Health Promoting Lifestyle Profile II (HPLPII)

1. Abstract

The Health Promoting Lifestyle Profile II (HPLPII) is a widely recognized, multidimensional psychometric instrument developed by Nola J. Pender, Susan Noble Walker, and Karen R. Sechrist to measure the frequency of self-reported engagement in health-promoting behaviors. Rooted fundamentally in Pender’s Health Promotion Model (HPM), the instrument assesses a behavioral pattern composed of self-initiated actions and perceptions that serve to maintain or enhance the level of wellness, self-actualization, and personal fulfillment of the individual. The HPLPII constitutes a substantial revision of the original 47-item Health-Promoting Lifestyle Profile (HPLP) published in 1987, refining item wording, updating nutritional and physical activity guidelines, and expanding the assessment to 52 items across six distinct behavioral dimensions: Health Responsibility (9 items), Physical Activity (8 items), Nutrition (9 items), Spiritual Growth (9 items), Interpersonal Relations (9 items), and Stress Management (8 items).

Responses are recorded using a 4-point Likert-type scale ranging from 1 (Never) to 4 (Routinely), yielding both an overall health-promoting lifestyle score and individual subscale scores expressed as arithmetic means. Across extensive psychometric investigations, the HPLPII has demonstrated exceptional internal consistency, with total scale Cronbach’s alpha coefficients typically ranging from .92 to .95, and subscale coefficients consistently falling between .75 and .90 across diverse demographic cohorts, clinical populations, and linguistic adaptations. Construct validity is supported by both exploratory and confirmatory factor analyses, verifying the six-dimensional structure, as well as significant convergent associations with measures of health-related quality of life, perceived self-efficacy, internal health locus of control, and psychological well-being. Today, the HPLPII serves as a benchmark assessment in clinical nursing, behavioral medicine, public health epidemiology, and occupational health research worldwide.

2. Keywords

Health Promoting Lifestyle Profile II, HPLPII, Nola Pender, Health Promotion Model, health-promoting behaviors, physical activity, nutrition, stress management, spiritual growth, interpersonal relations, health responsibility, psychometrics, health-related quality of life.

3. Authors

The Health Promoting Lifestyle Profile II (HPLPII) was developed by a team of prominent nurse researchers and behavioral scientists affiliated with the University of Nebraska Medical Center, Northern Illinois University, and the University of Michigan:

• Susan Noble Walker, EdD, RN, FAAN: Professor Emerita at the College of Nursing, University of Nebraska Medical Center (UNMC). Dr. Walker was instrumental in leading the psychometric development, factor analytic validation, and iterative refinement of both the original HPLP and the HPLPII.
• Karen R. Sechrist, PhD, RN, FAAN: Nurse researcher, measurement methodologist, and research consultant. Dr. Sechrist contributed extensive methodological and statistical expertise in instrument construction, reliability estimation, and construct validation across clinical and community samples.
• Nola J. Pender, PhD, RN, FAAN: Professor Emerita of Nursing at the University of Michigan School of Nursing and former Director of the Center for Nursing Research. Dr. Pender is internationally renowned as the architect of the Health Promotion Model (HPM), which provided the foundational theoretical architecture for the HPLPII. Her scholarly work has transformed preventive healthcare and nursing by shifting empirical focus from disease avoidance to proactive health enhancement.

The primary developmental repository and copyright administration for the instrument have been maintained through the University of Michigan’s institutional repository (Deep Blue), ensuring standardized academic access to the instrument, scoring guides, and international language translations.

4. Purpose

The overarching purpose of the Health Promoting Lifestyle Profile II (HPLPII) is to quantitatively operationalize, assess, and monitor the multidimensional pattern of self-initiated behaviors that individuals enact to maintain or elevate their current state of health, functional competence, and psychological flourishing. Distinct from primary prevention paradigms that conceptualize health behavior primarily through the lens of pathogenic defense, disease avoidance, or risk factor mitigation (e.g., smoking cessation, immunization, screening adherence), the HPLPII was intentionally formulated to capture actions oriented toward actualizing inherent human health potential, enhancing vitality, and fostering holistic well-being.

Research Applications

In empirical health science research, the HPLPII is widely utilized as either a primary outcome variable or a critical mediating/moderating construct. Investigators employ the tool to:

• Investigate structural relationships proposed by the Health Promotion Model, examining how individual characteristics, prior-related behaviors, perceived self-efficacy, barriers, benefits, and socio-environmental influences shape sustained lifestyle patterns.
• Evaluate the clinical efficacy of lifestyle modification interventions, community wellness initiatives, digital health applications, and occupational health programs across randomized controlled trials (RCTs) and quasi-experimental designs.
• Conduct cross-sectional and longitudinal epidemiological studies to delineate baseline lifestyle behaviors across diverse cultural, developmental, and socio-economic strata.

Clinical and Preventive Medicine Applications

Within clinical nursing practice, ambulatory care, cardiac rehabilitation, oncology survivorship, and primary care settings, the HPLPII functions as a diagnostic and behavioral profiling instrument. By reviewing an individual’s total and dimension-specific profile, clinicians can rapidly identify specific areas of behavioral vulnerability—such as deficits in nutritional balancing, irregular physical exertion, inadequate stress management, or social isolation—and collaboratively design targeted, patient-centered lifestyle prescriptions. The instrument’s modular subscale structure allows healthcare teams to benchmark behavioral change longitudinally, offering objective metrics for patient self-management and motivational interviewing interventions.

5. Psychological Construct

The construct assessed by the HPLPII is the health-promoting lifestyle, defined theoretically as a multidimensional constellation of ongoing self-initiated actions and perceptions that serve to maintain or enhance an individual’s level of wellness, self-actualization, and life fulfillment. Rather than treating healthy living as a single homogeneous behavior, the HPLPII operationalizes the construct across six distinct, complementary behavioral dimensions:

1. Health Responsibility

Health Responsibility (9 items) assesses an individual’s active engagement in personal wellness self-advocacy, health information-seeking, and systematic bodily surveillance. This dimension reflects an internal locus of causality regarding one’s physical state. Behavioral indicators include routinely inspecting one’s body for warning signs or unusual physiological alterations, consulting healthcare professionals promptly when symptoms manifest, questioning clinical providers to ensure complete comprehension of medical instructions, reading educational materials, and attending community health workshops.

2. Physical Activity

Physical Activity (8 items) captures regular participation in planned, structured exercise, incidental bodily movement, and recreational physical pursuits designed to foster cardiovascular fitness, muscular endurance, flexibility, and overall somatic vigor. Items assess adherence to planned exercise regimens, light-to-moderate physical exertion (e.g., sustained walking 30–40 minutes several times weekly), vigorous aerobic activity, structured flexibility and stretching routines, integrating movement into daily activities (such as taking stairs), and physiological self-monitoring (e.g., checking pulse rate or monitoring target heart rate).

3. Nutrition

Nutrition (9 items) assesses intentional dietary choices and eating patterns aligned with evidence-based dietary recommendations for sustained metabolic health and disease prevention. This dimension measures behavioral habits such as choosing balanced meals, following dietary guidelines regarding whole grains, fruits, vegetables, and lean proteins, deliberately limiting the intake of refined sugars, cholesterol, and saturated fats, reading nutritional labels on packaged foods, and maintaining consistent metabolic routines such as eating breakfast daily.

4. Spiritual Growth

Spiritual Growth (9 items)—formerly conceptualized in the original HPLP as self-actualization—encompasses intrinsic intrapsychic resources, personal development, existential purpose, and holistic transcendence. This dimension operationalizes psychological flourishing, self-awareness, personal growth, existential goal-directedness, a sense of peace and contentment, looking forward to the future with optimism, and experiencing a subjective connection to a transcendent force or broader purpose greater than the self.

5. Interpersonal Relations

Interpersonal Relations (9 items) focuses on the development and maintenance of meaningful social connections, relational intimacy, emotional communication, and mutual social support networks. Behavioral indicators include discussing personal concerns with trusted confidants, demonstrating affection, warmth, and praise toward others, actively seeking relational intimacy, using collaborative dialogue and compromise to navigate conflicts, and cultivating a reliable social safety net of caring peers and family members.

6. Stress Management

Stress Management (8 items) measures the deployment of both physiological and cognitive coping strategies aimed at regulating psychological distress, balancing life demands, and preserving homeostatic stability. This dimension includes obtaining restorative sleep, pacing physical activities to prevent exhaustion, balancing vocational demands with leisure, engaging in formal relaxation or meditation techniques (e.g., 15–20 minutes daily), cultivating calming cognitions at bedtime, accepting immutable life circumstances, and utilizing systematic stress-reduction strategies.

6. Theoretical Framework

The theoretical framework underpinning the HPLPII is Pender’s Health Promotion Model (HPM), initially formulated by Nola J. Pender in 1982 and revised substantially in 1996. The HPM was established to provide an integrative nursing perspective on health behaviors that operates independently of threat- or illness-avoidance frameworks such as Becker’s Health Belief Model (HBM).

Core Assumptions of the Health Promotion Model

The HPM conceptualizes individuals as holistic biopsychosocial organisms that interact continuously with their interpersonal and physical environments, actively pursuing conditions of positive health. The foundational theoretical assumptions include:

• Individuals actively seek to regulate their own behavior within their personal environments.
• Individuals possess the capacity for reflective self-awareness, agency, and goal-directed behavioral change.
• Health professionals constitute an influential component of the interpersonal environment, exerting influence on individuals throughout their lifespan.
• Self-initiated reconfiguration of person-environment interactive patterns is essential for sustaining health-promoting lifestyle behaviors.

Key Model Components and Psychological Mechanisms

The revised HPM categorizes the determinants of health-promoting behavior into three major structural domains:

1. Individual Characteristics and Experiences: This domain includes prior related behavior (the best single predictor of future behavioral enactment, reflecting habit formation and automaticity) and personal biological, psychological, and socio-cultural factors (e.g., age, body mass index, self-esteem, socioeconomic status, and health literacy).
2. Behavior-Specific Cognitions and Affect: Considered the primary motivational core amenable to nursing and educational intervention. These include:
   • Perceived Benefits of Action: Anticipated positive outcomes that directly reinforce behavior (e.g., increased stamina, emotional calm).
   • Perceived Barriers to Action: Perceived personal, financial, spatial, or temporal hurdles that directly block behavioral enactment.
   • Perceived Self-Efficacy: Drawn from Albert Bandura‘s Social Cognitive Theory, this construct reflects an individual’s confidence in organizing and executing the necessary courses of action to achieve targeted health outcomes. High self-efficacy reduces perceived barriers and directly elevates behavioral commitment.
   • Activity-Related Affect: Subjective feeling states (positive, neutral, or negative) generated during and immediately following behavior.
   • Interpersonal Influences: Norms, social support, and behavioral modeling provided by family, peers, and health professionals.
   • Situational Influences: Environmental perceptions regarding behavioral options, aesthetic appeal, and situational demand characteristics.
3. Behavioral Outcome: The immediate antecedent to behavior is the commitment to a plan of action, accompanied by effective strategies for overcoming immediate competing demands and preferences. The terminal outcome of the model is sustained engagement in a health-promoting lifestyle, operationalized across the six behavioral dimensions of the HPLPII.

7. Validity

The psychometric validity of the HPLPII has been established through extensive empirical testing across clinical, community, occupational, and cross-cultural cohorts.

Construct Validity

Construct validity was initially established during the iterative transition from the 47-item HPLP to the 52-item HPLPII. In developmental investigations conducted by Walker, Sechrist, and Pender, exploratory factor analysis (EFA) demonstrated that all 52 items loaded significantly onto their hypothesized six dimensions, confirming construct differentiation. In a benchmark study by Walker, Volkan, Sechrist, and Pender (1988) examining lifestyle patterns across age cohorts, construct validity was corroborated by showing that the instrument reliably differentiated lifestyle patterns between younger adults, middle-aged adults, and older adults.

Subsequent psychometric investigations have subjected the six-factor model to structural equation modeling (SEM) and confirmatory factor analysis (CFA). For example, Mohamadian et al. (2011) utilized SEM to test Pender’s model among adolescent populations, verifying that the six latent constructs of the HPLPII fit observed behavioral indicators well and mediated the path between cognitive-perceptual factors and health-related quality of life.

Convergent and Discriminant Validity

Convergent validity is substantiated by robust, statistically significant correlations between HPLPII scores and conceptually related psychological and physiological indices:

• Health-Related Quality of Life: Strong positive correlations (ranging from r = .45 to .68, p < .001) have been documented between HPLPII composite scores and the physical and mental component summaries of the Short Form Health Survey (SF-36).
• Self-Efficacy: In concordance with Bandura’s theory, composite and subscale HPLPII scores correlate positively with generalized and domain-specific self-efficacy scales (r = .40 to .62, p < .001).
• Psychological Distress: Discriminant validity is demonstrated by moderate to strong negative correlations between the HPLPII (particularly the Stress Management and Spiritual Growth subscales) and measures of perceived stress (Cohen’s PSS; r = -.38 to -.54), generalized anxiety, and depressive symptomatology on the Beck Depression Inventory (BDI).

Cross-Cultural and Population Validity

Cross-cultural adaptations have replicated the instrument’s valid construct space across numerous cultural groups. Investigations in Iran by Aubi et al. (2012), Mohammadi Zeidi et al. (2012), and Taheri Tanjani et al. (2016) among community-dwelling adults and older populations confirmed convergent and discriminant validity using multi-trait scaling analysis and demonstrated that HPLPII scores accurately discriminated between individuals with controlled versus uncontrolled chronic non-communicable diseases.

8. Reliability

The Health Promoting Lifestyle Profile II demonstrates exceptional reliability across multiple measurement parameters, including internal consistency and temporal stability.

Internal Consistency

In standard psychometric evaluations of the English instrument, the total 52-item HPLPII consistently yields a total scale Cronbach’s alpha ranging between .92 and .94, indicating outstanding internal consistency without excessive item redundancy. Subscale alpha coefficients consistently meet or exceed the standard .70 benchmark for psychological instruments:

• Health Responsibility: α = .81 to .86
• Physical Activity: α = .81 to .87
• Nutrition: α = .78 to .83
• Spiritual Growth: α = .84 to .89
• Interpersonal Relations: α = .80 to .87
• Stress Management: α = .75 to .81

In international psychometric studies, these robust indices have been largely replicated. For instance, in the Persian validation by Mohammadi Zeidi, Pakpour, and Zeidi (2012), the overall scale Cronbach’s alpha was .94, with subscale alphas ranging from .79 (Stress Management) to .91 (Physical Activity). Similarly, Taheri Tanjani et al. (2016) reported a total scale alpha of .82 in an Iranian geriatric cohort.

Temporal Stability (Test-Retest Reliability)

The stability of the HPLPII over time has been verified across several test-retest intervals ranging from two to four weeks in stable populations:

• In developmental investigations by Walker and colleagues, test-retest reliability over a two-week interval yielded an overall intraclass correlation coefficient (ICC) or Pearson’s r of .89.
• Subscale test-retest correlations over the same timeframe ranged from .81 (Stress Management) to .91 (Physical Activity), indicating that the instrument captures stable behavioral lifestyle patterns while remaining sensitive to true behavioral changes resulting from structured interventions.

9. Factor Analysis

The structural dimensionality of the HPLPII has been investigated using both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) across diverse international populations.

Exploratory Factor Analysis (EFA)

During the developmental phase of the HPLPII, Walker, Sechrist, and Pender conducted principal components analysis (PCA) followed by both orthogonal (Varimax) and oblique (Promax/Oblimin) rotations to delineate the empirical clustering of the expanded 52-item pool. The exploratory analyses supported a six-factor solution:

• The six extracted factors accounted for approximately 47.1% to 52.4% of the total variance across diverse adult cohorts.
• Item factor loadings predominantly ranged from .42 to .74 on their designated primary factors, with minimal cross-loadings exceeding the conventional .30 threshold.
• The analysis confirmed the emergence of Spiritual Growth as a distinct existential dimension distinct from Interpersonal Relations, resolving structural overlap observed in earlier iterations.

Confirmatory Factor Analysis (CFA) and Model Fit

Subsequent contemporary structural evaluations have used CFA to evaluate both first-order six-factor models and hierarchical (second-order single general factor with six first-order sub-factors) specifications. Representative fit indices from contemporary structural investigations (e.g., Mohammadi Zeidi et al., 2012; Taheri Tanjani et al., 2016) demonstrate adequate to good fit:

• Comparative Fit Index (CFI): Values typically range from .90 to .95, reflecting adequate model fit relative to the baseline null model.
• Tucker-Lewis Index (TLI): Consistently recorded between .89 and .94 across adult validation datasets.
• Root Mean Square Error of Approximation (RMSEA): Estimates consistently fall between .042 and .068 (with 90% confidence intervals bounded below .08), indicating close approximation in the population.
• Standardized Root Mean Square Residual (SRMR): Values routinely fall below the recommended .07 threshold.

While some studies have noted minor shared error variance between specific lifestyle behaviors—such as nutrition items and health responsibility information-seeking—the six-factor oblique model consistently demonstrates superior statistical fit compared to unidimensional or three-factor alternative models.

10. Instrument / Measurement Tool

The Health Promoting Lifestyle Profile II (HPLPII) is structured as follows:

• Test Type: Standardized self-report multidimensional behavioral rating inventory.
• Format: Paper-and-pencil or secure digital/web-based questionnaire.
• Number of Items: 52 items arranged sequentially.
• Response Scale: 4-point Likert-type frequency scale:
  • 1 = Never (N)
  • 2 = Sometimes (S)
  • 3 = Often (O)
  • 4 = Routinely (R)
• Subscale Item Composition:
  • Health Responsibility (9 items): Items 3, 9, 15, 21, 27, 33, 39, 45, 51
  • Physical Activity (8 items): Items 4, 10, 16, 22, 28, 34, 40, 46
  • Nutrition (9 items): Items 2, 8, 14, 20, 26, 32, 38, 44, 50
  • Spiritual Growth (9 items): Items 6, 12, 18, 24, 30, 36, 42, 48, 52
  • Interpersonal Relations (9 items): Items 1, 7, 13, 19, 25, 31, 37, 43, 49
  • Stress Management (8 items): Items 5, 11, 17, 23, 29, 35, 41, 47
• Scoring and Computational Rules:
  • Directionality: All 52 items are positively keyed. There are no reverse-coded items.
  • Subscale Scores: Calculated as the arithmetic mean of all completed items within that subscale (sum of subscale item scores divided by the number of answered items in that subscale). Scores range continuously from 1.00 to 4.00.
  • Overall Composite Score: Calculated as the arithmetic mean of all 52 items (sum of all item scores divided by 52). Scores range continuously from 1.00 to 4.00.
  • Metric Advantage: Calculating mean scores rather than raw sums preserves the original 1 to 4 metric, allowing direct comparative evaluation across subscales containing unequal item counts (e.g., 8-item vs. 9-item dimensions).
• Completion Time: Approximately 10 to 15 minutes for adult respondents.

11. Permissions & Fee and Test Year

The revised Health Promoting Lifestyle Profile II was finalized and released by Susan Noble Walker, Karen R. Sechrist, and Nola J. Pender in 1995 (with accompanying foundational documentation published in 1996).

• Access and Usage Permissions: The authors have made the HPLPII openly accessible for non-commercial academic research, educational instruction, and clinical evaluation purposes. Researchers are granted permission to reproduce and administer the profile provided full intellectual attribution is credited to the original authors.
• Fees: There is no licensing fee or royalty requirement for non-commercial scholarly research and educational dissertations.
• Repository and Documentation: Official downloadable PDF copies of the instrument, scoring protocols, and authorized linguistic translations (e.g., Spanish) are maintained through the University of Michigan’s institutional repository: Deep Blue – Health Promoting Lifestyle Profile II.
• Commercial Inquiries: Any commercial adaptation, integration into proprietary clinical software, or for-profit utilization requires prior formal inquiry and licensing authorization from the copyright holders.

12. References

Aubi, E., Shadnoush, M., Nazarzadeh, M., Bidel, Z., Ranaei, A., & Delpisheh, A. (2012). Translation and assessment of validity and reliability of the health-promoting lifestyle questionnaire, using factor analysis. Pejouhandeh, 17(3), 114–120.

Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman and Company.

Mohamadian, H., Eftekhar, H., Rahimi, A., Mohamad, H. A., Shojaiezadeh, D., & Montazeri, A. (2011). Predicting health-related quality of life by using a health promotion model among Iranian adolescent girls: A structural equation modeling approach. Nursing & Health Sciences, 13(2), 141–148. https://doi.org/10.1111/j.1442-2018.2011.00593.x

Mohammadi Zeidi, I., Pakpour, A. H., & Zeidi, B. M. (2012). Reliability and validity of Persian version of the health-promoting lifestyle profile. Journal of Mazandaran University of Medical Sciences, 21(1), 102–113.

Pender, N. J. (1996). Health promotion in nursing practice (3rd ed.). Appleton & Lange.

Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2014). Health promotion in nursing practice (7th ed.). Pearson.

Taheri Tanjani, P., Azadbakht, M., Garmaroudi, G., Sahaf, R., & Fekrizadeh, Z. (2016). Validity and reliability of Health Promoting Lifestyle Profile II in the Iranian elderly. International Journal of Preventive Medicine, 7, 74. https://doi.org/10.4103/2008-7802.182731

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

Walker, S. N., Volkan, K., Sechrist, K. R., & Pender, N. J. (1988). Health-promoting life styles of older adults: Comparisons with young and middle-aged adults, correlates and patterns. Advances in Nursing Science, 11(1), 76–90. https://doi.org/10.1097/00012272-198810000-00008

13. Items of the Scale (Questionnaire)