ORIGINAL ARTICLE

Fordyce happiness program and postpartum

depression
Leili Rabiei, Maryam Amidi Mazaheri, Reza Masoudi1, Sayed Ali Mohammad Hasheminia1
Health Services Department, School of Health, Isfahan University of Medical Sciences, Isfahan, 1Department of Nursing, Shahrekord University
of Medical Sciences, Shahrekord, Iran

Background: Postpartum depression is endangering the health of mothers and has negative impacts on the evolution of social
communication and newborns evolution. This study was conducted to determine the effects of Fordyce Happiness program on the
postpartum depression. Materials and Methods: This quasi-experimental intervention carried out on postpartum mothers that
referred to 4 health centers in Isfahan. A total of 133 mothers were selected by convenient sampling and then randomly allocated
in two groups (63 and 70 mothers for intervention and control respectively). Maternal depression 3 times before, immediate and 1
months after intervention in both groups was evaluated with Beck Depression Inventory-II-Persian standardized questionnaires.
Educational sessions based on the Fordyce happiness program were conducted for intervention group. Data was analyzed in SPSS17
(SPSS Inc, Chicago, Illinois) descriptive and analytic statistical tests at significance level of 0.05. Results: No significant differences
in demographic variables between the two groups (P ≥ 0.05). No significant differences in depression scores in the two groups before
training. However after 2 months a significant difference in depression score was observed between two groups (control group: 19.38
± 3.94; intervention group: 16.24 ± 4.8; P < 0.001). Furthermore in intervention group showed significant differences in depression
scores before and after intervention (19.15 ± 3.41 and 16.24 ± 4.83; P < 0.001). However in the control group had not any significant
change. Conclusion: Fordyce happiness program was effective in reducing postpartum depression in our study. With attention to the
effectiveness and low cost of this program, it is recommended that this program might be considered for all mothers after childbirth
in health centers or other community-based settings.

Key words: Fordyce happiness program, mothers, postpartum depression

How to cite this article: Rabiei L, Amidi Mazaheri M, Masoudi R, Hasheminia AM. Fordyce happiness program and postpartum depression. J Res
Med Sci 2014;19:251-6.

INTRODUCTION of postpartum depression is 10-15%.[6] However, there

is evidence that Asian women are at greater risk.[7]
Obstetric and postpartum is the most critical stages of Prevalence of postpartum depression in Iran has been
women’s lives, which can affect the heavily feelings reported 27.3% in 2004.[8]
and thoughts of women. [1] During pregnancy and
postpartum mood changes that made them very Etiology of postpartum depression is still unknown.
sensitive to emotional stimuli and sometimes caused However, biological factors are involved such as
mental problems.[2] The highest rates of psychiatric estrogen levels drop suddenly a er delivery, drop in
disorder in women 15-44 years old occurs in the first 2 progesterone, increased urinary excretion of cortisol
months a er delivery. Regarding mental disorder a er and thyroid antibodies, prolactin and oxytocin and β
delivery postpartum have been identified three major endorphins.[9]
phenomena such as blues, postpartum depression and
postpartum psychosis.[3] Symptoms of postpartum It is worth noting that most studies has been reported
depression includes depressed mood, mental confusion, commonly risk factors associated with paranoid
sleep and eating disorders, feelings of guilt and of personality disorder, were factors such as maternal
inadequacy for caring neonate.[4] age, professional status and income instability, marital
discord and crisis in the 1st years before the birth.[9]
Diagnostic Statistical Manual Mental Disorders-IV
knows depression a er the birth starting at 4 weeks Maternal depression in the 1st weeks and months a er
a er postpartum. Given the severity of the disorder childbearing may undermine the relationship between
that may continue up to 3-6 months and in rare cases mother and child and can lead to the emergence of
up to 12 months a er birth[5] The overall prevalence behavioral problems later in childhood.[10]

Address for correspondence: Dr. Maryam Amidi Mazaheri, Department of Health Education and Promotion, School of Health, Isfahan University of
Medical Sciences, Isfahan, Iran. E-mail: [email protected]
Received: 12-03-2013; Revised: 15-07-2013; Accepted: 22-01-2014

251 Journal of Research in Medical Sciences | March 2014 |

 Rabiei, et al.: Fordyce happiness model and postpartum depression

One of the factors that lead to decrease postpartum Considering the negative consequences of the postpartum
depression and therefore coping with stress is happiness.[11] depression for the mother and child and the impact of
Happiness is an inner sense with inner sources that has as Fordyce happiness program on different groups in literature
well as outer effect. Happiness is degree of judge or extent reviews and with regard to the novelty of present study
of a quality of life and utility of person’s. Happiness means to observed the effect of Fordyce happiness model on
that how likes person his/her life’s.[12] postpartum depression, the research was perform this
study in 2011-2012 years in Isfahan and promising results
The most common mode of our mental state is happiness. for a way to control and reduce postpartum depression in
Barriers to access and experience that we are happy or the mothers.
put away negative acquired processes. When we discover
an inherent positive feelings and keeps us from barriers MATERIALS AND METHODS
that ge ing it out of the way, we achieve experience more
meaningful and beautiful life. These positive emotions are This quasi-experimental intervention carried out in 2011-
not simply changing with other events and things, but their 2012 on the postpartum mothers that referred to 4 health
influence in our lives are inevitable. A ention to this state centers in Isfahan. A total of 133 mothers were selected
allows us to be more alive and unpretentious. What’s the by convenient sampling and then randomly allocated
status of this positive outlook justified or not.[13] in two groups (63 and 70 mothers for intervention and
control respectively). Inclusion criteria: included was
Maeland has identified three different meanings for Health: mothers experiences delivery in the last 4-8 weeks, having
Absence of disease, personal characteristics and mode of depression score above 16, minimum age 17 years and
relaxation, well-being and happiness.[14] Human desire for maximum 35 years and literate mothers. “Exclusion criteria
happiness is easy to engage in social activities. Therefore, were: mothers with past history of depression, history of
happiness is expressed by the social glue is ties that a ached infertility or recurrent abortion, fetal abnormality in past
to each other.[15] or current pregnancy and a premature or stillbirth and
depression score below 16 were not included in the study.
Happy people have high self-esteem, self-respect and self- Also participants who became suicidal or psychotic which
love, These people have paid much a ention to ethics and needed medications were excluded”.
behave rationally.[16]
In this study data 3 times before, immediate a er and 2
Lack of happiness can be stressful and stress can cause months a er intervention in both groups were evaluated
serious illness.[17,18] Happiness is necessary for mental with the demographic questionnaire and Persian-language
development and is useful because it helps to cope with version of the Beck Depression Inventory (BDI-II-Persian)
stress. Some experts believe that the first condition for by self-report method.
the establishment of health, is happiness.[19] Those who
are happy, feel more security, easier to decide, have Demographic questionnaire has contains 8 questions
more collaborative spirit and are more satisfi ed with including age, occupation, education, income adequacy,
their lives.[20] unwanted pregnancy, history of premenstrual syndrome
(PMS), satisfaction with infant gender, history of abortion and
Lama and Katler (2003) believes that the first step to gain to Persian-language version of the BDI-II-Persian has contains
happiness, is learned it and can be taught to people to learn 21 questions in a Likert scale of 4°, which was graded as 0-3.
how to be happy.[21] One way rejoicing education model, is Maximum and minimum scale score was of 63 and zero.
Fordyce happiness.
This questionnaire showed distribution in patients with these
Fordyce (1983) has developed a program to increase the conditions to each of questions in order to: Social isolation,
happiness of the community consists of 14 elements. lack of assertiveness, lack of decision making, flexibility,
This program has eight cognitive element and six fatigue, loss of appetite, weight loss, health concerns,
elements of behavioral. She believes that with educating reduced sexual interest, sadness, pessimism, sense of failure,
these components, individuals are able to increase their dissatisfaction, guilt, expectation of punishment, self-hate,
happiness.[22] self-blame, suicidal ideas, crying, changing a itudes about
body image, insomnia and feeling of displeasure.
A study by Moradi et al. (2007) conducted a study with
used Fordyce methods to increase happiness of teachers The scale range is as follows: 0-9 normal, 10-19 mild
in Isfahan city discovered positive impact on the business depression, 20-29 moderate depression and 30-63 severe
practices of teachers happily.[22] depression.

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 Rabiei, et al.: Fordyce happiness model and postpartum depression

In a study by Ghassemzadeh et al. BDI-II-Persian had answered by instructor. Then they were completed the BDI-
high internal consistency (Cronbach’s alpha = 0.87) and II-Persian. Women for their participation in the program
acceptable test-retest reliability (r = 0.74).[23] were acknowledged and time of follow-up session was set
up for 2 months later.
In this study, a er the mothers were divided randomly
into two groups and a er doing pre-test, education was BDI-II-Persian depression questionnaire was used to
conducted for mothers of intervention group in meeting complete in control group. The results were reviewed and
room in one of the health centers. The education was analyzed with statistical tests for the effectiveness of the
done by trained instructor and dominates on Fordyce Fordyce happiness program.
happiness program and its duration was eight sessions and
each session about 1-1.5 h. (two sessions in a week) and Data obtained from before and a er of intervention in the
conducted with Lecture, discussion and question - response two groups analyzed with using Chi-square tests, Mann-
methods. Hence half time of each session was devoted to Whitney and Kruskal-Wallis in SPSS so ware version 17.
presentations of the meeting and a er a rest period, the
second half of the training session was devoted for group Ethical consideration
discussion on the subject and question and answer exercises. Ethics approval was obtained from vice-chancellery for
At the end of each session, assignment was offered to all research in Isfahan University of Medical Sciences. The
women in out of positions of educational topics for exercise. participants in the intervention group were intimated
with details of the study and were asked to read and sign
Outlines of the intervention program includes a consent form and were assured of the confidentiality.
First session: Definition of depression and symptoms Participation to study was voluntary; participants were
of postpartum depression, definition of happiness, the given the opportunity to leave the study if they become
necessity and importance through review of studies on uncomfortable. The control group was given the opportunity
happiness. to participate in the Fordyce happiness program a er the
study was completed. Also, mothers who had severe
Second session: Techniques to increase physical activity — depression were referred to a psychiatrist and counselor.
being productive and doing something useful and
meaningful techniques. RESULTS

Third Session: Techniques of principles for be er planning According to the findings obtained from this study, Chi-
and organization - techniques for off the concerns — square and U-Mann Whitney test showed no significant
techniques to reduce the demands and wishes. differences in demographic variables between two groups
(P ≥ 0.05) [Table 1].
Fourth Session: Creativity increased techniques-moment
living in the present techniques. Among the demographic characteristics, Chi-square
test showed statistical significant relationship between
Fi h Session: social enhancement techniques — being real postpartum depression and other characters such as
techniques. education level (P = 0.001) mothers job (P = 0.047),
financial status (P = 0.01), unplanned pregnancy (P =
Sixth Session: Techniques for increase intimacy as the 0.003), history of PMS (P = 0.021) and satisfaction of baby’s
primary source of happiness, prioritizing happiness, gender (P = 0.037).
techniques and in valuing of great happiness.
Mean age of the samples was 24.32 years (mean in
Seventh Session: Techniques of expression and optimistic intervention group 24.25 and control 24.41). 41.8% of
enhancement. samples were educated in cycle, 47.7% diploma and
12.5% had a college education. There was no significant
Eighth Session: An overview of all techniques, conducted a difference between two groups in education level. This
post-test (immediately) and determination time of post-test subject indicates that lower educational levels correlated
(2 months later). with postpartum depression of mothers.

At the end of program, a summary of all happiness Majority of them had housekeeping Jobs (87.6%) and their
techniques overviewed with help of mothers and were husbands jobs was free (67%) and the economic status
asked questions about the current level of happiness and of women according to their self-report were moderated
optimism of those. If they had questions about them, were (59.9%), respectively.

253 Journal of Research in Medical Sciences | March 2014 |

 Rabiei, et al.: Fordyce happiness model and postpartum depression

The frequency of depression among mothers showed that Table 1: Demographic and obstetric characteristics of
most mothers had mild depression in both groups [Table 2]. the intervention and control groups
Variable Group
Furthermore, independent t-test showed that there was no Trial group Control group P value
significant difference in depression score between two groups N = 63 N = 70
before intervention. But a er the intervention, there was Age (years) 24.25±6.43 24.41±7.61 0.81
significant difference in depression score between two groups. Education
Cycle 22 (41.2) 24 (42.6) 0.47
The intervention group scores a er intervention was be er
Diploma 28 (47.4) 31 (50.4)
than the control group scores (16.24 ± 4.83 in intervention and
Collegiate 13 (11.4) 8 (7.2)
19.38 ± 3.94 in control respectively) (P < 0.001). Paired t-test
Financial status
showed significant differences in depression scores before Good 11 (13.2) 9 (12.6) 0.37
and a er the intervention group (P < 0.001). But the control Average 39 (68.6) 41 (69.2)
group did not change significantly [Table 3]. Weak 13 (18.2) 13 (18.2)
Unplanned pregnancy
DISCUSSION Yes 44 (70.5) 46 (74.6) 0.53
No 29 (29.5) 27 (35.4)
The findings showed that, most mothers have average History of abortion 21 (32.5) 25 (35.4) 0/6
depression based on scores of the BDI-II-Persian. With History of PMS 28 (47.5) 25 (45.5) 0.33
regard the negative result of postpartum depression on Satisfaction of baby sex 44 (62.5) 39 (57.5) 0.71
Mothers jobs
child development and family processes a empt to identify
Employee 14 (19) 13 (18.2) 0.63
related factors is inevitable.
Free 11 (13.2) 10 (12.4)
Housekeeper 35 (66.6) 39 (68.6)
The results of this study indicated that among demographic PMS = Premenstrual syndrome
characteristics the educational levels and postpartum
depression have statistical significant relationship.
Table 2: Distribution of maternal depression in both
Hassan Zahraee results confirm these findings.[24] Also
groups
results of Tannous et al. and Segre et al. study confirm Variable Group
these findings that indicate lower education is associated Depression
with postpartum depression.[25,26] Education level as an Weak Average Severe
effective component in be er control and management of Frequency Frequency Frequency
problems can be regarded as an indicator for health care (percentage) (percentage) (percentage)
providers. Therefore, health care providers in their plans Intervention group 37 (58.7) 25 (39.7) 1 (1.6)
and programs should be considering more a ention to Control group 36 (51.4) 31 (44.3) 3 (4.3)
these high risk and sensitive groups.
Table 3: Mean maternal depression at different times
In this study, significant relationship was shown between Variable Group P value*
women job and postpartum depression symptoms but Intervention Control
postpartum depression frequency was higher in employed group N = 63 group N = 70
women. This finding contrasts with that of Mazhari and Mean SD Mean SD
Nakhaee study that postpartum depression was higher in Before intervention 19.15 3.41 19.95 4.43 0.31
housekeepers.[27] Immediately after the 17.77 3.71 20.78 5.36 P<0.001
intervention
Two months after the 16.24 4.83 19.38 3.94 P<0.001
This incompatible finding may be due to different working intervention
conditions for women. P value** 0.001 0.33
*t-test; **ANOVA with repeated. SD = Standard deviation

In this study, there was not statistical significant relationship

between postpartum depression and age. Although in some financial problems following the birth of a new child,[25]
studies, low mother age is known risk factors and high Economic status is an independent variable that in the
mother age protective factors for postpartum depression.[2] study is referred to as a risk factor,[2] also, in the study
shown significant relationship between family income and
In contrast, in some communities, such as our community, maternal depression.
high mother age was with number of children, Unwanted
pregnancy and unwillingness to accept responsibility The results showed significant relationship between
for taking care of other children in the imposition of unplanned pregnancy and the postpartum depression.

| March 2014 | Journal of Research in Medical Sciences 254

 Rabiei, et al.: Fordyce happiness model and postpartum depression

Some researchers believe that delivery is known one of system, would recommend the use of such program as a safe
pathologic stress to mothers. However, if this is the problem and free of any risk for the mother and the child and family.
of unwanted pregnancy maternal multiply function
conflict in the unwanted pregnancies that lead to a state of There are several limitations involved in this study which
acceptance and rejection of infant. There are physical and must be addressed. Initially, the more serious concern
psychological side-effects for women.[2] is about the validity and accuracy of self-reported data
regarding postpartum depression; further researches
Another important finding of the present study is the effects must use combination of self-report and clinical interview
of Fordyce happiness program on postpartum depression. used to diagnose postpartum depression. Due to the
small sample size, generalization of the results must
Fordyce happiness intervention lead to significant be interpreted with caution and continued research
differences in depression scores in the two groups’ should include larger sample sizes to draw more
intervention and control. accurate conclusions. Another limitation of this study
is not addressing the underlying factors of postpartum
Mansouri in her studies showed that Fordyce happiness depression; future studies should focus on life crises,
program was effectiveness training in reducing symptoms social support and marital satisfaction.
of PMS and increased happiness of women with PMS.
Training eight sessions of Fordyce happiness program CONCLUSIONS
was effective to decrease the symptoms of PMS, anxiety,
symptoms of PMS, irritable PMS symptoms, the physical Based on the results of this study, Fordyce happiness
symptoms of PMS and increased happiness[28] Mansouri program was effective in reducing postpartum depression.
findings coincide with the findings of this study focuses So with consider that this program to be effective and
on the effectiveness of these programs and to control the without being charged for women, it is recommended that
transient symptoms of hormone imbalance can be used to this program be considered for all mothers a er childbirth
greatly that health care providers can use this technique to in health centers or other community based se ings.
learn and quick to help mothers at risk for mental disorders.
ACKNOWLEDGMENT
Alison study showed that the education of happiness lead
to reduction depressed mood and increased happiness on This article resulted from a project in Isfahan University of Medical
New Zealand’s Canterbury University students[29] In this Sciences. Project’s number was 290372. We would like to acknowledge
regard it should be noted that mothers a er childbirth if of family health personnel in selected health centers and all mothers
participating in this study for their devotional corporation.
participated to this programs to control his depression, can
be happier and have higher capacity to be more successful
in their life.
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