An-Najah National University Faculty of Graduate Studies Prevalence of Antenatal Depression Symptoms in Primary Health Care Centers in Nablus Governorate By Sawsan Saeed Abd Al Rahman Supervisors Dr. Jamal Qaddumi Dr. Mohammad Marie This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Community Mental Health Nursing, Faculty of Graduate Studies, An-Najah National University, Nablus, Palestine. 2021 II Prevalence of Antenatal Depression Symptoms in Primary Health Care Centers in Nablus Governorate By Sawsan Saeed Abd Al Rahman This Thesis was defended successfully on 10/11/2021 and approved by: Defense Committee Members Signature  Dr. Jamal Qaddumi / Supervisor ….……..…………  Dr. Mohammad Marie / Co- Supervisor ……..…………….  Dr. Ahmad Iydi / External Examiner ….………………..  Dr. Adnan Sarhan / Internal Examiner …..……………….. III Dedication الإرادة ةوقو والعزم واجلسدية النفس ية القوة منحي اذلي طيبا كثريا محدا تعاىل هلل امحلد .املناسب الوقت يف الاطروحة هذه لإجناز م الإجناز هذا اهدي هللا امد قليب عىل العزيز وادلي- امسه حبمل رشفين من اىل فشر امل .-هعمر ب .-الغالية ايم- ولرويح لقليب بلسم دعواهتا اكنت من اىل ،قليب وهمجة عيين نور اىل الشف درجة واانل دلراس يت اتفرغ حىت بييت تومسؤوليا مسؤوليايت لك محل من اىل .-الغايل العزيز زويج- والامتياز ما لهلو اذلي نالرمح عبد عالء ايخ وخاصة -واخوايت اخواين- والساعد والعضد الس ند اىل .احلمل هذا حققت زويج ادلةو - مقابل دون وحناهنا حبهبا تغدق جدة مبثابة واكنت وعطفها حبهبا مغرتين من اىل .-العزيزة .-شقري منال زويج اخت- وصديقيت حبيبيت ،ولبنايت يل ةاثني ام اكنت من اىل ياذل النفيس ادلمع لك عىل هلم حيب لوصف لكاميت احتارت من اىل ابخرا، وليس أ خريا اسة،ابدلر خاصة أ نفسهم عىل ااعمتدو حيث ابملصاعب امللكل املشوار هذا خالل يل قدموه .ميال( منال، غزل، زاهرة،) ال ربعة زهرايت قليب فذلة IV Acknowledgement ح جاانطالقا من العرفان ابمجليل فانه يرسين ويثلج صدري أ ن أ عرب عن امتناين وشكري جلامعة الن العرفان و الوطنية وخاصة أ عضاء هيئة التدريس اذلين مل يبخلوا عيّل بعطاهئم من علمهم، وأ خص ابلشكر ساندة املشف الرئييس عىل رساليت ادلكتور جامل القدويم اذلي مدين من منابع علمه ابلكثري من امل و ملل، امعة دون لكل أ واملساعدة، وأ انر دريب بتسلق درجات التقدم يف البحث العلمي منذ دخويل اجل لئ ًا يف نور وأ محد هللا بأ ن يرسه يف دريب ويرس به أ مري وعىس أ ن يطيل هللا بعمره ليبقى نرباسا متل .العمل والعلامء النفيس كام أ نين أ منت جبزيل العرفان والشكر لدلكتور محمد مرعي املشف الثاين اذلي قدم يل ادلمع ىل التوجيه والإ .رشاد العلمي بشلك مس متروالتشجيع ابلإضافة اإ يس اليت كام اتقدم جبزيل شكري وتقديري ملنسقة برانمج الصحة النفس ية العميدة ادلكتورة عايدة القي .منحتين وقهتا المثني لنصحي وارشادي قته وعلمه.وأ يضا أ تقدم جبزيل الشكر والعرفان لدلكتور القدير عدانن رسحان، واذلي اكن خسي العطاء بو لدلكتورة رشوق قادوس ولك زماليئ يف رحةل ماجس تري الصحة النفس ية اذلين أ صبحوا ولك الشكر .نعم ال خوة والس ند اء يف قراءة كام أ تقدم جبزيل الشكر لاكفة أ عضاء جلنة املناقشة املوقرين اذلين تكبدوا الكثري من العن .رساليت املتواضعة واغناهئا مبقرتحاهتم القمية ة عائشة حميبش يف خاصة ادلكتور-قدم جبزيل الشكر والتقدير لاكفة الزميالت وأ خريًا وليس ابخرا أ ت نوا اس تقبايل ومعلوا عىل توفري البيئة اللوايت أ حس -مراكز الرعاية الصحية ال ولية مبديرية حصة انبلس .اس يتكن بدر املناس بة مجلع البياانت وأ شكر اكفة املشاراكت ابدلراسة اللوايت منحين ثقهتن ووقهتن وشار V قراراإل أنا الموقعة أدناه، مقدمة الرسالة التي تحمل العنوان: Prevalence of Antenatal Depression Symptoms in Primary Health Care Centers in Nablus Governorate يه ما اشتملت عليه هذه الرسالة إنما هو نتاج جهدي الخاص، باستثناء ما تمت اإلشارة إل أقر بأن حث بهذه الرسالة كاملة أو أي جزء منها، لم ُيقدم من قبل للحصول على أي لقب أو حيثما ورد، وأن لدى أي مؤسسة بحثية أخرى. Declaration The work provided in this thesis unless otherwise referenced is the researcher own work and has not been submitted elsewhere for any other degree or qualification. :Student’s Name سوسن سعيد عبد الرحمن اسم الطالب: :Signature التوقيع: :Date 10//2021/11 التاريخ: VI Table of Contents Dedication ................................................................................................... III Acknowledgement ....................................................................................... IV Declaration ................................................................................................... V Table of Contents ........................................................................................ VI List of Tables ................................................................................................ X List of Figures ........................................................................................... XII List of Abbreviations ................................................................................ XIII Abstract ..................................................................................................... XV Chapter One ................................................................................................... 2 Introduction ................................................................................................... 2 1.1 Research Overview: .................................................................... 2 1.2 Socio-Demographic context: ........................................................ 5 1.3 Palestinian primary health care context: ........................................ 8 1.4 Community mental health context: ............................................. 10 1.5 Antenatal depression in Palestine: .............................................. 13 1.6 Problem Statement: ................................................................... 15 1.7 Significant: .............................................................................. 18 1.8 Aims of the study: .................................................................... 19 1.8.1 General aim: ....................................................................... 19 1.8.2 Specific aims: ..................................................................... 19 1.10 Null Hypotheses:………………………………………………….…………………….20 1.11 Conceptual framework: ............................................................ 21 1.12 Conceptual and operational definition of the study variables: ....... 22 Chapter Two: Theoretical and literature review ......................................... 27 Theoretical review for antenatal depression: ...................................... 27 VII 2.1 Signs and symptoms: ................................................................ 27 2.2 Causes: .................................................................................... 28 2.3 Risk factors: ............................................................................. 28 2.4 Assessment and Diagnosis: ........................................................ 29 2.5 Depression DSM-5 Diagnostic Criteria ....................................... 30 2.6 Treatment: ............................................................................... 32 2.7 Complications: ......................................................................... 36 Chapter Three: Methodology ...................................................................... 51 3.1 Research Design: ...................................................................... 51 3.2 Study Population: ..................................................................... 51 3.3 Study Setting: ........................................................................... 52 3.4 Study Period: ........................................................................... 52 3.5 Sample Size: ............................................................................ 53 3.6 Sampling Technique: ................................................................ 53 3.7 Inclusion & Exclusion Criteria: .................................................. 54 3.8 Study Tool: .............................................................................. 55 3.9 Validity and Reliability of questionnaire: .................................... 56 3.10 Pilot Study: ............................................................................. 58 3.11 Data Collection: ...................................................................... 59 3.12 Statistical Analysis: ................................................................. 60 3.13 Ethical Consideration: .............................................................. 60 Chapter Four: Results .................................................................................. 63 4.1 Sample distribution according to socio-demographic data. ............ 63 4.1.1 Distribution of the study participants according to their place of residency. .................................................................................... 63 4.1.2 Distribution of the study participants according to their age. .... 64 VIII 4.1.3 Distribution of the study participants according to education level. ……………………………………………………………………………………………….65 4.1.4 Distribution of the study participants according to their sociodemographic characteristics. .................................................. 66 4.2 Distribution of the study participants according to their health history. ……………………………………………………………………………………………………..67 4.3 Distribution of the study participants according to their obstetric characteristics. ................................................................................ 68 4.4. Distribution of the study participants according to their complications during pregnancy. ........................................................................... 71 4.5. Distribution of the study participants according to their stressful life events during this pregnancy. ........................................................... 72 4.6. Distribution of the study participants according to their emotional support during pregnancy. ............................................................... 74 4.7 Total scores of levels of depression ............................................ 76 4.8. Distribution of the study participants according to their levels of depression. ..................................................................................... 77 4.9 Mean difference of depression related to socio-demographic data among the study participants. ........................................................... 78 4.10 Mean difference of depression related to health history among the study participants. ........................................................................... 82 4.11 Mean difference of depression related to obstetric characteristics among the study participants. ........................................................... 83 4.12 The mean difference of depression related to their complications during pregnancy. ........................................................................... 91 4.13 The mean difference of depression related to their stressful life events during this pregnancy. ..................................................................... 92 IX 4.14 The mean difference of depression related to their emotional support during pregnancy. ........................................................................... 93 Chapter Five ................................................................................................ 96 Discussion ................................................................................................... 96 5.1 Sociodemographic data. ............................................................ 96 5.2 Health history. ........................................................................ 106 5.3 Obstetric characteristics. ......................................................... 109 5.4 Pregnancy-related complications. ............................................. 118 5.5 Stressful life events during this pregnancy. ................................ 119 5.6 Emotional support during pregnancy. ....................................... 123 5.7 Prevalence of antenatal depression: .......................................... 125 Chapter Six: Conclusion and Recommendations ...................................... 132 6.1 Conclusion: ............................................................................ 132 6.2 Recommendations: ................................................................. 135 6.3 Strong points and Limitations of the study: ............................... 136 6.3.1 Strong points: ................................................................... 136 6.3.2 Limitations of the study: .................................................... 137 References ................................................................................................. 138 Annexes ..................................................................................................... 152 ب ........................................................................................................... الملخص X List of Tables Table (1.1): Conceptual and operational definition of the study variables. 23 Table (3.1) :Reliability of the research for BDI-II domain. ........................ 57 Table (4.1): Distribution of the study participants according to their sociodemographic characteristics. .......................................... 67 Table (4.2): Distribution of the study participants according to their health history. .................................................................................... 68 Table (4.3): Distribution of the study participants according to their obstetric characteristics. ......................................................................... 70 Table (4.4): Distribution of the study participants according to their complications during pregnancy. ............................................ 71 Table (4.5): Distribution of the study participants according to their stressful life events during this pregnancy. ........................................... 73 Table (4.6): Distribution of the study participants according to their emotional support during pregnancy. ..................................... 75 Table (4.7): Total scores of levels of depression. ....................................... 76 Table (4.8): Distribution of the study participants according to their levels of depression. .............................................................................. 77 Table (4.9): The mean difference of depression related to socio-demographic data among the study participants. .......................................... 79 Table (4.10): Post Hoc test of mean difference of depression related to their age groups among the study participants. ............................... 80 Table (4.11): Post Hoc test of mean difference of depression related to their education levels among the study participants. ...................... 80 Table (4.12): Post Hoc test of mean difference of depression related to their place of residence among the study participants. ................... 82 XI Table (4.13): The mean difference of depression related to health history data among the study participants. ................................................. 83 Table (4.14): The mean difference of depression related to obstetric characteristics data among the study participants. .................. 85 Table (4.15): Post Hoc test of mean difference of depression related to their number of gravidities including this pregnancy among the study participants. ............................................................................. 87 Table (4.16): Post Hoc test of mean difference of depression related to their number of parities among the study participants. ................... 88 Table (4.17): Post Hoc test of mean difference of depression related to their number of sons among the study participants. ....................... 89 Table (4.18): Post Hoc test of mean difference of depression related to their number of daughters among the study participants. ............... 89 Table (4.19): Post Hoc test of mean difference of depression related to their number of abortions among the study participants. ................ 91 Table (4.20): The mean difference of depression related to their complications during pregnancy. ............................................ 92 Table (4.21): The mean difference of depression related to their stressful life events during this pregnancy. ................................................. 93 Table (4.22): The mean difference of depression related to their emotional support during pregnancy. ...................................................... 94 XII List of Figures Figure (1.1): Distribution of New Reported Psychiatric Cases by Sex & Age Groups in West Bank, Palestine (Palestinian MOH, 2021). 13 Figure (1.2): Conceptual framework that developed by researcher. ........... 22 Figure (4.1): Distribution of the study participants according to their place of residency. .......................................................................... 64 Figure (4.2): Distribution of study participants according to their age. ..... 65 Figure (4.3): Distribution of study participants according to education levels. ............................................................................................... 66 XIII List of Abbreviations AD Antenatal Depression ANC Antenatal Care APH Antepartum Hemorrhage BDI-II Second Beck's Depression Inventory CBT Cognitive behavior therapy D Error proportion DM Diabetes Mellites DSM-IV The fifth edition of the Diagnostic and Statistical Manual of Mental Disorder. DVT Deep Vein Thrombosis ECT Electroconvulsive Therapy EMS Emergency Medical Services ENT Ears, Nose and Throat EPDS Edinburgh Postnatal Depression Scale etc. Et cetera F One way ANOVA GBV Gender-Based Violence GP General Practitioner HTN Hypertension IPT Interpersonal Psychotherapy IPV Intimate partner violence IRB Institutional Review Board IVF In vitro fertilization Km Kilometer Max Maximum MCH Clinic Maternal & Child Health Clinic MDD Major Depressive Disorder Min Minimum MOH Ministry of Health n Number N Population size NGO Non-Governmental Organizations NVP Nausea & Vomiting of Pregnancy XIV oPt occupied Palestinian territory P Population proportion PA Palestinian Authority PCBS Palestinian Central Bureau of Statistics PHC Primary Health Care PHQ Patient Health Questionnaire PPH Postpartum Hemorrhage SD Standard Deviation SPSS Statistical Package for Social Sciences SSRIs Selective Serotonin Reuptake Inhibitors T Independent t-test TCAs Tricyclic Antidepressants UNRWA United Nations Relief and Works Agency USA United States of America WHO World Health Organization Z Confidence level % Percentage XV Prevalence of Antenatal Depression Symptoms in Primary Health Care Centers in Nablus Governorate By Sawsan Saeed Abd Al Rahman. Supervisors Dr. Jamal Qaddumi. Dr. Mohammad Marie Abstract Background: Antenatal depression is a depression that exists during the mother's pregnancy period. It has major and important negative effects for the well-being and health of mothers, babies and their families. Estimated 10% to 20% of the pregnant women in the world are affected by antenatal depression. Many factors are believed to be linked with antenatal depressive disorders such as past obstetric complications, lack of husband support, previous abortion, financial difficulties and unplanned pregnancy. Moreover, poor or lack antenatal care, chronic medical diseases and past psychiatric disorders have been recorded. Aim: The study aims to determine the prevalence of antenatal depression symptoms in governmental primary health care centers in Nablus governorate. Method: A quantitative, descriptive, cross sectional study design was used in this study. The sample consist of 343 pregnant women. A convenience sampling technique was used in this study. Self-administered questionnaire and Second Beck's Depression Inventory (BDI-II) scale were introduced in the present study for data collection. XVI Results: Most of the study participants living now in the village (62.4%) and the majority of the participants were married (99.4%). The results showed that 63.6% of participants were in the third trimester and 7.3% suffering from complications during this pregnancy. However, 41.1% of the participants were feeling constant stress during pregnancy and some of the participants suffering from family conflicts (16.0%). About one third (32.7%) of participants were exposed to violence from husband. On the other hands, according to the results that there is low score of depression levels among the participants (26.08%) and about half of participants (47.2%) have minimal depression, while 19.8% of them have mild depression, 19.3% of them have moderate depression and 13.7% of them have severe depression. Finally, the results showed that there is relation between depression levels and age group, level of education, place of residency, smoking, a family history, the number of gravidity & parities, suffering from any complications during previous pregnancies and husbands support (P<0.05). Conclusion: Depression levels among pregnant women is low score of the minimal depression and few percentages have severe depression. Also, depression levels associated with age, level of education, place of residency, smoking, a family history, the number of gravidity & parities, suffering from any complications during previous pregnancies and husband’s support. Key words: Prevalence, antenatal depression, primary health care centers, Nablus governorate, Palestine. 1 Chapter One Introduction 2 Chapter One Introduction 1.1. Research Overview: Pregnancy is defined as a well-being period which allows women to feel complete biologically, supported their emotional well-being, caused enjoyment and fulfillment, and at the same time led to a moment of stress and related changes (Murtaja & Thabet, 2017). The onset of pregnancy can temporarily alter the hormonal balance in women which predispose them to a different form of affective disorders such as depression. Depression is one of the medical and psychological conditions in pregnancy. Maternal depression is often considered to be a predictor of increased incidence of preterm births, miscarriages, retarded fetal growth which can manifest as low birth weight and so on (Okagbue, et al., 2019). Pregnancy is not considered as a pathological state; however, pregnancy heightens the vulnerability to emotional and psychological condition such as depression. Untreated depression during pregnancy can negatively affect the fetus and mother (Gadanya, Abulfathi, & Ahmad, 2018). Depression is the fourth leading reason for burden of disease and the world's greatest causes of non- fatal burden accounting for nearly 12% of overall years lived with disability. It is one of the oldest and most common 3 human diseases. Patients with depression are at least as severely disabled as people with other chronic diseases such as rheumatoid arthritis, Hypertension (HTN) and Diabetes Mellites (DM) (Beyene, Gebremichael, & Gebreselassie, 2020). Depression and pregnancy have an effect on each other. Pregnancy is an important psychological event, as well as, physiological one. With an increases of persistent life stressors, women can find themselves incapable to deal with the additional pregnancy demands (Thompson & Ajayi, 2016). Nearly, one out of four women suffered from depression at some point in her life (Beyene, Gebremichael, & Gebreselassie, 2020). Antenatal depression is a depression that exists during the mother's pregnancy period. It is characterized by symptoms of depression such as impaired sleep or concentration, feelings of guilt or poor self-worth, low energy and changes of appetite, lack of interest in daily tasks and a constant of depressed mood (Mahendran, Puthussery, & Amalan, 2019). Other symptoms include poor memory, feeling irritable and resentful, feeling inadequate and worthless, numbness and suicidal or abortion thinking. Many women may have negative feelings about pregnancy, especially those living in poverty or already with dependent children. Issues or memories surrounding poor parenting or violence suffered by women may reassert themselves and cause distress. Relationships are 4 predominantly being under pressure because domestic abuse increases during pregnancy (Thompson & Ajayi, 2016). During the antenatal phase, the progression of depressive symptoms increases dramatically; also, the clinically significant depressive symptoms are prevalent throughout the second and third trimesters. Many studies have indicated that depressive symptoms are more prevalent during pregnancy than during the postnatal phase (Zegeye, et al., 2018). In low- and lower-middle-income countries, prevalence of antenatal mental disorders tend to be higher than their prevalence in high-income countries, and there have been significant differences recorded between countries in some regions (Mahendran, Puthussery, & Amalan, 2019). Antenatal depression prevalence in developed countries is estimated to be 10-15% and 19-25% in economically poorer countries (Thompson & Ajayi, 2016). The causes of antenatal depression are unknown, but environmental and neurobiological influences together with genetic predisposition are thought to be important factors (Thompson & Ajayi, 2016). Many factors are believed to be linked with antenatal depressive disorders such as past obstetric complications, lack of husband support, previous abortion, financial difficulties and unplanned pregnancy. Moreover, poor or lack antenatal care, chronic medical diseases and past psychiatric 5 disorders have been recorded. Antenatal depressive disorders also have been documented that they lead to high repeat spontaneous abortions, postnatal depressive disorders and poor rearing capacity in children. Also, the consequences of unmanaged antenatal depressive disorders are often immune-related illnesses, low social functioning, intrauterine growth retardation, recurrent child diarrheal diseases, impaired postnatal growth and preterm delivery. Furthermore, preterm delivery, low birth weight, substance misuse and poor attendance at antenatal services have all been linked with depressive mood during pregnancy (Zegeye, et al., 2018). The present research was conducted to determine the prevalence of antenatal depression in government primary health care centers and to identify its risk factors. 1.2. Socio-Demographic context: Palestine is a low-income country with few resources, it is located between east of the Mediterranean Sea and west of Jordan River. Palestine is an occupied country by the Israeli military occupation. Where Israel occupied most of the Palestinian lands and cities in 1948, with the exception of the West Bank and Gaza Strip, which were occupied since1967, and, for Palestinians, travel between the two entities is rendered impossible. Thus, the two communities remain isolated from each other and many families remain split. Now, the occupied Palestinian territory includes the two geographically separate areas of the West Bank and Gaza Strip. The areas 6 feature several historical cities including East Jerusalem, Bethlehem, Hebron, Jericho, Nablus and Gaza City (WHO, 2006). With regard to Nablus city, it is a large city within the Palestinian Territories in the northern West Bank in Palestine; lies in a strategic position, it stands at an elevation of around 550 meters above sea level. Nearby cities and towns include Huwara and Aqraba to the south, Beit Furik to the southeast, Tammun to the northeast, Asira ash-Shamaliya to the north and Kafr Qaddum and Tell to the west. Also, it located between Mount Ebal and Mount Gerizim. Nablus city enjoys a significant strategic location links north with the south as it is located in the main road conjunction extends from Nazareth to Jenin in the north to Hebron in the south, and from Jafa in the west to Jericho in the East. The city is 69 km distance from Jerusalem and 42 km distance from the Mediterranean Sea with 35,16 longitude and 32,13 latitudes (An Najah National University, 2020). In 2020, according to the Palestinian Central Bureau of Statistics (PCBS) Estimated, the population of Palestine was 5,101,152 of whom 2.59 million were males compared to 2.50 million females, of which West Bank had 3.05 million inhabitants, and represents 59.9 % of the total population of Palestine, while the population of Gaza Strip was 2.04 million, and represents 40.1% of the total population of Palestine. Regarding to Nablus, the population was 407,754 individuals, which represent 8.0% of the total population of Palestine (Palestinian Central Bureau of Statistics, 2020). 7 The Palestinian society is a young society. In 2020, the population of the age under 15 years was 38.2% of the total population in Palestine. While the individuals of aged from 15 - 49 years was represent 25.6% of the total population. Also, the individuals of aged from 50 - 64 years was represent 4.2% of the total population. And the individuals of aged 65 years and above were 3.3%. The rate of population natural increase in Palestine was 2.5%. The sex ratio in Palestine was 103.4 males per 100 females, where the male’s ratio in the West Bank was 103.9 males per 100 females. The number of females of reproductive age (15 - 49 years) was 1,262,314 which 24.7% of the total population in 2020, in West Bank 766,264 which 25.1% of the total population in West Bank (Palestinian MOH, 2021). According to the Palestinian Central Bureau of Statistics (PCBS), the local Palestinian population is characterized by high total fertility rates 3.8 births per woman, 3.9 in Gaza Strip and 3.8 in West Bank. And also characterized by large family size, with an average of 5.5 children per family (Awad, 2021). The number of unemployed in Palestine was 343,800 in 2019, distributed as 215,100 in Gaza Strip and 128,700 in the West Bank. The unemployment rate in West Bank was 15%. In addition, the unemployment rate for males in Palestine was 21% compared with 41% for females. There is a large gap in the labour force participation rate between males and females. About 7 out of 10 of males are participated in the labor force, 8 compared with about 2 out of 10 of females (Palestinian Central Bureau of Statistics, 2020). The percentage of female-headed households in Palestine was 10.6% in 2017, 11.2% in the West Bank and 9.5% in Gaza Strip. Fifth of the persons in Palestine got married at an early age (less than 18 years) in 2016. Where the early marriage reached to 20.5% among females and 1.0% among males of the total married population in Palestine; the rate was 19.9% out of the total married population in West Bank end 2016 (Palestinian Central Bureau of Statistics, 2019). Despite the rise in literacy rates among females over the last decade, the gap is still in favor of males by 3.0%, female literacy rates were 95.6% compared to 98.6% for male literacy in the year 2017. PCBS data showed that male enrollment in high schools was 5.06%, compared to female enrollment which was 4.08% for the year 2015-2017 (Palestinian Central Bureau of Statistics, 2019). 1.3. Palestinian primary health care context: The number of MoH primary health care centers in Palestine increased from 203 at the end of 1994 to 475 in 2020, an increase of 134%. The Ministry of Health classifies primary health care centers in four levels in addition to mobile clinics. Primary health care (PHC) centers in MoH, offer a range of health services, 282 centers provide family planning services, 234 provide specialized services (such as Dermatology clinics, Pediatrics, 9 Diabetic, Psychiatry, Pulmonology, Gynecology, Orthopedic, ENT, Communicable and Non- Communicable disease, and Endocrinology), 40 provide oral and dental health services, and 200 provide laboratory services. The high-risk pregnancy service is available in 78 clinics, while mammography is provided at 12 clinics and X-ray service in 17 centers in West Bank. Also, it provides several services such as mother & child health care, immunization, health education, First aid, GP medical care, Gynecology and obstetrics, and emergency medical services (EMS) (Palestinian MOH, 2021). In 2020, there were 2,012,524 visitors to primary health care centers. where the total number of pregnant visits to PHC centers was 97,360. The total number of pregnant women registered (first visit) in the MOH PHC centers was 28,547, with coverage of 37.4% of pregnant women; the average visit rate for pregnant women to the centers during pregnancy was 3.4 visits. In addition, 5,310 pregnant women were referred to high risk pregnancy clinics which constituted 18.6% of total pregnant women registered in different MoH MCH clinics, while total visits to high-risk pregnancy centers amounted to 24,965 during the same period. Also, the total number of visits by mothers to maternal and child centers in 2020 were 10,252 visits per physician at 13.4% of the reported live births and 52,429 visits per nurse at 68.6% of reported live births (Palestinian MOH, 2021). 10 1.4. Community mental health context: Despite Palestine being subjected to Israeli military rule since 1967, the Israeli Mental Health Law has not been applied to the West Bank and Gaza Strip. Therefore, there were no laws in which mental health is practiced in Palestine. The Palestinians were in dire need of mental and psychological health care in light of the Israeli war, unemployment, displacement, and destruction of the infrastructure (Giacaman , et al., 2010). Anecdotal evidence from many mental health sources leads to the conclusion that the high levels of acute and chronic stress in the occupied Palestinian territory, due to the socio-political situation, render the entire Palestinian population more vulnerable to mental health problems and, in particular, to a higher incidence of symptoms of anxiety and/or depression amongst the general population. Recent studies in the occupied Palestinian territory have shown that the stressors present in everyday Palestinian life due to the Israeli occupation (severe restrictions on freedom of movement, unemployment, lack of access to education and healthcare, etc.) seriously impact on personal, familial and community functioning (WHO, 2006). In 2002, the first situation analysis undertaken by WHO in West Bank and Gaza revealed no mental health policy and a lack of public mental health services. The mental health system was still more hospital-based than community-based. Psychiatric hospitals in Bethlehem and Gaza were still the main assets to mental health care, while community mental health 11 provision was extremely patchy and rooted in a traditional and biomedical- oriented approach. Services were fragmented, under-developed, poorly resourced and, in many areas, no services were available. Mental health human resources were extremely scarce, and existing staff were over- worked, burnt out, poorly trained and demotivated. The public were unaware of the nature of mental illness, had misconceived views and held very stigmatizing and fixed beliefs surrounding mental illness. There was a lack of knowledge of mental health at primary health care level, no referral system or cooperation between different parts of the public health sectors or between the public health sector and the private sector or Non- Governmental Organizations (NGO) sectors. Some non-governmental organizations were, indeed, providing good mental health services but in an uncoordinated way; therefore, these fragmented good practices were not able to influence the general mental health system and actually were leaving untouched the culture of public sector services (WHO, 2006). Due to the social structure of Palestinian society, and its emphasis on the extended family, even the severely mentally ill tend to remain in the family environment and are cared for by relatives. This may in part account for a relatively low occupancy level in psychiatric hospitals. It also reinforces the need to strengthen community-based outpatient services, as well as to build support systems for the families of those suffering from mental health problems (WHO, 2006). 12 Currently, mental health services are providing in Palestine through 16 specialized mental and community health clinics (Palestinian MOH, 2021). The Mental health services are lack human and infrastructure resources because no specific budget directed for mental health services in the occupied Palestinian territory (oPt). An estimate of 2 % of the Palestinian Authority (PA) health care expenditures is used for mental health (WHO, 2014). Most mental health services are limited and depended on externally funded programs (Marie, Hannigan, & Jones, 2016). In 2020, there were 2,093 new patients registered in the various mental health centers in the West Bank, with rate of 76.0 per 100,000 population. The distribution of new psychiatric cases registered in mental health and community centers by gender showed 1,187 males which represents 56.7% of the total registered new cases, and 906 females which represents 42.3% of the total registered new cases. The age distribution showed that the largest number of these cases was distributed in the 25-49 age group, amounting to 822 cases and represents 39.3% of the total recorded new cases. The total number of visitors to community mental health centers in West Bank was 84,852. In addition, mood (affective) disorders - including depression - was 13,378 of new visitors, it was second after schizophrenia (28,782 visitors) (Palestinian MOH, 2021). 13 Figure (1.1): Distribution of New Reported Psychiatric Cases by Sex & Age Groups in West Bank, Palestine (Palestinian MOH, 2021). 1.5. Antenatal depression in Palestine: In Palestine, according to a study conducting by Al-Tel & Abu Iznait in 2017, the incidence rates of different level of antenatal depression were 59.5% in the West Bank. They reported that 34% were a mild level of depression, 17.2% were a moderate level of depression, and 2.1% were a severe level of depression (Abu- Iznait & Al -Tell, 2017). While, in 2017, according to a study conducting by Murtaja & Thabet in Gaza, the incidence rate of mild symptoms of depression was 23.3%, moderate symptoms were 33.3% and 18.5% were reported severe depression symptoms (Murtaja & Thabet, 2017). Palestinian studies and reports have pointed to the fact that several factors are associated with an increased risk of developing antenatal depression, the most important of which are patriarchal traditions and gender biases inherent in Palestinian culture with a preference for male children, 14 unplanned pregnancy exposes (Qandil, Jabr, Wagler, & Collin, 2016). Besides, the presence of fetal defects, labour pains, lack of a support person, exposure to violence from husband, increase in the number of gravidae and births (Abu- Iznait & Al -Tell, 2017). Accommodation in the camp refugee, low income and low educated level (Murtaja & Thabet, 2017) and increased the high-risk pregnancy rate increased from 17.5% in 2018 to 19.5% in 2019 of the total Palestinian pregnant women (Palestinian MOH, 2021). Moreover, regarding to Gender-Based Violence (GBV), the rate of GBV increased by 117% compared to the cases reported in 2017. 84.5% of the cases were married women. The husband was the perpetrator in 62.8% of GBV reported cases (Palestinian MOH, 2021). The husband was the cause of sexual violence in 57.1% of pregnant women who reported a moderate degree of depression (Abu- Iznait & Al -Tell, 2017). While 42.0% of reported GBV cases were psychological violence, followed and 39.9% of cases reported compound violence, which led to an increase in the percentage of women suffering mental disorders, from 42.6% in 2018 to 43.6% in 2019. Especially with the increasing times of conflicts in the region (Palestinian MOH, 2021). Also, pregnancy heightens the vulnerability to emotional and psychological condition such as depression (Gadanya, Abulfathi, & Ahmad, 2018). 15 All of this are considered as risks factors for antenatal depression in Palestine. In addition, the results of a Palestinian study showed that the healthcare system in Palestine continues faced specific challenges linked to occupation and political conflict (Hamdana & Defever, 2002). This led to an increased gap in the continuity and quality of health and psychological services across the antenatal period and increased restrictions on health care access due to political conflict (Abdul Rahim, et al., 2009). Finally, despite its significant, adverse effects on the wellbeing and health of families, babies, women and society in general, the issue still unrecognized in several regions and countries around the world (Mahendran, Puthussery, & Amalan, 2019). Little attention has been given to the consequences and existence of either family medical practice, psychiatric, obstetrical or mental health services (Beyene, Gebremichael, & Gebreselassie, 2020). 1.6. Problem Statement: Depression is one of the main global contributors to diseases burden, affecting about 322 million people around the world and it considered a leading cause for suicide (Beyene, Gebremichael, & Gebreselassie, 2020). Most maternal depression studies have concentrated on postnatal depression. However, antenatal depression, is the most common 16 psychiatric disease during pregnancy and it is considered important for public health, for three reasons: First, during pregnancy, the burden of depression is high. Second, the most potent risk factors for post-natal depression were depression and anxiety during pregnancy. Third, untreated depression is related to a number of negative antenatal effects, involving, poor growth in the first year of life, preterm birth, as well as low birth weight "babies of depressed mothers are between 2 - 3 times greater likelihood to be of low birth weight" (Pereira, Lovisi, Pilowsky, Lima, & Legay, 2009). Estimated 10% to 20% of the pregnant women in the world are affected by antenatal depression. Pregnancy has traditionally been regarded as a time protective against occurrence of depression; thus, little attention has been given to the consequences and existence of either family medical practice, psychiatric, obstetrical or mental health services (Beyene, Gebremichael, & Gebreselassie, 2020). Antenatal depression is considered a severe mental health disorder that can have a negative effect on women's lives. Depressive disorders are not only widespread and chronic among women all over the world but also it is one of the main causes of disability (Beyene, Gebremichael, & Gebreselassie, 2020). Antenatal depression has significant and negative impacts on the well- being and health of mothers, children, and their families. A variety of 17 complications are more likely to occur during pregnancy, including a higher risk of poor fetal development, premature birth, miscarriage, nausea and vomiting in women with antenatal depression. Also untreated antenatal depression itself is a significant contributor to the development postnatal depression, therefor the women with antenatal depression are at greater risk of experiencing other psychological disorders such as panic, anxiety and bipolar disorders. Despite its significant negative impacts on the well-being and health of the family, babies, women and society in general, this issue is still not recognized in many regions and countries around the world due to the lack of accurate prevalence rates (Mahendran, Puthussery, & Amalan, 2019). The antenatal depression contemplated now to be a worldwide public health concern because of its seriousness, recurrence and chronic nature as well as its detrimental impacts on women's health and children's development (Zegeye, et al., 2018). Although it is a major public health concern, there is no studies about this disease in governmental health care centers in Westbank. On the other hand, there is a study conducted in the health centers of the United Nations Relief and Works Agency for Refugees by Abu Zneit in 2017. Since the lack of information and limited attention to the disorder may worsen the effects of the problem and may restrict the action to be taken. And considering the potential negative effects of depression in pregnant 18 women; studies on the prevalence, causes and risk factors related to antenatal depression are required. 1.7. Significant: The early identification of symptoms may facilitate timely treatment and keep the disease from worsening and deteriorating. Also, the early detection of antenatal depression can improve pregnancy outcomes and may act as an early predictor of postnatal depression. In addition, early detection of maternal depression and the associated causes can also be an important method for minimizing maternal mortality and morbidity related to antenatal depression so that early screening of antenatal depression will enhance the capacity to identify the level of antenatal depression and improves treatment that ensures optimal health outcomes. The outcomes of this research will help policymakers and program managers devise effective strategies for reducing antenatal depression in Palestine and will be taken into consideration in taking appropriate steps and measurements to minimize maternal mortality and morbidity. Moreover, the results of the study will be an important source of information for health care providers and researchers when conducting additional investigation in related topics in Palestine. 19 This research would also include relevant and useful information for health workers to determine the prevalence and level of antenatal depression and associated factors that lead health workers to provide comprehensive professionally antenatal care, to remain alert for related factors, and provide psychological support throughout the antenatal phase. 1.8. Aims of the study: 1.8.1. General aim: The general objective of this study is to determine the prevalence of antenatal depression symptoms in government primary health care centers in Nablus governorate. 1.8.2. Specific aims: o To determine the level of antenatal depression symptoms among pregnant women in government primary health care centers in Nablus governorate. o To recognize the most common risk factors for antenatal depression symptoms in pregnant women in government primary health care centers in Nablus governorate. o To identify the association between the risk factors and level of antenatal depression among pregnant women in government primary health care centers in Nablus governorate. 1.9. Research questions: 20 o What is the prevalence of antenatal depression symptoms in government primary health care centers in the Nablus governorate? o What is the level of antenatal depression symptoms among pregnant women in governmental primary health care centers in the Nablus governorate? o What are the most prevalent risk factors of antenatal depression symptoms among pregnant women in government primary health care centers in Nablus governorate? o What is the association between the risk factors and level of antenatal depression among pregnant women in government primary health care centers in Nablus governorate? 1.10. Null Hypotheses: o There is no relationship between the prevalence of antenatal depression and the risk factors of antenatal depression symptoms among pregnant women in governmental primary health care centers in the Nablus governorate, at the level p-value ≤ 0.05. o There is no relationship between the level of antenatal depression and the risk factors of antenatal depression among pregnant women in governmental primary health care centers in the Nablus governorate, at the level p-value ≤ 0.05. o There is no relationship between sociodemographic factors and antenatal depression among pregnant women in the Nablus governorate, at the level p-value ≤ 0.05. 21 o There is no relationship between health history and antenatal depression among pregnant women in the Nablus governorate, at the level p-value ≤ 0.05. o There is no relationship between obstetric characteristics and antenatal depression among pregnant women in the Nablus governorate, at the level p-value ≤ 0.05. o There is no relationship between complications during pregnancy and antenatal depression among pregnant women in the Nablus governorate, at the level p-value ≤ 0.05. o There is no relationship between emotional support during pregnancy and antenatal depression among pregnant women in the Nablus governorate, at the level p-value ≤ 0.05. o There is no relationship between stressful life events during this pregnancy and antenatal depression among pregnant women in the Nablus governorate, at the level p-value ≤ 0.05. 1.11. Conceptual framework: Based on the review of the available literature, the researcher established the conceptual framework. The conceptual framework is the map that directs the design & achievement of the study, and to summarize and clarify the study's variables, also it used to guide the research process and make the findings more significant and relevant. 22 Figure (1.2): Conceptual framework that developed by researcher. 1.12. Conceptual and operational definition of the study variables: Dependent variable: Antenatal Depression. Independent variables: Age of mother, level of education, residential area, economic status & nature of the work, marital condition, polygamous 23 husband, conflicts in the family, violence against pregnant women, loss of social support "such as loss support of husband or community", smoking history "such as cigarettes or hookah", antenatal follow-up, obstetric factors such as "unwanted or unplanned pregnancy, gender of the fetus, pregnancy trimesters, complications associated with pregnancy, primigravida, multigravida, etc.", history of stillbirth, history of abortions, and history of mental or psychiatric diseases. Table (1.1): Conceptual and operational definition of the study variables. Variable Conceptual definitions Operational definition Antenatal Depression The fifth edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM- IV) defines antenatal depression as Major Depressive Disorder (MDD), which mostly associated with environmental and genetic factors (American Psychiatric Association, 2013) that affect a pregnant woman, and makes her feel sad all the time for weeks or months throughout pregnancy, and can be a precursor to postpartum depression if not properly treated. The disorder can range from mild to severe and it can affect women in various ways (Tommy's PregnancyHub, 2018). This question is answered according to BDI-II scale 0–13 Non or Minimal depression. 14–19 Mild depression. 20–28 Moderate depression. 29–63 Severe depression. Polygamou s husband Polygamous: It is defined as a marriage to more than one spouse at a time (Mabaso, Malope, & Simbayi , 2018). This question is answered by choosing yes or no. Violence against pregnant women The term violence against women means any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life (Department of Social Services, Australian Government, 2020). This question is answered by choosing yes or no. If yes, specify:  Emotional violence.  Physical violence.  Sexual violence. 24 Antenatal follow-up Antenatal follow-up or antenatal care: It is the care that women get from health professionals during their pregnancy to make sure that she and her baby are as best as possible (National Health Service, 2020). This question is answered by choosing yes or no. Unplanned pregnancy Unplanned pregnancy is a pregnancy that is either unwanted, such as the pregnancy occurred when no children or no more children were desired. Also, the pregnancy is mistimed, such as the pregnancy occurred earlier than desired (National Center for Chronic Disease Prevention and Health Promotion, 2021). This question is answered by choosing yes or no. Pregnancy trimesters First trimester: From the first week to the thirteenth week. Second trimester: From the fourteenth week to the twenty-eighth week. Third trimester: From the twenty-ninth week until the end of pregnancy. (University of California San Francisco, 2020) This question is answered by selecting one of the following:  First trimester.  Second trimester.  Third trimester. Gravidity Gravidity is defined as the number of times that a woman has been pregnant (Tidy, 2019). This question is answered by selecting one of the following:  First one  2-3  4-5  6 or more Parity Parity is defined as the number of times that she has given birth to a fetus with a gestational age of 24 weeks or more, regardless of whether the child was born alive or was stillborn (Tidy, 2019). This question is answered by selecting one of the following:  0  1-3  4-5  6 and more History of stillbirth A stillbirth is when a fetus dies after the mother’s 20th week of pregnancy. The baby may have died in the uterus weeks or hours before labor. Rarely, the baby may die during labor. Although prenatal care has drastically improved over the years, the reality is stillbirths still happen and often go unexplained (Cleveland Clinic medical professional, 2020). This question is answered by choosing yes or no. History of abortions An abortion is a loss of pregnancy due to the premature exit of the products of conception (the fetus, fetal membranes, and placenta) This question is answered by selecting 25 from the uterus due to any cause. An abortion may occur spontaneously (termed a miscarriage) or may be medically induced (Marks, 2021). the number of abortions.  0  1  2  More than 2. History of mental or psychiatric diseases A mental disorder, also called a mental illness or psychiatric disorders are health conditions involving changes in emotion, thinking or behavior (or a combination of these). Mental illnesses are associated with distress and/or problems functioning in social, work or family activities (Parekh, 2018). This question is answered by choosing yes or no. 26 Chapter Two Theoretical and Literature Review 27 Chapter Two Theoretical and literature review Theoretical review for antenatal depression: 2.1. Signs and symptoms: In general, it is characterized by symptoms of depression such as impaired sleep or concentration, feelings of guilt or poor self-worth, low energy and changes of appetite, lack of interest in daily tasks and a constant of depressed mood (Mahendran, Puthussery, & Amalan, 2019). Other symptoms include poor memory, feeling irritable and resentful, feeling inadequate and worthless, numbness and suicidal or abortion thinking (Thompson & Ajayi, 2016). Other common signs and symptoms included Feelings “such as feeling depressed or extremely sad most of the day nearly every day, feeling irritable or angry, feeling very guilty or worthless, feeling hopeless, feeling overwhelmed, not enjoying the baby; and not interested in or able to enjoy activities that she used to enjoy”; Behaviors “such as sleeping a lot more or less than usual, eating a lot more or less than usual, and withdrawing from family, friends and social contact”; Physical Symptoms “such as crying for no apparent reason, feeling restless, having little energy, having difficulty concentrating or making decisions, and having physical symptoms like headaches or upset stomach”; and Thoughts “such as having 28 thoughts that she is a ‘bad’ or ‘terrible’ mother and having frightening thoughts including harming herself and/or the baby, or even suicidal thoughts” (Haring, Smith, Bodnar, & Ryan, 2011). 2.2. Causes: There are many causes that may contribute or cause depression during pregnancy, including: The physical situation of the family leads to extreme pressure on the lady and herself, especially if there are other children; Tired pregnancy symptoms can also affect mental health, as well as hormonal changes; Fear of new responsibility, especially if the woman is going to be a mother for the first time; Changes in relationships with life partner, or lack of self-confidence; Worrying - if the family already has children - about how they will be affected by the new baby; Complications in pre- pregnancy or childbirth are an important cause of pregnancy depression; and Previous infertility or abortion, it is normal for a woman to be worried about pregnancy if she finds it difficult to conceive before, or has had an abortion before (Sedky, 2019). 2.3. Risk factors: Anyone can become depressed during pregnancy, though some people are more vulnerable. The most common risk factors for antenatal depression, including: Previous history of depression, Little or no exercise, Not having a partner, A history of abuse or trauma, Abuse by a partner, feeling out of control, Smoking, using certain drugs, such as opioids, Sleep problems, 29 Immune system problems, having an unintended pregnancy, and not having a job (Legg & Villines, 2019). In addition, many factors are believed to be linked with antenatal depressive disorders such as past obstetric complications, lack of husband support, previous abortion, financial difficulties and unplanned pregnancy. Moreover, poor or lack antenatal care, chronic medical diseases and past psychiatric disorders have been recorded. Antenatal depressive disorders also have been documented that they lead to high repeat spontaneous abortions, postnatal depressive disorders and poor rearing capacity in children. Also, the consequences of unmanaged antenatal depressive disorders are often immune-related illnesses, low social functioning, intrauterine growth retardation, recurrent child diarrheal diseases, impaired postnatal growth and preterm delivery. Furthermore, preterm delivery, low birth weight, substance misuse and poor attendance at antenatal services have all been linked with depressive mood during pregnancy (Zegeye, et al., 2018). 2.4. Assessment and Diagnosis: Simple screening questions can be used at regular intervals during pregnancy. It is beneficial, but not always possible, to assess a woman with a history of mental health disorders before she conceives. This allows any anticipated treatment to be planned with respect to using the safest and most effective options (The Best Practice Advocacy Centre, 2010). 30 2.5. Depression DSM-5 Diagnostic Criteria A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day. 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 31 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day. 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or to another medical condition. Note: Criteria A–C represent a major depressive episode. Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of 32 clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss. D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. E. There has never been a manic episode or a hypomanic episode. Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition. (American Psychiatric Association, 2013). 2.6. Treatment: a) Psychological treatment Psychotherapy is recommended for any woman suffering from antenatal depression, as it is an effective way for the mother to express her feelings in her own words. Specifically, Cognitive Behavioral Therapy effectively helps decrease symptoms of antenatal depression (Li, et al., 2020). Familial support may also play a role in helping with the emotional aspects of antenatal depression (Hu, et al., 2019). 33 There are two specific types of psychological therapy that have been proven to be effective for depression.  Cognitive behavior therapy (CBT) Cognitive behavior therapy can help to identify the negative thinking that is likely to be affecting mood (feelings) and behavior. When a woman is depressed, they see life in a negative way – as it reflects the way that they are generally feeling about themselves and/or life in general. The cognitive aspect of this treatment is, therefore, about helping to identify this negative thinking style, and begin to challenge negative thoughts by looking at the evidence for them and rationalizing them. The behavioral aspect of this treatment for depression may involve doing things that was avoided or no longer doing. When woman depressed, she often doesn’t gain interest or pleasure out of things that they used to do, and so often stop doing these things – which takes even more pleasure out of life, can make she feel more isolated and robs her of the feeling of satisfaction when she achieves something. Therefore, often treatment also involves setting small goals and, although they may seem hard to do at first, but they will become easier and give the opportunity to experience pleasure again – thus playing an important role in recovery (Centre of Perinatal Excellence, 2021). 34  Interpersonal Psychotherapy (IPT) As depression may be associated with past losses and/or changes, this type of therapy can assist woman to resolve these losses, changes or manage conflicts which may be contributing to her experience of depression (Centre of Perinatal Excellence, 2021). b) Exercise Therapy Studies suggest that forms of exercise can help with depressive symptoms both before and after birth, but not prevent it entirely. Exercise options that have been studied to help reduce symptoms: Yoga, Walking, Stretching, and Aerobic exercise (Daley, et al., 2015). c) Medical treatment  Antidepressant medications Antidepressant medications are most commonly used for the treatment of depression. There are antidepressants that are safe to use during pregnancy, as they are not associated with any birth defects. Unlike the earlier antidepressants, the medications that are available now are not only safe, but also effective and not addictive. Taking antidepressants can also help protect against potential negative impacts of depression on developing baby. The National Perinatal Mental Health Guideline identifies two types of antidepressant medication that can be used in pregnancy, namely selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) (Centre of Perinatal Excellence, 2021). 35 There are several kinds of antidepressants. Most affect chemicals in the brain called neurotransmitters, but each kind does it in a different way. And each has risks and benefits during pregnancy. Antidepressants that may be used during pregnancy include:  Serotonin reuptake inhibitors (also called SSRIs). SSRIs are the most commonly prescribed antidepressant medicines. SSRIs that may be used during pregnancy include citalopram (Celexa®), fluoxetine (Prozac®) and sertraline (Zoloft®).  Serotonin and norepinephrine reuptake inhibitors (also called SNRIs), like duloxetine (Cymbalta®) and venlafaxine (Effexor XR®).  Tricyclic antidepressants (also called TCAs), like nortriptyline (Pamelor®).  Bupropion (Wellbutrin®). (March of Dimes organization, 2019).  Electroconvulsive therapy (ECT) This type of treatment is only used in pregnancy for the treatment of severe depression when other treatments are not having any effect and the risk of not treating symptoms (such as suicidal thoughts) outweighs the risk of the treatment itself. As this is a very specialist treatment, it can only be prescribed by an antenatal psychiatrist who generally performs the treatment alongside obstetrician and a specialist obstetric anesthetist. Together, the specialist team work to ensure the close monitoring of 36 woman and unborn baby. The risks to the woman and baby from the treatment are low and, in many cases, is a life-saving treatment for women with severe depression in pregnancy (Centre of Perinatal Excellence, 2021). 2.7. Complications: Antenatal depression is associated with increased risk of: Miscarriage; Preterm delivery; Increased pregnancy symptoms, pain relief in labour and worse obstetric outcome; Higher incidence of lower birth weight, caesarean section but not infant mortality; Attempted/completed suicide; Possible longer-term cognitive, emotional and behavioral difficulties in offspring; and Relationship and family break-up (Knott & Cox, 2016). In addition, Maternal depression has been associated with various detrimental health concerns for both the baby and the mother. Babies born to women with untreated depression are at risk of prematurity, low birth weight, and intrauterine growth restriction. The negative consequences of untreated maternal depression might also affect childhood development. Higher impulsivity, maladaptive social interactions, and cognitive, behavioral, and emotional difficulties have been shown to occur. The adverse outcomes of untreated maternal depression might also be detrimental to the mother. Importantly, pregnant women with depression are more at risk of developing postpartum depression and suicidality. Increased hospital admissions and pregnancy complications such as 37 preeclampsia have also been linked to untreated maternal depression. It has also been shown that pregnant women with depression are more likely to engage in high-risk health behavior. Some examples include smoking, illicit substance and alcohol abuse, and poor nutrition. To prevent this behavior, antidepressant treatment might be needed (Chan, Natekar, Einarson, & Koren, 2014). B. Literature review: Through a review of previous studies; the researcher reviewed the studies that dealt with the prevalence of Antenatal depression in health care centers, at the local, regional and international levels. The review of literature was carried out based on all accessible literature such as: books, theses, published research papers, systematic reviews, journal articles and websites. The researcher reviewed and looked at the prevalence of antenatal depression, signs & symptoms, risk factors, causes, diagnosis, classification and disorder management. The researcher was used both Medical and Psychiatric Research Sources (CINAHL, PsycINFO, PubMed and Google Scholar), to pick related studies and articles on this subject, in single or combined phrases, with the following main words: prenatal/antenatal depression; prenatal/antenatal depression in Palestine; depression during pregnancy; causes of prenatal/antenatal depression; and risk factors for prenatal/antenatal depression. Further consideration was given to the related papers cited in 38 the references of selected articles for inclusion in the literature review. Original literatures have been involved if they have been written and published in English language. Moreover, after cross-referencing the various sources and removing duplicates and irrelevant documents, the literatures documents were chosen. In addition, the studies were omitted whether the risk factors examined, the periods of assessments, the measures used and the statistical analysis were not explicitly defined, or if they had explored risk factors for depression in the postnatal stage and it was not possible to ascertain if the risk factors were unambiguously relevant to the antenatal stage. In regards to the causes of major depression in the general population, the scientific literature is detailed and systematic. Nevertheless, the evidence on depression predictors in women during the pre and postnatal stages is rare (Silva, et al., 2010). There are no firm estimates of antenatal depression and no consensus on appropriate screening tools around the world. The prevalence rates are likely to differ among studies and countries due to choose of measures and sociocultural determinants. Studies have used either screening measures or structured interview schedules to confirm the diagnosis. Many research has reported the risks of not detecting and treating antenatal depression. In addition to impacting psychological wellbeing, the antenatal 39 depressive symptoms are often linked with an elevated of obstetrics risk (Silva, et al., 2010). According to a recent systematic review of cohort studies, the antenatal depression prevalence was 14%, compared to a 10.5% pooled prevalence of postnatal depression. Furthermore, in a study of pregnant women in an urban community in Pakistan showed that 18% of the women were anxious and/or depressed. Also, in a study conducted in Malaysia, the prevalence of anxiety and depression disorders among antenatal mothers using diagnostic clinical interview were 9.1% and 8.6%, respectively (Murtaja & Thabet, 2017). There is a study that was done by Kaiyo-Utete et.al in Harare, the Republic of Zimbabwe. The study was done between January to April 2018. It aims to investigate the prevalence and relevant factors of antenatal depression among pregnant women. The sample size was including 375 pregnant women, the study tool was electronic questionnaire form and structured clinical interview for DSM-IV to measure antenatal depression. Statistical tests were performed to identify the relationship between antenatal depression and characteristics of the participants. The findings showed that 23.5% of participants were depressed. Antenatal depression was related to a chronic sickness diagnosed throughout this pregnancy, not having somebody to speak to once feeling inundated with life. Women who have witnessed violence from her partner were 2.5 times a lot of doubtless to 40 possess antenatal depression than those who didn't. Those women who experienced had an unfavorable life event in the past year were twice as likely to have antenatal depression as those who don't had such event. However, being married or cohabiting with the father of the child lowered the risk of experiencing an antenatal depression (Kaiyo-Utete, et al., 2020). In addition, there was analytical cross-sectional study conducted by Mansour Ghanaie M et.al. It aimed to identify the prevalence and factors related to depression, with focus on fetal sex. The study tool was a questionnaire including three parts: demographic data, obstetric factors and Beck Depression Scale. The prevalence of depression was determined to be 27.4% in 500 pregnant women. mother's job condition, children number same sex of fetus with previous children, length of notice from fetus sex, depression history in the family, spousal satisfaction, and stressful event were factors correlated with depression in pregnancy and were determined as the most potent variables influencing the occurrence of antenatal depression. And it showed that there was significant relationship between depression during pregnancy and "the same gender of fetus with previous child and duration of knowledge of fetal sex" (Ghanaie, Solimani, kazemnejad, Samadi.Sophi, & Asgari.Galebin, 2019). At the same way, there was a prospective, observational, longitudinal study conducted by Bozzo et.al in 2011 to determine whether Nausea & vomiting of pregnancy (NVP) is associated with depression in women with no history of depression prior to pregnancy. In which data were analyzed 41 obtained from 57 women. It was observed no association between depressive symptoms and Nausea & vomiting of pregnancy (NVP) (Bozzo, Einarson, Koren, & Einarson, 2011). Another study was performed by Manikkam & Burns, to determine the prevalence and risk factors associated with antenatal depressive symptoms in a KwaZulu-Natal population. The Edinburgh Postnatal Depression Scale and a socio-demographic questionnaire in English and isiZulu were administered to 387 antenatal outpatients at King Edward VIII Hospital in Durban. It showed \that of the participants, 149 (38.5%) suffered from depression and 38.3% had thought of harming themselves in the preceding 7 days. Risk factors for depression included HIV seropositivity, a prior history of depression, recent thoughts of self-harm, single marital status and unplanned pregnancy (Manikkam & Burns, 2012). Besides, there is a study was performed by Arora & Aeri. The goal was to determine the depression burden and the risk factors related to it in pregnant Indian women. And showed that the prevalence of AD was found to be ranging from 9.18% to 65.0% in northern, western, and southern part of India. The factors such as unemployment, advancing pregnancy and age, male gender preference, abortion history, unplanned pregnancy, multigravidity, lower/lower‑middle socioeconomic status, poor education status of women, bad relations with in‑laws, and demand for dowry were significant predictors for AD (Arora & Aeri, 2019). 42 Likewise, a study done by Ayano, Tesfaw, & Shumet, and aimed to systematically summarize the current evidence for antenatal depression epidemiology in Ethiopia. Studies investigating the prevalence and related causes of antenatal depression from 3 electronic datasets (SCOPUS, EMBASE, and PubMed) have been systematically reviewed and meta- analyzed by the researchers. It showed that the pooled prevalence of antenatal depression in Ethiopia was 21.28%. A high risk of developing antenatal depression for pregnant women were linked to having a prior depression history, complications during pregnancy, stillbirth history, no antenatal care follow-up, irregular antenatal care follow-up, and not satisfied by antenatal care follow-up. The researchers also observed that the risk of experiencing antenatal depression was greater for women suffering from partner violence during pregnancy, medium or low social support, food insecurity, and those who were between the ages of 20-90 years old, house wives and farmers (Ayano, Tesfaw, & Shumet, 2019). In the same way, to synthesize logical data about the prevalence and possible risk factors of antenatal depression in Ethiopia. There was a study performed by Getinet, et al. In which the research team explored multiple databases to find published studies with evidence on the prevalence of antenatal depression. Nine papers were subsequently used for the prevalence of synthesis, of which four research were chosen for the study of the impact of unplanned pregnancy on antenatal depression. For the 5 researches chosen, which used BDI, the cumulative prevalence of antenatal 43 depression was 25.33. The other 4 researches that also used other diagnostic tools (1 PHQ and 3 EPDS) had the prevalence decreased to 23.56, and the cumulative impact of unplanned pregnancy on antenatal depression was 1.93. Variables like age, marital condition, level of income, employment, social support, conflict, mother age during pregnancy, complication during to pregnancy, unplanned pregnancy, antenatal follow- up and history of the previous mental disorder were related to antenatal depression (Getinet, et al., 2018). Additionally, there was a study conducted by Mirieri, Mweu, & Olenja, to recognize determinants of antenatal depression among women visiting a referral facility in Mombasa County, Kenya, at the antenatal clinic. In which the only risk factors (significant determinants) for antenatal depression in this setting were marital condition, employment, lack of social support and domestic violence (Mirieri, Mweu, & Olenja, 2020). Furthermore, to study the prevalence of depression during pregnancy and its associated obstetric risk factors among pregnant women attending routine antenatal checkup; there is a cross-sectional observational survey done by Ajinkya, Jadhav, & Srivastava, and showed that prevalence of depression during pregnancy was found to be 9.18% based upon BDI, and it was significantly associated with several obstetric risk factors like gravidity, unplanned pregnancy, history of abortions, and a history of obstetric complications, both present and past (Ajinkya, Jadhav, & Srivastava, 2013). 44 As well as, a community based- cross sectional study was conducted by Belete, Assega, Abajobir, Belay, & Tariku, to assess the antenatal depression prevalence and factors related to it among pregnant women in Aneded woreda, Northwest Ethiopia. And found that the prevalence of antenatal depression was 15.20%. Urban residence, marital status of being unmarried, occupation of being government employee and merchant, prim gravid, not attend antenatal care (ANC) follow up, intimate partner violence, unplanned pregnancy, and substance use were significantly factoring (Belete, Assega, Abajobir, Belay, & Tariku, 2019). Moreover, Tuksanawes, Kaewkiattikun, & Kerdcharoen, were conduct a cross-sectional study of 402 pregnant women to discover the prevalence, associated factors, and predictive factors of depression in pregnant women living in an urban area. The prevalence of depressive symptoms in pregnant women in an urban zone was 18.9% among a total of 402 pregnant women. Symptoms of depression in pregnant women were strongly linked to substance abuse, low family income, financial insufficiency, marital and family conflict, divorce, extended family, history of previous complications in pregnancy, history of previous abortion, The essential variables that predict depression in pregnant women were family conflict and extended marital (Tuksanawes, Kaewkiattikun, & Kerdcharoen, 2020). While Zegeye, et al., indicated that the progression of depressive symptoms increases dramatically during the antenatal phase; also, the 45 clinically significant depressive symptoms are prevalent throughout the second and third trimesters (Zegeye, et al., 2018). Also, a study performed by Sheeba, et al. to assess the prevalence of antenatal depression and its associated risk factors among pregnant women in Bangalore, Southern India, showed that the proportion of respondents who screened positive for antenatal depression was 35.7%. Presence of domestic violence was found to impose a five times higher and highly significant risk of developing antenatal depression among the respondents (Sheeba, et al., 2019). As well as, in a systematic review examining mental health diseases of African women living in Africa, the polygamous relations, separated/divorced, specifically single and marital status in general have been reported as a risk factors of antenatal depression (Sawyer, Ayers, & Smith, 2010). While a descriptive cross-sectional study was conducted by Al-Azri et.al, at Muscat, Oman. The study was conducted between January and November 2014. It aims to investigate the prevalence of antenatal depression and the risk factors that related to its progression among Omani women. The survey includes a total of 959 pregnant women≥ 32 gestational weeks who visited one of 12 local primary health care centers at random basis. The research instrument was the Arabic form of the validated Edinburgh Postnatal Depression Scale (EPDS) self-administered 46 questionnaire for assessing and measure antenatal depression. The findings demonstrated that the prevalence of antenatal depression among the Omani women surveyed was (24.3%). Bivariate analysis results showed a significantly associated between antenatal depression with marital conflict, unplanned pregnancies, and history of depression in the family (Al-Azri, et al., 2016). Also, there is a study conducted by Al Hejji, Al Khudhair, Al Musaileem, & Al Eithan, it was aimed to measure the prevalence and associated risk factors of antenatal depression (AD) among women attending antenatal clinics at primary care centers in the Ministry of Health in Al‑Ahsa, Saudi Arabia. It found that the prevalence of AD among pregnant women in Al‑Ahsa is 31.9%. The researchers found a significant association between AD and factors such as difficulty in sleeping, having a smoker husband, having one previous pregnancy, and having postabortion psychological complications (Al-Hejji, Al-Khudhair, Al-Musaileem, & Al-Eithan, 2019). Moreover, a study that was done by Murtaja and Thabet in 2017 at Gaza Strip, Palestine. It aims to examine the levels of depression and anxiety for pregnant women who presenting primary healthcare clinics. Four hundred women attending primary healthcare centers for antenatal care, with 60% of the participants attending in government clinics, and 40% going to the UNRWA clinic in the Near East, the study tool was Beck Depression Scale and Socio-Demographic characteristics questionnaire. Statistical tests "such as independent t-test and One-way ANOVA" were used to examine 47 the differences in depression among pregnant women based on sociodemographic variables. The results showed that women who attended UNRWA clinics reported a higher incidence of depression than those who attended governmental clinics. At the same time, women living in refugee camps were comparatively more depressed than those living in a city or a village, and uneducated women reported a greater incidence of depression relative to the other groups. women with more than 8 children were more depressed than those with 5-7 children, and 4 and a smaller number of children. finally, results were showed that one-third of the women reported moderate depression 33.3%, and 23.3% mild symptoms of depression, and18.5% had a more severe form of depression (Murtaja & Thabet, 2017). At the same way, a cross-sectional, quantitative descriptive study, was conducted by Abu-Iznait & Al -Tell in antenatal centers at 9 refugee camps in the West Bank, Palestine. The study was conducted between April to June 2016. It aims to investigate the prevalence of anxiety and depression for pregnant women and the relevant factors. The sample size was including 327 pregnant women who were randomly chosen, the study tool was (PHQ-9) Scale to measure the degree of depression. The principal results indicated that the pervasiveness of depression among pregnant women was high (59.5%) in the refuge. The pregnant women revealed the various levels of depression as follows: 34% of participants experiencing from mild depression, 17.2% experiencing from moderate depression, 6.1% experiencing from moderate to severe depression, and 2.1% 48 experiencing from severe depression. It concluded that the most important factors related to antenatal depression are participants age and gravity number (Abu- Iznait & Al -Tell, 2017). Summary: It became noticeable that the studies agreed on a range of outcomes, such as many studies support that depression are the most prevalent psychiatric diseases during pregnancy with an estimated prevalence ranging from 4% to 25%; Also, the prevalence of antenatal depression is higher in low income countries compared to high income countries; Moreover, the prevalence of antenatal depression is increase among women with family conflicts, loss of support, unwanted pregnancy, complications associated with pregnancy, primigravida, multigravida, history of abortions, and history of mental or psychiatric diseases; finally, the results of the researches in both Palestinian studies agreed that the prevalence of antenatal depression among pregnant women in Palestine, especially in the camps, was higher than it was in city or village, whether in the West Bank or Gaza Strip, and the reason for this may be due to the harsh conditions experienced by Palestinian women in camps in the West Bank and Gaza Strip. While previous studies are differed in several issues such as the prevalence of antenatal depression is different among Palestinian women on the one hand, and Arab and international women on the other hand, as the rate in 49 Palestinian studies was higher than Arab and international studies; Also, there is a large difference in the sample size between Arab studies on the one hand and international and Palestinian studies on the other hand, as the sample size in Arab studies was much higher than the sample size of international and Palestinian studies; and there was a difference in the study tool between all the studies reviewed. 50 Chapter Three Methodology 51 Chapter Three Methodology 3.1. Research Design: A quantitative, descriptive, cross sectional study design was used in this study. As the descriptive statistics are often used to illustrate the basic characteristics of the research data. It provides brief summaries about the measures and the sample; Also, it forms the base of nearly every quantitative data analysis, along with simple graphics analysis (Trochim, 2020). While the cross-sectional study is one of the kinds of research designs, that include looking at data from a population at a single point in time. This method was used to make inferences about possible relationships and to gather preliminary data to support further research and experimentation (Cherry, 2019). 3.2. Study Population: The target group was all pregnant women who attended to the government antenatal clinics in Nablus until 30th of April 2021. Their number is 3149 pregnant, according to the Palestinian Ministry of Health. 52 Thirty-eight pregnant women were excluded, in which 37 women were excluded because of their pregnancy In Vitro Fertilization (IVF), and one pregnant woman was excluded because her age was less than 16 years. Therefore, the target population number during the study period is 3111. 3.3. Study Setting: This study was performed in Nablus at governmental primary health care clinics affiliated with the Palestinian Ministry of Health. These clinics are: Balata, Almakhfia, Ras Al Ain, Beit Furik, Hawara, Asira ash-Shamaliya, An-Nassariya, Sebastia, Beta, Burqa, Jamma'in, Deir Sharaf, Qabalan, As- Sawiya, Al Naqoura, Bizzariya, Burin, Beit Imrin, Beit Iba, Bayt Dajan, Central care clinic, Talfit, Rujeib, Deir al-Hatab, Sarra, Azmut, Awarta, Urif, Einabus, Qaryout, Talluza, Aqraba, Qusra, Qusin, Majdal Bani Fadil, Yasid, Yatma, Tell, Al-Badhan, Duma, Salim, Al-Lubban ash-Sharqiya, Asira al-Qibliya and Osarin. 3.4. Study Period: The study was beginning in March 2021, after receiving approval from the Institutional Review Board (IRB) of An-Najah National University and approval from the Research Ethics Committee of the Palestinian Ministry of Health. The pilot study was conducted between 1-15 May 2021. Data collection was started in 19 May 2021, to 19 July 2021. Data was entry on 25 July 2021. Also, data analysis, reviewing of literature and writing the study was continued until end of August 2021. 53 3.5. Sample Size: It was included 343 pregnant women, and calculated by two methods: First: By an online sample size calculator (Annex 1). It is accessible on website "Select Statistical Services"; and it used to calculate the accurate sample size (Select Statistical Services Limited, 2020). Second: By Stephen Thompson Equation. Which use the following formula for the sample size: Where, n: Sample size; N: Population size; z: Confidence level at 95% = (1.96); d: Error proportion = (0.05); and p: Population proportion (expressed as a decimal) = 0.50 (Thompson S. K., 2012). 3.6. Sampling Technique: A convenience sampling technique was used in this study. It is often referred to as availability sampling, which considered one of the types of non-probability sampling method that focuses on collection of the data from members of the population that are conveniently available to participate in study. The researcher chose this technique because it has several advantages, including: Simplicity of sampling and the ease of research; Helpful for pilot studies and for hypothesis generation; Data        ppzdN ppN n    11 1 22 54 collection can be facilitated in short duration of time; and Cheapest to implement that alternative sampling methods (Dudovskiy, 2020). 3.7. Inclusion & Exclusion Criteria: Inclusion Criteria: o All Pregnant women in Nablus governorate, who had a spontaneous pregnancy. o Pregnant women who were attending routine antenatal care in governmental primary health care centers in Nablus governorate. o Pregnant women who aged 16 years and over. o Pregnant women who resident in the research area. o Pregnant women who were available at the study period. o Pregnant women who had the ability to read, write, and use mobile phones or laptops. Exclusion Criteria: o Pregnant women who didn’t have a spontaneous pregnancy (such as having IVF). o Pregnant women who didn’t attending routine antenatal care in governmental primary health care centers in Nablus governorate. o Pregnant women who didn’t resident in the research area. o Pregnant women who refuse participation in this study. o Pregnant women who not interested to participate in this study. o Pregnant women who were on treatment for mental disorders. 55 o Pregnant women who aged under 16 years. 3.8. Study Tool: In order to meet the aims of the study, self-administered questionnaire (Annex 2) was introduced in the present study for data collection. It was prepared with the assistance of the supervisor of the researcher, and with collaboration of mental-health experts, after seeing, reading of many questions and questionnaires from different related previous literatures and studies. The questionnaire was composed of many sections, including questions about: age group, level of education, residential area, employment & income, marital condition, family type, number of family members, having a polygamous husband , conflicts in the family, violence against pregnant women, loss of social support, smoking history, suffering from medical diseases, gravidities, parities, history of abortions, number of male children, number of female children, antenatal follow-up, unwanted or unplanned pregnancy, gender of the fetus, pregnancy trimesters, complications associated with pregnancy, history of stillbirth, history of abortions, history of mental or psychiatric diseases and levels of antenatal depression. Antenatal depression was measured and assessed by using second Beck's Depression Inventory (BDI-II) scale because it is the most appropriate scales for the objectives of the study. Where the BDI-II is a brief, self- 56 report inventory designed to measure the severity of depressive symptomatology. It is consisting of 21 items, each with 4-point Likert-type response scale. A score ranging from 0 (absence of symptom) to 3 (severe manifestation of symptom) was allocated to each answer, showing the severity of the symptom. Depression severity is graded based on the overall score; in a normal community sample, BDI-II score 0–13 indicated "non or minimal depression", 14–19 "mild depression", 20–28 "moderate depression", and 29–63 "severe depression". Guidance on using this test, Age ranges from 13 through 80 years. The examiner is to circle and rate each statement according to their feelings over the last two weeks. The reading level of the BDI-II is 5th to 6th-grade level and may be read aloud if needed. The BDI-II is quick and easy to administer, takes 5-10 minutes to complete, and can be administered individually (mental health matters website, 2021). Arabic version of BDI-II scale was translated by Dr. Gharib Abdel Fattah Gharib (Professor and Head of the Department of Mental Health - College of Education - Al-Azhar University). With regard to approval of the use of BDI-II scale, it has been obtained formally from Dr. Gharib through connecting with him on social media (Annex 3). 3.9. Validity and Reliability of questionnaire: The questionnaire was submitted and sent to a panel of academics and professionals with qualifications and expertise in mental health, 57 gynecologists and midwives fields to evaluate whether the questionnaire used is scientifically accurate or not, and to know if the questionnaire is reasonably well structured to analyze the factors & variables and to examine the relationships; to provide judgment and suggestions on the appropriateness of the questionnaire; and to evaluate and decide if the questions are important and related to the goals of the study. All feedbacks and amendments to the questionnaire were considered. Moreover, a pilot study was carried out prior to data collection starts. Regarding to BDI-II being a universal scale, it considered a valid depression screening tool in primary health care centers, because it has already been tested for its reliability and validity. In Palestinian Society, the Arabic form of the scale was also validated. The BDI-II showed a strong internal consistency, with coefficients alpha of 0.86 and 0.80 for non-psychiatric and psychiatric groups respectively (Murtaja & Thabet, 2017). In this study, the reliability of BDI-II was measured by calculating the Cronbach’s Alpha coefficient. Table 3.1 shows the values of Cronbach's Alpha for BDI-II domain of participants. The values of Cronbach's Alpha were 0.883 which indicates good reliability of the entire questionnaire. Table (3.1) :Reliability of the research for BDI-II domain. No. Domains No. of item Cronbach's Alpha 1. BDI-II domain 21 0.883 58 3.10. Pilot Study: A pilot study is considered one of the most significant phases of a research project (Abu Hassan, Schattner, & Mazza, 2006). A pilot analysis was carried out on 10% of the sample size (34 participants) as a pre-test prior to the begin the actual data collection, in order to provide feedback on the questionnaire; check the questionnaire's reliability & validity; to estimate response rate; to assess the actual time required to complete the questionnaire; to identify topic recruitment; to know areas of vagueness; to identify language weaknesses; and to gain evident opinion on the questionnaire in order to avoid question ambiguity & length. All of them (34 participants) were from different age groups, levels of education, and living area. A comprehensive overview about the study and its purposes was provided to all of them prior collecting the data. The researcher found acceptance by the participants when distributing the questionnaire to them – response rate was 100%-. The data collection time was not l