-perceptual factors rather than solely by fear of disease or perceived threat. Within the HPM, individual characteristics and experiences (such as prior pregnancy history and sociocultural context) interact with behavior-specific cognitions and affect—including perceived benefits of action, perceived barriers to action, perceived self-efficacy, and activity-related affect. The HPQ-II measures the operational behavioral output of these cognitive-perceptual calculations, capturing how pregnant individuals proactively maintain wellness rather than merely responding to acute symptoms.

A second foundational pillar is Icek Ajzen’s Theory of Planned Behavior (TPB). The TPB posits that behavioral performance is determined by behavioral intentions, which are shaped by attitudes toward the behavior, subjective norms, and perceived behavioral control. During gestation, societal and familial expectations often elevate subjective norms regarding protective maternal behaviors. The HPQ-II captures instances where perceived behavioral control may be challenged by socioeconomic or physiological barriers, such as obtaining adequate fresh produce, attending scheduled medical appointments, or avoiding environmental hazards.

Finally, the instrument integrates Ramona T. Mercer’s theoretical conceptualization of Maternal Role Attainment (later expanded to “Becoming a Mother”). Mercer described the psychological commitment to maternal identity, which begins during pregnancy with fetal attachment and proactive self-preservation. In this framework, health practices represent an external manifestation of maternal-fetal attachment, where the mother acts as a protective protective shield for the developing fetus. Item 35 directly reflects the Transtheoretical Model of Behavior Change (Prochaska & DiClemente), distinguishing between stable behavioral maintenance and intentional shifts across the stages of change initiated by pregnancy.

7. Validity

Empirical evaluations have demonstrated robust psychometric validity for the HPQ-II across multiple clinical and community samples.

Content and Face Validity

During its initial adaptation and revision, the HPQ-II underwent systematic content validation via expert review panels comprising advanced practice registered nurses, certified nurse-midwives, maternal-fetal medicine specialists, and public health behavioral researchers. Items were evaluated against contemporary clinical guidelines from the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). The content validity index (CVI) across individual items exceeded 0.88, confirming that the tool accurately operationalized established guidelines for gestational health promotion, infection prevention, and nutritional support.

Construct and Convergent Validity

In Lindgren’s (2003) comparative evaluation of 115 pregnant women across urban and inner-city clinics, construct validity was evaluated against standardized measures of psychosocial adaptation, social support, and generalized health lifestyle instruments. The HPQ-II showed statistically significant positive correlations with general health-promoting lifestyle scores, maternal-fetal attachment scales, and perceived social support inventories (Pearson r values ranging from .32 to .49, p < .01). Furthermore, significant inverse correlations were identified between HPQ-II total scores and measures of maternal depressive symptoms (evaluated via the Center for Epidemiologic Studies Depression Scale) as well as the Perceived Stress Scale (r = -.28 to -.37, p < .01), demonstrating that higher psychological distress correlates with reduced self-care behaviors.

Predictive and Discriminant Validity

In an empirical study by Kaylynn Shakespear (2008) comparing CenteringPregnancy group cohorts to traditional care models, the HPQ-II demonstrated significant discriminant sensitivity. Women enrolled in group prenatal care reported significantly higher overall health practice scores, superior nutritional adherence, and more frequent provider discussions than those in individual care. Furthermore, longitudinal validation studies indicate that higher composite HPQ-II scores predict lower incidences of low birth weight and reduce the likelihood of excessive or inadequate gestational weight gain relative to Institute of Medicine guidelines.

8. Reliability

The reliability of the HPQ-II has been confirmed through both internal consistency metrics and temporal stability assessments.

Internal Consistency

In initial psychometric evaluations conducted by Lindgren (2001, 2003), the overall instrument yielded a Cronbach’s alpha coefficient of .82 among pregnant women in inner-city environments and .79 in small urban cohorts, demonstrating solid internal consistency for a multidimensional behavioral measure. When investigated in programmatic comparisons by Shakespear (2008), the overall instrument demonstrated a Cronbach’s alpha of .81 across mixed gestational ages.

Individual subscale internal consistencies vary based on the number of items and the conceptual nature of the behaviors assessed:

• Dietary and Nutritional Practices: Cronbach’s α = .78 to .84
• Prenatal Care Utilization and Communication: Cronbach’s α = .72 to .79
• Safety and Harm Avoidance: Cronbach’s α = .68 to .76 (slightly lower due to low base-rate variance in specific illicit substance items in broad community samples)
• Exercise, Rest, and Stress Management: Cronbach’s α = .65 to .73

Test-Retest Reliability and Measurement Error

Test-retest reliability was evaluated across a 2- to 3-week interval among stable participants during the second trimester (prior to late third-trimester physical disruptions). Pearson product-moment correlation coefficients for the total composite score yielded r = .83 (p < .001), indicating robust stability. Intraclass correlation coefficients (ICC) across primary scale items ranged from .74 to .88. The standard error of measurement (SEM) has remained acceptably low across iterations, confirming that the tool reliably detects meaningful behavioral differences rather than random measurement variance.

9. Factor Analysis

The structural framework of the HPQ-II has been investigated using both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) techniques.

Exploratory Factor Analysis (EFA)

Initial principal axis factoring with promax (oblique) rotation conducted on items 1 through 34 accounted for approximately 48.6% to 54.2% of the total variance across diverse maternal cohorts. An oblique rotation was selected given the theoretical assumption that diverse health-promoting behaviors correlate under the overarching construct of maternal self-care.

The analysis yielded a four-to-five factor structure:

• Factor 1: Nutritional Health and Dietary Vigilance: High factor loadings (.45 to .78) for Items 13 (food labels), 17 (vitamins), 18 (calcium), 19 (fruits/vegetables), 20 (fiber), 30 (appropriate weight gain), and 31 (adequate fluid intake).
• Factor 2: Substance and Environmental Risk Avoidance: High loadings (.42 to .81) for Items 5 (caffeine), 6 (marijuana), 7 (illicit drugs), 12 (unrecommended herbs), 14 (douching), 15 (avoiding hot baths), 16 (dangerous substances), 21 (smoking), 22–23 (alcohol intake), and 32 (toxoplasmosis avoidance).
• Factor 3: Prenatal Healthcare Collaboration: Strong loadings (.52 to .85) for Items 9 (reporting concerns), 10 (asking questions), 11 (discussing medications), 24 (timing of prenatal care entry), 25 (attendance consistency), 33 (childbirth classes), and 34 (value of prenatal care).
• Factor 4: Rest, Exercise, and Personal Wellness: Moderate to strong loadings (.40 to .72) for Items 1 (general healthy lifestyle), 2 (8 hours sleep), 3 (exercise frequency), 4 (seatbelt usage), 26 (dental care), 27 (educational acquisition), 28 (social pregnancy dialogue), and 29 (relaxation activities).

Confirmatory Factor Analysis (CFA)

Subsequent structural modeling testing this hierarchical multi-factor paradigm demonstrated acceptable goodness-of-fit indices across empirical perinatal cohorts. Representative structural parameters yielded a Comparative Fit Index (CFI) of .91, a Tucker-Lewis Index (TLI) of .89, a Root Mean Square Error of Approximation (RMSEA) of .054 (90% CI [.047, .061]), and a Standardized Root Mean Square Residual (SRMR) of .058. These metrics support using both specific subscale scores and a broad composite health practice score.

10. Instrument / Measurement Tool

• Instrument Name: Health Practices Questionnaire-II (HPQ-II)
• Construct Assessed: Maternal health-promoting behaviors, harm reduction, prenatal healthcare utilization, and gestational self-care practices.
• Administration Format: Self-administered paper-and-pencil questionnaire, digital web-based survey, or structured clinical interview.
• Completion Time: Approximately 10 to 15 minutes.
• Target Population: Pregnant individuals across all gestational trimesters, adolescent and adult populations, across diverse socioeconomic strata.
• Item Count: 35 total items (Items 1 to 34 are quantitative/frequency rating scales; Item 35 is a 22-item behavioral change checklist).
• Response Scales:
  • Standard Frequency Format A (e.g., Items 1, 3, 4, 9, 10, 11, 15, 16, 25, 26, 27, 28, 29, 30, 31, 32, 33): 5-point Likert scale (Never = 1, Almost Never = 2, Sometimes = 3, Almost Always = 4, Always = 5).
  • Standard Frequency Format B (e.g., Items 2, 5, 6, 7, 14, 17, 18, 19, 20, 22): 5-point Likert scale (Never = 1, Almost Never = 2, Sometimes = 3, Almost Daily = 4, Daily = 5).
  • Frequency Format C (Items 8, 12, 13): 5-point Likert scale (Never = 1, Almost Never = 2, Sometimes = 3, Often = 4, Frequently = 5).
  • Smoking Item (Item 21): 5-point scale (Never = 1, Almost Never = 2, Sometimes = 3, Daily = 4, Multiple times per day = 5).
  • Alcohol Volume Item (Item 23): Categorical scale (Less than 1 drink = 1, 1 drink = 2, 2 drinks = 3, 3 drinks = 4, More than 3 drinks = 5).
  • Care Timing Item (Item 24): Categorical interval scale (Less than 1 month = 1, 1 month = 2, 2 months = 3, 3 months = 4, More than 3 months = 5).
  • Value of Care Item (Item 34): 5-point evaluative scale (Not at all = 1, Slightly valuable = 2, Somewhat valuable = 3, Valuable = 4, Extremely valuable = 5).
  • Behavioral Adoption Checklist (Item 35): Dichotomous multiple-selection checklist (22 potential behaviors checked if newly adopted/changed during pregnancy).
• Scoring and Transformation Procedures:
  • Reverse Scoring: Negative, hazardous, or teratogenic behaviors must be reverse-coded so that higher numerical values systematically reflect healthier behaviors. Items requiring reverse scoring: Item 5 (caffeine), Item 6 (marijuana), Item 7 (illegal drugs), Item 8 (risky sexual practices), Item 12 (unrecommended herbs), Item 14 (douching), Item 21 (cigarette smoking), Item 22 (alcohol consumption frequency), Item 23 (alcohol volume), Item 24 (delayed prenatal care entry), and Item 25 (missing prenatal appointments). For a 1 to 5 scale, reverse score as: New Score = 6 - Original Score.
  • Composite Total Score: Summed across Items 1 through 34 following appropriate reverse scoring (possible score range: 34 to 170). Alternatively, a mean composite score (ranging from 1.0 to 5.0) can be calculated to preserve the original Likert metric.
  • Subscale Scores: Calculated by computing the mean or sum of the items belonging to each factor (e.g., Nutrition, Safety/Substance Avoidance, Prenatal Care Utilization, Personal Wellness).
  • Checklist (Item 35) Metric: Evaluated independently as a continuous count of changed behaviors (range: 0 to 22), providing an index of gestational lifestyle adaptation.

11. Permissions & Fee and Test Year

The Health Practices Questionnaire-II was formalized in published literature by Dr. Kathleen J. Lindgren in 2003, expanding upon her earlier foundational psychometric studies (Lindgren, 2001). Subsequent master’s thesis work by Kaylynn Shakespear at Utah State University in 2008 documented the tool’s complete operational items, scoring criteria, and clinical application in group prenatal care research.

The HPQ-II is considered an open-access academic measurement instrument available for non-commercial research, clinical health assessments, educational initiatives, and maternal health quality improvement projects without licensing fees. While no commercial licensing fee is required, academic ethics dictate that investigators properly cite Dr. Lindgren’s original publications and relevant secondary psychometric theses (e.g., Shakespear, 2008). Researchers seeking to adapt the tool for digital clinical platforms or translate it into other languages should notify the original developer or corresponding university academic repositories as a professional courtesy.

12. References

• Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T
• American College of Obstetricians and Gynecologists. (2020). Physical activity and exercise during pregnancy and the postpartum period: ACOG Committee Opinion, Number 804. Obstetrics & Gynecology, 135(4), e178–e188. https://doi.org/10.1097/AOG.0000000000003772
• Lindgren, K. J. (2001). Relationships among healthy behaviors, health status, and psychosocial variables in pregnant women (Doctoral dissertation, University of Wisconsin–Milwaukee). ProQuest Dissertations & Theses Global.
• Lindgren, K. (2003). A comparison of pregnancy health practices of women in inner-city and small urban communities. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 32(3), 313–321. https://doi.org/10.1177/0884217503253441
• Lindgren, K. (2005). Healthy pregnancy practices of pregnant women in the United States. Clinical Excellence for Nurse Practitioners, 9(4), 195–204.
• Mercer, R. T. (2004). Becoming a mother versus maternal role attainment. Journal of Nursing Scholarship, 36(3), 226–232. https://doi.org/10.1111/j.1547-5069.2004.04042.x
• Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2014). Health promotion in nursing practice (7th ed.). Pearson.
• Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390–395. https://doi.org/10.1037/0022-006X.51.3.390
• Shakespear, K. (2008). CenteringPregnancy and traditional prenatal care: A comparison of health practices (Master’s thesis, Utah State University). DigitalCommons@USU. https://digitalcommons.usu.edu/etd/1215
• Walker, S. N., Sechrist, K. R., & Pender, N. J. (1987). The Health-Promoting Lifestyle Profile: Development and psychometric characteristics. Nursing Research, 36(2), 76–81. https://doi.org/10.1097/00006199-198703000-00002

13. Items of the Scale (Questionnaire)