Skip to main content
Download PDF

Preventing postpartum depression in pregnant women using an app-based health-promoting behaviors program (Pender’s health promotion model): a randomized Controlled Trial

BMC Psychology volume 13, Article number: 243 (2025) Cite this article

Abstract

Background

Depression is a prevalent mood disorder. Women face a heightened risk of depression during pregnancy and after childbirth, which can have negative consequences for both the mother and her family. It is essential to explore preventive strategies.

Objective

To assess the impact of education focused on health-promoting behaviors in preventing postpartum depression (PPD) through social messaging among pregnant women.

Methods

This randomized controlled trial study involved 108 non-depressed eligible pregnant women with a gestational age of 28–30 weeks during 2022–2023. Participants were randomly assigned to intervention and control groups using a block randomization method. The intervention group received virtual education based on health-promoting behaviors weekly over six sessions. The Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionnaire-9 (PHQ-9), and Health Promoting Lifestyle Profile II (HPLP II) questionnaires were utilized to evaluate outcomes. Data analysis was performed using SPSS software version 23, with a significance level set at P < 0.05.

Results

The mean differences between the scores of EPDS, PHQ-9 and HPLP II before and after the intervention in two groups were − 4.85 (CI95%= -3.22, -6.48), -6.22 (CI95%= -4.43, -8.00) and 28.22 (CI95%= 23.41, 33.03), respectively, which were statistically significant (P < 0.001). The findings regarding the dimensions of health-promoting behaviors also indicated that all dimensions increased significantly in the intervention group. The greatest and least amount of change was observed in the physical activity dimension at 5.50 (CI95%= 4.31, 6.68) and in interpersonal relations at 3.48 (CI95%= 2.24, 4.72), respectively. The number needed to treat (NNT) for depression, based on the Edinburgh questionnaire six weeks postpartum was approximately 2.571, indicating that nearly one in two mothers who received education benefited.

Conclusion

The app-based health-promoting behaviors intervention-benefiting from not requiring in-person referrals and providing a common platform for communication-is effective in enhancing health-promoting behaviors, reducing depression scores and decreasing the frequency of PPD. In other words, this type of intervention led to the prevention of postpartum depression and the promotion of health-promoting behaviors among pregnant women.

Registration

The study was retrospectively registered with the IRCT Registry on 31/05/2024 (registration number: IRCT20221109056451N2).

Peer Review reports

Introduction

In recent years, there has been growing concern about depression in various populations, including pregnant women. The significant changes experienced by women during pregnancy can lead to a range of psychological problems [1]. During the postpartum period, mothers are more vulnerable to emotional and mood disorders, including depression, due to factors such as hormonal fluctuations (a decrease in estrogen and progesterone levels), lifestyle changes, psychosocial influences, sleep disturbances and stress related to baby care [2]. Despite the numerous concerns for mothers during this time, postpartum depression and its clinical management strategies remain unresolved issues [3].

Postpartum depression is the most common mental health problem associated with childbirth, typically beginning four to six weeks after delivery [3, 4]. The global prevalence of postpartum depression in mothers is reported to be 17.22%, with rates of 25% in developing countries and 25.3% in Iran. Within specific subgroups, such as unintended pregnancy, illiteracy, housewives, and a history of depression, the prevalence rates are reported to be 43.4%, 31.6%, 30.7%, and 45.2%, respectively [5,6,7,8]. Postpartum depression can have various negative effects on both the mother and her infant, including an increased risk of serious health and social problems, growth disorders, difficulties with breastfeeding, strained mother-child relationships [9], and long-term impacts on emotional, cognitive, and behavioral child development [10]. Additionally, it can reduce the quality of life for mothers [11] and delay language and personal-social skills in children [12, 13]. The results of a systematic review study showed that postpartum depression increases the likelihood of malnutrition (stunting and underweight), common infant diseases, and non-exclusive breastfeeding [14].

Given the prevalence and negative consequences of postpartum depression, it is essential to consider preventive strategies from a public health perspective [15]. Numerous studies have been conducted aimed at developing preventive strategies for postpartum depression. Beydokhti et al. (2021) reported that the prevalence of depression was significantly lower in the group that received an educational-counseling intervention [16]. However, the results of another study by McCarter-Spaulding et al. suggest that education provided by nurses at the time of hospital discharge did not reduce depression scores [17]. A systematic review conducted in 2022 indicated that psychological interventions have very limited effectiveness in preventing postpartum depression in non-depressed women. More clinical trials with low bias risk and more effective interventions are needed [18].

Mental health and lifestyle share a reciprocal relationship, where mental health is fostered through a healthy lifestyle, and conversely, a healthy lifestyle is supported by mental health [19, 20]. Lifestyles encompass the awareness, attitudes, and behaviors related to health in individuals or groups [21]. A health-promoting lifestyle consists of six dimensions: nutrition, physical activity, spiritual growth, stress management, interpersonal relationships, and health responsibility [22]. Theorists assert that a health-promoting lifestyle positively impacts an individual’s quality of life and can even prevent and treat various physical and mental issues [22, 23]. The Pender Health Promotion Model is one of the oldest comprehensive frameworks used to predict health-promoting behaviors [24].

Pender’s Health Promotion Model, a widely used framework in nursing research, organizes health promotion into three key areas: individual characteristics and experiences (including past behaviors and personal attributes); behavior-specific cognitions and affect (such as perceived benefits, self-efficacy, perceived barriers, feelings, and interpersonal/situational influences); and behavioral outcomes (the commitment and execution of health behaviors, influenced by competing demands and preferences) [24]. This model, suitable for intervention, ultimately seeks to encourage healthy behaviors [25]. Given that the Pender Health Promotion Model has been applied in various populations and has proven effective in addressing certain psychological issues [26], this study selected this model as an intervention method to evaluate its efficacy in preventing postpartum depression.

On the other hand, smartphone technology is regarded as a valuable tool for disseminating health information, offering psychological education, and facilitating interactions through text messages or mutual communication between patients and healthcare professionals. There is also evidence indicating that remote communication between patients and healthcare providers in mobile health programs is flexible, cost-effective, and particularly advantageous for individuals who encounter barriers in accessing health services due to time and location constraints [27]. Therefore, recognizing the significance of preventing postpartum depression and selecting the most effective intervention or approach, this study aimed to assess the impact of health-promoting behaviors education (Pender’s health promotion model) on preventing postpartum depression in pregnant women using social messaging platforms.

Materials and methods

Study design and setting

This randomized controlled trial study was conducted between August 2022 and April 2023 on 108 eligible pregnant women who referred to prenatal clinics related the teaching hospitals in Babol (North of Iran). The Research Ethics Committee of Babol University of Medical Sciences approved this study (code: IR.MUBABOL.HRI.REC.1401.094). The current study was registered retrospectively (IRCT20221109056451N2). Necessary permissions were obtained from the clinics’ management prior the data collection. Women participated voluntary and were assured that their data would remain anonymous. The purpose of the study was explained to the women and written informed consent was obtained from them after the interview. All methods were conducted in accordance with the relevant guideline and the ethical standards of the declaration of Helsinki.

The sample size was determined based on the study by Sanaati et al. [28], considering the comparison of means, standard deviation differences, a 95% confidence interval, a study power of 80%, an effect size of 0.42 from a similar study, and a correlation coefficient of 0.59 using G-power software version 3. The calculated sample size was 94 participants. Considering a 10% dropout rate, the final sample size was determined to be 108 participants (54 women in each group).

Study participants and sampling

Participants were recruited using convenience sampling based on the inclusion criteria. Written informed consent was obtained after participants were informed about the study objectives. They were then assigned to either the intervention or control groups according to a random block allocation protocol with a 1:1 ratio (generated by random allocation software). The study’s dropout rate was 2.8% (1 woman in the intervention group and 2 women in the control group; Fig. 1).

Fig. 1
figure 1

Selection of the study sample Algorithm

Full size image

The inclusion criteria for participation in the study were as follows: gestational age of 28–30 weeks, low-risk pregnancy (no chronic diseases, no pregnancy complications such as gestational diabetes or preeclampsia), ability to read and write, no history of infertility or use of assisted reproductive technologies, no history of abnormal fetus or child, no addiction or habitual use of alcohol and drugs (according to the mother’s personal statements), no history of depression or psychiatric hospitalization (according to the mother’s personal statements), an Edinburgh score of less than 12, possession of a smartphone, and at least one social messenger such as WhatsApp or Eitaa, along with a willingness to participate in the study. The exclusion criteria included preterm birth, loss of close relatives during the study, divorce or other severe emotional problems during the study, unwillingness to participate at any stage of the study, and incomplete questionnaires in the follow-up stages of the study.

Data collection tool and measurement

The data was collected using four questionnaires: demographic and fertility information questionnaire, Edinburgh postnatal depression scale (EPDS), patient health questionnaire-9 (PHQ-9) and health-promoting lifestyle profile II (HPLP II). Prior to the intervention, the questionnaires were completed through face-to-face interviews at prenatal clinics by the researcher. Following the intervention, due to limited in-person access to participants, the questionnaires were completed by the researcher via telephone calls.

The demographic and fertility information questionnaire includes questions such as age, education level, spouse’s education level, occupation, spouse’s occupation, family income status, height, weight, pre-pregnancy body mass index (BMI), number of gravidity and parity, history of abortion, gestational age, planning status of pregnancy, sources of health information, number of received prenatal cares, type of delivery, gestational age at childbirth, received postpartum cares and its number, participation in childbirth preparation classes and the number of sessions attended until the end of pregnancy.

The Edinburgh Postnatal Depression Scale was developed by Cox and colleagues in 1978 and revised in 1994 [29]. This tool consists of 10 multiple-choice questions, that options arranged from low to high intensity for some questions (questions 1, 2 and 4) and from high to low intensity for others (questions 3 and 5 to 10). Each question has a score ranging from 0 to 3, resulting in a total score that varies from 0 to 30. Individuals select the responses that reflect their feelings over the past week. Different cutoff points have been reported for various cultures and languages, with a cutoff point of 12 being considered for the Persian language version of this questionnaire [30]. The validity of this questionnaire has been assessed in Iran by Montazeri et al., who reported a Cronbach’s alpha of 0.86 [31].

The Patient Health Questionnaire is a survey consisting of 9 questions that individuals answer based on their condition over the past two weeks. The score range of this questionnaire varies from 0 to 27. Each item’s score can be zero (not at all), one (some days), two (more than half of the days), or three (nearly every day). Dadfar et al. reported a Cronbach’s alpha of 0.88 and a test-retest reliability of 0.79 for this questionnaire [32].

The Health-Promoting Lifestyle Profile 𝛱 comprises 52 questions across six dimensions. The score range for this questionnaire varies from 52 to 208. It employs a Likert-type response scale with scores from 1 to 4, representing the options of never, sometimes, often, and always [33]. The total scores from this questionnaire are categorized into four levels: poor for the range of 52–90, moderate for 91–129, good for 130–168, and excellent for 169–208 [34]. Mohammad Zeidi et al. confirmed the validity of this questionnaire with a Cronbach’s alpha of 0.82 [35].

Intervention

In the intervention group, in addition to receiving routine prenatal and postpartum education based on national guidelines [36], educational content based on the six dimensions of health-promoting behaviors was provided to the pregnant women as PDF and audio files on a specific day and time chosen by the mothers. The educational content was sent starting from the 30th week of pregnancy and continued for six weeks. Two days after each educational session was sent, the researcher confirmed receipt and review of the educational material by checking the seen status on WhatsApp and Eitaa (√√) and sending a follow-up text message. Participants were also encouraged to ask questions and receive answers.

The educational content based on the six dimensions of health-promoting behaviors include nutrition, physical activity, stress management, health responsibility, spiritual growth, and interpersonal relations (Table 1). The educational content was developed in accordance with the guidelines set forth by the Ministry of Health and Medicine of Iran, the World Health Organization (WHO), the Centers for Disease Control and Prevention, authoritative texts, and relevant articles. The credibility of the content was validated by the research team members, which included faculty members from Babol University of Medical Sciences holding PhDs in reproductive health and women’s health, as well as a master’s student in midwifery counseling.

Table 1 The outline of the educational sessions in the intervention group
Full size table

The control group received only the standard prenatal and postpartum education based on national guidelines. The HPLP questionnaire was administered two weeks after the intervention concluded. The EPDS, PHQ-9, and follow-up fertility variables were assessed six weeks after childbirth (Fig. 1).

Statistical analysis

Descriptive statistical analysis of participants’ data was reported using measures of mean, standard deviation, or number and percentage. Analytical statistical analysis included paired t-tests, t-tests, chi-square tests, and Fisher’s exact tests. An ANCOVA test was also conducted to compare the questionnaire scores after the intervention in both groups, considering the scores before the intervention and baseline variables. The analyses were performed using SPSS version 23, with a significance level of P < 0.05 considered. All data were analyzed with an intention-to-treat approach.

Results

The mean age and standard deviation of the pregnant women participating in the study were 28.71 ± 5.70 years. The two groups were relatively similar in terms of demographic variables and did not exhibit statistically significant differences (Table 2). Among the fertility variables assessed in both groups, significant differences were observed only in the variables of parity, postpartum care, and the number of received postpartum care, which were included in the ANCOVA model (Table 3). The scores of EPDS, PHQ-9, HPLP II, and its dimensions did not show a statistically significant difference between the two groups before the intervention. The findings after the intervention, based on effect size, indicate that the educational intervention focused on health-promoting behaviors resulted in a decrease of 4.85 points in PHQ-9, a decrease of 6.22 points in EPDS and an increase of 28.22 points in the total score of HPLP𝛱 (Table 4).

Table 2 Demographic characteristics of participants in the intervention and control group
Full size table
Table 3 Fertility characteristics of pregnant women in intervention and control groups
Full size table
Table 4 Comparison of outcomes’ mean differences (net and standardized effect size) between the intervention and control groups before and after intervention
Full size table

The prevalence of postpartum depression, as measured by the EPDS and PHQ-9, was 7.4% and 3.7% in the intervention group, compared to 46.3% and 27.8% in the control group. These differences were statistically significant between the two groups. The index of number needed to treat (NNT) — the most applicable index for assessing intervention effectiveness — for depression was calculated using the website https://www.medcalc.org/calc/relative_risk.php. The NNT for depression, according to the Edinburgh questionnaire six weeks after delivery, was approximately 2.571, indicating that nearly one in two mothers who received education benefited.

Finally, after adjusting for baseline variables through an analysis of covariance and comparing the post-intervention scores between the two groups, while considering the partial differences in pre-intervention scores and other baseline factors, the findings indicate that there were statistically significant differences between the two groups in terms of PHQ-9, EPDS, total HPLP II score, and each dimension of health-promoting behaviors (Table 5).

Table 5 Analysis of covariance of study outcomes by adjusting to baseline variables (scores before the intervention and other variables)
Full size table

Discussion

The present study aimed to investigate the effect of an educational intervention based on health-promoting behaviors in preventing postpartum depression using a social messenger. The results indicated that this virtual education intervention, grounded in Pender’s model and conducted between 30 and 35 weeks of pregnancy, significantly reduced the mean score of the Edinburgh Postnatal Depression Scale (EPDS), which was the primary outcome of the study. A study closely resembling ours was conducted by Sanaati et al., focusing on the effects of lifestyle-based education on depression and anxiety during pregnancy and the postpartum period in three groups of 63 pregnant women and their spouses. The results of this study demonstrated a significant decrease in the EPDS score and anxiety levels in both the couple education and women education groups compared to the control group. Furthermore, the reduction in these scores was also significant in the couple education group compared to the women education group [28]. These findings were consistent with our study. However, the differences between the two studies were that the present study assessed all six main dimensions of health-promoting behaviors. Additionally, the education in the study by Sanaati et al. was conducted through face-to-face sessions, while our study provided virtual education without time and place restrictions, allowing for easier access for mothers and greater flexibility. Other interventional studies have focused on specific dimensions such as physical activity or nutritional interventions, and their results were also consistent with our findings [37,38,39].

In line with the findings of the present study, which utilized a virtual intervention approach, Zhou et al. reported in their systematic review and meta-analysis that mobile health interventions are effective for preventing and treating postpartum depression [40]. In another study conducted by Seo et al. in South Korea, the effectiveness of a mobile phone program (an eight-week intervention) did not show a difference in postpartum depression between the intervention and control groups [41]. Considering that all the mothers in Seo et al.‘s study were depressed, it appears that such interventions alone cannot reduce depression scores in these women.

Given that this study also assessed depression in women using the PHQ-9, data analysis revealed that the mean PHQ-9 scores in the intervention group were significantly lower than those in the control group. Despite searching for articles, no study was found that examined the impact of educational interventions on postpartum depression scores using the PHQ questionnaire. However, Barros et al. conducted a cross-sectional study to investigate the relationship between health behaviors and depression in 65,803 adults aged 18–59 years using the PHQ-9 questionnaire. Their findings indicated a significant relationship between lifestyle factors and depression in Brazilian adults. They recommended the adoption of comprehensive and integrated strategies, considering the association between depression and health behaviors, to reduce early deaths from non-communicable chronic diseases [42].

According to the findings of the present study, the prevalence of postpartum depression using the EPDS was 7.4% in the intervention group and 46.3% in the control group. The prevalence using the PHQ-9 (at approximately major and severe levels) was 3.7% in the intervention group and 27.8% in the control group. The difference in the prevalence of postpartum depression can vary depending on the questionnaire used. A study conducted in 2023 reported that the prevalence of postpartum depression before, during, and after the early stages of the COVID-19 epidemic was 36%, 60%, and 42%, respectively [43]. Considering that our study was conducted towards the end of this epidemic, the prevalence of postpartum depression in our study aligns with these findings.

The results of the present study also showed that the virtual educational intervention based on Pender’s Health Promotion Model had a significant effect on increasing the mean score of health-promoting behaviors in the intervention group, which is consistent with previous studies conducted [44,45,46].

Furthermore, the results of this study demonstrated a positive effect across all dimensions of health-promoting behaviors, with physical activity having the greatest impact and interpersonal relationships the least. Several studies have indicated that a healthy lifestyle can provide a protective effect against depression [47]. A study conducted by Zhao et al. revealed a strong link between lifestyle choices and immune and metabolic functions. In other words, an unhealthy lifestyle adversely affects our immune system and metabolism, thereby increasing the likelihood of depression [48]. Therefore, lifestyle factors are recognized as modifiable targets that play a crucial role in addressing the rising prevalence of depression.

The present study has some limitations. Given the nature of the research and the type of intervention, blinding was not feasible. To minimize bias, the statistical analyst was unaware of the group codes. Additionally, the contact numbers of all participants were recorded in a code on a separate SIM card in another phone, ensuring that the researcher would not know the participant group type when completing the follow-up questionnaires. Furthermore, to mitigate the possibility of communication between participants in the two groups, women were instructed not to share educational content with anyone until the study concluded (to prevent information contamination). Moreover, the intervention in this study commenced at the third trimester; it is advisable that future studies initiate earlier and compare the outcomes. Given the effectiveness of this individual educational intervention in preventing postpartum depression, it is recommended to conduct a study comparing individual-based health-promoting behavior education with its group-based approach for time management and optimal educational use.

The strength of this study lies in its comprehensive approach to all dimensions of health-promoting behaviors and the use of two questionnaires to assess depression.

Conclusion

The findings of the current study demonstrated that the educational intervention, which focused on health-promoting behaviors based on Pender’s Health Promotion Model using social messenger, had a significant impact on “reducing the mean score of postpartum depression based on EPDS,” “reducing the mean score of postpartum depression based on PHQ-9” and “increasing the mean score of HPLP𝛱.” In other words, this type of intervention led to the prevention of postpartum depression and the promotion of health-promoting behaviors among pregnant women.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

PPD:

Postpartum Depression

PHQ-9:

Patient Health Questionnaire 9

EPDS:

Edinburgh Postnatal Depression Scale

HPLP𝛱:

Health-promoting Lifestyle Profile𝛱

NNT:

Number needed to treat

BMI:

Body Mass Index

References

  1. Wolford E, Lahti M, Tuovinen S, Lahti J, Lipsanen J, Savolainen K, et al. Maternal depressive symptoms during and after pregnancy are associated with attention-deficit/hyperactivity disorder symptoms in their 3- to 6-year-old children. PLoS ONE. 2017;12(12):e0190248.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Carlson K, Mughal S, Azhar Y et al. Postpartum Depression. [Updated 2024 Aug 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519070/

  3. Chow R, Huang E, Li A, Li S, Fu SY, Son JS, et al. Appraisal of systematic reviews on interventions for postpartum depression: systematic review. BMC Pregnancy Childbirth. 2021;21(1):18.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Kettunen P, Koistinen E, Hintikka J. Is postpartum depression a homogenous disorder: time of onset, severity, symptoms and hopelessness in relation to the course of depression. BMC Pregnancy Childbirth. 2014;14(1):402.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Wang Z, Liu J, Shuai H, Cai Z, Fu X, Liu Y, et al. Mapping global prevalence of depression among postpartum women. Translational Psychiatry. 2021;11(1):543.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Shorey S, Chee CYI, Ng ED, Chan YH, Tam WWS, Chong YS. Prevalence and incidence of postpartum depression among healthy mothers: A systematic review and meta-analysis. J Psychiatr Res. 2018;104:235–48.

    Article  PubMed  Google Scholar 

  7. Veisani Y, Delpisheh A, Sayehmiri K, Rezaeian S. Trends of postpartum depression in Iran: a systematic review and meta-analysis. Depress Res Treat. 2013;2013:291029.

    PubMed  PubMed Central  Google Scholar 

  8. Dafei M, Mojahed S, Dastjerdi G, Dehghani A, Ardakani TS. The effect of cognitive-behavioral counseling of pregnant women with the presence of a spouse on stress, anxiety, and postpartum depression. J Educ Health Promot. 2021;10:131.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Madlala SS, Kassier SM. Antenatal and postpartum depression: effects on infant and young child health and feeding practices. South Afr J Clin Nutr. 2018;31(1):1–7.

    Article  Google Scholar 

  10. Saharoy R, Potdukhe A, Wanjari M, Taksande AB. Postpartum depression and maternal care: exploring the complex effects on mothers and infants. Cureus. 2023;15(7).

  11. Sadat Z, Abedzadeh-Kalahroudi M, Kafaei Atrian M, Karimian Z, Sooki Z. The impact of postpartum depression on quality of life in women after child’s birth. Iran Red Crescent Med J. 2014;16(2):e14995–e.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Martucci M, Aceti F, Giacchetti N, Sogos C. The mother-baby bond: a systematic review about perinatal depression and child developmental disorders. Rivista Di Psichiatria. 2021;56(5):223–36.

    PubMed  Google Scholar 

  13. Usmani S, Greca E, Javed S, Sharath M, Sarfraz Z, Sarfraz A, et al. Risk factors for postpartum depression during COVID-19 pandemic: A systematic literature review. J Prim Care Community Health. 2021;12:21501327211059348.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Dadi AF, Miller ER, Mwanri L. Postnatal depression and its association with adverse infant health outcomes in low- and middle-income countries: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2020;20(1):416.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Tol WA. Stemming the tide: promoting mental health and preventing mental disorders in low- and middle-income countries. Global Mental Health (Cambridge England). 2015;2:e11.

    Article  PubMed  Google Scholar 

  16. Beydokhti TB, Dehnoalian A, Moshki M, Akbary A. Effect of educational- counseling program based on precede-proceed model during pregnancy on postpartum depression. Nurs Open. 2021;8(4):1578–86.

    Article  PubMed  PubMed Central  Google Scholar 

  17. McCarter-Spaulding D, Shea S. Effectiveness of discharge education on postpartum depression. MCN Am J Matern Child Nurs. 2016;41(3):168–72.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Martín-Gómez C, Moreno-Peral P, Bellón JA, Conejo-Cerón S, Campos-Paino H, Gómez-Gómez I, et al. Effectiveness of psychological interventions in preventing postpartum depression in non-depressed women: a systematic review and meta-analysis of randomized controlled trials. Psychol Med. 2022;52(6):1001–13.

    Article  PubMed  Google Scholar 

  19. Rahimi A, Wardak MF, Shayan NA. Assessing the relationship between lifestyle factors and mental health outcomes among Afghan university students. J Affect Disord Rep. 2024;17:100827.

    Article  Google Scholar 

  20. Schütz DM, Rossi T, de Albuquerque NS, Costa DB, Machado JS, Fritsch L, et al. The relationship between lifestyle, mental health, and loneliness in the elderly during the COVID-19 pandemic. Healthcare. 2024;12(9):876.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Coreil J, Levin JS, Jaco EG. Life style: an emergent concept in the sociomedical sciences. Cult Med Psychiatry. 1985;9(4):423–37.

    Article  PubMed  Google Scholar 

  22. Mohaddesi H, Razavi SR, Khalkhali HR, Bahadori F, Saeigharenaz m. The effect of counseling on health promotion behaviors in diabetic mothers referred to Motahhari hospital of urmia at 2015. Nurs Midwifery J. 2016;14(9):757–66.

    Google Scholar 

  23. Basharpoor S, Heidarirad H, Soleimani E, Degdar B. The role of Health-Promoting behaviors in predicting the quality of life of pregnant women. J Res Dev Nurs Midwifery. 2017;14(1):36–43.

    Article  Google Scholar 

  24. Namdari AR, Ghazavi Z, Sabohi F, Salehidoost R. An evaluation on the impacts of pender Model-based educational programs on the psychological Well-being of patients with type II diabetes mellitus. J Diabetes Nurs. 2018;6(2):472–82.

    Google Scholar 

  25. Eghtedar S, Chalak Z, Parizad N, Alinezhad V. Training health-promoting behaviors based on Pender’s model on psychological well-being to Hemodialysis patients. Nurs Midwifery J. 2022;20(4):344–58.

    Article  Google Scholar 

  26. BehnamMoradi M, Ahadi H, Seirafi M. The effect of educational intervention based on Pender’s health promotion model on Self-Actualization and interpersonal relations in menopausal women. Community Health J. 2019;13(3):10–9.

    Google Scholar 

  27. Chan KL, Leung WC, Tiwari A, Or KL, Ip P. Using smartphone-based psychoeducation to reduce postnatal depression among first-time mothers: randomized controlled trial. JMIR mHealth uHealth. 2019;7(5):e12794.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Sanaati F, Charandabi SM, Eslamlo HF, Mirghafourvand M. A randomized controlled trial on the effect of lifestyle education for Iranian women and their husbands on post-partum anxiety and depression. Health Educ Res. 2018;33(5):416–28.

    Article  PubMed  Google Scholar 

  29. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh postnatal depression scale. Br J Psychiatry: J Mental Sci. 1987;150:782–6.

    Article  Google Scholar 

  30. Zubaran C, Schumacher M, Roxo MR, Foresti K. Screening tools for postpartum depression: validity and cultural dimensions. Afr J Psychiatry. 2010;13(5):357–65.

    Google Scholar 

  31. Montazeri A, Torkan B, Omidvari S. The Edinburgh postnatal depression scale (EPDS): translation and validation study of the Iranian version. BMC Psychiatry. 2007;7:11.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Dadfar M, Kalibatseva Z, Lester D. Reliability and validity of the Farsi version of the patient health Questionnaire-9 (PHQ-9) with Iranian psychiatric outpatients. Trends Psychiatry Psychother. 2018;40(2):144–51.

    Article  PubMed  Google Scholar 

  33. Baygi F, Jensen OC, Mohammadi-Nasrabadi F, Qorbani M, Mansourian M, Mirkazemi R, et al. Factors affecting health-promoting lifestyle profile in Iranian male seafarers working on tankers. Int Maritime Health. 2017;68(1):1–6.

    Article  Google Scholar 

  34. Alzahrani SH, Malik AA, Bashawri J, Shaheen SA, Shaheen MM, Alsaib AA, et al. Health-promoting lifestyle profile and associated factors among medical students in a Saudi university. SAGE Open Med. 2019;7:2050312119838426.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Mohammadi Zeidi I, Pakpour Hajiagha A, Mohammadi Zeidi B. Reliability and validity of Persian version of the health-promoting lifestyle profile. J Mazandaran Univ Med Sci. 2012;21(1):102–13.

    Google Scholar 

  36. MHME. The iranian integrated maternal health care guideline. 9th ed2023.

  37. Demissie Z, Siega-Riz AM, Evenson KR, Herring AH, Dole N, Gaynes BN. Physical activity and depressive symptoms among pregnant women: the PIN3 study. Arch Women Ment Health. 2011;14(2):145–57.

    Article  Google Scholar 

  38. Yuan M, Chen H, Chen D, Wan D, Luo F, Zhang C, et al. Effect of physical activity on prevention of postpartum depression: A dose-response meta-analysis of 186,412 women. Front Psychiatry. 2022;13:984677.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Surkan PJ, Gottlieb BR, McCormick MC, Hunt A, Peterson KE. Impact of a health promotion intervention on maternal depressive symptoms at 15 months postpartum. Matern Child Health J. 2012;16(1):139–48.

    Article  PubMed  Google Scholar 

  40. Zhou C, Hu H, Wang C, Zhu Z, Feng G, Xue J, et al. The effectiveness of mHealth interventions on postpartum depression: A systematic review and meta-analysis. J Telemed Telecare. 2022;28(2):83–95.

    Article  PubMed  Google Scholar 

  41. Seo J-M, Kim S-J, Na H, Kim J-H, Lee H. Effectiveness of a mobile application for postpartum depression Self-Management: evidence from a randomised controlled trial in South Korea. Healthcare. 2022;10(11):2185.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Barros MBA, Medina LPB, Lima MG, Azevedo RCSd S, Malta NFS. DC. Association between health behaviors and depression: findings from the 2019 Brazilian National health survey. Revista Brasileira De Epidemiologia. 2021;24.

  43. Droke K, Bartosek N, Kopkau H, Stanford M, Dyer C, Hoke M, et al. The COVID-19 pandemic and the experience of postpartum depression. J Psychosom Obstet Gynaecol. 2023;44(1):2250070.

    Article  PubMed  Google Scholar 

  44. Ebrahimi F, Aghamolaei T, Abedini S, Rafati S. Effect of educational intervention using mobile on life style of women who referred to health centers in Bandar Abbas. Iran J Health Educ Health Promotion. 2017;5(2):81–9.

    Article  Google Scholar 

  45. Moshki M, Gholamiyan Bajestani R, Nezami H, Bahri N. The effects of group discussion and multimedia package education interventions on healthy lifestyle of pregnant women: A field trial study. J Res Health. 2023;13(3):189–96.

    Article  Google Scholar 

  46. Bakhshi F, Shojaeizadeh D, Sadeghi R, Nedjat S, Taghdisi MH, Laverack G. The effect of internet-based intervention on lifestyle and healthy nutrition habits of women in North of Iran: a field-based trial study. Casp J Health Res. 2022;7(4):209–18.

    Article  Google Scholar 

  47. Kunugi H. Depression and lifestyle: focusing on nutrition, exercise, and their possible relevance to molecular mechanisms. J Neuropsychiatry Clin Neurosci. 2023;77(8):420–33.

    Google Scholar 

  48. Zhao Y, Yang L, Sahakian BJ, Langley C, Zhang W, Kuo K, et al. The brain structure, immunometabolic and genetic mechanisms underlying the association between lifestyle and depression. Nat Mental Health. 2023;1(10):736–50.

    Article  Google Scholar 

Download references

Acknowledgements

This work has extracted from the thesis related to Master’s Degree of midwifery counseling was supported by Babol University of Medical Sciences. The authors hereby thank the honorable Research Vice-Chancellor of Babol University of Medical Sciences, the staff of the prenatal clinics and the pregnant women who participated in the study.

Funding

This study was supported by Babol University of Medical Sciences. This research did not receive external funding.

Author information

Authors and Affiliations

  1. Student Research Committee, Faculty of Nursing and Midwifery, Babol University of Medical Sciences, Babol, Iran

    Nastaran Rafat

  2. Infertility and Reproductive Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran

    Fatemeh Bakouei & Mouloud Agajani Delavar

  3. Social Determinants of Health Research Center, Health Research Institute, Department of Epidemiology and Biostatistics, School of Public Health, Babol University of Medical Sciences, Babol, Iran

    Hossein-Ali Nikbakht

Authors
  1. Nastaran Rafat
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Fatemeh Bakouei
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Mouloud Agajani Delavar
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Hossein-Ali Nikbakht
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

NR and FB conceptualized the study. NR, FB, MA and HN contributed to the design of the research. Data collection was carried out by NR. HN and NR analyzed the data. All authors read and approved the final manuscript to publish.

Corresponding author

Correspondence to Fatemeh Bakouei.

Ethics declarations

Ethical approval and consent to participate

This study was conducted after obtaining the ethical code (IR.MUBABOL.HRI.REC.1401.094) from the Ethics Committee of Babol University of Medical Sciences. We also adhered to ethical considerations, such as obtaining written informed consent, explaining the study objectives to participants before their involvement, maintaining the confidentiality of research information and allowing participants to withdraw from the study at any time.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rafat, N., Bakouei, F., Delavar, M.A. et al. Preventing postpartum depression in pregnant women using an app-based health-promoting behaviors program (Pender’s health promotion model): a randomized Controlled Trial. BMC Psychol 13, 243 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s40359-025-02547-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s40359-025-02547-w

Keywords

BMC Psychology

ISSN: 2050-7283

Contact us