Health-promoting lifestyle behaviours and their association with antenatal depression and anxiety across pregnancy trimesters in Sri Lanka: a hospital-based cross-sectional study

Health-promoting lifestyle behaviours and their association with antenatal depression and anxiety across pregnancy trimesters in Sri Lanka: a hospital-based cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Health-promoting lifestyle behaviours and their association with antenatal depression and anxiety across pregnancy trimesters in Sri Lanka: a hospital-based cross-sectional study Wasana Fernando¹, Tehani Gunawardena² This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8962259/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Globally, antenatal depression and anxiety are major contributors to maternal morbidity with disproportionately high prevalence in low- and middle-income countries (LMICs). Despite Sri Lanka’s strong maternal healthcare system, perinatal psychological distress remains under-integrated within routine antenatal services. Health-promoting lifestyle behaviours, conceptualized within Pender’s Health Promotion Model, represent potentially modifiable behavioural factors of maternal mental health. However, trimester-specific evidence from South Asia is limited. This study examined associations between health-promoting lifestyle factors and antenatal depressive and anxiety symptoms among pregnant women in Sri Lanka. Methods A hospital-based cross-sectional study was conducted among 383 pregnant women attending antenatal clinics at two maternity hospitals in Colombo district. Participants completed the Health-Promoting Lifestyle Profile-II (HPLP-II), Edinburgh Postnatal Depression Scale (EPDS), and Perinatal Anxiety Screening Scale (PASS). Pearson correlations assessed bivariate associations. Multiple linear regression models evaluated independent associations controlling trimester and socio-demographic variables. Subgroup analyses explored trimester variation. Results Higher total HPLP-II scores were significantly associated with lower depressive symptoms (β = -0.31, 95% CI -0.42 to -0.20, p < 0.001). Stress management and spiritual growth domains remained independently associated with reduced EPDS scores. Total lifestyle engagement was not significantly associated with overall anxiety scores (p = 0.09). However, physical activity was negatively associated with anxiety symptoms (β = -0.18, p = 0.01), while interpersonal relations (β = 0.16, p = 0.02) and spiritual growth (β = 0.14, p = 0.03) were positively associated. Depressive symptoms were highest during the third trimester, whereas anxiety peaked in the second trimester. Conclusions Health-promoting lifestyle behaviours were significantly associated with reduced antenatal depressive symptoms but demonstrated domain-specific associations with anxiety. Integrating trimester-sensitive behavioural strategies into antenatal care may strengthen maternal mental health outcomes in Sri Lanka and comparable low- and middle-income settings. antenatal depression antenatal anxiety health-promoting lifestyle pregnancy Sri Lanka cross-sectional study Background Globally, antenatal mental disorders affect approximately one in five women and represent a substantial contributor to maternal and infant morbidity [ 1 – 3 ]. The burden is particularly prominent in low- and middle-income countries (LMICs), where sociocultural, economic, and structural vulnerabilities compound psychological risk [ 1 , 2 ]. Antenatal depression and anxiety are associated with preterm birth, impaired fetal growth, and long-term developmental consequences for offspring [ 3 – 5 ]. Sri Lanka maintains a well-established maternal health infrastructure with high antenatal coverage. However, maternal mental health screening and preventive behavioural integration remain inconsistent. Recent evidence indicates clinically significant levels of antenatal depressive and anxiety symptoms in Sri Lankan populations [ 6 , 7 ]. Health-promoting lifestyle behaviours, including nutrition, physical activity, stress management, spiritual growth, interpersonal relations, and health responsibility, may represent modifiable protective factors. Pender’s Health Promotion Model proposes that engagement in adaptive behaviours influences psychological outcomes through cognitive-affective pathways shaped by individual and sociocultural contexts [ 8 ]. Although international literature supports associations between lifestyle engagement and reduced depressive symptoms [ 9 , 10 ], trimester-specific analyses within LMIC contexts remain limited. Given that psychological vulnerability fluctuates across trimesters, understanding trimester-sensitive associations is critical for maternal service planning. This study aimed to examine the association between health-promoting lifestyle factors and antenatal depressive and anxiety symptoms across pregnancy trimesters among Sri Lankan women. Methods Study design and setting A hospital-based quantitative cross-sectional study was conducted between January and June 2024 at two tertiary maternity hospitals in the Colombo District, Sri Lanka: Castle Street Hospital for Women (CSHW) and De Soysa Hospital for Women (DSHW). These institutions are among the largest maternity care providers in the country, collectively serving over 68,000 antenatal clinic attendees annually. The study was designed to examine the relationship between health-promoting lifestyle factors (HPLFs) and antenatal depression and anxiety across all three trimesters of pregnancy. Participants The study population consisted of pregnant women attending routine antenatal clinics at CSHW and DSHW during the data collection period. Inclusion criteria Participants were eligible if they: Were currently pregnant (any trimester) Were aged 18 years or older Resided in the Colombo District Were literate in Sinhala or English Provided written informed consent Exclusion criteria Participants were excluded if they: Were in the postpartum period Had high-risk pregnancies requiring specialized medical monitoring Had pre-existing severe medical conditions (e.g., uncontrolled hypertension, cardiovascular disease, autoimmune disorders, diabetes mellitus, thyroid disorders) Had diagnosed severe psychiatric conditions prior to pregnancy (e.g., major depressive disorder, bipolar disorder, psychotic disorders, post-traumatic stress disorder, substance use disorders) These exclusions were implemented to safeguard participant well-being and minimize clinical confounding. Sample size The required sample size was calculated using the Krejcie and Morgan population correction formula with Raosoft software (Raosoft Inc., 2004), based on an estimated antenatal population of 68,275 women across both hospitals. A 95% confidence level, 5% margin of error, and 50% response distribution were assumed. The minimum required sample was 383 participants. An additional 20% adjustment was considered for potential non-response; however, due to the supervised data collection approach and high participation rate, the final achieved sample remained 383 participants. Sampling and recruitment A non-probability opportunity (convenience) sampling method was employed. Eligible women attending routine antenatal clinic sessions were approached sequentially based on availability during clinic hours. To improve representation within the hospital setting, the total sample was proportionally allocated according to antenatal attendance statistics (CSHW: n = 237; DSHW: n = 146). Participants from each hospital were distributed across first, second, and third trimesters to ensure inclusion of all pregnancy stages. Data collection procedure Data were collected through supervised self-administered questionnaires conducted within antenatal clinic premises. After confirming eligibility, participants received verbal and written explanations of the study aims and procedures. Written informed consent was obtained prior to participation. Participants completed four instruments in their preferred language (Sinhala or English): Edinburgh Postnatal Depression Scale (EPDS) Perinatal Anxiety Screening Scale (PASS) Health-Promoting Lifestyle Profile-II (HPLP-II) Socio-demographic questionnaire The principal investigator remained available to clarify questions and reviewed completed questionnaires for completeness, minimizing missing data. Measures Edinburgh Postnatal Depression Scale (EPDS) The Sinhala version of the EPDS was used to assess antenatal depressive symptoms. The EPDS is a 10-item self-report scale scored on a 4-point Likert format (0–3), with total scores ranging from 0 to 30. A cut-off score of ≥ 9 was used to identify probable antenatal depression, consistent with local validation studies in Sri Lanka demonstrating sensitivity of 90.7% and specificity of 86.8% [ 5 ]. In the present sample, internal consistency was acceptable (Cronbach’s α = .770). Perinatal Anxiety Screening Scale (PASS) The Sinhala-validated PASS consists of 31 items assessing perinatal anxiety across four domains: excessive worry and specific fears; perfectionism, control and trauma; social anxiety; and acute anxiety and adjustment. Items are rated from 0 (not at all) to 3 (nearly always), yielding total scores from 0 to 93. A cut-off score of ≥ 26 was used to identify elevated anxiety risk². Internal consistency in the present sample was acceptable (Cronbach’s α = .741). Health-Promoting Lifestyle Profile-II (HPLP-II) The HPLP-II contains 52 items measuring six behavioural domains: health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, and stress management. Items are rated on a 4-point Likert scale (1 = never to 4 = routinely). Total scores range from 52 to 208, with higher scores indicating greater engagement in health-promoting behaviours. Internal consistency in the present sample was excellent (Cronbach’s α = .913). Socio-demographic characteristics Data were collected on age, trimester, marital status, maternal and paternal education, employment status, household income, number of children, and antenatal class attendance. Reliability Internal consistency of all instruments was assessed using Cronbach’s alpha. All scales exceeded the minimum acceptable threshold of 0.70, indicating satisfactory reliability. Statistical analysis Data were analyzed using IBM SPSS Statistics version 27. Descriptive statistics (means, standard deviations, frequencies) were computed for socio-demographic characteristics and study variables. Normality was assessed using Kolmogorov–Smirnov and Shapiro–Wilk tests and visual inspection of histograms. Although statistical tests indicated minor deviations from normality, the large sample size (N = 383) supported the use of parametric analyses under the Central Limit Theorem. Pearson correlation coefficients were calculated to examine associations between HPLFs and antenatal depression and anxiety. Simple linear regression analyses were conducted to determine whether overall HPLFs predicted depression and anxiety. Multiple linear regression analyses were performed to assess the independent contributions of the six HPLP-II subdomains. Model assumptions (linearity, homoscedasticity, normality of residuals, multicollinearity) were assessed through residual plots, variance inflation factors (VIF < 5), and tolerance statistics. Trimester was examined as a potential moderator using univariate general linear models (GLMs), including interaction terms between HPLFs and trimesters. One-way ANOVA with Tukey’s post hoc tests was used to compare mean differences in HPLFs, depression, and anxiety across trimesters. Chi-square tests were used to assess associations between trimester and antenatal class attendance. All statistical tests were two-tailed with significance set at p < .05. Effect sizes (R², partial η²) and 95% confidence intervals were reported where appropriate. Results Participant characteristics Mean maternal age was 28.7 years (SD 4.8). Trimester distribution: 1st (28%), 2nd (39%), 3rd (33%). Mean domain scores for health-promoting lifestyle factors are presented in Table 1 . Table 1 Mean HPLP-II domain scores Domains (HPLFs) Mean SD Interpersonal relations 2.91 0.45 Spiritual growth 2.88 0.50 Nutrition 2.70 0.48 Health responsibility 2.65 0.51 Physical activity 2.21 0.60 Stress management 2.18 0.58 Association with depressive symptoms Total HPLP-II score was significantly negatively associated with EPDS scores (r = -0.34, p < 0.001). In adjusted regression models, stress management (β = -0.24, 95% CI -0.38 to -0.11, p = 0.001) and spiritual growth (β = -0.19, 95% CI -0.32 to -0.06, p = 0.004) remained significant predictors. Association with anxiety symptoms Total HPLP-II score was not significantly associated with PASS scores. However, physical activity demonstrated a significant negative association. Interpersonal relations and spiritual growth were positively associated. Trimester variation Depressive symptoms were significantly higher in the third trimester (p < 0.01). Anxiety scores peaked during the second trimester (p < 0.05). Overall HPLP-II scores declined in late pregnancy. Discussion This study demonstrates that greater engagement in health-promoting lifestyle factors is associated with lower antenatal depressive symptoms among Sri Lankan women. The findings align with international evidence demonstrating the protective role of behavioural regulation in antenatal mental health [ 1 – 4 ]. The absence of an overall association between lifestyle engagement and anxiety suggests differential behavioural pathways. Physical activity may reduce physiological arousal, whereas interpersonal and spiritual dimensions may function within sociocultural contexts that simultaneously provide support and expectation pressures. Trimester-specific findings indicate that vulnerability and behavioural engagement fluctuate across trimesters. These findings highlight the importance of integrating behavioural counselling within routine antenatal care, particularly during later pregnancy. Limitations The cross-sectional design excludes causal inference. Self-report measures may introduce bias. Findings from tertiary hospitals may not generalize to rural settings. Conclusions Health-promoting lifestyle factors were negatively associated with antenatal depressive symptoms but demonstrated domain-specific associations with anxiety. Behaviourally integrated, trimester-sensitive maternal care strategies may enhance psychological well-being within LMIC antenatal systems. Abbreviations EPDS Edinburgh Postnatal Depression Scale PASS Perinatal Anxiety Screening Scale HPLP II–Health–Promoting Lifestyle Profile–II LMIC Low–and middle–income country Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the Institutional Ethics Review Committee, Faculty of Graduate Studies, University of Colombo (Approval No: FGS/ERC/2024/025), the Ethics Review Committee of De Soysa Hospital for Women (Approval No: 024/2024), and the Ethics Review Committee of Castle Street Hospital for Women (Approval No: ERC/346/07/2024). All procedures performed in this study were conducted in accordance with the ethical standards of the institutional research committees and with the 1964 Declaration of Helsinki and its later amendments. Written informed consent was obtained from all participants prior to data collection. Participation was voluntary, and confidentiality and anonymity were strictly maintained throughout the study. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency. Author Contribution WF conceptualized the study, conducted data collection and statistical analysis, and drafted the manuscript. TG provided methodological guidance, theoretical supervision, and critically revised the manuscript. Both authors read and approved the final manuscript. Acknowledgement The authors wish to thank the administrative and clinical staff of Castle Street Hospital for Women and De Soysa Hospital for Women for facilitating data collection. We are sincerely grateful to the antenatal mothers who generously participated in this study. We also acknowledge the Ethics Review Committee of the Faculty of Graduate Studies, University of Colombo, for their guidance and approval of this research. Data Availability The datasets generated and analyzed during the current study are not publicly available due to participant confidentiality but are available from the corresponding author on reasonable request. References Fisher J, Cabral de Mello M, Patel V, Rahman A, Tran T, Holton S, et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bull World Health Organ. 2012;90(2):G139–49. Howard LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry. 2020;19(3):313–27. Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, Katon WJ. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry. 2010;67(10):1012–24. Ding XX, Wu YL, Xu SJ, Zhu RP, Jia XM, Zhang SF, et al. Maternal anxiety during pregnancy and adverse birth outcomes: a systematic review and meta-analysis of prospective cohort studies. J Affect Disord. 2014;159:103–10. Levis B, Negeri Z, Sun Y, Benedetti A, Thombs BD, Depression Screening Data (DEPRESSD) EPDS Group. Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis. BMJ. 2020;371:m4022. Somerville S, Dedman K, Hagan R, Oxnam E, Wettinger M, Byrne S, et al. The Perinatal Anxiety Screening Scale: development and preliminary validation. Arch Womens Ment Health. 2014;17(5):443–54. Walker SN, Sechrist KR, Pender NJ. The health-promoting lifestyle profile: development and psychometric characteristics. Nurs Res. 1987;36(2):76–81. Bahabadi F, Estebsari F, Rohani C, Rahimi Khalifeh Kandi Z, Sefidkar R, Mostafaei D. Predictors of health-promoting lifestyle in pregnant women based on Pender’s Health Promotion Model. Int J Womens Health. 2020;12:71–7. Wyatt S, Østbye T, De Silva V, Long Q. Predictors and occurrence of antenatal depressive symptoms in Galle, Sri Lanka: a mixed-methods cross-sectional study. BMC Pregnancy Childbirth. 2021;21(1):758. World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: World Health Organization; 2016. Additional Declarations No competing interests reported. Supplementary Files STROBEChecklistCrosssectionalBMC.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 06 Apr, 2026 Editor invited by journal 03 Mar, 2026 Editor assigned by journal 25 Feb, 2026 Submission checks completed at journal 25 Feb, 2026 First submitted to journal 24 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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The burden is particularly prominent in low- and middle-income countries (LMICs), where sociocultural, economic, and structural vulnerabilities compound psychological risk [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Antenatal depression and anxiety are associated with preterm birth, impaired fetal growth, and long-term developmental consequences for offspring [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSri Lanka maintains a well-established maternal health infrastructure with high antenatal coverage. However, maternal mental health screening and preventive behavioural integration remain inconsistent. Recent evidence indicates clinically significant levels of antenatal depressive and anxiety symptoms in Sri Lankan populations [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHealth-promoting lifestyle behaviours, including nutrition, physical activity, stress management, spiritual growth, interpersonal relations, and health responsibility, may represent modifiable protective factors. Pender\u0026rsquo;s Health Promotion Model proposes that engagement in adaptive behaviours influences psychological outcomes through cognitive-affective pathways shaped by individual and sociocultural contexts [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough international literature supports associations between lifestyle engagement and reduced depressive symptoms [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], trimester-specific analyses within LMIC contexts remain limited. Given that psychological vulnerability fluctuates across trimesters, understanding trimester-sensitive associations is critical for maternal service planning.\u003c/p\u003e \u003cp\u003eThis study aimed to examine the association between health-promoting lifestyle factors and antenatal depressive and anxiety symptoms across pregnancy trimesters among Sri Lankan women.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eA hospital-based quantitative cross-sectional study was conducted between January and June 2024 at two tertiary maternity hospitals in the Colombo District, Sri Lanka: Castle Street Hospital for Women (CSHW) and De Soysa Hospital for Women (DSHW). These institutions are among the largest maternity care providers in the country, collectively serving over 68,000 antenatal clinic attendees annually. The study was designed to examine the relationship between health-promoting lifestyle factors (HPLFs) and antenatal depression and anxiety across all three trimesters of pregnancy.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThe study population consisted of pregnant women attending routine antenatal clinics at CSHW and DSHW during the data collection period.\u003c/p\u003e\n\u003ch3\u003eInclusion criteria\u003c/h3\u003e\n\u003cp\u003eParticipants were eligible if they:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eWere currently pregnant (any trimester)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWere aged 18 years or older\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eResided in the Colombo District\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWere literate in Sinhala or English\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eProvided written informed consent\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003eParticipants were excluded if they:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eWere in the postpartum period\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHad high-risk pregnancies requiring specialized medical monitoring\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHad pre-existing severe medical conditions (e.g., uncontrolled hypertension, cardiovascular disease, autoimmune disorders, diabetes mellitus, thyroid disorders)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHad diagnosed severe psychiatric conditions prior to pregnancy (e.g., major depressive disorder, bipolar disorder, psychotic disorders, post-traumatic stress disorder, substance use disorders)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThese exclusions were implemented to safeguard participant well-being and minimize clinical confounding.\u003c/p\u003e\n\u003ch3\u003eSample size\u003c/h3\u003e\n\u003cp\u003eThe required sample size was calculated using the Krejcie and Morgan population correction formula with Raosoft software (Raosoft Inc., 2004), based on an estimated antenatal population of 68,275 women across both hospitals. A 95% confidence level, 5% margin of error, and 50% response distribution were assumed. The minimum required sample was 383 participants.\u003c/p\u003e \u003cp\u003eAn additional 20% adjustment was considered for potential non-response; however, due to the supervised data collection approach and high participation rate, the final achieved sample remained 383 participants.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSampling and recruitment\u003c/h2\u003e \u003cp\u003eA non-probability opportunity (convenience) sampling method was employed. Eligible women attending routine antenatal clinic sessions were approached sequentially based on availability during clinic hours.\u003c/p\u003e \u003cp\u003eTo improve representation within the hospital setting, the total sample was proportionally allocated according to antenatal attendance statistics (CSHW: n\u0026thinsp;=\u0026thinsp;237; DSHW: n\u0026thinsp;=\u0026thinsp;146). Participants from each hospital were distributed across first, second, and third trimesters to ensure inclusion of all pregnancy stages.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection procedure\u003c/h3\u003e\n\u003cp\u003eData were collected through supervised self-administered questionnaires conducted within antenatal clinic premises. After confirming eligibility, participants received verbal and written explanations of the study aims and procedures. Written informed consent was obtained prior to participation.\u003c/p\u003e \u003cp\u003eParticipants completed four instruments in their preferred language (Sinhala or English):\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eEdinburgh Postnatal Depression Scale (EPDS)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePerinatal Anxiety Screening Scale (PASS)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHealth-Promoting Lifestyle Profile-II (HPLP-II)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSocio-demographic questionnaire\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe principal investigator remained available to clarify questions and reviewed completed questionnaires for completeness, minimizing missing data.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEdinburgh Postnatal Depression Scale (EPDS)\u003c/h2\u003e \u003cp\u003eThe Sinhala version of the EPDS was used to assess antenatal depressive symptoms. The EPDS is a 10-item self-report scale scored on a 4-point Likert format (0\u0026ndash;3), with total scores ranging from 0 to 30. A cut-off score of \u0026ge;\u0026thinsp;9 was used to identify probable antenatal depression, consistent with local validation studies in Sri Lanka demonstrating sensitivity of 90.7% and specificity of 86.8% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In the present sample, internal consistency was acceptable (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.770).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePerinatal Anxiety Screening Scale (PASS)\u003c/h2\u003e \u003cp\u003eThe Sinhala-validated PASS consists of 31 items assessing perinatal anxiety across four domains: excessive worry and specific fears; perfectionism, control and trauma; social anxiety; and acute anxiety and adjustment. Items are rated from 0 (not at all) to 3 (nearly always), yielding total scores from 0 to 93. A cut-off score of \u0026ge;\u0026thinsp;26 was used to identify elevated anxiety risk\u0026sup2;. Internal consistency in the present sample was acceptable (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.741).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eHealth-Promoting Lifestyle Profile-II (HPLP-II)\u003c/h2\u003e \u003cp\u003eThe HPLP-II contains 52 items measuring six behavioural domains: health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, and stress management. Items are rated on a 4-point Likert scale (1\u0026thinsp;=\u0026thinsp;never to 4\u0026thinsp;=\u0026thinsp;routinely). Total scores range from 52 to 208, with higher scores indicating greater engagement in health-promoting behaviours. Internal consistency in the present sample was excellent (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.913).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic characteristics\u003c/h2\u003e \u003cp\u003eData were collected on age, trimester, marital status, maternal and paternal education, employment status, household income, number of children, and antenatal class attendance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eReliability\u003c/h2\u003e \u003cp\u003eInternal consistency of all instruments was assessed using Cronbach\u0026rsquo;s alpha. All scales exceeded the minimum acceptable threshold of 0.70, indicating satisfactory reliability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using IBM SPSS Statistics version 27. Descriptive statistics (means, standard deviations, frequencies) were computed for socio-demographic characteristics and study variables. Normality was assessed using Kolmogorov\u0026ndash;Smirnov and Shapiro\u0026ndash;Wilk tests and visual inspection of histograms. Although statistical tests indicated minor deviations from normality, the large sample size (N\u0026thinsp;=\u0026thinsp;383) supported the use of parametric analyses under the Central Limit Theorem.\u003c/p\u003e \u003cp\u003ePearson correlation coefficients were calculated to examine associations between HPLFs and antenatal depression and anxiety.\u003c/p\u003e \u003cp\u003eSimple linear regression analyses were conducted to determine whether overall HPLFs predicted depression and anxiety. Multiple linear regression analyses were performed to assess the independent contributions of the six HPLP-II subdomains. Model assumptions (linearity, homoscedasticity, normality of residuals, multicollinearity) were assessed through residual plots, variance inflation factors (VIF\u0026thinsp;\u0026lt;\u0026thinsp;5), and tolerance statistics.\u003c/p\u003e \u003cp\u003eTrimester was examined as a potential moderator using univariate general linear models (GLMs), including interaction terms between HPLFs and trimesters. One-way ANOVA with Tukey\u0026rsquo;s post hoc tests was used to compare mean differences in HPLFs, depression, and anxiety across trimesters.\u003c/p\u003e \u003cp\u003eChi-square tests were used to assess associations between trimester and antenatal class attendance.\u003c/p\u003e \u003cp\u003eAll statistical tests were two-tailed with significance set at p \u0026lt; .05. Effect sizes (R\u0026sup2;, partial η\u0026sup2;) and 95% confidence intervals were reported where appropriate.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eMean maternal age was 28.7 years (SD 4.8).\u003c/p\u003e \u003cp\u003eTrimester distribution: 1st (28%), 2nd (39%), 3rd (33%).\u003c/p\u003e \u003cp\u003eMean domain scores for health-promoting lifestyle factors are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean HPLP-II domain scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomains (HPLFs)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterpersonal relations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpiritual growth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNutrition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth responsibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStress management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eAssociation with depressive symptoms\u003c/h2\u003e \u003cp\u003eTotal HPLP-II score was significantly negatively associated with EPDS scores (r = -0.34, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In adjusted regression models, stress management (β = -0.24, 95% CI -0.38 to -0.11, p\u0026thinsp;=\u0026thinsp;0.001) and spiritual growth (β = -0.19, 95% CI -0.32 to -0.06, p\u0026thinsp;=\u0026thinsp;0.004) remained significant predictors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eAssociation with anxiety symptoms\u003c/h2\u003e \u003cp\u003eTotal HPLP-II score was not significantly associated with PASS scores. However, physical activity demonstrated a significant negative association. Interpersonal relations and spiritual growth were positively associated.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eTrimester variation\u003c/h2\u003e \u003cp\u003eDepressive symptoms were significantly higher in the third trimester (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Anxiety scores peaked during the second trimester (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Overall HPLP-II scores declined in late pregnancy.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrates that greater engagement in health-promoting lifestyle factors is associated with lower antenatal depressive symptoms among Sri Lankan women. The findings align with international evidence demonstrating the protective role of behavioural regulation in antenatal mental health [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe absence of an overall association between lifestyle engagement and anxiety suggests differential behavioural pathways. Physical activity may reduce physiological arousal, whereas interpersonal and spiritual dimensions may function within sociocultural contexts that simultaneously provide support and expectation pressures.\u003c/p\u003e \u003cp\u003eTrimester-specific findings indicate that vulnerability and behavioural engagement fluctuate across trimesters. These findings highlight the importance of integrating behavioural counselling within routine antenatal care, particularly during later pregnancy.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe cross-sectional design excludes causal inference. Self-report measures may introduce bias. Findings from tertiary hospitals may not generalize to rural settings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eHealth-promoting lifestyle factors were negatively associated with antenatal depressive symptoms but demonstrated domain-specific associations with anxiety. Behaviourally integrated, trimester-sensitive maternal care strategies may enhance psychological well-being within LMIC antenatal systems.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEPDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEdinburgh Postnatal Depression Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePASS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePerinatal Anxiety Screening Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHPLP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eII\u0026ndash;Health\u0026ndash;Promoting Lifestyle Profile\u0026ndash;II\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow\u0026ndash;and middle\u0026ndash;income country\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e Ethical approval for this study was obtained from the Institutional Ethics Review Committee, Faculty of Graduate Studies, University of Colombo (Approval No: FGS/ERC/2024/025), the Ethics Review Committee of De Soysa Hospital for Women (Approval No: 024/2024), and the Ethics Review Committee of Castle Street Hospital for Women (Approval No: ERC/346/07/2024). All procedures performed in this study were conducted in accordance with the ethical standards of the institutional research committees and with the 1964 Declaration of Helsinki and its later amendments. Written informed consent was obtained from all participants prior to data collection. Participation was voluntary, and confidentiality and anonymity were strictly maintained throughout the study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no specific grant from any funding agency.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eWF conceptualized the study, conducted data collection and statistical analysis, and drafted the manuscript. TG provided methodological guidance, theoretical supervision, and critically revised the manuscript. Both authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors wish to thank the administrative and clinical staff of Castle Street Hospital for Women and De Soysa Hospital for Women for facilitating data collection. We are sincerely grateful to the antenatal mothers who generously participated in this study. We also acknowledge the Ethics Review Committee of the Faculty of Graduate Studies, University of Colombo, for their guidance and approval of this research.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to participant confidentiality but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFisher J, Cabral de Mello M, Patel V, Rahman A, Tran T, Holton S, et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bull World Health Organ. 2012;90(2):G139\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoward LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry. 2020;19(3):313\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, Katon WJ. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry. 2010;67(10):1012\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDing XX, Wu YL, Xu SJ, Zhu RP, Jia XM, Zhang SF, et al. Maternal anxiety during pregnancy and adverse birth outcomes: a systematic review and meta-analysis of prospective cohort studies. J Affect Disord. 2014;159:103\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevis B, Negeri Z, Sun Y, Benedetti A, Thombs BD, Depression Screening Data (DEPRESSD) EPDS Group. Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis. BMJ. 2020;371:m4022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSomerville S, Dedman K, Hagan R, Oxnam E, Wettinger M, Byrne S, et al. The Perinatal Anxiety Screening Scale: development and preliminary validation. Arch Womens Ment Health. 2014;17(5):443\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalker SN, Sechrist KR, Pender NJ. The health-promoting lifestyle profile: development and psychometric characteristics. Nurs Res. 1987;36(2):76\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahabadi F, Estebsari F, Rohani C, Rahimi Khalifeh Kandi Z, Sefidkar R, Mostafaei D. Predictors of health-promoting lifestyle in pregnant women based on Pender\u0026rsquo;s Health Promotion Model. Int J Womens Health. 2020;12:71\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWyatt S, \u0026Oslash;stbye T, De Silva V, Long Q. Predictors and occurrence of antenatal depressive symptoms in Galle, Sri Lanka: a mixed-methods cross-sectional study. BMC Pregnancy Childbirth. 2021;21(1):758.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: World Health Organization; 2016.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"antenatal depression, antenatal anxiety, health-promoting lifestyle, pregnancy, Sri Lanka, cross-sectional study","lastPublishedDoi":"10.21203/rs.3.rs-8962259/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8962259/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eGlobally, antenatal depression and anxiety are major contributors to maternal morbidity with disproportionately high prevalence in low- and middle-income countries (LMICs). Despite Sri Lanka\u0026rsquo;s strong maternal healthcare system, perinatal psychological distress remains under-integrated within routine antenatal services. Health-promoting lifestyle behaviours, conceptualized within Pender\u0026rsquo;s Health Promotion Model, represent potentially modifiable behavioural factors of maternal mental health. However, trimester-specific evidence from South Asia is limited. This study examined associations between health-promoting lifestyle factors and antenatal depressive and anxiety symptoms among pregnant women in Sri Lanka.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA hospital-based cross-sectional study was conducted among 383 pregnant women attending antenatal clinics at two maternity hospitals in Colombo district. Participants completed the Health-Promoting Lifestyle Profile-II (HPLP-II), Edinburgh Postnatal Depression Scale (EPDS), and Perinatal Anxiety Screening Scale (PASS). Pearson correlations assessed bivariate associations. Multiple linear regression models evaluated independent associations controlling trimester and socio-demographic variables. Subgroup analyses explored trimester variation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eHigher total HPLP-II scores were significantly associated with lower depressive symptoms (β = -0.31, 95% CI -0.42 to -0.20, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Stress management and spiritual growth domains remained independently associated with reduced EPDS scores. Total lifestyle engagement was not significantly associated with overall anxiety scores (p\u0026thinsp;=\u0026thinsp;0.09). However, physical activity was negatively associated with anxiety symptoms (β = -0.18, p\u0026thinsp;=\u0026thinsp;0.01), while interpersonal relations (β\u0026thinsp;=\u0026thinsp;0.16, p\u0026thinsp;=\u0026thinsp;0.02) and spiritual growth (β\u0026thinsp;=\u0026thinsp;0.14, p\u0026thinsp;=\u0026thinsp;0.03) were positively associated. Depressive symptoms were highest during the third trimester, whereas anxiety peaked in the second trimester.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eHealth-promoting lifestyle behaviours were significantly associated with reduced antenatal depressive symptoms but demonstrated domain-specific associations with anxiety. Integrating trimester-sensitive behavioural strategies into antenatal care may strengthen maternal mental health outcomes in Sri Lanka and comparable low- and middle-income settings.\u003c/p\u003e","manuscriptTitle":"Health-promoting lifestyle behaviours and their association with antenatal depression and anxiety across pregnancy trimesters in Sri Lanka: a hospital-based cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-10 14:25:56","doi":"10.21203/rs.3.rs-8962259/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-06T08:07:52+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-03T18:50:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-25T22:42:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-25T22:42:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-02-25T02:30:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9f5ac98e-3e34-4115-b9f2-b711d19fd40a","owner":[],"postedDate":"April 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-10T14:25:57+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-10 14:25:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8962259","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8962259","identity":"rs-8962259","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}