612119
research-article2015
ISP0010.1177/0020764015612119International Journal of Social PsychiatryMoshki et al.
E CAMDEN SCHIZOPH
Original Article
Relationships among depression during pregnancy, social support and health locus of control among Iranian pregnant women
International Journal of Social Psychiatry 1–8 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764015612119 isp.sagepub.com
Mahdi Moshki1 and Khadijeh Cheravi1
Abstract Background: Prenatal depression is a significant predictor of postpartum depression and is detrimental to fetal development. Aim: To examine whether depression during pregnancy is associated with social support and health locus of control (HLC). Method: Data were collected from a sample of 208 Iranian pregnant women using a demographic questionnaire, the Edinburgh Postnatal Depression Scale, the multidimensional HLC Scale and the social support appraisals. Results: Depression was experienced by 37% of participants. Overall, women reported higher level of family support (6.88 ± 1.15) than other supports (6.87 ± 1.29). Protective supports from other resources (6.87 ± 1.29) were higher than those from friends (5.94 ± 1.5). Internal, powerful others and chance beliefs had the highest mean scores. Social support and chance HLC significantly influenced the proposed mediator (depressive mood) in the linear regression model. Bivariate analysis showed significant associations between social support (friend, family and others) and depressive mood. Internal HLC had a significant association with social support and powerful others HLC. However, Pearson correlation coefficient was not significant between depressive mood and all dimensions of HLC. Conclusion: Clinicians could assess social support and chance HLC to identify and treat women at risk of prenatal depression. By providing support during pregnancy, depression levels in women and its effects on the fetus may be decreased, which could prevent postpartum depression. Keywords Pregnancy, depression, social support, health locus of control
Introduction During pregnancy, respect to the maternal role is vitally important to ensure the infant’s safety, survival and wellbeing, although it does not come without costs (Logsdon, Wisner, & Pinto-Foltz, 2006). In addition to the physical aspects, respect to social and psychological aspects is necessary (Tabrizi & Lorestani, 2011). Today, there is more emphasis on the study of individual mental health because mental disorders are chains that negatively affect individuals and their family functions, economic condition and public health. Mental illnesses are the secondary sources of disease resulting in economic problems (Mo & Mak, 2008), which have been shown to cause disability among women worldwide (Patel & Wisner, 2011). The peak prevalence of major depressive disorder in women is during the childbearing years. A recent population-based survey of more than 15,000 women found that the prevalence of major depressive disorder during pregnancy is 8.4%. Its prevalence is 1.5–3 times more in women (particularly in
childbearing age) than in men (Patel & Wisner, 2011). The risk factors for depression during pregnancy are similar to those for postpartum depression. These include having a history of depression, anxiety, unintended pregnancy, family violence, stressful lifestyle, unsuitable socioeconomic status and lack of social support (Lancaster et al., 2010; Stewart, 2011). Because of less evidence to support an etiology or symptomatology, differentiating depressive symptoms during pregnancy from other life stages 1Department
of Public Health, School of Health; Social Development & Health Promotion Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
Corresponding author: Khadijeh Cheravi, Social Development & Health Promotion Research Center, Gonabad University of Medical Sciences, P.O. Box: 397, Gonabad, Iran. Email: [email protected]
Downloaded from isp.sagepub.com at UNIV OF PENNSYLVANIA on December 12, 2015
2
International Journal of Social Psychiatry
is difficult (Chaudron, 2013). In addition, the physical experiences of pregnancy, such as fatigue, sleep disruption, weight change and concentration difficulties, can overlap with the symptoms of depression and thus confuse the person investigating (Chaudron, 2013). Antenatal depression increases the risk of adverse outcomes, including preterm birth, pre-eclampsia, fetal growth restriction and infant behavior disorders (Grote et al., 2010; Yonkers et al., 2009). Depressed pregnant mothers are at risk of weight loss, drug abuse and neglect to maternal care. Untreated depression during pregnancy can result in a worse condition such as the thought of or attempting suicide. In addition, women with depression during pregnancy are at extra risk of postpartum depression, which may be a risk factor for the health and well-being of both mothers and infants. Thus, prevention, identification and treatment of perinatal depression are major public health priorities (Lisa et al., 2012). Social supports (such as family, friends, organizations and colleagues) have obviously been linked to positive health results. These supporters can provide several benefits for both the physical and the mental health of pregnant women (Copertaro et al., 2014). For example, prevalence of mortality because of diseases is lower among women receiving greater social supports (Stanton & Campbell, 2014). Social supports (family, friends, neighbors, colleagues and community members) make individuals feel that they are a member of a group in which one can share affection, aid and obligation (Lin et al., 2013). Research studies show that social supports are based on five dimensions: material support (financial assistance and provision of resources), emotional support (love, affection, respect and empathy), affective support (physical demonstrations of love and affection), positive interaction support (availability of people for fun and relaxation) and information support (guidance, advice and information; Yamashita, Amendola, Gaspar, Alvarenga, & Oliveira, 2013). Social support theory considers positive social support as a protective barrier against negative effects of depression on mental and physical health. Therefore, the lack of suitable social support may be a dangerous means for increasing depressive symptoms. Social support is similar to a tampon that reduces the stressful life events and helps patients in overcoming emotional tension (Nazik, Ozdemir, & Soydan, 2014). Finally, social support, as a social determinant of health, plays an important role in the promotion of psychosocial conditions in the lives of people (Setareh Forouzan et al., 2013). According to Basinska and Andruszkiewicz (2012), every person has specific ideas and beliefs, which are essential elements to take decisions such as those about his or her health. For the promotion of personal attitude about one’s health behaviors, the health locus of control (HLC) is an essential method for a healthy life environment. This theory attempts to make persons believe that their health is related to their own behavior (internal health locus of control (IHLC)) or
to some external consequences (external health locus of control (EHLC); Luszczynska & Schwarzer, 2005). Some subsequent forms of EHLC are powerful others health locus of control (PHLC) and chance health locus of control (CHLC). Individuals with IHLC are more successful in protecting their health and in recovery and rehabilitation after diseases than others. In fact, the belief in IHLC is an active and intelligent way of overcoming stress, and it is also a positive psychological and physical adaptor during illness. In contrast, individuals with EHLC are more prone to passive behaviors during problems and illnesses. In general, PHLC and CHLC are external stimuli in persons with chronic illnesses and negative emotions such as depression, hostility, anxiety and physical disorders (Basinska & Andruszkiewicz, 2012). Dibaba et al. (2013) showed that women who reported moderate and high social support during pregnancy were significantly less likely to report depressive symptoms. Elsenbruch et al. (2007) also reported that the lack of social support constitutes an important risk factor for maternal well-being during pregnancy and has adverse effects on pregnancy outcomes. Gabry (2005) suggested that the locus of control may be related to prenatal depression. Another study found that the external locus of control (ELOC-chance) was a statistically significant predictor of prenatal depression (Richardson, Field, Newton, & Bendell, 2012). Due to the lack of standardized practices and policies in the healthcare system, new mothers experiencing symptoms of depression could be lost for followup, and without appropriate intervention, these women may remain in a state of untreated depression for years, thus affecting their own health as well as the health of their partners and children (Abraham, 2008). Therefore, this study attempts to examine the associations between social support, HLC and depressive symptoms among pregnant women in Iran.
Method Procedures and participants This cross-sectional study was conducted on a sample of 208 pregnant women in 2013 in Gonabad, Iran. The inclusion criteria were as follows: to be pregnant for 26 weeks or more, without clinical and obstetric complications, with no past or present history of depression, literate (ability to read and write), with a healthy fetus on ultrasound and psychiatric treatment. The exclusion criteria were preterm delivery during intervention, history of hospitalization or stillbirth, serious physical and mental problems such as death of a first-degree relative during intervention and subject’s disinclination to continue the study. Permission to collect data was obtained from the Research Ethics Committee of University of Medical Sciences, Iran. Women waiting for prenatal medical appointments at the
Downloaded from isp.sagepub.com at UNIV OF PENNSYLVANIA on December 12, 2015
3
Moshki et al. healthcare offices were recruited using random selection method. Most of the pregnant women participated in the study and accepted the initial invitation. Few of them (2%– 3%) refused, citing lack of time or interest in the research topic. The participants filled in the questionnaires before the medical appointment.
Questionnaires 1. A socio-demographic questionnaire was used to collect data regarding the pregnant women, which included age, education, financial status, child’s gender, planned or unplanned pregnancy of mothers, number of previous pregnancies, number of living children and gestational age at the time of research. 2. Edinburgh Postnatal Depression Scale (EPDS): EPDS is a screening tool used to detect prenatal and postnatal depression. This is a 10-item selfreporting questionnaire with four possible responses. The response categories are scored 0, 1, 2 and 3 according to increasing severity of symptoms; items 3 and 5–10 are reverse scored (i.e. 3, 2, 1 and 0; Husain et al., 2012). Scores less than 12 are considered non-depressed and 12 and above are considered depressed. Validity and reliability of the questionnaires have been confirmed according to other standardized questionnaires in Iran. Cronbach’s α coefficient and test–retest reliability were found to be .86 and .80, respectively (Montazeri, Torkan, & Omidvari, 2007). 3. Multidimensional Health Locus of Control Scale (MHLCS): The HLC questionnaire was administered in order to examine the extent to which centenarians believed that they had control over their health (IHLC) or if it was primarily due to fate (CHLC) or other people’s influence (PHLC; Tigani, Artemiadis, Alexopoulos, Chrousos, & Darviri, 2011). In this study, Form B comprising 18 items in three components (6 items each) was used. All items contained 6-point Likert style, scoring 1–6 marks, so that a person’s score could vary from 6 to 36 for each component, and they will not be summed up together, but calculated independently. There is no cut-off point in this tool, and the mean score is used for final evaluation (Wallston, 2005). A total of 496 university students participated in this study (Moshki & Ghofranipour, 2011). The reliability coefficients were calculated in two different methods: test–retest, parallel tests and Cronbach’s α. In order to assess the validity of the scale, Moshki used three methods including content validity, concurrent validity and construct validity. The corresponding validity scores of the questionnaire, as measured by Levenson’s IPC
scale, were .57 (p
research-article2015
ISP0010.1177/0020764015612119International Journal of Social PsychiatryMoshki et al.
E CAMDEN SCHIZOPH
Original Article
Relationships among depression during pregnancy, social support and health locus of control among Iranian pregnant women
International Journal of Social Psychiatry 1–8 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764015612119 isp.sagepub.com
Mahdi Moshki1 and Khadijeh Cheravi1
Abstract Background: Prenatal depression is a significant predictor of postpartum depression and is detrimental to fetal development. Aim: To examine whether depression during pregnancy is associated with social support and health locus of control (HLC). Method: Data were collected from a sample of 208 Iranian pregnant women using a demographic questionnaire, the Edinburgh Postnatal Depression Scale, the multidimensional HLC Scale and the social support appraisals. Results: Depression was experienced by 37% of participants. Overall, women reported higher level of family support (6.88 ± 1.15) than other supports (6.87 ± 1.29). Protective supports from other resources (6.87 ± 1.29) were higher than those from friends (5.94 ± 1.5). Internal, powerful others and chance beliefs had the highest mean scores. Social support and chance HLC significantly influenced the proposed mediator (depressive mood) in the linear regression model. Bivariate analysis showed significant associations between social support (friend, family and others) and depressive mood. Internal HLC had a significant association with social support and powerful others HLC. However, Pearson correlation coefficient was not significant between depressive mood and all dimensions of HLC. Conclusion: Clinicians could assess social support and chance HLC to identify and treat women at risk of prenatal depression. By providing support during pregnancy, depression levels in women and its effects on the fetus may be decreased, which could prevent postpartum depression. Keywords Pregnancy, depression, social support, health locus of control
Introduction During pregnancy, respect to the maternal role is vitally important to ensure the infant’s safety, survival and wellbeing, although it does not come without costs (Logsdon, Wisner, & Pinto-Foltz, 2006). In addition to the physical aspects, respect to social and psychological aspects is necessary (Tabrizi & Lorestani, 2011). Today, there is more emphasis on the study of individual mental health because mental disorders are chains that negatively affect individuals and their family functions, economic condition and public health. Mental illnesses are the secondary sources of disease resulting in economic problems (Mo & Mak, 2008), which have been shown to cause disability among women worldwide (Patel & Wisner, 2011). The peak prevalence of major depressive disorder in women is during the childbearing years. A recent population-based survey of more than 15,000 women found that the prevalence of major depressive disorder during pregnancy is 8.4%. Its prevalence is 1.5–3 times more in women (particularly in
childbearing age) than in men (Patel & Wisner, 2011). The risk factors for depression during pregnancy are similar to those for postpartum depression. These include having a history of depression, anxiety, unintended pregnancy, family violence, stressful lifestyle, unsuitable socioeconomic status and lack of social support (Lancaster et al., 2010; Stewart, 2011). Because of less evidence to support an etiology or symptomatology, differentiating depressive symptoms during pregnancy from other life stages 1Department
of Public Health, School of Health; Social Development & Health Promotion Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
Corresponding author: Khadijeh Cheravi, Social Development & Health Promotion Research Center, Gonabad University of Medical Sciences, P.O. Box: 397, Gonabad, Iran. Email: [email protected]
Downloaded from isp.sagepub.com at UNIV OF PENNSYLVANIA on December 12, 2015
2
International Journal of Social Psychiatry
is difficult (Chaudron, 2013). In addition, the physical experiences of pregnancy, such as fatigue, sleep disruption, weight change and concentration difficulties, can overlap with the symptoms of depression and thus confuse the person investigating (Chaudron, 2013). Antenatal depression increases the risk of adverse outcomes, including preterm birth, pre-eclampsia, fetal growth restriction and infant behavior disorders (Grote et al., 2010; Yonkers et al., 2009). Depressed pregnant mothers are at risk of weight loss, drug abuse and neglect to maternal care. Untreated depression during pregnancy can result in a worse condition such as the thought of or attempting suicide. In addition, women with depression during pregnancy are at extra risk of postpartum depression, which may be a risk factor for the health and well-being of both mothers and infants. Thus, prevention, identification and treatment of perinatal depression are major public health priorities (Lisa et al., 2012). Social supports (such as family, friends, organizations and colleagues) have obviously been linked to positive health results. These supporters can provide several benefits for both the physical and the mental health of pregnant women (Copertaro et al., 2014). For example, prevalence of mortality because of diseases is lower among women receiving greater social supports (Stanton & Campbell, 2014). Social supports (family, friends, neighbors, colleagues and community members) make individuals feel that they are a member of a group in which one can share affection, aid and obligation (Lin et al., 2013). Research studies show that social supports are based on five dimensions: material support (financial assistance and provision of resources), emotional support (love, affection, respect and empathy), affective support (physical demonstrations of love and affection), positive interaction support (availability of people for fun and relaxation) and information support (guidance, advice and information; Yamashita, Amendola, Gaspar, Alvarenga, & Oliveira, 2013). Social support theory considers positive social support as a protective barrier against negative effects of depression on mental and physical health. Therefore, the lack of suitable social support may be a dangerous means for increasing depressive symptoms. Social support is similar to a tampon that reduces the stressful life events and helps patients in overcoming emotional tension (Nazik, Ozdemir, & Soydan, 2014). Finally, social support, as a social determinant of health, plays an important role in the promotion of psychosocial conditions in the lives of people (Setareh Forouzan et al., 2013). According to Basinska and Andruszkiewicz (2012), every person has specific ideas and beliefs, which are essential elements to take decisions such as those about his or her health. For the promotion of personal attitude about one’s health behaviors, the health locus of control (HLC) is an essential method for a healthy life environment. This theory attempts to make persons believe that their health is related to their own behavior (internal health locus of control (IHLC)) or
to some external consequences (external health locus of control (EHLC); Luszczynska & Schwarzer, 2005). Some subsequent forms of EHLC are powerful others health locus of control (PHLC) and chance health locus of control (CHLC). Individuals with IHLC are more successful in protecting their health and in recovery and rehabilitation after diseases than others. In fact, the belief in IHLC is an active and intelligent way of overcoming stress, and it is also a positive psychological and physical adaptor during illness. In contrast, individuals with EHLC are more prone to passive behaviors during problems and illnesses. In general, PHLC and CHLC are external stimuli in persons with chronic illnesses and negative emotions such as depression, hostility, anxiety and physical disorders (Basinska & Andruszkiewicz, 2012). Dibaba et al. (2013) showed that women who reported moderate and high social support during pregnancy were significantly less likely to report depressive symptoms. Elsenbruch et al. (2007) also reported that the lack of social support constitutes an important risk factor for maternal well-being during pregnancy and has adverse effects on pregnancy outcomes. Gabry (2005) suggested that the locus of control may be related to prenatal depression. Another study found that the external locus of control (ELOC-chance) was a statistically significant predictor of prenatal depression (Richardson, Field, Newton, & Bendell, 2012). Due to the lack of standardized practices and policies in the healthcare system, new mothers experiencing symptoms of depression could be lost for followup, and without appropriate intervention, these women may remain in a state of untreated depression for years, thus affecting their own health as well as the health of their partners and children (Abraham, 2008). Therefore, this study attempts to examine the associations between social support, HLC and depressive symptoms among pregnant women in Iran.
Method Procedures and participants This cross-sectional study was conducted on a sample of 208 pregnant women in 2013 in Gonabad, Iran. The inclusion criteria were as follows: to be pregnant for 26 weeks or more, without clinical and obstetric complications, with no past or present history of depression, literate (ability to read and write), with a healthy fetus on ultrasound and psychiatric treatment. The exclusion criteria were preterm delivery during intervention, history of hospitalization or stillbirth, serious physical and mental problems such as death of a first-degree relative during intervention and subject’s disinclination to continue the study. Permission to collect data was obtained from the Research Ethics Committee of University of Medical Sciences, Iran. Women waiting for prenatal medical appointments at the
Downloaded from isp.sagepub.com at UNIV OF PENNSYLVANIA on December 12, 2015
3
Moshki et al. healthcare offices were recruited using random selection method. Most of the pregnant women participated in the study and accepted the initial invitation. Few of them (2%– 3%) refused, citing lack of time or interest in the research topic. The participants filled in the questionnaires before the medical appointment.
Questionnaires 1. A socio-demographic questionnaire was used to collect data regarding the pregnant women, which included age, education, financial status, child’s gender, planned or unplanned pregnancy of mothers, number of previous pregnancies, number of living children and gestational age at the time of research. 2. Edinburgh Postnatal Depression Scale (EPDS): EPDS is a screening tool used to detect prenatal and postnatal depression. This is a 10-item selfreporting questionnaire with four possible responses. The response categories are scored 0, 1, 2 and 3 according to increasing severity of symptoms; items 3 and 5–10 are reverse scored (i.e. 3, 2, 1 and 0; Husain et al., 2012). Scores less than 12 are considered non-depressed and 12 and above are considered depressed. Validity and reliability of the questionnaires have been confirmed according to other standardized questionnaires in Iran. Cronbach’s α coefficient and test–retest reliability were found to be .86 and .80, respectively (Montazeri, Torkan, & Omidvari, 2007). 3. Multidimensional Health Locus of Control Scale (MHLCS): The HLC questionnaire was administered in order to examine the extent to which centenarians believed that they had control over their health (IHLC) or if it was primarily due to fate (CHLC) or other people’s influence (PHLC; Tigani, Artemiadis, Alexopoulos, Chrousos, & Darviri, 2011). In this study, Form B comprising 18 items in three components (6 items each) was used. All items contained 6-point Likert style, scoring 1–6 marks, so that a person’s score could vary from 6 to 36 for each component, and they will not be summed up together, but calculated independently. There is no cut-off point in this tool, and the mean score is used for final evaluation (Wallston, 2005). A total of 496 university students participated in this study (Moshki & Ghofranipour, 2011). The reliability coefficients were calculated in two different methods: test–retest, parallel tests and Cronbach’s α. In order to assess the validity of the scale, Moshki used three methods including content validity, concurrent validity and construct validity. The corresponding validity scores of the questionnaire, as measured by Levenson’s IPC
scale, were .57 (p
