Introduction
About half of the population living in Iran are females who play an undeniable role in the development of the country. Therefore, paying attention to women’s occupation and its relationship with women’s health is advisable. Women are the main pillars of social development and the main support of the family health. They have important roles and duties in the family and social circles. All these roles and duties require complete state of mental and physical health. Women’s health is one of the most important aspects of community development and known as the overall health priority [1, 2]. 
Changes in the traditional families as well as the advancement of technology, has defined new roles for the family members. These changes have created a suitable context for women’s activities in various social, academic, artistic, and cultural fields and their employment as well. These activities could influence their quality of life. Moreover, health improvement will help people through enhancing and controlling their own health. Approximately 50% of all people’s expenses are due to an unhealthy lifestyle [3]. According to the statistics, the rate of economic participation of women in Iran has risen from 11.9% in 2000 to 18.5% in 2005 [4] and up to 38.9% in 2010 [5]. Thus, women are compelled to perform housekeeping tasks on one hand, and work and pursue tasks outside the house on the other hand. Women have multiple roles including wife, mother, and worker/employee along with diverse expectations [6]. Responding to all of those tasks with many concurrent outcomes affects their lifestyle. Employed women, like men, are affected by work-related physical and psychological problems, besides enjoying income and self-value. Consequently, they face physical and mental illnesses and their mental health is in danger. On the other hand, healthy behaviour is influenced by physical and social activities of women. Their health-promotion behaviors are linked to quantity and quality of care [7‑10]. 
Babies establish the most emotional interactions with their mothers right from birth. Mother is the main core of sense of security and peace. Mother plays a role in the formation of nutritional behaviour during toddlerhood [11]. Azmoode in a study on the source of concern in nulliparous women found that they were concerned about the health of their future babies, the infant’s current health, their ability in taking care of the baby, child nutrition, sexual life, their own health after the time of delivery, quality of their relationship with husband, household tasks, career and educational problems [12]. 
Given the increased need of intensive care in all physical, psychological, and social aspects in toddlers, increased pressure would be imposed on the mother. A working mother is naturally under more pressure to manage home and take care of the child [11]. Therefore, occupation on one hand and having a toddler on the other hand, could affect mother’s lifestyle. Lifestyle is one of the important factors that affect health [13]. Lifestyle is of highly important, because it affects the quality of life and could prevent diseases [14]. Health specialists’ have described lifestyle as an important effective factor for health [15]. Sehati admitted that mothers have fundamental roles in maintaining family health, in every society. As a result, they are the protectors of the society’s health and they are always of great importance. A mother is the main core of the family unit, in respect of the health and success factors of other members. Therefore, the health and development of a society largely depends on women’s health. Thus, maintaining mother’s health should be a priority of health services [16]. Also, the World Health Organization in its annual report has introduced women’s health as one of the indicators of development in countries. 
The role of healthcare providers in health education and behaviour change is very important. They prevent the occurrence of many diseases and help people achieve optimal health. They emphasis on the importance of lifestyle in self-care, maintaining health and disease prevention [17]. They also help maintain and promote mothers’ health, as well as children’s health, and identify barriers to the promotion of a healthy lifestyle. Mothers of toddlers have some difficulties in caring their children and themselves. These problems can influence their lifestyle and quality of life in various aspects. Hence, the present study aimed to determine the barriers to a healthy lifestyle of working mothers with toddlers from the mother’s perspective. 
Material and Methods
This was a cross-sectional analytical study in which 60 working mothers with toddlers (one to three years old) were investigated in November 2015 in Semnan Province, Iran. To access mothers across the five regions of Semnan, five kindergartens were randomly selected and then one of them was selected through convenience sampling method and all of the mothers with toddlers were examined. To collect data, a questionnaire was used which consisted of three parts: The demographic part included age, marital status, number of children, level of education, shift work status, hours of work per day, work experience, employment status, and housing status. 
Lifestyle Questionnaire (LSQ) was designed by Lali et al. in 2012. It was developed to investigate mother’s current lifestyle. It has 70 questions with 10 aspects of physical health (8 questions), sports and fitness (7 questions), weight and nutrition management (7 questions), prevention of diseases (7 questions), psychological health (7 questions), spiritual health (6 questions), social health (7 questions), avoiding drugs (6 questions), prevention of disasters (8 questions), and environmental health (7 questions). A 4-point Likert-type scale (never, sometimes, often, always) was used for rating each question. To obtain the total score of mothers’ lifestyle, the sum of points of questions related to each aspect were divided by the number of questions. Therefore, scores below 135 was considered as weak, and scores between 135 and 185 as medium, and scores from 186 to 210 as good. The same was done for each aspect. 
This questionnaire on obstacles to healthy lifestyle investigated 34 obstacles to health-related lifestyle in working mothers with toddlers (1-3 years old) in three aspects of physical health (17 barriers), psychological health (9 barriers), and social health (8 barriers). Each barrier had (Yes/No) choices and mothers could choose if there would be a collision with the obstacle or not. 
After designing the questionnaire of barriers to promote a healthy lifestyle, its validity was evaluated by 10 members of the Nursery academic staff. In order to examine the reliability, the designed questionnaire was completed by 10 mothers with toddlers. Then, its reliability coefficient was measured by retest and Pearson correlation coefficient with 95% confidence. The total reliability was 85%. The physical and psychological health, each gained a reliability coefficient of 85% and social health, gained a reliability coefficient of 71%. The validity and reliability of the lifestyle questionnaire was also confirmed using Cronbach α test in the study by Lali et al. in 2012. They used the Factor Analysis test to assess the validity of the lifestyle questionnaire structure as a multidimensional tool for evaluating and measuring lifestyle. 
In the present study, the reliability of the questionnaire was calculated using Cronbach α, which was 0.89 for physical health, 0.87 for sports and fitness, 0.85 for weight and nutrition management, 0.87 for prevention of diseases, 0.88 for psychological health, 0.84 for mental health, 0.82 for social health, 0.79 for avoiding drug, 0.85 for preventing disasters, 0.76 for environmental health, and 0.87 for all aspects. SPSS (V. 16) was used to analyze the obtained data. Descriptive statistics were used to describe the data and the Chi-square test was used to determine the relationship between study variables and the significance level was considered as P<0.05. 
Results
The analysis of demographic data showed that 70% of mothers were 30 years or old. Of all, 28.3% were officially employed, and 15% worked on part-time jobs. Table 1 presents additional information about mothers.  Lifestyle data showed that the highest average score of healthy lifestyle belonged to the prevention of disasters, and the lowest belonged to sports and fitness (Table 2). In total, according to the scores obtained by mothers in healthy lifestyle which included, poor (17%), average (70%), and strong (13%), most of the mothers had a moderate healthy lifestyle. 
Data on barriers to a healthy lifestyle from the mothers’ perspective showed that in the physical aspect, the highest (71.7%) factor was neglect of physical activity due to abundant occupation, and in terms of psychological health, fear and concern that a working mother experiences due to her child’s disease in kindergarten was the most important in this aspect (61.7%), also in terms of social health, too much (65%) occupation due to the exigencies of family life (as mother, wife) gained the highest points as an obstacle to a healthy lifestyle (Table 3). In examining the relationship between barriers to promotion of mother’s health and their demographic information, the Chi-square test showed that with the exception of age, other demographic characteristics had no significant relationship with physical, psychological, and social barriers (Table 4). 
Discussion
This study, descriptively and analytically examined the barriers to a healthy lifestyle in working mothers with toddlers. The greatest problem of working mothers was in the physical aspect, due to exhaustion from work. Regarding the social health, unwarranted expectations of other people from working mothers with toddlers (attending parties, and so on), and in psychological health, lack of adequate information on how to manage stress. Despite the importance of the health of working mothers with toddlers, this topic has been overlooked. There 

are a few studies available in this field and employment is regarded as a disorder of lifestyle. In the study by Rezai the status of self-esteem and mental health, somatic symptoms, anxiety symptoms, social functioning, and symptoms of depression in unemployed women were better than employed women [18]. 
Abedi investigated health-promoting lifestyle and the related factors in women of reproductive age in Ahwaz 

 

 

City, Iran and concluded that the education and occupation of women affects health-promoting lifestyle, but age had no such effect [19]. However, Kordi in a study to examine the lifestyle of employed and unemployed women of the city of Sari found a difference between the lifestyle of employed and unemployed women regarding the social aspect, and also found a significant relationship between age, education, family income, and lifestyle [20]. 
The findings suggest a significant relationship between age and obstacles to healthy lifestyle, which could be due to reasons like higher marriage and childbearing age, lack of healthy lifestyle in youth, lack of equilibrium between work and life exigencies, and the stress of social and professional responsibilities of working mothers, regardless of their role in the family or the mothers’ high expectations from themselves or society’s expectations. However, because of insufficient energy and time, fatigue induced by work, even in the absence of any disease, mothers prefer to dedicate their time and energy to their children, rather than the health promoting behaviours. On the other hand, older mothers are more reluctant to leave their children to relatives for day care and dealing with health promoting behaviours, which could be another reason to the relationship between age and barriers to healthy lifestyle. However, as studies indicate, age can be or cannot be associated with a healthy lifestyle. So if efforts to have a healthy lifestyle be started and founded early on, then the necessity to maintain and develop health promoting behaviours would also be realized and practiced at higher ages. In this way, the addition of new roles in life and commitment to social responsibilities would cause fewer problems for older people. In our study, the number of children in all aspects of obstacles to lifestyle, and mother’s educational level, only had a significant relationship in controlling spiritual and mental stress in the workplace. 
The exhaustion due to occupation, abundant work, lack of adequate time to engage in physical activities (sports, etc.), neglect of physical activity due to concerns arising from the maternal role, were addressed as barriers to a healthy lifestyle in the physical aspect, which is consistent with the findings of Heidari and Kermanshahi study about obstacles to exploiting public health 

promoting behaviours in assistants. Given the fact that according to the findings of this study, the lack of enough time is considered as one the most important obstacles to health promotion in physical aspects and the social health of lifestyle, teaching time management strategies should be stressed [21]. 
A healthy lifestyle and better quality of life are closely related together. In other words, those who enjoy a healthy lifestyle may enjoy a satisfactory quality of life. For example, the balance between activity and rest and prevention from tiredness in terms of physical health and stress management in respect with psychological health is induced by a healthy lifestyle. This also affects the quality of a person’s life. In working women, this is further developed due to the nature of their interactions with family, career and life issues. In working mothers who have more children, barriers to a healthy lifestyle are further experienced. 
Ahamdifaraz et al. explained the experiences of employed women about the maternal role, and showed that accepting multiple roles of wife, mother and employer in working women, create diverse role expectations and obligations in family and society. However because the motherhood is one of the most important roles of women, this can certainly, desired or not, affect women’s roles. As the results show, playing this important role in working mothers is associated with a lot of hardship that differs from the non-working women condition and could affect their physical and mental health [22]. 
Because of increased responsibility of child care, working mothers with toddlers, need an appropriate lifestyle to maintain their own and families’ health. To inculcate a healthy lifestyle in mothers is influenced by numerous factors. Identifying barriers to a healthy lifestyle has an important role in promoting their lifestyle. Therefore, the results of this study can be useful for family planners to develop educational strategies and promote a good lifestyle among employed mothers with toddlers. 
This study show that mothers have a medium level of lifestyle and encounter some obstacles. Thus it is important that they pay attention to their health and lifestyle. We suggest that future studies investigate the improvement in mothers’ lifestyle with the presence of full-time or part-time nurses through a partnership between the Welfare Organization and kindergartens on one hand, and the Ministry of Health and Medical Educations on the other hand. The results of such studies can be useful to identify the barriers to a healthy lifestyle and offer strategies for improving mothers’ lifestyle. 
The limitations of this study include non-generalizability of findings and the impact of respondents’ mental health during response which is likely to affect the outcome. 
Ethical Considerations
Compliance with ethical guidelines
The Ethics Committee of Tarbiat Modares University approved the study under the No. 1198332. All participants provided their written consent.
Funding
This study is extracted from the MS thesis in Paediatric Nursing approved in the Research Council of the Faculty of Medical Sciences of Tarbiat Modarres University. 
Conflict of interest
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors certify that they have no affiliation with or involvement in any organization or entity with any financial interest, or non- financial interest in the subject matter or materials dismissed in this manuscript.
Acknowledgments
The authors are grateful to the honourable personnel of Semnan kindergartens and mothers of toddlers for their cooperation in performing this research. 


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