020 which country

In the present sample, power distance scores ranged between 11 Austria and 93 Russia. Individualism describes a preference for a loosely knit social framework in which individuals are expected to take care of only themselves and their immediate families as opposed to Collectivism, which describes a preference for a tightly knit framework in society in which individuals are integrated into strong, cohesive in-groups. In the present sample, Individualism scores ranged between 8 Ecuador and 90 Australia.

Masculinity describes a preference in society for achievement, heroism, assertiveness, and material rewards for success as opposed to Femininity, which refers to a preference for cooperation, modesty, caring for the weak, and quality of life. In the present sample, Masculinity scores ranged between 5 Sweden and 95 Japan.

Uncertainty Avoidance describes the degree to which the members of a society feel uncomfortable with uncertainty and ambiguity.

In the present sample, Uncertainty Avoidance scores ranged between 29 Sweden and 99 Uruguay. Long-Term Orientation relates to how a society deals with the challenges of the present and the future. Indulgence describes a society that allows relatively free gratification of basic and natural human drives related to enjoying life and having fun. In the present sample, Indulgence scores ranged between 0 Pakistan and 83 Colombia. Before merging samples, we conducted a number of checks on the individual database of each country.

We then searched for the presence of outliers. For instance, the level of education i. Outlier values were removed. For instance, the PBA had to be coded from 0 to 6 and not from 1 to 7. Sex had to be coded 1 for fathers and 2 for mothers. We made the corrections when necessary. After proceeding to these preliminary checks, we performed the statistical analyses.

One country had a very low internal consistency coefficient 0. The authors of the country in question asked us to disregard this database and put another person in charge of the data collection.

We received a new database from this country 6 months later. The reliability of the PBA was 0. After ensuring that all variables were encoded in the exact same way and that they were in the exact same order in all the databases, we merged the data from all countries. Skewness and kurtosis values indicated that several items displayed deviations from normality.

Conceptually, these deviations from normality make sense: like most mental health indicators, burnout is expected to present an asymmetric distribution i. The estimation method used was diagonally weighted least squares DWLS with asymptotic covariance and polychoric correlation matrices. We then tested the factorial invariance including metric and scalar invariance of the PBA across sex and languages.

For measurement invariance, we implemented a set of nested models with gradually increasing parameters and constraints using a stepwise multiple group confirmatory factor analysis or MG-CFA. In the first step, we tested the parental burnout model for configural invariance as the basic level of measurement invariance.

In the second step, we assessed item factor loadings in a metric invariance model. In the third step, we tested scalar invariance with the intercepts set as equal across groups. Finally, we verified the invariance of measurement errors for a model in which all error variances were constrained to be equal across groups. We examined the mean level and prevalence of parental burnout in each country. Comparing prevalence across countries requires a common cutoff score on the PBA. Since the choice of diagnostic thresholds is always debatable, we worked with two cutoff scores and we estimated parental burnout prevalence twice.

The first cutoff score was based on the response scale: parents were judged to have parental burnout if their score was equal to or greater than 92 i. The second cutoff score was derived from the combination of several parental burnout indicators, based on a preregistered multi-method and multi-informant analysis strategy i.

We then considered the most stringent cutoff, i. The idea to use the most conservative prevalence values stems from our wish to avoid overdiagnosis of parental burnout.

Because country samples were unequal in size and in sex distribution, we then reassessed prevalence rates after controlling for these inequities. We dealt with sample size inequity by randomly selecting parents in all samples with more than subjects.

To control for overrepresentation of mothers in the survey and the related risk of overestimating the prevalence of parental burnout in countries where mothers report more burnout , we used a post-stratification weight by adding a value to each case in the data file which indicates how much each case will count in the statistical procedure. The value was obtained by dividing the sex proportion in the general population i.

Thus, the weight value of 0. We examined the Pearson moment correlations between both the prevalence and mean level of parental burnout in each country and the six cultural values.

We then performed multilevel random coefficient modeling analyses in Stata We first ran the unconditional model. After checking for the absence of multicollinearity, individual- and country-level variables were entered in three steps. In step 1 conditional model 1 , we controlled for sociodemographic variables age, sex, educational level, and type of neighborhood [disadvantaged, average, prosperous], working status [having or not a paid professional activity]; all of these being measured at the individual level.

In step 2 conditional model 2 , we introduced variables influencing parental workload number of children, family type [single parent, two parents, multigenerational], age of the youngest child, number of women taking care of the children on a daily basis, number of men taking care of the children on a daily basis, average number of hours spent with the child[ren] on a daily basis; all these variables being measured at the individual level.

In step 3 conditional model 3 , we included the growth national product GNP; database, and the six cultural values i. The multilevel random coefficient modeling analyses take into account that many covariates vary both within and between countries.

Thus, the effect of all sociodemographic characteristics that we entered in the two first steps was controlled for when we introduced cultural values in the third model.

Greater values indicate greater explanatory power. The analyses first revealed that the measure of parental burnout used in this research i. Both the original four-factor structure Roskam et al. Because we used the total score of parental burnout in the current study, we tested measurement invariance of the second-order factor model across both sex and the 21 languages. Metric and scalar invariances were supported as well, and measurement errors in item responses were also equivalent across sex and languages.

This allowed us to examine the mean level and prevalence of parental burnout in each country cutoff scores: 92 and 86 on a scale from 0 to The resulting prevalence rates corrected for inequities in sample size and sex, respectively, are figured in the penultimate and last column of Table 1.

As shown in Fig. This is true even when we control for sample size or sex imbalance see Table 1. These differences between countries are also reflected in the mean level of parental burnout in each country see Table 1.

There is a difference of 33 points between the country with the lowest mean level i. Figure 1 Percentage of parents who have parental burnout i. The size of the differences in parental burnout between countries suggested that cultural factors might be operative.

To investigate whether cultural values are associated with parental burnout, and knowing that there is no cultural indicator specifically related to parenting that would be available for the majority of the countries included in this study, we obtained the position of each country on the six cultural values defined by Hofstede, ; i.

The correlations between each cultural value and both the prevalence and mean level of parental burnout in each country are displayed in Table 6. Individualism was the sole value to be significantly associated with both the mean level and prevalence of parental burnout. We represented the association between Individualism and the mean level of parental burnout on the scatter plot depicted in Fig.

As shown in this figure, the higher the individualism of a given country, the higher the mean level of parental burnout in that same country. As also shown in Fig. Figure 2 Correlation between the level of parental burnout in a country and the position of that country on the level of individualism. To examine whether individualism predicted parental burnout over and above sociodemographic variables, parental workload, economic inequalities across countries, and the other cultural values i.

We found significant effects for several sociodemographic variables. In particular, parental burnout was higher among younger parents, mothers, parents in disadvantaged neighborhoods, non-working parents, parents with more children, parents with younger children, parents in two-parent families compared to those in multigenerational families , single parents compared to those in both two-parent and multigenerational families , and parents in step families compared to those in both two-parent and multigenerational families.

The results of this study demonstrate that the prevalence of parental burnout varies across the globe and that parental burnout is linearly related to individualism. This relation held even when sociodemographic variables i.

The findings suggest that culture has a major impact on parental burnout and that parents from individualistic countries seem particularly exposed. The mechanisms that link individualism and parental burnout remain to be studied. Whereas parenting is the subject of relatively little social or political discourse in some parts of the world, in Euro-American countries, parenting has become a matter of increasing public interest and normative prescriptions Faircloth, What parents feed their children, how they discipline them, where they put them to bed, how they play with them: all of these have become politically and morally charged questions Faircloth, , p.

The expectations towards parents have drastically evolved over the last 50 years, to such an extent that parents who would have been considered as good and attentive parents 50 years ago would now be viewed as neglectful at best Nelson, The distinction between what children need and what might enhance their development has disappeared, and anything less than optimal parenting is framed as perilous Wolf, , p.

The current results have important implications for both science and practice. Regarding the implications for practice, our findings show the limits of individualism and invite reflection on solutions to counter its adverse effects on parents. The much lower prevalence of parental burnout in collectivistic countries—even when socioeconomic inequalities and other factors are controlled—suggests that strengthening the social network of mutual aid and solidarity around families might well help to decrease the prevalence of parental burnout in individualistic countries.

This accords with recent findings obtained in Poland a rather individualistic country showing that the availability of social support is a very strong protective factor vis-a-vis parental burnout Szczygiel et al. This is clearly not the only potential pathway, and further studies are needed to clarify why parents in more individualistic countries are more exposed to parental burnout than those from less individualistic countries. Such research will provide much-needed prevention or treatment avenues that can be tailored to specific individual and cultural contexts.

In interpreting our findings, several limitations bear noting. First, sample sizes vary across countries from 95 Colombia to 1, Finland. However, when prevalence rates were reassessed on samples of approximately randomly selected parents in all samples with more than participants, the resulting prevalence remained essentially unchanged. Second, mothers were overrepresented in the survey in almost all countries.

Again, when prevalence rates were reassessed weighting for sex frequencies in each country, the resulting prevalence remained essentially unchanged. Third, although we adjusted for several potential confounding factors, residual confounding by unmeasured factors cannot be ruled out. Finally, we cannot rule out the possibility that the measure of parental burnout used in this study captures a type of parenting that is more relevant to individualistic cultures than to collectivistic cultures.

However, this would not fully explain the correlation found between parental burnout and individualism. These limitations do not diminish the robustness of our main finding that individualism is associated with a much higher risk of exhaustion in the parental role.

Raising a child in Euro-American countries, i. This country study provides the first window onto the role of culture in parental burnout. It points to the importance of considering parental burnout not only at the level of the individual but also at the level of the culture, highlighting its relevance to world psychiatry. Arnett, J. American Psychologist, 63 7 , — Article Google Scholar. Bleidorn, W. Age and sex differences in self-esteem—A cross-cultural window.

Journal of Personality and Social Psychology, 11 3 , Bornstein, M. Parenting and child mental health: A cross-cultural perspective. World Psychiatry, 12 3 , — Brianda, M. Treating parental burnout: Impact of two treatment modalities on burnout symptoms, emotions, hair cortisol, and parental neglect and violence. Psychotherapy and Psychosomatics. Hair cortisol concentration as a biomarker of parental burnout. Psychoneuroendocrinology, , Article PubMed Google Scholar.

Bristow, J. The double bind of parenting culture: Helicopter parents and cotton wool kids. The phone interview obtained data on sociodemographic factors, health behaviors, self-rated health and the existence of a previous medical diagnosis of a set of chronic conditions. In the first home visit, blood and urine samples were collected and sent to a central laboratory for analytical determinations; and in the second visit, a validated electronic diet history was obtained and a physical examination was performed [ 32 ].

Study participants have been followed-up to December of mean follow-up to 8. That left a sample size of 11, for the analyses Additional file 1 : Figure S1. The diet history included different foods and a set of photographs that helped to quantify food portions. Standard food composition tables were used to estimate nutrient and energy intake [ 32 ]. Leisure-time activity was reported as the time spent in walking, cycling and other types of exercise, as well as in household chores, gardening and do-it-yourself activities.

Data regarding sleep, nap, conviviality and habits around meals were also self-reported. Briefly, the MEDLIFE consists of 28 items divided into three blocks: 1 food consumption 15 items ; 2 dietary habits 7 items ; and 3 physical activity, rest and conviviality 6 items.

However, we could not compute the item on water consumption for not having appropriate information in the ENRICA study. Each item of the score weights 0 negative or 1 point positive , and the score ranged from 0 to 27 best adherence Additional file 1 : Table S1. Waist circumference was measured with a flexible non-stretchable tape at the midpoint between the last rib and the iliac crest after a normal expiration.

Blood glucose was determined by the glucose oxidase technique after 12 h fasting. Blood pressure was measured by trained personnel using a standard protocol, with validated automatic devices Omron M6 and cuffs of 3 sizes according to arm circumference.

Two sets of blood pressure readings were taken separated by 90 min. In each set, blood pressure was measured 3 times at 1—2-min intervals, after resting between 3 and 5 min in a seated position.

For the analyses, average systolic and diastolic blood pressure was calculated for those who had at least 3 measurements, after discarding the first reading. Triglycerides were determined by the glycerol phosphate oxidase method [ 36 ].

In addition, insulin was determined by immunoradiometric assay. Finally, high-sensitivity C-reactive protein hs-CRP was assessed by latex-enhanced nephelometry to assess chronic inflammation.

The date and cause of death were ascertained from a computerized search of the vital registry of the Spanish National Institute of Statistics from baseline — to the end of follow-up on December 31, ; there is evidence of the completeness, accuracy, and reliability of this vital-status information [ 38 , 39 , 40 ]. The date and cause of death was determined from the death certificate by a nosologist and was coded according to the International Classification of Diseases, 10th Revision ICD ; specifically, CVD death was encoded as group I00—I Censoring was set at the date of death or at the end of the follow-up December 31, , whichever occurred first.

At baseline, we collected information on sociodemographic and lifestyle characteristics including age, sex, educational level no formal or primary education, secondary education, and university and tobacco smoking former, never, current [ 31 ]. Also, weight and height were measured twice in each subject under standardized conditions; the BMI was calculated as weight in kg divided by squared height in m [ 31 ].

Three multivariable models were built based on the existing evidence that the variables are risk factors for the outcome [ 41 ] and observed association with MEDLIFE. Model 1 adjusted for sex, age, and education. And model 3 further adjusted for cancer, respiratory disease, depression, number of morbidities excluding the previously mentioned conditions , and number of drug treatments.

Cox proportional regression models were fitted to assess the association between quartiles of adherence to the MEDLIFE score at baseline and all-cause mortality and CVD mortality, using the lowest quartile Q1 as reference. As above, we fitted three hierarchical models and we added a fourth one, which was further adjusted for some intermediate clinical risk factors components of the MS. The proportional-hazards assumption was tested using the Schoenfeld residuals method.

In ancillary analysis, we stratified by morbidity presence or not of any chronic condition , sex, age at baseline or age at death only for the mortality analysis and BMI. Likelihood ratio tests with 3 degrees of freedom, the 3 upper quartiles of MEDLIFE and a dichotomous potential effect modifier were performed to evaluate possible interactions. Other sensitivity analysis included the assessment of the association between each component block of the MEDLIFE and the clinical risk factors and mortality, using restricted cubic spline analysis with 3 knots for all-cause mortality or CVD mortality.

Additionally, residual confounding by unmeasured confounders were addressed by calculating the E-value following the methodology described by VaderWeele and Ding [ 42 ]. The analyses were performed using Stata version The survey command was used in the analyses to account for the complex sampling design. The frequency of the components of the MS was also lower. Additionally, participants with higher adherence were more likely to have higher education and to be never smokers, and less often had depression or respiratory disease.

A total of prevalent MS cases were documented. In addition, after adjustment for model 2 the inverse association was also statistically significant for elevated triglycerides and high blood pressure P-trend 0. Analyses were adjusted as in Model 3. The incidence rate of overall mortality is 0. Including the clinical CVD risk factors in the model did not materially change the results for total mortality but turned them into non-significant for CVD death model 4.

Multivariable-adjusted Kaplan—Meier graph for a all cause-death, and b cardiovascular death. Adjusted as in Model 4 in Table 3.

Results of secondary analyses did not show substantial changes in comparison with the main analysis. Again, regarding all-cause mortality, no statistically significant interactions were found Additional file 1 : Table S3. Within the components of the Block 3, physical activity and collective and non-collective sports were driving the association Additional file 1 : Table S5. In this cohort, representative of the adult Spanish population, a higher adherence to a Mediterranean lifestyle was associated with lower prevalence of the MS and several biological CVD risk factors as well as lower all-cause and CVD mortality after an average follow-up of almost 9 years.

Of note, the MEDLIFE index which represents the Mediterranean lifestyle includes food consumption as well as other dietary habits and health behaviors conviviality, eating in company, rest and social habits characteristic of the traditional Mediterranean culture and support the importance of cultural habits, beyond mere food habits, as strong determinants of health.

This is important because, despite the evidence of the benefits of Mediterranean diet on multiple outcomes [ 14 , 19 , 43 , 44 , 45 ], the fact that our study combines a Mediterranean lifestyle all-inclusive is a clear addition to the literature that emphasizes the synergistic effect of the whole lifestyle rather than their individual components. This message can now be addressed to the population within behavioral counseling, and can possibly translate into improved health outcomes.

Our results add to the evidence that a healthy lifestyle is associated with cardiovascular health and inversely associated with all-cause mortality [ 21 , 22 , 26 , 46 , 47 , 48 , 49 , 50 ].

In the large SUN cohort, comprising university graduates in Spain, a better adherence to a joint healthy lifestyle was associated with lower risk of hypertension [ 49 ], MS [ 51 ], and CVD [ 23 ]. Our stratified analyses were robust and the associations were in line with the main analyses by subgroups by morbidity status, sex, age, age, and BMI and no significant interaction was found. When we assessed the separate effect of the three different blocks of the MEDLIFE, the dimension that captured physical activity, social interaction, rest and conviviality was the only one showing statistically significant results, mainly due to physical activity, collective and non-collective sports.

Despite the wide supporting evidence of the benefits of physical activity on cardiovascular health and mortality [ 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 ], we cannot rule out positive effects of other components such as napping, social interaction, or eating in company that are not usually included in other previously published scores [ 22 , 25 , 61 ].

Our findings may highlight the importance of those components in the context of a healthy Mediterranean dietary pattern. However, we did not assess the isolated effect of each item of the score because we relied on the joint, and possibly synergistic effect of the combination of several behaviors related to the traditional Mediterranean culture; this may contribute to explain why we did not find an association with the other two blocks capturing food consumption and dietary components.

Indeed, lifestyle behaviors are often correlated, thus by simultaneously examining the effect of several lifestyle variables, we accounted for the clustering of healthful types of behavior within the same individual. Additionally, the MEDLIFE score was not designed with the aim of assessing each block separately but to evaluate the comprehensive Mediterranean lifestyle reflecting culture and tradition.

Therefore, the main drivers of the association could be different in each population but the overall effect may provide a better understanding of the whole Mediterranean lifestyle, tradition and culture in a holistic approach, and therefore adding the novelty of going beyond the exclusive focus on the foods consumed.

Our results are in line with those of previous studies showing the benefits of a healthy lifestyle on the MS. Also a systematic review of 11 interventions found that lifestyle modifications on MS were effective in resolving the proportions of patients with MS in comparison with conventional education [ 62 ]. Several studies evaluating other lifestyle scores like the American Heart Association Life Simple 7, that includes 4 lifestyle behaviors BMI, smoking, diet, physical activity and 3 clinical risk factors blood pressure, high cholesterol, and diabetes have found important inverse associations with CVD and total-mortality in different cohorts [ 63 , 64 , 65 , 66 , 67 , 68 ].

In addition, reductions in alcohol intake and energy intake over 1 year in participants with diabetes diagnosis was association with lower hazard of CVD [ 69 ]. However, the effect of behavioral factors may be attenuated after the development of the clinical risk factors which are associated with CVD.

While this suggests that the expected protective association of the Mediterranean lifestyle on mortality is substantially greater than that expected only from the reduced frequency of the MS and other clinical risk factors also observed in our study, no etiological conclusion can be drawn.

Strengths of our study include the long follow-up and large size of the cohort, which is representative of the adult population of a whole country and allows for generalization of the results. Lifestyle information included very detailed questions with a validated dietary history comprising a variety of foods and cooking methods, and a validated physical activity questionnaire.

In addition, we used a previously validated lifestyle index MEDLIFE reflecting the Mediterranean culture and lifestyle that includes common components across the Mediterranean countries reflecting culture and tradition social interaction, short nap, meals in company, physical activity with others, etc.

Limitations of this study include potential measurement errors due to the self-reported nature of some of the data, although this bias is most likely to be non-differential and thus would drive the association towards the null. Lifestyle information was only assessed at baseline and, thus, no changes over time were assumed, which could dilute the actual associations.

In addition, despite extensive adjustment for known risk factors, some residual confounding may persist; to address this issue we calculated the E-value [ 42 ], and it showed that after accounting for confounders measured in this study, the HR of 0.

Thus, given the high E-value 3. Additionally, although our results come from a representative Spanish population, generalizability to non-Mediterranean countries or different ethnic groups should be explored. Lastly, although the MEDLIFE aims to be a comprehensive Mediterranean lifestyle index, it is possible that factors not considered, such as spending time in open-air spaces [ 70 ], belonging to extended families, or having religious beliefs and practices mostly Catholic in Southern Europe may also contribute to cardiovascular health [ 71 , 72 ].

Future studies should determine if this also applies to other Mediterranean countries, and whether a Mediterranean-like lifestyle may improve cardiovascular health outside the Mediterranean basin. The Mediterranean diet: a historical perspective on food for health. Mediterranean diet pyramid today. Science and cultural updates.

Public Health Nutr. The effect of Mediterranean diet on metabolic syndrome and its components: a meta-analysis of 50 studies and , individuals. J Am Coll Cardiol. Mediterranean diet and metabolic syndrome: an updated systematic review. Rev Endocr Metab Disord. Adherence to the Mediterranean diet is inversely associated with metabolic syndrome occurrence: a meta-analysis of observational studies. Want to follow suit? Take a look at our London-based numbers , which are all compatible with our -Day Free Trial , which are all compatible with our Day Money Back Guarantee.

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