Development and Validation of a Pictorial Self-Report Questionnaire to Assess Women’s Awareness of Pregnancy-Induced Postural Changes and Musculoskeletal Risks

Development and Validation of a Pictorial Self-Report Questionnaire to Assess Women’s Awareness of Pregnancy-Induced Postural Changes and Musculoskeletal Risks | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development and Validation of a Pictorial Self-Report Questionnaire to Assess Women’s Awareness of Pregnancy-Induced Postural Changes and Musculoskeletal Risks M Anbupriya, Abirami Srinivasan, Niveditha Jayaraman This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8678898/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: Pregnancy results in progressive biomechanical and postural adaptations as fetal growth shifts the maternal center of gravity anteriorly. Compensatory changes such as increased lumbar lordosis, pelvic tilt, and thoracic curvature may alter postural stability and contribute to musculoskeletal discomfort. Evidence suggests that pregnant women demonstrate changes in center of pressure displacement, delayed activation of key stabilizing muscles (including multifidus and biceps femoris), and increased dependence on visual and somatosensory input to maintain balance. Despite the clinical relevance of these adaptations, awareness among women remains limited, and no validated tool is currently available to assess awareness of pregnancy-induced postural changes and related musculoskeletal risks. This study aimed to develop and validate a self-report questionnaire with pictorial guidance to assess women’s awareness of pregnancy-induced postural changes and associated musculoskeletal issues. Methods: A close-ended pictorial questionnaire was developed through a multi-phase process including literature review, item generation, expert review, and revision. Content validity was evaluated by a multidisciplinary expert panel using the Content Validity Index (CVI). Test-retest reliability of the final version was assessed using a 2-day interval. Results: The questionnaire demonstrated strong content validity with a Scale-level Content Validity Index/Average (S-CVI/Ave) of 0.876 . The overall scale showed excellent test-retest reliability with a Pearson correlation coefficient of r = 0.989 ( p < 0.001 ). Conclusion: The newly developed pictorial self-report questionnaire is a valid and reliable instrument for assessing women’s awareness of pregnancy-related postural changes and musculoskeletal risks. It may support early identification of awareness gaps and guide preventive education and physiotherapy interventions. Pregnancy Postural changes Self-report questionnaire Pictorial guidance Content validity Test-retest reliability Awareness assessment Introduction Pregnancy is accompanied by substantial physiological and biomechanical adaptations that occur as part of normal maternal changes. As gestation progresses, maternal body mass increases and the centre of gravity shifts anteriorly, which is compensated by postural adjustments such as increased lumbar lordosis, altered thoracic curvature, and pelvic alignment changes to maintain stability and functional balance [1]. These postural adaptations, although necessary, may increase loading on the spine and pelvic structures, contributing to musculoskeletal discomfort. Musculoskeletal symptoms are highly prevalent during pregnancy and are among the most frequently reported physical complaints in antenatal populations. A recent systematic review and meta-analysis reported that the global prevalence of back pain during pregnancy is approximately 40.5% [2]. Similarly, pregnancy-related pelvic girdle pain (PGP) has been described as a common condition, with pooled and reported prevalence estimates ranging around 45% in published literature, although variability exists depending on diagnostic criteria and population [3]. Lumbopelvic pain (including low back and pelvic girdle pain) has also been reported at high pooled prevalence levels, indicating a significant burden across pregnancy [4]. These symptoms are not only physically limiting but can affect sleep, daily activities, and quality of life. Biomechanical and postural contributors are increasingly recognized in pregnancy-related pain. Observational studies have reported pregnancy-associated changes in spinal posture and alignment, including modifications in lumbar and thoracic curvature, which may correlate with back pain onset and severity [5]. Postural deviations can lead to abnormal mechanical strain on ligaments, joints, and surrounding soft tissues, thereby increasing the risk of pain or dysfunction [6]. From a preventive health perspective, postural awareness is important, as awareness influences behaviour (ergonomics, activity adaptation, and help-seeking), and may support risk reduction strategies for musculoskeletal symptoms. Despite a strong body of evidence documenting pregnancy-related pain and postural adaptations, awareness of pregnancy-induced postural changes among women remains under explored, particularly among women who are yet to experience pregnancy. While several validated instruments are available for assessing specific pregnancy-related symptoms and functional problems, such tools generally focus on isolated symptoms rather than awareness of biomechanical/postural changes. Moreover, available pregnancy questionnaires such as the Pregnancy Physical Activity Questionnaire (PPAQ) assess activity levels rather than understanding or awareness of postural adaptation and associated musculoskeletal risks [7]. Likewise, screening tools such as the Get Active Questionnaire for Pregnancy primarily evaluate readiness for physical activity rather than awareness of pregnancy-related postural risks [8]. Existing postural awareness tools have been validated in other populations such as chronic pain patients, workers, and young adults, but are not specific to the pregnancy context [9]. Questionnaire-based measurement is widely used for awareness and health behaviour research; however, instruments intended for clinical or research use require rigorous development and psychometric evaluation. The Content Validity Index (CVI) is recommended for evaluating expert agreement on relevance during tool development and is considered a standard approach in establishing content validity [10]. In addition, the incorporation of pictorial guidance has been shown to improve comprehension and response accuracy in health questionnaires, particularly among participants with varying educational or health literacy levels [11]. Visual aids can reduce cognitive load and increase the clarity of abstract physiological concepts, making this approach relevant for assessing awareness of pregnancy-related postural adaptations. Therefore, the present study aimed to develop and validate a self-report pictorial questionnaire to assess awareness of pregnancy-induced postural changes and associated musculoskeletal issues among women. Methods Study design To assess awareness regarding pregnancy-induced postural changes and associated musculoskeletal issues among women who have not yet experienced pregnancy-related physiological adaptations, a community-based non-experimental exploratory study was conducted at SRM Medical College Hospital and Research Centre. The study was planned for 8–12 weeks following ethical clearance. Study population Participants were recruited from women attending the outpatient services of Obstetrics and Gynecology at SRM Medical College Hospital and Research Centre using convenient sampling. Women aged 18–40 years who were nulligravida or primiparum in the first trimester were included, comprising collegiate students, working women, and homemakers meeting eligibility criteria. Women were excluded if they were multigravida or had musculoskeletal conditions requiring treatment, cognitive or psychological disorders, communication impairment, postural deformities, or neurological/neuromuscular conditions with management. Medical students were excluded to avoid response bias related to prior knowledge. Ethical considerations Each participant provided written informed consent prior to enrollment. The study protocol was approved by the Institutional Ethics Committee of SRM Medical College Hospital and Research Centre (Ethical clearance no: ST0125-2139; approved on March 5, 2025), and registered with the Clinical Trials Registry of India (Trial registration no: REF/2025/06/088428). This research was funded by SRM Institute of Science and Technology, Kattankulathur, India, with no involvement of the funder in study design, data collection, analysis, interpretation, or manuscript preparation. Participant anonymity and confidentiality were maintained. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Development of the Questionnaire The questionnaire was developed through a systematic multi-stage process. Initially, an extensive literature review examined previous instrument development studies ( 12 , 13 ) and identified common pregnancy-induced postural adaptations and musculoskeletal complaints ( 14 – 16 ), revealing a lack of validated tools assessing awareness in pregnant women and establishing the need for a population-specific questionnaire. Primary data were collected through focus group discussions and expert interviews to obtain insights on postural complaints, awareness levels, and domain relevance. Based on these inputs, a 52-item draft covering physiological, psychosocial, and functional aspects was developed. The questionnaire initially assessed demographics, postural awareness, musculoskeletal pain, daily impact, coping strategies, preparedness, and prevention attitude; following expert consultation, it was refined to focus on postural changes and associated pain, and submitted for critique. During review, repetitive items were removed, and the tool was reduced to 26 items under four domains: postural changes, pain, psychosocial impact, and prevention attitude. So, an author-developed pictorial questionnaire was used to assess awareness of pregnancy-related postural changes (Supplementary File 1). Copyright registration is currently under process.” Ten prevalent postural changes identified from literature ( 14 – 16 ) were incorporated with corresponding pain patterns and pictorial representations, resulting in 20 images. Swelling and numbness of the foot were combined into one item with two images, psychosocial aspects were grouped under psychosocial impact, and preventive awareness under prevention attitude with three images. Pictorial guidance followed previous questionnaire development approaches ( 13 ). The Cornell Musculoskeletal Discomfort Questionnaire informed pain structuring to consolidate indicators into fewer questions ( 17 ), reducing respondent burden and improving clarity ( 13 , 17 ). After content validation, pretesting among primigravid women up to 14 weeks assessed clarity and feasibility. Test–retest reliability followed, and the final version was prepared for implementation. Table 1 Distribution of Questionnaire Domains, Items, and Pictorial Components Category Question Numbers No. of Questions No of Pictures Postural Changes Awareness QN No. 1–10 10 2*10 Pain Awareness QN No. 11,17 2 2*2 Psychosocial Impact QN No. 12–14 3 0 Prevention Attitude QN No. 15,16 2 1*3 Total — 17 27 Table 1 summarizes item distribution. Postural changes awareness included questions 1–10 with 20 pictures, pain awareness questions 11 and 17 with four pictures, psychosocial impact questions 12–14 without pictures, and prevention attitude questions 15 and 16 with three pictures. Overall, the questionnaire comprised 17 questions and 27 pictures. Scoring of Questionnaire All questions used a 3-point Likert scale (Yes = 2, No = 1, Not sure = 0). A maximum score of 42 indicated adequate awareness, lower scores reflected poor knowledge, and mid-range scores suggested ambivalence. Scores of 0 or 1 indicated uncertainty. Question 17 used a checklist format, with each selected box scoring one mark out of ten. Content Validation Procedure Content validation was conducted through expert panel review ( 18 ) involving four physiotherapists, two obstetricians, one orthopedician, one clinical psychologist, one antenatal nurse, and one multigravidal woman, all with at least 10 years of experience. Items were rated using a 5-point Likert scale ( 18 ). Experts received the tool with background information and an evaluation form. Based on feedback, revisions were made and the second version was re-evaluated. Some reviewers questioned items 2, 7, and 10; however, most female experts supported their inclusion based on clinical experience, and they were retained. Scores from all experts for the 17 items were statistically analyzed ( 10 ), as removing items could compromise tool comprehensiveness. Testing–Retesting Reliability Test–retest reliability assessed questionnaire stability ( 19 ). A total of 170 participants were recruited, and the questionnaire was administered twice following informed consent and baseline assessment. Due to constraints, the interval was two days ( 19 ). Different interviewers conducted each session, and question order was altered during retest to minimize recall bias. Responses were compared for reliability. For comprehension, the questionnaire was translated into Tamil for participants who preferred it ( 20 ), and responses were compiled for statistical analysis. Data Analysis Content validity was assessed by calculating the Item-level Content Validity Index (I-CVI) for each of the 17 items based on ratings from 10 experts using Microsoft Excel. The I-CVI was calculated as: I-CVI = Number of experts scoring 3, 4, or 5 / N and used to determine item retention, revision, or removal. Interpretation followed Lynn’s criteria, where values > 0.79 indicate appropriateness, 0.70–0.79 suggest revision, and < 0.70 indicate elimination. Test–retest reliability assessed response stability across two administrations (n = 170). Spearman’s rank correlation coefficient was calculated for each item and total score using SPSS version 29 to examine associations between time points, while Pearson’s correlation coefficient (r) evaluated agreement of overall scores. Higher positive coefficients indicated stronger reliability and stability, with both Spearman’s and Pearson’s values ranging from − 1 to + 1, reflecting relationship strength and direction. Results Content Validation The items of the tool were evaluated by an expert panel to determine the clarity of language and pertinence for applied practice. Based on the recommendations received, revisions were incorporated particularly for Items 14 and 16, after which the corrected version of the tool was circulated again to the same experts for approval of the final version. The tool was considered appropriate and valid, with the majority of ratings ranging between 5 (strongly agree) and 4 (agree). All feedback and recommendations provided by experts who selected “strongly disagree” or “disagree” were carefully reviewed, and relevant modifications were made to improve the instrument’s clarity and relevance. Content validity was further quantified by calculating the Item-level Content Validity Index (I-CVI) for 17 items across 10 experts. All items achieved an I-CVI ≥ 0.80, except Q14 and Q16, which demonstrated I-CVI values of 0.70 and were therefore critically reviewed and revised. In addition, the Scale-level Content Validity Index/Average (S-CVI/Ave) was computed and found to be 0.876, indicating strong overall content validity of the instrument. Items with comparatively lower I-CVI scores were re-examined to ensure adequacy before finalization. Table 2 Expert Agreement on Questionnaire Items Based on Item-Level CVI Item No I-CVI QN. No 1 0.9 QN No 2 0.9 QN No 3 0.8 QN No 4 0.8 QN No 5 0.9 QN No 6 0.9 QN No 7 0.8 QN No 8 0.9 QN No 9 1 QN No 10 0.8 QN No 11 0.9 QN No 12 1 QN No 13 0.9 QN No 14 0.7 QN No 15 1 QN No 16 0.7 QN No 17 1 Overall CVI 0.876471 Table 2 presents the Item-level Content Validity Index (I-CVI) scores for each of the 17 questionnaire items (Q1-Q17) based on evaluation by 10 experts. The I-CVI values ranged from 0.7 to 1.0, indicating that most items demonstrated good to excellent agreement among experts regarding clarity, relevance, and appropriateness. The majority of items achieved I-CVI values between 0.8 and 1.0, reflecting strong content validity and supporting their retention in the final version of the tool. Specifically, Q9, Q12, Q15, and Q17 obtained the highest I-CVI score of 1.0, indicating complete agreement among experts. Several items such as Q1, Q2, Q5, Q6, Q8, Q11, and Q13 achieved 0.9, showing very high agreement, while Q3, Q4, Q7, and Q10 scored 0.8, indicating acceptable relevance with minor scope for refinement if necessary. However, Q14 and Q16 recorded the lowest I-CVI value of 0.7, suggesting comparatively lower agreement among experts and indicating that these items required revision to improve clarity or relevance. The overall content validity of the scale was strong, as reflected by the overall CVI (S-CVI/Ave) of 0.876, confirming that the questionnaire possesses good overall content validity and is suitable for further reliability testing and field application. Test-Retest Reliability: Of the 170 individuals recruited for the reliability assessment, each participant provided a second response to the questionnaire, which was re-administered one hour after the initial completion. A total of 17 items were included for assessing reliability. As shown below in Table 3 , test-retest reliability was evaluated using Spearman’s rank correlation coefficient for each item and the total score across the two administrations (n = 170). The results demonstrated excellent stability and consistency of the questionnaire over time, with correlation coefficients ranging from 0.968 to 1.000, and several items (Q1, Q5, Q7, Q9, Q10, Q11, Q12, Q13, and Q17) showing perfect agreement (r = 1.0). The remaining items also exhibited very high correlations, including Q2 (0.977), Q3 (0.998), Q4 (0.981), Q6 (0.985), Q8 (0.968), Q14 (0.974), Q15 (0.989), and Q16 (0.979). All items showed statistically significant correlations (p < 0.001), confirming that the instrument possesses excellent test-retest reliability. Table 3 Item-Wise Test–Retest Reliability of the Questionnaire Based on Correlation Analysis Item No. Correlation Significance (p) QN. No 1 1 0 QN No 2 0.977 0 QN No 3 0.998 0 QN No 4 0.981 0 QN No 5 1 0 QN No 6 0.985 0 QN No 7 1 0 QN No 8 0.968 0 QN No 9 1 0 QN No 10 1 0 QN No 11 1 0 QN No 12 1 0 QN No 13 1 0 QN No 14 0.974 0 QN No 15 0.989 0 QN No 16 0.979 0 QN No 17 1 0 Table 4 Overall Scale Reliability Based on Pearson Correlation Analysis Item Correlation Significance (p) Total Score 0.989 0 Table 4 presents the test-retest reliability results for the overall instrument score, analysed using Pearson’s correlation coefficient. To assess the reliability of the overall instrument score, Pearson’s correlation coefficient was computed for the test-retest agreements. The Pearson’s correlation, r = 0.989 (p < .001), indicates outstanding test-retest reliability of the overall scale, suggesting that the instrument produces highly consistent results. The combination of high item-level Spearman’s rho values and the near-perfect Pearson correlation for the total score confirms that the instrument possesses excellent test-retest reliability. Out of 17 items, 9 items demonstrated a correlation value of 1.0, whereas the remaining 8 items showed correlation values ranging between 0.96 and 0.99. Importantly, no item recorded a value below 0.7, indicating that all items are highly consistent, stable, and reliable across repeated administrations. Discussion The present study responds to an important gap in maternal health research by developing and validating a self-report questionnaire to understand how well women recognise pregnancy-related postural changes and the musculoskeletal problems linked to them. Pregnancy is a period of major physical transformation. Hormonal changes, gradual weight gain, ligament laxity, and a forward shift in the centre of gravity together alter spinal curvature and pelvic alignment, and may also disturb balance and gait ( 21 ). These biomechanical adjustments, although natural, can lead to pain, reduced mobility, difficulty in daily activities, and an overall decline in quality of life ( 3 , 22 ). In this context, the key value of the present study lies in offering a psychometrically sound, multidomain awareness tool that captures women’s perceptions and understanding of these bodily changes. Existing research shows that musculoskeletal pain during pregnancy-especially low back pain, pelvic girdle pain, and sacroiliac joint pain-is highly prevalent ( 3 , 22 ). Despite this strong evidence, awareness and education about these changes continue to receive limited attention within routine antenatal care. Gutke et al. observed that many women experience these symptoms without fully understanding why they occur or how they can be managed, which may delay timely intervention and prolong discomfort ( 23 ). While biomechanical studies have clearly documented postural deviations during pregnancy, including changes in lordosis, trunk movement, and body alignment ( 4 , 29 , 30 ), these approaches largely focus on measurable physical changes rather than women’s own awareness and preparedness. The current tool therefore makes a unique contribution by focusing on the perceptual aspect, enabling structured assessment of knowledge, recognition, and readiness to respond to these changes. A major strength of this questionnaire is that it goes beyond simply documenting pain. Instead, it captures awareness across several connected domains such as postural awareness, musculoskeletal discomfort, psychosocial impact, and prevention attitude. This is particularly relevant because pregnancy adaptations are not purely physical-they influence emotional well-being, confidence, and coping ability as well ( 25 , 26 ). Additionally, the pictorially guided format is a valuable design element, as it can help women better understand posture-related deviations and pain localisation, making the tool easier to complete and interpret ( 27 , 28 ). From a clinical and public health perspective, the validated questionnaire has strong practical value. Awareness is often the first step towards health-seeking behaviour, willingness to adopt preventive strategies, and early referral to supportive care such as physiotherapy. The questionnaire can serve as a simple screening tool during antenatal visits by helping healthcare providers identify gaps in knowledge and misconceptions, allowing education to be tailored to individual needs. Such application aligns with recommendations supporting early management of pregnancy-related musculoskeletal complaints, including physiotherapy-based care ( 31 ) and proactive screening strategies integrated into antenatal services ( 32 ). By linking women’s awareness with known biomechanical changes, this tool encourages a more holistic maternal care approach that can improve comfort, functional independence, and overall quality of life. In terms of methodological robustness, internal validity is strengthened by the structured development process, inclusion of clinically meaningful domains, expert review, and iterative refinement. The tool’s foundation is consistent with established frameworks, including the Postural Awareness Scale (PAS) ( 24 ). The psychosocial domains are also supported by validated constructs related to psychological adaptation during pregnancy, including the Prenatal Self-Evaluation Questionnaire (PSEQ) and its applications ( 34 ). Since psychosocial factors such as anxiety and depression are well-recognised determinants of maternal health outcomes ( 31 , 32 ), their inclusion further strengthens the relevance of the instrument. External validity, however, may depend on participant characteristics such as education level, health literacy, and sociocultural background. This is important because awareness and maternal health behaviours are strongly shaped by access to reliable information and educational opportunities ( 35 ). Hence, although the tool provides a standardised approach for comparing awareness across contexts, additional validation in diverse populations would strengthen its generalisability. Another notable strength of the questionnaire is its multidimensional structure, which allows a more complete understanding of pregnancy-related health awareness. The pictorial support further strengthens the tool, as visual formats are known to improve comprehension, reduce ambiguity, and support accurate responses, particularly in populations with varied literacy levels ( 27 , 28 ). However, caution is required when interpreting awareness as direct evidence of behavioural change. Prenatal education literature consistently suggests that knowledge alone does not always result in preventive practice adoption unless it is supported through structured counselling, reinforcement, and follow-up ( 33 ). Moreover, being a self-report measure, responses may be affected by recall limitations and individual interpretation, which can influence accuracy. Future research should focus on evaluating whether questionnaire awareness scores predict meaningful clinical outcomes such as adoption of preventive behaviors, earlier physiotherapy utilization, and improved maternal comfort and function. Longitudinal studies may also be useful to track how awareness changes across trimesters and whether structured educational interventions lead to measurable improvements in both awareness and symptom burden. Further validation in populations with varying educational and sociocultural backgrounds is strongly recommended to enhance broader applicability and research usefulness. This study has certain limitations that should be acknowledged. First, the questionnaire validation and reliability testing were conducted within a single regional and institutional setting, which may limit the generalizability of findings to broader or culturally diverse populations without further cross-cultural adaptation and multicentric validation. Second, the study assessed awareness and instrument stability over a short retest interval; therefore, future longitudinal research is recommended to examine how awareness scores correlate with clinically meaningful outcomes, such as pregnancy-related musculoskeletal pain severity, functional limitation, adherence to preventive strategies, and postpartum musculoskeletal health over longer follow-up durations Conclusion This study developed and validated a reliable self-report questionnaire to assess women’s awareness of pregnancy-related postural changes and musculoskeletal discomfort. The tool demonstrates strong validity and reliability, making it suitable for clinical and research use. Its application may support early identification of awareness gaps and guide preventive education and ergonomic interventions, thereby contributing to improved maternal musculoskeletal health and holistic antenatal care. Operational Definitions 1. Awareness of Pregnancy-Induced Postural Changes In this study, awareness of pregnancy-induced postural changes refers to the participant’s knowledge and understanding regarding the common postural adaptations occurring during pregnancy, such as changes in spinal curvature, pelvic alignment, centre of gravity, and body posture, assessed through the questionnaire items under this domain. 2. Awareness of Pregnancy-Related Musculoskeletal Pain/Complaints In this study, awareness of musculoskeletal pain refers to the participant’s awareness about common pregnancy-related musculoskeletal discomforts, including back pain, pelvic girdle pain, hip pain and related symptoms, measured using items under the pain awareness domain in the questionnaire. 3. Awareness on Psychosocial Impact In this study, psychosocial impact refers to the participant’s awareness regarding the effect of pregnancy-induced postural changes and musculoskeletal issues on daily activities, emotional well-being, sleep, stress and quality of life, assessed under the psychosocial impact domain of the questionnaire. 4. Prevention Attitude In this study, prevention attitude refers to the participant’s awareness and attitude towards preventive and protective measures such as posture correction, proper body mechanics, ergonomic practices, physical activity/exercise and early management to reduce pregnancy-related musculoskeletal problems, assessed through the prevention attitude domain items. STATEMENTS AND DECLARATIONS Ethics approval and consent to participate: Each participant read and signed a written informed consent form prior to enrollment. The study protocol was approved by the Institutional Ethics Committee of SRM Medical College Hospital and Research Centre (Ethical clearance no: ST0125-2139; approved on March 5, 2025). The study was also registered in the Clinical Trials Registry of India (CTRI) (Trial registration no: REF/2025/06/088428). Competing interests: The authors declare that they have no competing interests. Funding: This research work was fully funded by the SRM Institute of science and technology, Kattankulathur, India . Authors' contributions: M Anbupriya : Provided overall conceptual guidance, supervised the study design and methodology, critically reviewed the analysis and interpretation of findings, and approved the final version of the manuscript. Abirami Srinivasan : Conceived the study design, conducted participant recruitment and data collection, performed statistical analysis, and contributed to interpretation of the results. Niveditha Jayaraman : Drafted the initial manuscript, organized the results and discussion sections, performed literature review, and revised the manuscript based on critical feedback. Acknowledgements -Not applicable Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Okanishi N, Kito N, Akiyama M, Yamamoto M. Spinal curvature and characteristics of postural change in pregnant women. Acta obstetricia et gynecologica Scandinavica. 2012 Jul;91(7):856-61. Salari N, Mohammadi A, Hemmati M, Hasheminezhad R, Kani S, Shohaimi S, Mohammadi M. The global prevalence of low back pain in pregnancy: a comprehensive systematic review and meta-analysis. BMC pregnancy and childbirth. 2023 Dec 2;23(1):830. Wu WH, Meijer OG, Uegaki K, Mens JM, Van Dieen JH, Wuisman PI, Östgaard HC. Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. European Spine Journal. 2004 Nov;13(7):575-89. Shanshan H, Liying C, Huihong Z, Yanting W, Tiantian L, Tong J, Jiawei Q. Prevalence of lumbopelvic pain during pregnancy: A systematic review and meta‐analysis of cross‐sectional studies. Acta obstetricia et gynecologica Scandinavica. 2024 Feb;103(2):225-40. Schröder G, Kundt G, Otte M, Wendig D, Schober HC. Impact of pregnancy on back pain and body posture in women. Journal of physical therapy science. 2016;28(4):1199-207. Paula Ribeiro A. Posture and gait biomechanical aspects during pregnancy and the importance of therapeutic exercise: Literature review. Current Women's Health Reviews. 2015 Apr 1;11(1):51-8. Chasan-Taber L, Schmidt MD, Roberts DE, Hosmer DA, Markenson GL, Freedson PS. Development and validation of a pregnancy physical activity questionnaire. Medicine & Science in Sports & Exercise. 2004 Oct 1;36(10):1750-60. Davenport MH, Neil-Sztramko S, Lett B, Duggan M, Mottola MF, Ruchat SM, Adamo KB, Andrews K, Artal R, Beamish N, Chari R. Development of the Get Active Questionnaire for Pregnancy: breaking down barriers to prenatal exercise. Applied Physiology, Nutrition, and Metabolism. 2022 Apr 20;47(7):787-803. Cramer H, Mehling WE, Saha FJ, Dobos G, Lauche R. Postural awareness and its relation to pain: validation of an innovative instrument measuring awareness of body posture in patients with chronic pain. BMC musculoskeletal disorders. 2018 Apr 6;19(1):109. Polit DF, Beck CT. The content validity index: are you sure you know what's being reported? Critique and recommendations. Research in nursing & health. 2006 Oct;29(5):489-97. Salman M, Bettany-Saltikov J, Kandasamy G, Aristegui Racero G. Development of a novel pictorial questionnaire to assess knowledge and behaviour on ergonomics and posture as well as musculoskeletal pain in university students: validity and reliability. InHealthcare 2024 Jan 26 (Vol. 12, No. 3, p. 324). MDPI. De Vet HC, Terwee CB, Mokkink LB, Knol DL. Measurement in medicine: a practical guide. Cambridge university press; 2011 Aug 11. Artino Jr AR, La Rochelle JS, Dezee KJ, Gehlbach H. Developing questionnaires for educational research: AMEE Guide No. 87. Medical teacher. 2014 Jun 1;36(6):463-74. Franklin ME, Conner-Kerr T. An analysis of posture and back pain in the first and third trimesters of pregnancy. Journal of Orthopaedic & Sports Physical Therapy. 1998 Sep;28(3):133-8. Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy: prevalence and risk factors. Spine. 2005 Apr 15;30(8):983-91. Van De Pol G, Van Brummen HJ, Bruinse HW, Heintz AP, Van Der Vaart CH. Pregnancy‐related pelvic girdle pain in the Netherlands. Acta obstetricia et gynecologica Scandinavica. 2007 Apr;86(4):416-22. Hedge A, Morimoto S, Mccrobie D. Effects of keyboard tray geometry on upper body posture and comfort. Ergonomics. 1999 Oct 1;42(10):1333-49. Hill MM, Hill A. Investigação por questionário, ed. Streiner DL, Norman GR, Cairney J. Health measurement scales: a practical guide to their development and use. Oxford university press; 2024 Feb 8. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000 Dec 15;25(24):3186-91. Whitcome KK, Shapiro LJ, Lieberman DE. Fetal load and the evolution of lumbar lordosis in bipedal hominins. Nature. 2007 Dec 13;450(7172):1075-8. Wang SM, Dezinno P, Maranets I, Berman MR, Caldwell-Andrews AA, Kain ZN. Low back pain during pregnancy: prevalence, risk factors, and outcomes. Obstetrics & Gynecology. 2004 Jul 1;104(1):65-70. Gutke A, Östgaard HC, Öberg B. Association between muscle function and low back pain in relation to pregnancy. Journal of rehabilitation medicine. 2008;40(4):304-11. Brink Y, Louw Q, Grimmer-Somers K. The quality of evidence of psychometric properties of three-dimensional spinal posture-measuring instruments. BMC musculoskeletal disorders. 2011 May 13;12(1):93. Alder J, Fink N, Bitzer J, Hösli I, Holzgreve W. Depression and anxiety during pregnancy: a risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. The Journal of Maternal-Fetal & Neonatal Medicine. 2007 Jan 1;20(3):189-209. Dennis CL, Falah-Hassani K, Shiri R. Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. The British Journal of Psychiatry. 2017 May;210(5):315-23. Houts PS, Doak CC, Doak LG, Loscalzo MJ. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient education and counseling. 2006 May 1;61(2):173-90. Katz MG, Kripalani S, Weiss BD. Use of pictorial aids in medication instructions: a review of the literature. American journal of health-system pharmacy. 2006 Dec 1;63(23):2391-7. Gilleard W, Crosbie J, Smith R. Effect of pregnancy on trunk range of motion when sitting and standing. Acta obstetricia et gynecologica Scandinavica. 2002 Jan 1;81(11):1011-20. Moore K, Dumas GA, Reid JG. Postural changes associated with pregnancy and their relationship with low-back pain. Clinical Biomechanics. 1990 Aug 1;5(3):169-74. Bastiaanssen JM, de Bie RA, Bastiaenen CH, Essed GG, Van den Brandt PA. A historical perspective on pregnancy-related low back and/or pelvic girdle pain. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2005 May 1;120(1):3-14. Walters C, West S, Nippita TA. Pelvic girdle pain in pregnancy. Australian journal of general practice. 2018 Jul;47(7):439-43. Lumbiganon P. Appropriate technology: antenatal care. International Journal of Gynecology & Obstetrics. 1998 Dec 1;63:S91-5. Lederman RP, Weis KL. Psychosocial anxiety, stress, and adaptation in pregnancy: Assessment of seven dimensions of maternal development. InPsychosocial adaptation to pregnancy: Seven dimensions of maternal development 2020 Sep 11 (pp. 1-50). Cham: Springer International Publishing. Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health promotion international. 2000 Sep 1;15(3):259-67. Additional Declarations No competing interests reported. Supplementary Files SupplimentaryFile1.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 17 Feb, 2026 Editor assigned by journal 16 Feb, 2026 Editor invited by journal 29 Jan, 2026 Submission checks completed at journal 29 Jan, 2026 First submitted to journal 29 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8678898","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":595240115,"identity":"461c6835-5a9f-4fbd-96b4-7f980869d62a","order_by":0,"name":"M Anbupriya","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYFACHhAhwcAPohIYoGQCMVokG8CKDYjWwsBgcABCMRBSz8A/u/eYdOEei2jj82efbnjw5w8DP3uOAcPDHbi1SNw5lyY945lE7rYb6WY3EtsMGCR73hgwJJ7BY82NHDNpngMgLWxsNxIbDBgMbgBtSWzDrUMepmVz/zG2Gwl/DBjsCWkxgGnZwJAG1MIGtEWCgBbDG3nJ1jOAWmbcAGpJbDPmkTjzrOAAPi1yN3IP3i44UJfbD3TYzR9/5OT425M3PvyJRwsIMCNzwNF0AL8GNC2jYBSMglEwCjAAAA83UaB0QxnEAAAAAElFTkSuQmCC","orcid":"","institution":"SRM Institute of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"M","middleName":"","lastName":"Anbupriya","suffix":""},{"id":595240116,"identity":"4c4b565d-68c4-4bcf-bf8b-9f2f01aba538","order_by":1,"name":"Abirami Srinivasan","email":"","orcid":"","institution":"SRM Institute of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Abirami","middleName":"","lastName":"Srinivasan","suffix":""},{"id":595240120,"identity":"c1cd7e18-a08c-476a-abad-ad81f70e1375","order_by":2,"name":"Niveditha Jayaraman","email":"","orcid":"","institution":"SRM Institute of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Niveditha","middleName":"","lastName":"Jayaraman","suffix":""}],"badges":[],"createdAt":"2026-01-23 11:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8678898/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8678898/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103505723,"identity":"871d046a-1a71-427d-afcf-ab94a8538b76","added_by":"auto","created_at":"2026-02-26 13:32:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":596601,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8678898/v1/7c4b3350-2838-44a0-a961-09347fb5d048.pdf"},{"id":103238920,"identity":"8c6ebe90-1e6f-481e-a936-2ef827c2b78c","added_by":"auto","created_at":"2026-02-23 13:42:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":2092409,"visible":true,"origin":"","legend":"","description":"","filename":"SupplimentaryFile1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8678898/v1/5ced2486861067718d4ce2cf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development and Validation of a Pictorial Self-Report Questionnaire to Assess Women’s Awareness of Pregnancy-Induced Postural Changes and Musculoskeletal Risks","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePregnancy is accompanied by substantial physiological and biomechanical adaptations that occur as part of normal maternal changes. As gestation progresses, maternal body mass increases and the centre of gravity shifts anteriorly, which is compensated by postural adjustments such as increased lumbar lordosis, altered thoracic curvature, and pelvic alignment changes to maintain stability and functional balance [1]. These postural adaptations, although necessary, may increase loading on the spine and pelvic structures, contributing to musculoskeletal discomfort.\u003c/p\u003e \u003cp\u003eMusculoskeletal symptoms are highly prevalent during pregnancy and are among the most frequently reported physical complaints in antenatal populations. A recent systematic review and meta-analysis reported that the global prevalence of back pain during pregnancy is approximately 40.5% [2]. Similarly, pregnancy-related pelvic girdle pain (PGP) has been described as a common condition, with pooled and reported prevalence estimates ranging around 45% in published literature, although variability exists depending on diagnostic criteria and population [3]. Lumbopelvic pain (including low back and pelvic girdle pain) has also been reported at high pooled prevalence levels, indicating a significant burden across pregnancy [4]. These symptoms are not only physically limiting but can affect sleep, daily activities, and quality of life.\u003c/p\u003e \u003cp\u003eBiomechanical and postural contributors are increasingly recognized in pregnancy-related pain. Observational studies have reported pregnancy-associated changes in spinal posture and alignment, including modifications in lumbar and thoracic curvature, which may correlate with back pain onset and severity [5]. Postural deviations can lead to abnormal mechanical strain on ligaments, joints, and surrounding soft tissues, thereby increasing the risk of pain or dysfunction [6]. From a preventive health perspective, postural awareness is important, as awareness influences behaviour (ergonomics, activity adaptation, and help-seeking), and may support risk reduction strategies for musculoskeletal symptoms.\u003c/p\u003e \u003cp\u003eDespite a strong body of evidence documenting pregnancy-related pain and postural adaptations, awareness of pregnancy-induced postural changes among women remains under explored, particularly among women who are yet to experience pregnancy. While several validated instruments are available for assessing specific pregnancy-related symptoms and functional problems, such tools generally focus on isolated symptoms rather than awareness of biomechanical/postural changes. Moreover, available pregnancy questionnaires such as the Pregnancy Physical Activity Questionnaire (PPAQ) assess activity levels rather than understanding or awareness of postural adaptation and associated musculoskeletal risks [7]. Likewise, screening tools such as the Get Active Questionnaire for Pregnancy primarily evaluate readiness for physical activity rather than awareness of pregnancy-related postural risks [8]. Existing postural awareness tools have been validated in other populations such as chronic pain patients, workers, and young adults, but are not specific to the pregnancy context [9].\u003c/p\u003e \u003cp\u003eQuestionnaire-based measurement is widely used for awareness and health behaviour research; however, instruments intended for clinical or research use require rigorous development and psychometric evaluation. The Content Validity Index (CVI) is recommended for evaluating expert agreement on relevance during tool development and is considered a standard approach in establishing content validity [10]. In addition, the incorporation of pictorial guidance has been shown to improve comprehension and response accuracy in health questionnaires, particularly among participants with varying educational or health literacy levels [11]. Visual aids can reduce cognitive load and increase the clarity of abstract physiological concepts, making this approach relevant for assessing awareness of pregnancy-related postural adaptations.\u003c/p\u003e \u003cp\u003eTherefore, the present study aimed to develop and validate a self-report pictorial questionnaire to assess awareness of pregnancy-induced postural changes and associated musculoskeletal issues among women.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design\u003c/p\u003e \u003cp\u003eTo assess awareness regarding pregnancy-induced postural changes and associated musculoskeletal issues among women who have not yet experienced pregnancy-related physiological adaptations, a community-based non-experimental exploratory study was conducted at SRM Medical College Hospital and Research Centre. The study was planned for 8\u0026ndash;12 weeks following ethical clearance.\u003c/p\u003e \u003cp\u003eStudy population\u003c/p\u003e \u003cp\u003eParticipants were recruited from women attending the outpatient services of Obstetrics and Gynecology at SRM Medical College Hospital and Research Centre using convenient sampling. Women aged 18\u0026ndash;40 years who were nulligravida or primiparum in the first trimester were included, comprising collegiate students, working women, and homemakers meeting eligibility criteria. Women were excluded if they were multigravida or had musculoskeletal conditions requiring treatment, cognitive or psychological disorders, communication impairment, postural deformities, or neurological/neuromuscular conditions with management. Medical students were excluded to avoid response bias related to prior knowledge.\u003c/p\u003e \u003cp\u003eEthical considerations\u003c/p\u003e \u003cp\u003e Each participant provided written informed consent prior to enrollment. The study protocol was approved by the Institutional Ethics Committee of SRM Medical College Hospital and Research Centre (Ethical clearance no: ST0125-2139; approved on March 5, 2025), and registered with the Clinical Trials Registry of India (Trial registration no: REF/2025/06/088428). This research was funded by SRM Institute of Science and Technology, Kattankulathur, India, with no involvement of the funder in study design, data collection, analysis, interpretation, or manuscript preparation. Participant anonymity and confidentiality were maintained. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.\u003c/p\u003e \u003cp\u003eDevelopment of the Questionnaire\u003c/p\u003e \u003cp\u003eThe questionnaire was developed through a systematic multi-stage process. Initially, an extensive literature review examined previous instrument development studies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) and identified common pregnancy-induced postural adaptations and musculoskeletal complaints (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), revealing a lack of validated tools assessing awareness in pregnant women and establishing the need for a population-specific questionnaire.\u003c/p\u003e \u003cp\u003ePrimary data were collected through focus group discussions and expert interviews to obtain insights on postural complaints, awareness levels, and domain relevance. Based on these inputs, a 52-item draft covering physiological, psychosocial, and functional aspects was developed. The questionnaire initially assessed demographics, postural awareness, musculoskeletal pain, daily impact, coping strategies, preparedness, and prevention attitude; following expert consultation, it was refined to focus on postural changes and associated pain, and submitted for critique. During review, repetitive items were removed, and the tool was reduced to 26 items under four domains: postural changes, pain, psychosocial impact, and prevention attitude. So, an author-developed pictorial questionnaire was used to assess awareness of pregnancy-related postural changes (Supplementary File 1). Copyright registration is currently under process.\u0026rdquo;\u003c/p\u003e \u003cp\u003eTen prevalent postural changes identified from literature (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) were incorporated with corresponding pain patterns and pictorial representations, resulting in 20 images. Swelling and numbness of the foot were combined into one item with two images, psychosocial aspects were grouped under psychosocial impact, and preventive awareness under prevention attitude with three images. Pictorial guidance followed previous questionnaire development approaches (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The Cornell Musculoskeletal Discomfort Questionnaire informed pain structuring to consolidate indicators into fewer questions (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), reducing respondent burden and improving clarity (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). After content validation, pretesting among primigravid women up to 14 weeks assessed clarity and feasibility. Test\u0026ndash;retest reliability followed, and the final version was prepared for implementation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of Questionnaire Domains, Items, and Pictorial Components\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuestion Numbers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo. of Questions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo of Pictures\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostural Changes Awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQN No. 1\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2*10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain Awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQN No. 11,17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2*2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychosocial Impact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQN No. 12\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevention Attitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQN No. 15,16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1*3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e17\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e27\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes item distribution. Postural changes awareness included questions 1\u0026ndash;10 with 20 pictures, pain awareness questions 11 and 17 with four pictures, psychosocial impact questions 12\u0026ndash;14 without pictures, and prevention attitude questions 15 and 16 with three pictures. Overall, the questionnaire comprised 17 questions and 27 pictures.\u003c/p\u003e \u003cp\u003eScoring of Questionnaire\u003c/p\u003e \u003cp\u003eAll questions used a 3-point Likert scale (Yes\u0026thinsp;=\u0026thinsp;2, No\u0026thinsp;=\u0026thinsp;1, Not sure\u0026thinsp;=\u0026thinsp;0). A maximum score of 42 indicated adequate awareness, lower scores reflected poor knowledge, and mid-range scores suggested ambivalence. Scores of 0 or 1 indicated uncertainty. Question 17 used a checklist format, with each selected box scoring one mark out of ten.\u003c/p\u003e \u003cp\u003eContent Validation Procedure\u003c/p\u003e \u003cp\u003eContent validation was conducted through expert panel review (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) involving four physiotherapists, two obstetricians, one orthopedician, one clinical psychologist, one antenatal nurse, and one multigravidal woman, all with at least 10 years of experience. Items were rated using a 5-point Likert scale (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Experts received the tool with background information and an evaluation form. Based on feedback, revisions were made and the second version was re-evaluated.\u003c/p\u003e \u003cp\u003eSome reviewers questioned items 2, 7, and 10; however, most female experts supported their inclusion based on clinical experience, and they were retained. Scores from all experts for the 17 items were statistically analyzed (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), as removing items could compromise tool comprehensiveness.\u003c/p\u003e \u003cp\u003eTesting\u0026ndash;Retesting Reliability\u003c/p\u003e \u003cp\u003eTest\u0026ndash;retest reliability assessed questionnaire stability (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). A total of 170 participants were recruited, and the questionnaire was administered twice following informed consent and baseline assessment. Due to constraints, the interval was two days (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Different interviewers conducted each session, and question order was altered during retest to minimize recall bias. Responses were compared for reliability. For comprehension, the questionnaire was translated into Tamil for participants who preferred it (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), and responses were compiled for statistical analysis.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eContent validity was assessed by calculating the Item-level Content Validity Index (I-CVI) for each of the 17 items based on ratings from 10 experts using Microsoft Excel. The I-CVI was calculated as: I-CVI\u0026thinsp;=\u0026thinsp;Number of experts scoring 3, 4, or 5 / N and used to determine item retention, revision, or removal. Interpretation followed Lynn\u0026rsquo;s criteria, where values\u0026thinsp;\u0026gt;\u0026thinsp;0.79 indicate appropriateness, 0.70\u0026ndash;0.79 suggest revision, and \u0026lt;\u0026thinsp;0.70 indicate elimination.\u003c/p\u003e \u003cp\u003eTest\u0026ndash;retest reliability assessed response stability across two administrations (n\u0026thinsp;=\u0026thinsp;170). Spearman\u0026rsquo;s rank correlation coefficient was calculated for each item and total score using SPSS version 29 to examine associations between time points, while Pearson\u0026rsquo;s correlation coefficient (r) evaluated agreement of overall scores. Higher positive coefficients indicated stronger reliability and stability, with both Spearman\u0026rsquo;s and Pearson\u0026rsquo;s values ranging from \u0026minus;\u0026thinsp;1 to +\u0026thinsp;1, reflecting relationship strength and direction.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eContent Validation\u003c/p\u003e \u003cp\u003eThe items of the tool were evaluated by an expert panel to determine the clarity of language and pertinence for applied practice. Based on the recommendations received, revisions were incorporated particularly for Items 14 and 16, after which the corrected version of the tool was circulated again to the same experts for approval of the final version. The tool was considered appropriate and valid, with the majority of ratings ranging between 5 (strongly agree) and 4 (agree). All feedback and recommendations provided by experts who selected \u0026ldquo;strongly disagree\u0026rdquo; or \u0026ldquo;disagree\u0026rdquo; were carefully reviewed, and relevant modifications were made to improve the instrument\u0026rsquo;s clarity and relevance.\u003c/p\u003e \u003cp\u003eContent validity was further quantified by calculating the Item-level Content Validity Index (I-CVI) for 17 items across 10 experts. All items achieved an I-CVI\u0026thinsp;\u0026ge;\u0026thinsp;0.80, except Q14 and Q16, which demonstrated I-CVI values of 0.70 and were therefore critically reviewed and revised. In addition, the Scale-level Content Validity Index/Average (S-CVI/Ave) was computed and found to be 0.876, indicating strong overall content validity of the instrument. Items with comparatively lower I-CVI scores were re-examined to ensure adequacy before finalization.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExpert Agreement on Questionnaire Items Based on Item-Level CVI\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem No\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI-CVI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN. No 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall CVI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.876471\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the Item-level Content Validity Index (I-CVI) scores for each of the 17 questionnaire items (Q1-Q17) based on evaluation by 10 experts. The I-CVI values ranged from 0.7 to 1.0, indicating that most items demonstrated good to excellent agreement among experts regarding clarity, relevance, and appropriateness.\u003c/p\u003e \u003cp\u003eThe majority of items achieved I-CVI values between 0.8 and 1.0, reflecting strong content validity and supporting their retention in the final version of the tool. Specifically, Q9, Q12, Q15, and Q17 obtained the highest I-CVI score of 1.0, indicating complete agreement among experts. Several items such as Q1, Q2, Q5, Q6, Q8, Q11, and Q13 achieved 0.9, showing very high agreement, while Q3, Q4, Q7, and Q10 scored 0.8, indicating acceptable relevance with minor scope for refinement if necessary.\u003c/p\u003e \u003cp\u003eHowever, Q14 and Q16 recorded the lowest I-CVI value of 0.7, suggesting comparatively lower agreement among experts and indicating that these items required revision to improve clarity or relevance. The overall content validity of the scale was strong, as reflected by the overall CVI (S-CVI/Ave) of 0.876, confirming that the questionnaire possesses good overall content validity and is suitable for further reliability testing and field application.\u003c/p\u003e \u003cp\u003eTest-Retest Reliability:\u003c/p\u003e \u003cp\u003eOf the 170 individuals recruited for the reliability assessment, each participant provided a second response to the questionnaire, which was re-administered one hour after the initial completion. A total of 17 items were included for assessing reliability. As shown below in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, test-retest reliability was evaluated using Spearman\u0026rsquo;s rank correlation coefficient for each item and the total score across the two administrations (n\u0026thinsp;=\u0026thinsp;170). The results demonstrated excellent stability and consistency of the questionnaire over time, with correlation coefficients ranging from 0.968 to 1.000, and several items (Q1, Q5, Q7, Q9, Q10, Q11, Q12, Q13, and Q17) showing perfect agreement (r\u0026thinsp;=\u0026thinsp;1.0). The remaining items also exhibited very high correlations, including Q2 (0.977), Q3 (0.998), Q4 (0.981), Q6 (0.985), Q8 (0.968), Q14 (0.974), Q15 (0.989), and Q16 (0.979). All items showed statistically significant correlations (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), confirming that the instrument possesses excellent test-retest reliability.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eItem-Wise Test\u0026ndash;Retest Reliability of the Questionnaire Based on Correlation Analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem No.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSignificance (p)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN. No 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.977\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.981\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.985\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.968\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.974\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.989\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.979\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQN No 17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverall Scale Reliability Based on Pearson Correlation Analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSignificance (p)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.989\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents the test-retest reliability results for the overall instrument score, analysed using Pearson\u0026rsquo;s correlation coefficient. To assess the reliability of the overall instrument score, Pearson\u0026rsquo;s correlation coefficient was computed for the test-retest agreements. The Pearson\u0026rsquo;s correlation, r\u0026thinsp;=\u0026thinsp;0.989 (p \u0026lt; .001), indicates outstanding test-retest reliability of the overall scale, suggesting that the instrument produces highly consistent results. The combination of high item-level Spearman\u0026rsquo;s rho values and the near-perfect Pearson correlation for the total score confirms that the instrument possesses excellent test-retest reliability. Out of 17 items, 9 items demonstrated a correlation value of 1.0, whereas the remaining 8 items showed correlation values ranging between 0.96 and 0.99. Importantly, no item recorded a value below 0.7, indicating that all items are highly consistent, stable, and reliable across repeated administrations.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study responds to an important gap in maternal health research by developing and validating a self-report questionnaire to understand how well women recognise pregnancy-related postural changes and the musculoskeletal problems linked to them. Pregnancy is a period of major physical transformation. Hormonal changes, gradual weight gain, ligament laxity, and a forward shift in the centre of gravity together alter spinal curvature and pelvic alignment, and may also disturb balance and gait (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). These biomechanical adjustments, although natural, can lead to pain, reduced mobility, difficulty in daily activities, and an overall decline in quality of life (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In this context, the key value of the present study lies in offering a psychometrically sound, multidomain awareness tool that captures women\u0026rsquo;s perceptions and understanding of these bodily changes.\u003c/p\u003e \u003cp\u003eExisting research shows that musculoskeletal pain during pregnancy-especially low back pain, pelvic girdle pain, and sacroiliac joint pain-is highly prevalent (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Despite this strong evidence, awareness and education about these changes continue to receive limited attention within routine antenatal care. Gutke et al. observed that many women experience these symptoms without fully understanding why they occur or how they can be managed, which may delay timely intervention and prolong discomfort (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). While biomechanical studies have clearly documented postural deviations during pregnancy, including changes in lordosis, trunk movement, and body alignment (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), these approaches largely focus on measurable physical changes rather than women\u0026rsquo;s own awareness and preparedness. The current tool therefore makes a unique contribution by focusing on the perceptual aspect, enabling structured assessment of knowledge, recognition, and readiness to respond to these changes.\u003c/p\u003e \u003cp\u003eA major strength of this questionnaire is that it goes beyond simply documenting pain. Instead, it captures awareness across several connected domains such as postural awareness, musculoskeletal discomfort, psychosocial impact, and prevention attitude. This is particularly relevant because pregnancy adaptations are not purely physical-they influence emotional well-being, confidence, and coping ability as well (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Additionally, the pictorially guided format is a valuable design element, as it can help women better understand posture-related deviations and pain localisation, making the tool easier to complete and interpret (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFrom a clinical and public health perspective, the validated questionnaire has strong practical value. Awareness is often the first step towards health-seeking behaviour, willingness to adopt preventive strategies, and early referral to supportive care such as physiotherapy. The questionnaire can serve as a simple screening tool during antenatal visits by helping healthcare providers identify gaps in knowledge and misconceptions, allowing education to be tailored to individual needs. Such application aligns with recommendations supporting early management of pregnancy-related musculoskeletal complaints, including physiotherapy-based care (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) and proactive screening strategies integrated into antenatal services (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). By linking women\u0026rsquo;s awareness with known biomechanical changes, this tool encourages a more holistic maternal care approach that can improve comfort, functional independence, and overall quality of life.\u003c/p\u003e \u003cp\u003eIn terms of methodological robustness, internal validity is strengthened by the structured development process, inclusion of clinically meaningful domains, expert review, and iterative refinement. The tool\u0026rsquo;s foundation is consistent with established frameworks, including the Postural Awareness Scale (PAS) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The psychosocial domains are also supported by validated constructs related to psychological adaptation during pregnancy, including the Prenatal Self-Evaluation Questionnaire (PSEQ) and its applications (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Since psychosocial factors such as anxiety and depression are well-recognised determinants of maternal health outcomes (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), their inclusion further strengthens the relevance of the instrument. External validity, however, may depend on participant characteristics such as education level, health literacy, and sociocultural background. This is important because awareness and maternal health behaviours are strongly shaped by access to reliable information and educational opportunities (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Hence, although the tool provides a standardised approach for comparing awareness across contexts, additional validation in diverse populations would strengthen its generalisability.\u003c/p\u003e \u003cp\u003eAnother notable strength of the questionnaire is its multidimensional structure, which allows a more complete understanding of pregnancy-related health awareness. The pictorial support further strengthens the tool, as visual formats are known to improve comprehension, reduce ambiguity, and support accurate responses, particularly in populations with varied literacy levels (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). However, caution is required when interpreting awareness as direct evidence of behavioural change. Prenatal education literature consistently suggests that knowledge alone does not always result in preventive practice adoption unless it is supported through structured counselling, reinforcement, and follow-up (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Moreover, being a self-report measure, responses may be affected by recall limitations and individual interpretation, which can influence accuracy.\u003c/p\u003e \u003cp\u003eFuture research should focus on evaluating whether questionnaire awareness scores predict meaningful clinical outcomes such as adoption of preventive behaviors, earlier physiotherapy utilization, and improved maternal comfort and function. Longitudinal studies may also be useful to track how awareness changes across trimesters and whether structured educational interventions lead to measurable improvements in both awareness and symptom burden. Further validation in populations with varying educational and sociocultural backgrounds is strongly recommended to enhance broader applicability and research usefulness. This study has certain limitations that should be acknowledged. First, the questionnaire validation and reliability testing were conducted within a single regional and institutional setting, which may limit the generalizability of findings to broader or culturally diverse populations without further cross-cultural adaptation and multicentric validation. Second, the study assessed awareness and instrument stability over a short retest interval; therefore, future longitudinal research is recommended to examine how awareness scores correlate with clinically meaningful outcomes, such as pregnancy-related musculoskeletal pain severity, functional limitation, adherence to preventive strategies, and postpartum musculoskeletal health over longer follow-up durations\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study developed and validated a reliable self-report questionnaire to assess women\u0026rsquo;s awareness of pregnancy-related postural changes and musculoskeletal discomfort. The tool demonstrates strong validity and reliability, making it suitable for clinical and research use. Its application may support early identification of awareness gaps and guide preventive education and ergonomic interventions, thereby contributing to improved maternal musculoskeletal health and holistic antenatal care.\u003c/p\u003e \u003cp\u003e \u003cb\u003eOperational Definitions\u003c/b\u003e \u003c/p\u003e \u003cp\u003e1. Awareness of Pregnancy-Induced Postural Changes\u003c/p\u003e \u003cp\u003eIn this study, awareness of pregnancy-induced postural changes refers to the participant\u0026rsquo;s knowledge and understanding regarding the common postural adaptations occurring during pregnancy, such as changes in spinal curvature, pelvic alignment, centre of gravity, and body posture, assessed through the questionnaire items under this domain.\u003c/p\u003e \u003cp\u003e2. Awareness of Pregnancy-Related Musculoskeletal Pain/Complaints\u003c/p\u003e \u003cp\u003eIn this study, awareness of musculoskeletal pain refers to the participant\u0026rsquo;s awareness about common pregnancy-related musculoskeletal discomforts, including back pain, pelvic girdle pain, hip pain and related symptoms, measured using items under the pain awareness domain in the questionnaire.\u003c/p\u003e \u003cp\u003e3. Awareness on Psychosocial Impact\u003c/p\u003e \u003cp\u003eIn this study, psychosocial impact refers to the participant\u0026rsquo;s awareness regarding the effect of pregnancy-induced postural changes and musculoskeletal issues on daily activities, emotional well-being, sleep, stress and quality of life, assessed under the psychosocial impact domain of the questionnaire.\u003c/p\u003e \u003cp\u003e4. Prevention Attitude\u003c/p\u003e \u003cp\u003eIn this study, prevention attitude refers to the participant\u0026rsquo;s awareness and attitude towards preventive and protective measures such as posture correction, proper body mechanics, ergonomic practices, physical activity/exercise and early management to reduce pregnancy-related musculoskeletal problems, assessed through the prevention attitude domain items.\u003c/p\u003e"},{"header":"STATEMENTS AND DECLARATIONS","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach participant read and signed a written informed consent form prior to enrollment. The study protocol was approved by the Institutional Ethics Committee of SRM Medical College Hospital and Research Centre (Ethical clearance no: ST0125-2139; approved on March 5, 2025). The study was also registered in the Clinical Trials Registry of India (CTRI) (Trial registration no: REF/2025/06/088428).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research work was fully funded by the SRM Institute of science and technology, Kattankulathur, India .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM Anbupriya :\u003csup\u003e\u0026nbsp;\u003c/sup\u003eProvided overall conceptual guidance, supervised the study design and methodology, critically reviewed the analysis and interpretation of findings, and approved the final version of the manuscript. Abirami Srinivasan\u0026nbsp;: Conceived the study design, conducted participant recruitment and data collection, performed statistical analysis, and contributed to interpretation of the results. Niveditha Jayaraman : Drafted the initial manuscript, organized the results and discussion sections, performed literature review, and revised the manuscript based on critical feedback.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e -Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eOkanishi N, Kito N, Akiyama M, Yamamoto M. Spinal curvature and characteristics of postural change in pregnant women. Acta obstetricia et gynecologica Scandinavica. 2012 Jul;91(7):856-61.\u003c/li\u003e\n \u003cli\u003eSalari N, Mohammadi A, Hemmati M, Hasheminezhad R, Kani S, Shohaimi S, Mohammadi M. The global prevalence of low back pain in pregnancy: a comprehensive systematic review and meta-analysis. BMC pregnancy and childbirth. 2023 Dec 2;23(1):830.\u003c/li\u003e\n \u003cli\u003eWu WH, Meijer OG, Uegaki K, Mens JM, Van Dieen JH, Wuisman PI, \u0026Ouml;stgaard HC. Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. European Spine Journal. 2004 Nov;13(7):575-89.\u003c/li\u003e\n \u003cli\u003eShanshan H, Liying C, Huihong Z, Yanting W, Tiantian L, Tong J, Jiawei Q. Prevalence of lumbopelvic pain during pregnancy: A systematic review and meta‐analysis of cross‐sectional studies. Acta obstetricia et gynecologica Scandinavica. 2024 Feb;103(2):225-40.\u003c/li\u003e\n \u003cli\u003eSchr\u0026ouml;der G, Kundt G, Otte M, Wendig D, Schober HC. Impact of pregnancy on back pain and body posture in women. Journal of physical therapy science. 2016;28(4):1199-207.\u003c/li\u003e\n \u003cli\u003ePaula Ribeiro A. Posture and gait biomechanical aspects during pregnancy and the importance of therapeutic exercise: Literature review. Current Women\u0026apos;s Health Reviews. 2015 Apr 1;11(1):51-8.\u003c/li\u003e\n \u003cli\u003eChasan-Taber L, Schmidt MD, Roberts DE, Hosmer DA, Markenson GL, Freedson PS. Development and validation of a pregnancy physical activity questionnaire. Medicine \u0026amp; Science in Sports \u0026amp; Exercise. 2004 Oct 1;36(10):1750-60.\u003c/li\u003e\n \u003cli\u003eDavenport MH, Neil-Sztramko S, Lett B, Duggan M, Mottola MF, Ruchat SM, Adamo KB, Andrews K, Artal R, Beamish N, Chari R. Development of the Get Active Questionnaire for Pregnancy: breaking down barriers to prenatal exercise. Applied Physiology, Nutrition, and Metabolism. 2022 Apr 20;47(7):787-803.\u003c/li\u003e\n \u003cli\u003eCramer H, Mehling WE, Saha FJ, Dobos G, Lauche R. Postural awareness and its relation to pain: validation of an innovative instrument measuring awareness of body posture in patients with chronic pain. BMC musculoskeletal disorders. 2018 Apr 6;19(1):109.\u003c/li\u003e\n \u003cli\u003ePolit DF, Beck CT. The content validity index: are you sure you know what\u0026apos;s being reported? Critique and recommendations. Research in nursing \u0026amp; health. 2006 Oct;29(5):489-97.\u003c/li\u003e\n \u003cli\u003eSalman M, Bettany-Saltikov J, Kandasamy G, Aristegui Racero G. Development of a novel pictorial questionnaire to assess knowledge and behaviour on ergonomics and posture as well as musculoskeletal pain in university students: validity and reliability. InHealthcare 2024 Jan 26 (Vol. 12, No. 3, p. 324). MDPI.\u003c/li\u003e\n \u003cli\u003eDe Vet HC, Terwee CB, Mokkink LB, Knol DL. Measurement in medicine: a practical guide. Cambridge university press; 2011 Aug 11.\u003c/li\u003e\n \u003cli\u003eArtino Jr AR, La Rochelle JS, Dezee KJ, Gehlbach H. Developing questionnaires for educational research: AMEE Guide No. 87. Medical teacher. 2014 Jun 1;36(6):463-74.\u003c/li\u003e\n \u003cli\u003eFranklin ME, Conner-Kerr T. An analysis of posture and back pain in the first and third trimesters of pregnancy. Journal of Orthopaedic \u0026amp; Sports Physical Therapy. 1998 Sep;28(3):133-8.\u003c/li\u003e\n \u003cli\u003eMogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy: prevalence and risk factors. Spine. 2005 Apr 15;30(8):983-91.\u003c/li\u003e\n \u003cli\u003eVan De Pol G, Van Brummen HJ, Bruinse HW, Heintz AP, Van Der Vaart CH. Pregnancy‐related pelvic girdle pain in the Netherlands. Acta obstetricia et gynecologica Scandinavica. 2007 Apr;86(4):416-22.\u003c/li\u003e\n \u003cli\u003eHedge A, Morimoto S, Mccrobie D. Effects of keyboard tray geometry on upper body posture and comfort. Ergonomics. 1999 Oct 1;42(10):1333-49.\u003c/li\u003e\n \u003cli\u003eHill MM, Hill A. Investiga\u0026ccedil;\u0026atilde;o por question\u0026aacute;rio, ed.\u003c/li\u003e\n \u003cli\u003eStreiner DL, Norman GR, Cairney J. Health measurement scales: a practical guide to their development and use. Oxford university press; 2024 Feb 8.\u003c/li\u003e\n \u003cli\u003eBeaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000 Dec 15;25(24):3186-91.\u003c/li\u003e\n \u003cli\u003eWhitcome KK, Shapiro LJ, Lieberman DE. Fetal load and the evolution of lumbar lordosis in bipedal hominins. Nature. 2007 Dec 13;450(7172):1075-8.\u003c/li\u003e\n \u003cli\u003eWang SM, Dezinno P, Maranets I, Berman MR, Caldwell-Andrews AA, Kain ZN. Low back pain during pregnancy: prevalence, risk factors, and outcomes. Obstetrics \u0026amp; Gynecology. 2004 Jul 1;104(1):65-70.\u003c/li\u003e\n \u003cli\u003eGutke A, \u0026Ouml;stgaard HC, \u0026Ouml;berg B. Association between muscle function and low back pain in relation to pregnancy. Journal of rehabilitation medicine. 2008;40(4):304-11.\u003c/li\u003e\n \u003cli\u003eBrink Y, Louw Q, Grimmer-Somers K. The quality of evidence of psychometric properties of three-dimensional spinal posture-measuring instruments. BMC musculoskeletal disorders. 2011 May 13;12(1):93.\u003c/li\u003e\n \u003cli\u003eAlder J, Fink N, Bitzer J, H\u0026ouml;sli I, Holzgreve W. Depression and anxiety during pregnancy: a risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. The Journal of Maternal-Fetal \u0026amp; Neonatal Medicine. 2007 Jan 1;20(3):189-209.\u003c/li\u003e\n \u003cli\u003eDennis CL, Falah-Hassani K, Shiri R. Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. The British Journal of Psychiatry. 2017 May;210(5):315-23.\u003c/li\u003e\n \u003cli\u003eHouts PS, Doak CC, Doak LG, Loscalzo MJ. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient education and counseling. 2006 May 1;61(2):173-90.\u003c/li\u003e\n \u003cli\u003eKatz MG, Kripalani S, Weiss BD. Use of pictorial aids in medication instructions: a review of the literature. American journal of health-system pharmacy. 2006 Dec 1;63(23):2391-7.\u003c/li\u003e\n \u003cli\u003eGilleard W, Crosbie J, Smith R. Effect of pregnancy on trunk range of motion when sitting and standing. Acta obstetricia et gynecologica Scandinavica. 2002 Jan 1;81(11):1011-20.\u003c/li\u003e\n \u003cli\u003eMoore K, Dumas GA, Reid JG. Postural changes associated with pregnancy and their relationship with low-back pain. Clinical Biomechanics. 1990 Aug 1;5(3):169-74.\u003c/li\u003e\n \u003cli\u003eBastiaanssen JM, de Bie RA, Bastiaenen CH, Essed GG, Van den Brandt PA. A historical perspective on pregnancy-related low back and/or pelvic girdle pain. European Journal of Obstetrics \u0026amp; Gynecology and Reproductive Biology. 2005 May 1;120(1):3-14.\u003c/li\u003e\n \u003cli\u003eWalters C, West S, Nippita TA. Pelvic girdle pain in pregnancy. Australian journal of general practice. 2018 Jul;47(7):439-43.\u003c/li\u003e\n \u003cli\u003eLumbiganon P. Appropriate technology: antenatal care. International Journal of Gynecology \u0026amp; Obstetrics. 1998 Dec 1;63:S91-5.\u003c/li\u003e\n \u003cli\u003eLederman RP, Weis KL. Psychosocial anxiety, stress, and adaptation in pregnancy: Assessment of seven dimensions of maternal development. InPsychosocial adaptation to pregnancy: Seven dimensions of maternal development 2020 Sep 11 (pp. 1-50). Cham: Springer International Publishing.\u003c/li\u003e\n \u003cli\u003eNutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health promotion international. 2000 Sep 1;15(3):259-67.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pregnancy, Postural changes, Self-report questionnaire, Pictorial guidance, Content validity, Test-retest reliability, Awareness assessment","lastPublishedDoi":"10.21203/rs.3.rs-8678898/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8678898/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003ePregnancy results in progressive biomechanical and postural adaptations as fetal growth shifts the maternal center of gravity anteriorly. Compensatory changes such as increased lumbar lordosis, pelvic tilt, and thoracic curvature may alter postural stability and contribute to musculoskeletal discomfort. Evidence suggests that pregnant women demonstrate changes in center of pressure displacement, delayed activation of key stabilizing muscles (including multifidus and biceps femoris), and increased dependence on visual and somatosensory input to maintain balance. Despite the clinical relevance of these adaptations, awareness among women remains limited, and no validated tool is currently available to assess awareness of pregnancy-induced postural changes and related musculoskeletal risks. This study aimed to develop and validate a self-report questionnaire with pictorial guidance to assess women’s awareness of pregnancy-induced postural changes and associated musculoskeletal issues.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eA close-ended pictorial questionnaire was developed through a multi-phase process including literature review, item generation, expert review, and revision. Content validity was evaluated by a multidisciplinary expert panel using the Content Validity Index (CVI). Test-retest reliability of the final version was assessed using a 2-day interval.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe questionnaire demonstrated strong content validity with a Scale-level Content Validity Index/Average (S-CVI/Ave) of \u003cstrong\u003e0.876\u003c/strong\u003e. The overall scale showed excellent test-retest reliability with a Pearson correlation coefficient of \u003cstrong\u003er = 0.989\u003c/strong\u003e (\u003cstrong\u003ep \u0026lt; 0.001\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The newly developed pictorial self-report questionnaire is a valid and reliable instrument for assessing women’s awareness of pregnancy-related postural changes and musculoskeletal risks. It may support early identification of awareness gaps and guide preventive education and physiotherapy interventions.\u003c/p\u003e","manuscriptTitle":"Development and Validation of a Pictorial Self-Report Questionnaire to Assess Women’s Awareness of Pregnancy-Induced Postural Changes and Musculoskeletal Risks","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-23 13:41:51","doi":"10.21203/rs.3.rs-8678898/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-02-17T13:02:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-16T13:53:47+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-29T13:58:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-29T11:53:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-01-29T11:12:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0c836dbd-c858-41be-9b72-cadfa128a00c","owner":[],"postedDate":"February 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T13:41:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-23 13:41:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8678898","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8678898","identity":"rs-8678898","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}