Evidence-Based Nursing Online First, published on February 27, 2015 as 10.

1136/ebnurs-2014-101985
Midwifery

Quantitative studyother

Womens health locus of control

during pregnancy may predict risk
for postpartum depression
10.1136/ebnurs-2014-101985

Elizabeth Mollard
University of Nebraska Medical Center, UNMC College of Nursing,
Lincoln, Nebraska, USA
Correspondence to: Elizabeth Mollard, University of Nebraska Medical
Center, UNMC College of Nursing, 1230 O Street, Ste 131, Lincoln, NE
68588, USA; Elizabeth.Mollard@UNMC.EDU

Commentary on: Moshki M, Baloochi Beydokhti T, Cheravi K. The effect

of educational intervention on prevention of postpartum depression: an
application of health locus of control. J Clin Nurs 2014;23:225663.

Implications for practice and research

A womans belief about health control (HLC including internal HLC
(IHLC) and chance HLC (CHLC)) may identify her risk for postpartum
depression (PPD).
Healthcare providers should consider assessing HLC to predict those
women who will be at greater risk for PPD.
Researchers should develop educational interventions targeting
internal and chance HLC that may have the potential to prevent PPD.

Context
PPD is a serious concern for women and their babies, yet there are few
ways to predict or prevent it. This study evaluated whether there was a
correlation between HLC and PPD and whether a HLC focused educational intervention could prevent PPD. HLC determines how much an
individual believes their health is controlled by internal or external
factors.1 With internal health locus of control (IHLC) the individual sees
their health as a result of their behaviours. An individual with external
beliefs would see their health as under control of chance (CHLC) or under
control of powerful others (PHLC) such as a healthcare provider.1

Methods
The purpose of the study was to test the relationship between HLC and
PPD and to test the efcacy of an educational intervention based on HLC
to prevent PPD. The study used a pre/post-test experimental design. Two
hundred and thirty pregnant women in Iran were given the
Multidimensional Health Locus of Control Scale (MHLCS) and randomly

divided into the control group or the experimental group. The experimental group received an educational intervention about pregnancy, childbirth and the postpartum period targeted to HLC. At 4 weeks postpartum,
participants were retested with the MHLCS and given the Edinburgh
Postnatal Depression Scale. Multiple statistical methods were applied.

Findings
In this sample, the prevalence of depression was 21.5%, which is higher
than the generally accepted 1015% prevalence rate, but lower than
some estimates of PPD prevalence in Iran.2 Women with a higher level of
IHLC had lower levels of PPD. Women with a higher level of CHLC had
higher rates of PPD. The intervention was shown to reduce PHLC,
although PHLC was not signicantly associated with PPD.

Commentary
Previous studies have shown that those with a high IHLC are more likely
to make positive health choices, including seeking care when needed.3
This study showed that those who have a higher IHLC are less likely to
have PPD and those with a high CHLC have higher levels of PPD.
Although PHLC was unrelated to PPD, the educational intervention did
reduce this type of HLC.
The importance of this study is twofold. First, healthcare providers
may be able to screen a woman using HLC during pregnancy to determine her risk of PPD. Second, although the intervention did not affect
PPD in this study, the intervention did lower levels of PHLC. If researchers were able to develop an intervention in pregnancy that could increase
levels of IHLC and decrease levels of CHLC, they might be able to prevent
PPD.
Although the Diagnostic and Statistical Manual of Mental Disorders
(Fifth Edition) supports the onset of PPD in the rst 4 weeks postpartum,
clinicians generally accept an onset of PPD within the rst 6 months or
more.4 The authors may have found an increased prevalence rate of PPD
or a change in HLC if they had conducted their post-test at 6 weeks postpartum or greater. The time frame for post-test should potentially be
lengthened in future studies. The use of control groups and randomisation increase validity in this study. Further studies with larger, diverse
samples are required to increase generalisability of results.
Competing interests None.
References
1. Wallston K, Strudler Wallston B, DeVellis R. Development of the multidimensional
health locus of control (MHLC) scales. Health Educ Behav 1978;6:16070.
2. Shobeiri F, Farhadi Nasab A, Nazari M. Detecting postpartum depression in referents
to medical and health centers in Hamadan city. J Hamadan Univ Med Sci
2007;3:248.
3. Wang R, Aldridge A, Malcarne V, et al. Health locus of control and assimilation of
cervical cancer information in deaf women. J Canc Educ 2010;25:3549.
4. OHara M, McCabe J. Postpartum depression: current status and future directions.
Annu Rev Clin Psychol 2013;9:379407.

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