Skip to main content
Top
Published in: Social Psychiatry and Psychiatric Epidemiology 4/2010

01-04-2010 | Original Paper

Perceived family stress, parenting efficacy, and child externalizing behaviors in second-generation immigrant mothers

Authors: Ayşe Yaman, Judi Mesman, Marinus H. van IJzendoorn, Marian J. Bakermans-Kranenburg

Published in: Social Psychiatry and Psychiatric Epidemiology | Issue 4/2010

Login to get access

Abstract

Objectives

Examining family stress and parenting efficacy in relation to child externalizing problems in immigrant families.

Method

In this study, we compared the levels of family stress, parenting efficacy, and toddler externalizing behaviors in Dutch (n = 175) and second-generation Turkish immigrant families (n = 175) living in the Netherlands. In addition, the influence of Turkish mothers’ acculturation on toddler externalizing behaviors and its association with perceived stress and efficacy were examined.

Results

Turkish mothers reported higher levels of daily stress and marital discord than Dutch mothers, but did not differ in perceptions of parenting efficacy and children’s externalizing behaviors. The associations between child and family variables were similar in the Dutch and the Turkish groups, as more family stress was related to more externalizing behaviors in toddlers. Low parenting efficacy was the most important predictor of child externalizing behaviors in both groups. Acculturation of Turkish mothers was not associated with family and child variables, and did not moderate the association between family variables and child externalizing behaviors. However, emotional connectedness to the Turkish culture was related to less daily stress and fewer marital problems.

Conclusions

The results support the no-group differences hypothesis and also imply that cultural maintenance may be adaptive for parental well-being.
Literature
1.
go back to reference Keenan K, Shaw D (1994) The development of aggression in toddlers: a study of low-income families. J Abnorm Child Psychol 22:53–77CrossRefPubMed Keenan K, Shaw D (1994) The development of aggression in toddlers: a study of low-income families. J Abnorm Child Psychol 22:53–77CrossRefPubMed
2.
go back to reference Van Zeijl J, Mesman J, Stolk MN, Alink LRA, Van IJzendoorn MH, Bakermans-Kranenburg MJ, Juffer F, Koot HM (2006) Terrible ones? Assessment of externalizing behaviors in infancy with the Child Behavior Checklist. J Child Psychol Psychiatr 47:801–810CrossRef Van Zeijl J, Mesman J, Stolk MN, Alink LRA, Van IJzendoorn MH, Bakermans-Kranenburg MJ, Juffer F, Koot HM (2006) Terrible ones? Assessment of externalizing behaviors in infancy with the Child Behavior Checklist. J Child Psychol Psychiatr 47:801–810CrossRef
3.
go back to reference Belsky J, Woodworth S, Crnic K (1996) Trouble in the second year: three questions about family interaction. Child Dev 67:556–578CrossRefPubMed Belsky J, Woodworth S, Crnic K (1996) Trouble in the second year: three questions about family interaction. Child Dev 67:556–578CrossRefPubMed
4.
go back to reference Carter AS, Briggs-Gowan MJ, Davis NO (2004) Assessment of young children’s social-emotional development and psychopathology: recent advances and recommendations for practice. J Child Psychol Psychiatr 45:109–134CrossRef Carter AS, Briggs-Gowan MJ, Davis NO (2004) Assessment of young children’s social-emotional development and psychopathology: recent advances and recommendations for practice. J Child Psychol Psychiatr 45:109–134CrossRef
5.
go back to reference Johnston C, Mash EJ (1989) A measure of parenting satisfaction and efficacy. J Clin Child Psychol 18:167–175CrossRef Johnston C, Mash EJ (1989) A measure of parenting satisfaction and efficacy. J Clin Child Psychol 18:167–175CrossRef
7.
go back to reference Berry JW, Poortinga YH, Segall MH, Dasen PR (2002) Cross-cultural psychology: research and applications, 2nd edn. Cambridge University Press, Cambridge Berry JW, Poortinga YH, Segall MH, Dasen PR (2002) Cross-cultural psychology: research and applications, 2nd edn. Cambridge University Press, Cambridge
8.
go back to reference Berry JW (1997) Immigration, acculturation, and adaptation. Appl Psychol Int Rev 46:5–68 Berry JW (1997) Immigration, acculturation, and adaptation. Appl Psychol Int Rev 46:5–68
9.
go back to reference Sodowsky GR, Maestas MV (2000) Acculturation, ethnic identity, and acculturative stress: evidence and measurement. In: Dana RH (ed) Handbook of cross-cultural and multicultural personality assessment. Erlbaum, Mahwah, pp 131–172 Sodowsky GR, Maestas MV (2000) Acculturation, ethnic identity, and acculturative stress: evidence and measurement. In: Dana RH (ed) Handbook of cross-cultural and multicultural personality assessment. Erlbaum, Mahwah, pp 131–172
10.
go back to reference Berry JW (2006) Acculturative stress. In: Wong PTP, Wong LCJ (eds) Handbook of multicultural perspectives on stress and coping. Springer, New York, pp 287–298CrossRef Berry JW (2006) Acculturative stress. In: Wong PTP, Wong LCJ (eds) Handbook of multicultural perspectives on stress and coping. Springer, New York, pp 287–298CrossRef
11.
go back to reference Wells-Parker E, Miller DI, Topping JF (1990) Development of control-of-outcome scales and self-efficacy scales for women in four life roles. J Pers Assess 54:564–575CrossRefPubMed Wells-Parker E, Miller DI, Topping JF (1990) Development of control-of-outcome scales and self-efficacy scales for women in four life roles. J Pers Assess 54:564–575CrossRefPubMed
12.
go back to reference Baker BL, Heller TL (1996) Preschool children with externalizing behaviors: experience of fathers and mothers. J Abnorm Child Psychol 24:513–532CrossRefPubMed Baker BL, Heller TL (1996) Preschool children with externalizing behaviors: experience of fathers and mothers. J Abnorm Child Psychol 24:513–532CrossRefPubMed
13.
go back to reference Reid WJ, Crisafulli A (1990) Marital discord and child behavior problems: a meta-analysis. J Abnorm Child Psychol 18:105–117CrossRefPubMed Reid WJ, Crisafulli A (1990) Marital discord and child behavior problems: a meta-analysis. J Abnorm Child Psychol 18:105–117CrossRefPubMed
14.
go back to reference Stevens GWJM, Vollebergh WAM (2008) Mental health in migrant children. J Child Psychol Psychiatr 49:276–294CrossRef Stevens GWJM, Vollebergh WAM (2008) Mental health in migrant children. J Child Psychol Psychiatr 49:276–294CrossRef
15.
go back to reference Atzaba-Poria N, Pike A, Barrett M (2004) Internalising and externalising problems in middle childhood: a study of Indian (ethnic minority) and English (ethnic majority) children living in Britain. Int J Behav Dev 28:449–460CrossRef Atzaba-Poria N, Pike A, Barrett M (2004) Internalising and externalising problems in middle childhood: a study of Indian (ethnic minority) and English (ethnic majority) children living in Britain. Int J Behav Dev 28:449–460CrossRef
16.
go back to reference Weiss SJ, Goebel P, Page A, Wilson P, Warda M (1998) The impact of cultural and familial context on behavioral and emotional problems of preschool Latino children. Child Psychiatr Hum Dev 29:287–301CrossRef Weiss SJ, Goebel P, Page A, Wilson P, Warda M (1998) The impact of cultural and familial context on behavioral and emotional problems of preschool Latino children. Child Psychiatr Hum Dev 29:287–301CrossRef
17.
go back to reference Campbell SB, Breaux AM, Ewing LJ, Szumowski EK (1986) Correlates and predictors of hyperactivity and aggression: a longitudinal study of parent-referred problem preschoolers. J Abnorm Psychol 14:217–234 Campbell SB, Breaux AM, Ewing LJ, Szumowski EK (1986) Correlates and predictors of hyperactivity and aggression: a longitudinal study of parent-referred problem preschoolers. J Abnorm Psychol 14:217–234
18.
go back to reference Ogbu JU (1981) Origin of human competence: a cultural–ecological perspective. Child Dev 52:413–429CrossRef Ogbu JU (1981) Origin of human competence: a cultural–ecological perspective. Child Dev 52:413–429CrossRef
19.
go back to reference Deater-Deckard K, Dodge KA, Bates JE, Pettit GS (1998) Multiple risk factors in the development of externalizing behavior problems: group and individual differences. Dev Psychopathol 10:469–493CrossRefPubMed Deater-Deckard K, Dodge KA, Bates JE, Pettit GS (1998) Multiple risk factors in the development of externalizing behavior problems: group and individual differences. Dev Psychopathol 10:469–493CrossRefPubMed
20.
go back to reference Lansford JE, Chang L, Dodge KA, Malone PS, Oburu P, Palmerus K, Bacchini D, Pastorelli C, Bombi AS, Zelli A, Tapanya S, Chaudhary N, Deater-Deckard K, Manke B, Quinn N (2005) Physical discipline and children’s adjustment: cultural normativeness as a moderator. Child Dev 76:1234–1246CrossRefPubMed Lansford JE, Chang L, Dodge KA, Malone PS, Oburu P, Palmerus K, Bacchini D, Pastorelli C, Bombi AS, Zelli A, Tapanya S, Chaudhary N, Deater-Deckard K, Manke B, Quinn N (2005) Physical discipline and children’s adjustment: cultural normativeness as a moderator. Child Dev 76:1234–1246CrossRefPubMed
21.
go back to reference Rowe DC, Vazsonyi AT, Flannery DJ (1994) No more than skin deep: ethnic and racial similarity in developmental process. Psychol Rev 101:396–413CrossRef Rowe DC, Vazsonyi AT, Flannery DJ (1994) No more than skin deep: ethnic and racial similarity in developmental process. Psychol Rev 101:396–413CrossRef
22.
go back to reference Ho C, Bluestein DN, Jenkins JM (2008) Cultural differences in the relationship between parenting and children’s behavior. Dev Psychol 44:507–522CrossRefPubMed Ho C, Bluestein DN, Jenkins JM (2008) Cultural differences in the relationship between parenting and children’s behavior. Dev Psychol 44:507–522CrossRefPubMed
23.
go back to reference Lau AS, Litrownik AJ, Newton RR, Black MM, Everson MD (2006) Factors affecting the link between physical discipline and child externalizing problems in black and white families. J Community Psychol 34:89–103CrossRef Lau AS, Litrownik AJ, Newton RR, Black MM, Everson MD (2006) Factors affecting the link between physical discipline and child externalizing problems in black and white families. J Community Psychol 34:89–103CrossRef
24.
go back to reference Wissink IB, Dekovic M, Meijer AM (2006) Parenting behavior, quality of the parent–adolescent relationship, and adolescent functioning in four ethnic groups. J Early Adolesc 26:133–159CrossRef Wissink IB, Dekovic M, Meijer AM (2006) Parenting behavior, quality of the parent–adolescent relationship, and adolescent functioning in four ethnic groups. J Early Adolesc 26:133–159CrossRef
25.
go back to reference Gaffari N (2004) Opvoeding, acculturatie en delinquent gedrag. Een vergelijkend onderzoek onder autochtone, Turkse en Marokkaanse jongeren. [Parenting, acculturation, and delinquent behavior. A comparative study among native Dutch, Turkish and Moroccan youth]. Unpublished master’s thesis. Leiden University, Leiden, The Netherlands Gaffari N (2004) Opvoeding, acculturatie en delinquent gedrag. Een vergelijkend onderzoek onder autochtone, Turkse en Marokkaanse jongeren. [Parenting, acculturation, and delinquent behavior. A comparative study among native Dutch, Turkish and Moroccan youth]. Unpublished master’s thesis. Leiden University, Leiden, The Netherlands
26.
go back to reference Bengi-Arslan L, Verhulst FC, van der Ende J, Erol N (1997) Understanding childhood (problem) behaviors from a cultural perspective: comparison of problem behaviors and competencies in Turkish immigrant, Turkish and Dutch children. Soc Psychiatry Psychiatr Epidemiol 32:477–484PubMed Bengi-Arslan L, Verhulst FC, van der Ende J, Erol N (1997) Understanding childhood (problem) behaviors from a cultural perspective: comparison of problem behaviors and competencies in Turkish immigrant, Turkish and Dutch children. Soc Psychiatry Psychiatr Epidemiol 32:477–484PubMed
27.
go back to reference Stevens GWJM, Pels T, Bengi-Arslan L, Verhulst FC, Vollebergh WAM, Crijnen AAM (2003) Parent, teacher and self-reported problem behavior in the Netherlands. Comparing Moroccan immigrant with Dutch and with Turkish immigrant children and adolescents. Soc Psychiatry Psychiatr Epidemiol 38:576–585CrossRefPubMed Stevens GWJM, Pels T, Bengi-Arslan L, Verhulst FC, Vollebergh WAM, Crijnen AAM (2003) Parent, teacher and self-reported problem behavior in the Netherlands. Comparing Moroccan immigrant with Dutch and with Turkish immigrant children and adolescents. Soc Psychiatry Psychiatr Epidemiol 38:576–585CrossRefPubMed
28.
go back to reference Crijnen AAM, Bengi-Arslan L, Verhulst FC (2000) Teacher-reported problem behaviour in Turkish immigrant and Dutch children: a cross-cultural comparison. Acta Psychiatr Scand 102:439–444CrossRefPubMed Crijnen AAM, Bengi-Arslan L, Verhulst FC (2000) Teacher-reported problem behaviour in Turkish immigrant and Dutch children: a cross-cultural comparison. Acta Psychiatr Scand 102:439–444CrossRefPubMed
29.
go back to reference Murad SD, Joung IMA, van Lenthe FJ, Bengi-Arslan L, Crijnen AAM (2003) Predictors of self-reported problem behaviours in Turkish immigrant and Dutch adolescents in the Netherlands. J Child Psychol Psychiatr 44:412–433CrossRef Murad SD, Joung IMA, van Lenthe FJ, Bengi-Arslan L, Crijnen AAM (2003) Predictors of self-reported problem behaviours in Turkish immigrant and Dutch adolescents in the Netherlands. J Child Psychol Psychiatr 44:412–433CrossRef
30.
go back to reference Alink LRA, Mesman J, Van Zeijl J, Stolk MN, Juffer F, Koot HM, Bakermans-Kranenburg MJ, Van IJzendoorn MH (2006) The early childhood aggression curve: development of physical aggression in 10- to 50-month-old children. Child Dev 77:954–966CrossRefPubMed Alink LRA, Mesman J, Van Zeijl J, Stolk MN, Juffer F, Koot HM, Bakermans-Kranenburg MJ, Van IJzendoorn MH (2006) The early childhood aggression curve: development of physical aggression in 10- to 50-month-old children. Child Dev 77:954–966CrossRefPubMed
31.
go back to reference Campbell SB (1995) Behavior problems in preschool children: a review of recent research. J Child Psychol Psychiatr 36:113–149CrossRef Campbell SB (1995) Behavior problems in preschool children: a review of recent research. J Child Psychol Psychiatr 36:113–149CrossRef
32.
go back to reference Sowa H, Crijnen AAM, Bengi-Arslan L, Verhulst FC (2000) Factors associated with problem behaviors in Turkish immigrant children in the Netherlands. Soc Psychiatry Psychiatr Epidemiol 35:177–184CrossRefPubMed Sowa H, Crijnen AAM, Bengi-Arslan L, Verhulst FC (2000) Factors associated with problem behaviors in Turkish immigrant children in the Netherlands. Soc Psychiatry Psychiatr Epidemiol 35:177–184CrossRefPubMed
33.
go back to reference CBS (2006) Allochtonen in Nederland [Migrants in The Netherlands]. Centraal Bureau voor de Statistiek Voorburg/Heerlen CBS (2006) Allochtonen in Nederland [Migrants in The Netherlands]. Centraal Bureau voor de Statistiek Voorburg/Heerlen
34.
go back to reference Distelbrink M, Hooghiemstra E (2005) Allochtone gezinnen: Feiten en cijfers. [Migrant families: facts and numbers]. In: Den Haag Nederlandse Gezinsraad: NGR Distelbrink M, Hooghiemstra E (2005) Allochtone gezinnen: Feiten en cijfers. [Migrant families: facts and numbers]. In: Den Haag Nederlandse Gezinsraad: NGR
35.
go back to reference Achenbach TM, Rescorla LA (2000) Manual for ASEBA preschool forms and profiles. University of Vermont, Research Center for Children, Youth & Families, Burlington Achenbach TM, Rescorla LA (2000) Manual for ASEBA preschool forms and profiles. University of Vermont, Research Center for Children, Youth & Families, Burlington
36.
go back to reference Erol N, Şimsek Z (1997) Türkiye Ruh Sağlığı Profili: Çocuk ve gençlerde yeterlik alanları ile sorun davranışların dağılımı [Mental health profile of Turkey: distribution of competence and behavioral problems]. In: Erol N, Kılıç C, Ulusoy M, Keçeci M, Şimşek Z (eds) Türkiye Ruh Sağlığı Profili: Ön Rapor [Mental health profile of Turkey: preliminary report]. Aydoğdu Ofset, Ankara, pp 12–33 Erol N, Şimsek Z (1997) Türkiye Ruh Sağlığı Profili: Çocuk ve gençlerde yeterlik alanları ile sorun davranışların dağılımı [Mental health profile of Turkey: distribution of competence and behavioral problems]. In: Erol N, Kılıç C, Ulusoy M, Keçeci M, Şimşek Z (eds) Türkiye Ruh Sağlığı Profili: Ön Rapor [Mental health profile of Turkey: preliminary report]. Aydoğdu Ofset, Ankara, pp 12–33
37.
go back to reference Stevens GWJM, Pels T, Vollebergh WAM, Crijnen AAM (2004) Patterns of psychological acculturation in adult and adolescent Moroccan immigrants living in the Netherlands. J Cross Cult Psychol 35:689–704CrossRef Stevens GWJM, Pels T, Vollebergh WAM, Crijnen AAM (2004) Patterns of psychological acculturation in adult and adolescent Moroccan immigrants living in the Netherlands. J Cross Cult Psychol 35:689–704CrossRef
38.
go back to reference Koot HM, Van den Oord EJCG, Verhulst FC, Boomsma DI (1997) Behavioral and emotional problems in young preschoolers: cross-cultural testing of the validity of the Child Behavior Checklist/2–3. J Abnorm Child Psychol 25:183–196CrossRefPubMed Koot HM, Van den Oord EJCG, Verhulst FC, Boomsma DI (1997) Behavioral and emotional problems in young preschoolers: cross-cultural testing of the validity of the Child Behavior Checklist/2–3. J Abnorm Child Psychol 25:183–196CrossRefPubMed
39.
go back to reference Van IJzendoorn MH, Bakermans-Kranenburg MJ, Juffer F (1999) The parental efficacy questionnaire. Unpublished Manuscript, Centre for Child and Family Studies, Leiden University, the Netherlands Van IJzendoorn MH, Bakermans-Kranenburg MJ, Juffer F (1999) The parental efficacy questionnaire. Unpublished Manuscript, Centre for Child and Family Studies, Leiden University, the Netherlands
40.
go back to reference Crnic KA, Greenberg MT (1990) Minor parenting stresses with young children. Child Dev 61:1628–1637CrossRefPubMed Crnic KA, Greenberg MT (1990) Minor parenting stresses with young children. Child Dev 61:1628–1637CrossRefPubMed
41.
go back to reference Kanner AD, Coyne JC, Schaffer C, Lazarus RS (1981) Comparison of two modes of stress measurement: daily hassles and uplifts versus major life events. J Behav Med 4:1–39CrossRefPubMed Kanner AD, Coyne JC, Schaffer C, Lazarus RS (1981) Comparison of two modes of stress measurement: daily hassles and uplifts versus major life events. J Behav Med 4:1–39CrossRefPubMed
42.
go back to reference Koot HM (1997) Handleiding bij de vragenlijst voor gezinsproblemen [Manual accompanying the Dutch family problems questionnaire]. Sophia Kinderziekenhuis/Erasmus Universiteit, Afdeling Kinder- en Jeugdpsychiatrie Rotterdam Koot HM (1997) Handleiding bij de vragenlijst voor gezinsproblemen [Manual accompanying the Dutch family problems questionnaire]. Sophia Kinderziekenhuis/Erasmus Universiteit, Afdeling Kinder- en Jeugdpsychiatrie Rotterdam
43.
go back to reference Van Oort FVA, van der Ende J, Crijnen AAM, Verhulst FC, Mackenbach JP, Bengi-Arslan L, Joung IMA (2006) Cultural ambivalence as a risk factor for mental health problems in ethnic minority young adults. Unpublished doctoral dissertation, Erasmus Medical Center Rotterdam, The Netherlands Van Oort FVA, van der Ende J, Crijnen AAM, Verhulst FC, Mackenbach JP, Bengi-Arslan L, Joung IMA (2006) Cultural ambivalence as a risk factor for mental health problems in ethnic minority young adults. Unpublished doctoral dissertation, Erasmus Medical Center Rotterdam, The Netherlands
44.
go back to reference Tabachnick BG, Fidell LS (2007) Using multivariate statistics, 5th edn. Allyn and Bacon, Boston Tabachnick BG, Fidell LS (2007) Using multivariate statistics, 5th edn. Allyn and Bacon, Boston
45.
go back to reference Hampel FR, Ronchetti EM, Rousseeuw PJ (1986) Robust statistics: the approach based on influence functions. Wiley, New York Hampel FR, Ronchetti EM, Rousseeuw PJ (1986) Robust statistics: the approach based on influence functions. Wiley, New York
46.
go back to reference Mistry RS, Biesanz JC, Chien N, Howes C, Benner AD (2008) Socioeconomic status, parental investments, and the cognitive and behavioral outcomes of low-income children from immigrant and native households. Early Child Res Q 23:193–212CrossRef Mistry RS, Biesanz JC, Chien N, Howes C, Benner AD (2008) Socioeconomic status, parental investments, and the cognitive and behavioral outcomes of low-income children from immigrant and native households. Early Child Res Q 23:193–212CrossRef
47.
go back to reference Leyendecker B, Schölmerich A, Çıtlak B (2006) Similarities and differences between first- and second-generation Turkish migrant mothers in Germany: the acculturation gap. In: Bornstein MH, Cote LR (eds) Acculturation and parent–child relationships: measurement and development. Erlbaum, London, pp 297–315 Leyendecker B, Schölmerich A, Çıtlak B (2006) Similarities and differences between first- and second-generation Turkish migrant mothers in Germany: the acculturation gap. In: Bornstein MH, Cote LR (eds) Acculturation and parent–child relationships: measurement and development. Erlbaum, London, pp 297–315
48.
go back to reference Diener E, Suh EM, Smith H, Shao L (1995) National differences in reported subjective well-being: why do they occur? Soc Indicat Res 34:7–32CrossRef Diener E, Suh EM, Smith H, Shao L (1995) National differences in reported subjective well-being: why do they occur? Soc Indicat Res 34:7–32CrossRef
49.
go back to reference Deater-Deckard K, Atzaba-Poria N, Pike A (2004) Mother- and father–child mutuality in Anglo and Indian British families: a link with lower externalizing problems. J Abnorm Child Psychol 32:609–620CrossRefPubMed Deater-Deckard K, Atzaba-Poria N, Pike A (2004) Mother- and father–child mutuality in Anglo and Indian British families: a link with lower externalizing problems. J Abnorm Child Psychol 32:609–620CrossRefPubMed
50.
go back to reference Vazsonyi AT, Trejos-Castillo E, Huang L (2006) Are developmental processes affected by immigration? Family processes, internalizing, and externalizing behaviors. J Youth Adolesc 35:799–813 Vazsonyi AT, Trejos-Castillo E, Huang L (2006) Are developmental processes affected by immigration? Family processes, internalizing, and externalizing behaviors. J Youth Adolesc 35:799–813
51.
go back to reference Edwards CP, Liu WL (2002) Parenting toddlers. In: Bornstein MH (ed) Handbook of parenting. Volume 1: Children and parenting, 2nd edn. Lawrence Erlbaum Associates Inc, Mahwah, pp 45–71 Edwards CP, Liu WL (2002) Parenting toddlers. In: Bornstein MH (ed) Handbook of parenting. Volume 1: Children and parenting, 2nd edn. Lawrence Erlbaum Associates Inc, Mahwah, pp 45–71
Metadata
Title
Perceived family stress, parenting efficacy, and child externalizing behaviors in second-generation immigrant mothers
Authors
Ayşe Yaman
Judi Mesman
Marinus H. van IJzendoorn
Marian J. Bakermans-Kranenburg
Publication date
01-04-2010
Publisher
Springer-Verlag
Published in
Social Psychiatry and Psychiatric Epidemiology / Issue 4/2010
Print ISSN: 0933-7954
Electronic ISSN: 1433-9285
DOI
https://doi.org/10.1007/s00127-009-0097-2

Other articles of this Issue 4/2010

Social Psychiatry and Psychiatric Epidemiology 4/2010 Go to the issue