Ricardo Gomez-Huelgas

Jose Mancera-Romero

Rosa Bernal-Lopez
email: rbernallopez@yahoo.es

Sergio Jansen-Chaparro

Antonio J Baca-Osorio

Estefania Toledo

Rita Perez-Gonzalez

Ricardo Guijarro

Francisco J Tinahones

Miguel A Martínez-González

Carlos Haya

Jose Bernal-Lopez

Sergio Baca-Osorio

Antonio Toledo

Estefania Perez-Gonzalez

Rita Guijarro

J Martínez-González

M Rosa Bernal-Lopez

Ricardo Guijarro-Merino

Miguel A Martínez-Gonzalez

Prevalence of cardiovascular risk factors in an urban adult population from southern Spain. IMAP Study (Multidisciplinary Intervention in Primary Care)

Keywords: Risk factors, Educational level, Epidemiology, Population

ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

for 33% of all deaths. In terms of years of potential life lost, CVD are in third position, behind tumours and external causes of mortality [1]. The health costs due to CVD in our country were close to seven billion euros in 2003 [START_REF] Leal | Economic burden of cardiovascular disease in the enlarged European Union[END_REF]. Furthermore, the prevalence of obesity, diabetes, hypertension and hypercholesterolaemia in Spain have all risen over the past 20 years at an alarming rate [START_REF] Basterra-Gortari | Tendencias de la obesidad, diabetes mellitus, hipertensión e hipercolesterolemia en España (1997-2003)[END_REF]; this is likely to be reflected in a future increase in cardiovascular morbidity and mortality. Consequently, due to the high social and economic impact of CVD, these disorders represent one of the main priorities of health care policies.

Prevention strategies should be based on evidence from the understanding and control of classic cardiovascular risk factors (CVRF). Given the magnitude of the problem, studies in local populations are still justified to improve our overall information in this field and to define priorities for action in specific populations. In Spain, two recent papers [START_REF] Medrano | Factores de riesgo cardiovascular en la población española: metaanálisis de estudios transversales[END_REF][START_REF] Gabriel | Prevalencia, distribución y variabilidad geográfica de los principales factores de riesgo cardiovascular en España. Análisis agrupado de datos individuales de estudios epidemiológicos poblacionales: estudio ERICE[END_REF] have brought together different cross-sectional studies in different Spanish geographical areas to provide an overview of the epidemiology of CVRF in our country. The distribution of cardiovascular morbidity and mortality is not uniform throughout Spain and Malaga is among the Spanish provinces with higher rates of cardiovascular morbidity and mortality [START_REF] Boix | Tendencias en la mortalidad por cardiopatía isquémica en 50 provincias españolas[END_REF]. Socioeconomic and cultural factors have been suggested to play a decisive role in the geographical differences in health indicators [START_REF] Lantz | Socioeconomic factors, health behaviors, and mortality. Results from a nationally representative prospective study of US adults[END_REF].

Despite the high impact of CVD in the regions of southern Spain, like Andalusia, the few cross-sectional studies examining the overall frequency of exposure to CVRF in Andalusia were published over a decade ago [START_REF]Grupo colaborativo andaluz de estudios sobre factores de riesgo vascular[END_REF][START_REF] Estudio | Dieta y riesgo de enfermedades cardiovasculares en Andalucía[END_REF], with more recent studies being local and focusing on the rural population [START_REF] Soriguer | Prevalence of obesity in south-east Spain and its relation with social and health factors[END_REF] or older people [START_REF] López-Suárez | Prevalencia de obesidad, diabetes, hipertensión, hipercolesterolemia y síndrome metabólico en adultos mayores de 50 años de Sanlúcar de Barrameda[END_REF]. The aim of this study was to determine the prevalence of several CVRF in the general adult population belonging to the urban area of Malaga (Spain).

MATERIAL AND METHODS

The IMAP study (Multidisciplinary Intervention in Primary Care) is a populationbased study designed with two aims: to establish the prevalence of the metabolic syndrome (MS) in the urban population of Malaga and to study the effectiveness of three years of a multidisciplinary intervention on diet and physical activity conducted in primary care to reduce the prevalence of MS. To study the prevalence of MS, we designed a crosssectional epidemiological and analytical study in a representative random sample of the adult population (18-80 years) assigned to the "Ciudad Jardin" Health Centre in Malaga (29,818 persons). The methodology of this study has recently been published [START_REF] Gomez-Huelgas | Hypertriglyceridemic waist: an alternative to the metabolic syndrome? Results of the IMAP Study (Multidisciplinary Intervention in Primary Care)[END_REF].

The education level was stratified into two categories: low (illiterate or primary education) and high (secondary or university studies). We considered sedentary subjects to be those who, in their free time, did not do any exercise equivalent to walking at a moderate pace no more than 150 minutes weekly. Subjects were considered to be smokers if they smoked or had smoked any type or amount of tobacco in the previous 6 months, exsmokers subjects who had quit smoking at least six months before the study and nonsmokers if they had never smoked.

The samples were analyzed in the reference hospital laboratory and biochemical determinations were obtained by routine methods. Low density lipoprotein cholesterol (LDLc) was calculated using the Friedewald formula.

Abdominal obesity was diagnosed when the waist circumference was ≥94 cm in men or ≥80 cm in women. Obesity was defined as mild, moderate-severe or morbid when the BMI was 30-34.9 kg/m 2 , 35-39.9 kg/m 2 or ≥40 kg/m 2 , respectively. Blood pressure was defined as optimal, normal and normal-high when the SBP and DBP were <120 and <80 mmHg, between 120-129 and / or 80-84 mmHg, and between 130-139 mmHg and/or 85-89 mmHg, respectively. Subjects were considered to be diabetic if they had a previous diagnosis of diabetes, if they were on pharmacological treatment for diabetes, or their fasting blood glucose was ≥126mg/dL (7.0 mmol/L). Impaired fasting glucose (IFG) was defined as a

Statistical Analysis

Normality of quantitative variables was verified by the Kolmogorov-Smirnov test.

Qualitative variables are expressed as a percentage with a confidence interval of 95%. The quantitative variables are shown as the mean and standard deviation or the median and the 25 and 75 quartiles in the case of a non-normal distribution. We used the Mann-Whitney nonparametric test for comparison of quantitative variables in two independent groups. For qualitative variables we used the Chi-square test, and 2x2 tables Fisher's exact test. In order to evaluate the relationship between several CVRF (dependent variables) and level of studies we applied a multivariate logistic regression model for sex and age range, adjusting for confounding variables. We used SPSS version 12.0.

RESULTS

Of the total sample of 2,492 subjects, 154 (6.17%) were excluded for failing to fulfil the inclusion criteria, 56 (2.24%) could not be located and 12 (0.48%) refused to participate in the study. Thus, the final analysis comprised 2,270 persons. The prevalence of smoking was 27.7%.

The mean BMI was in the range of overweight (26.9 ± 5.1 kg/m 2 ) and was higher in men; 61.2% of the sample were overweight (38.3%) or obese (22.9%), and 2% had morbid obesity. The prevalence of abdominal obesity was 55.8%. Only 25.9% had optimal blood pressure. The population rate of hypertension was 33.1%, and 14.1% of the population had previously unknown hypertension.

The prevalence of dyslipidaemia was 65.4%; 47.2% of the patients had a total cholesterol ≥ 200 mg/dL (5.2 mmol/L) (11.2% of the population ≥250 mg/dL (6.5 mmol/L)), [START_REF] Gutiérrez-Fisac | Prevalencia de obesidad en la población adulta española: 14 años de incremento continuado[END_REF].4% had LDL-c ≥ 160 mg/dL (4.1 mmol/L) (41.3% had LDL-c ≥ 130 mg/dL (3.4 mmol/L)), 7.1% had hypertriglyceridaemia ≥200 mg/dL (2.3 mmol/L) (18.4% had hypertriglyceridaemia ≥150 mg/dL (1.7 mmol/L)) and 25.3% had low HDL-c (<40 mg/dL (1.0 mmol/L) in men or <50 mg/dL (1.3 mmol/L) in women).

The prevalence of diabetes was 7.1% and of IFG it was 15.4%.

Analysis of the clustering of modifiable CVRF (hypertension, dyslipidaemia,

diabetes, abdominal obesity, smoking and sedentarism), showed that the percentage of subjects with 0, 1, 2, 3, 4, 5 and 6 risk factors was 8.1%, 28.1%, 34.1%, 20.7%, 7.2%, 1.6% and 0.2%, respectively. The population prevalence of CVD was 4.1%.

The men had a higher prevalence of smoking, hypertension, hypertriglyceridaemia and IFG, while the women had a higher frequency of physical inactivity and abdominal obesity (p<0.001).

The prevalence of all CVRF increased with age, with the exception of smoking which was predominant in men younger than 60 years and women younger than 50 years of age (p<0.001). The highest rate of smoking was among men aged 40-59 years (41.2%).

In all age groups, smoking was more prevalent in men, except in the 30-39 year age group, where it was higher in women (24.6% vs 25.3%; p<0.001). Above the age of 50 years, 82.4% of the population had abdominal obesity and 84.1% were overweight or obese. The prevalence of hypertension, dysglycaemia and hypercholesterolaemia was 66.2%, 47.1% and 83%, respectively. In men the prevalence of hypercholesterolaemia and low HDL-c was lower after the ages of 60 and 70 years, respectively (p<0.005). The prevalence of hypertriglyceridaemia was reduced with effect from the age of 70 years in both sexes (p<0.001).

Analysis of the prevalence of different CVRF by educational level showed that a low level of studies was associated with a higher prevalence of CVRF (p<0.001), with the exception of smoking and low HDL-c. When we adjusted for sex and age, a low level of studies was associated with smoking, obesity and hypertriglyceridaemia, with odds ratios (OR) (95% CI) of 1.6 (1.3-1.9), 1.4 (1.1-1.8) and 1.7 (1.1-2.6), respectively. The prescription of cardiovascular drugs (antihypertensive, lipid-lowering, antidiabetic, antiaggregant) was also higher in subjects with a low educational level (p<0.001).

DISCUSSION

We found a high prevalence of CVRF in our study: 29.7% of the subjects had three or more modifiable CVRF (hypertension, dyslipidaemia, diabetes, abdominal obesity, smoking and/or sedentarism).

It is noteworthy that over 60% of the adults studied were overweight or obese, and 56% had abdominal obesity. These data are consistent with other studies performed in our environment [START_REF] Soriguer | Prevalence of obesity in south-east Spain and its relation with social and health factors[END_REF][START_REF] López-Suárez | Prevalencia de obesidad, diabetes, hipertensión, hipercolesterolemia y síndrome metabólico en adultos mayores de 50 años de Sanlúcar de Barrameda[END_REF]13,[START_REF] Gutiérrez-Fisac | Prevalence of overweight and obesity in Spain: crosssectional study of a national sample of persons aged 60 and over[END_REF] and confirm that Andalusia has one of the highest obesity rates as compared with the remaining regions of Spain [START_REF] Aranceta-Bartrina | Prevalencia de obesidad en España[END_REF]. Over recent decades Spain has suffered a continuous increase in the prevalence of obesity [START_REF] Gutiérrez-Fisac | Prevalencia de obesidad en la población adulta española: 14 años de incremento continuado[END_REF] and has the highest child and adolescent obesity rates in Europe [START_REF] Yusuf | infarction in 27000 participants from 52 countries: a case-control study[END_REF]. In our study, a worrying fact is that 35.5% of the population subgroup aged 18-29 years was overweight or obese. [START_REF] Lantz | Socioeconomic factors, health behaviors, and mortality. Results from a nationally representative prospective study of US adults[END_REF]. Consequently, the low level of studies in our population should be a decisive factor in the elevated prevalence of overweight and obesity, already highlighted by other Spanish authors [START_REF] Regidor | Influencia a lo largo de la vida de las circunstancias socioeconómicas, de la inactividad física y de la obesidad sobre la prevalencia de síndrome metabólico[END_REF].

The inactivity rate in our population, about 80%, was almost twice the Spanish mean [19], with a particularly striking high percentage found among women. In Spain there is significant geographic variation in the percentage of physically inactive persons, ranging from 70% in Andalusia to 40% in the Basque Country [START_REF] Regidor | La salud de la población española en el contexto europeo y del Sistema Nacional de Salud[END_REF], with the figures coinciding with the distribution of obesity by Spanish Autonomous Communities. As with obesity, physical inactivity during free time presents a clear social gradient [START_REF] Regidor | La salud de la población española en el contexto europeo y del Sistema Nacional de Salud[END_REF], increasing with a decrease in the educational level, a fact that we also noted in our environment. About a quarter of the Spanish adult population smokes [19] and 16% of coronary and cerebrovascular deaths in Spain are attributable to smoking [START_REF] Banegas | La mortalidad atribuible al tabaquismo comienza a descender en España[END_REF]. Fortunately, recent years have seen a reduction in the consumption of tobacco [START_REF] Villalbí | Cambios en el patrón de tabaquismo de la población: Barcelona, 1983-2006[END_REF], but preventive measures appear to be less effective in young women [START_REF] Regidor | La salud de la población española en el contexto europeo y del Sistema Nacional de Salud[END_REF]. We found a higher rate of smoking in younger subjects, and among those aged 30-39 years consumption was higher in women.

High smoking levels in young women have been highlighted in other studies in Spain [START_REF] Regidor | La salud de la población española en el contexto europeo y del Sistema Nacional de Salud[END_REF][START_REF] Villalbí | Cambios en el patrón de tabaquismo de la población: Barcelona, 1983-2006[END_REF].

Mean levels of serum lipids (except HDL-c) are tending to increase in the general Spanish population [START_REF] Basterra-Gortari | Tendencias de la obesidad, diabetes mellitus, hipertensión e hipercolesterolemia en España (1997-2003)[END_REF]. Our study agrees with others showing that the Andalusian population has the highest levels of total cholesterol and LDL-c in Spain [START_REF] Basterra-Gortari | Tendencias de la obesidad, diabetes mellitus, hipertensión e hipercolesterolemia en España (1997-2003)[END_REF][START_REF] Medrano | Factores de riesgo cardiovascular en la población española: metaanálisis de estudios transversales[END_REF].

The rate of hypercholesterolaemia increases with age [START_REF] Basterra-Gortari | Tendencias de la obesidad, diabetes mellitus, hipertensión e hipercolesterolemia en España (1997-2003)[END_REF]. Thus, the lower rate of hypercholesterolaemia (defined by the presence of LDL-c ≥160 mg/dL (4.1 mmol/L) or the use of lipid-lowering drugs) found in men above the age of 60 years could be explained by a survivor bias or the lower indication for lipid-lowering drugs in advanced age [START_REF] Jacobson | Overcoming 'ageism' bias in the treatment of hypercholesterolaemia. A review of safety issues with statins in the elderly[END_REF]. A reduction in the prevalence of hypertriglyceridaemia after the age of 70 years was also observed, probably due to the lower rate of obesity in these age groups. Like other studies [START_REF] Cabrera De León | Presentación de la cohorte "CDC Canarias": objetivos, diseño y resultados preliminares[END_REF], we found no age pattern in the prevalence of low HDL-c. Nor did we find any gender differences in the prevalence of the components of dyslipidaemia, except for hypertriglyceridaemia, which was more common in men [START_REF] López-Suárez | Prevalencia de obesidad, diabetes, hipertensión, hipercolesterolemia y síndrome metabólico en adultos mayores de 50 años de Sanlúcar de Barrameda[END_REF].

The prevalence of hypertension in Spain shows a tendency for a small increase in relation to population aging and the obesity epidemic and at present is nearly 35% in the adult Spanish population [START_REF] Basterra-Gortari | Tendencias de la obesidad, diabetes mellitus, hipertensión e hipercolesterolemia en España (1997-2003)[END_REF][START_REF] Medrano | Factores de riesgo cardiovascular en la población española: metaanálisis de estudios transversales[END_REF][START_REF] Gabriel | Prevalencia, distribución y variabilidad geográfica de los principales factores de riesgo cardiovascular en España. Análisis agrupado de datos individuales de estudios epidemiológicos poblacionales: estudio ERICE[END_REF], reaching almost 70% in those aged 60-65 years [START_REF] Banegas | Hypertension magnitude and management in the elderly population of Spain[END_REF]. Our results are consistent with these data.

It has been estimated that 20% of deaths attributable to blood pressure in Spain occur in subjects with normal or high-normal blood pressure [START_REF] Banegas | Mortalidad relacionada con la presión arterial y la hipertensión en España[END_REF]. In our population, only 38.7% of the adult population maintained optimal blood pressure. Although considerable progress has been made over recent decades in the detection and control of hypertension in Spain [START_REF] Gutiérrez-Fisac | Blood pressure in Spain: distribution, awareness, control, and benefits of a reduction in average pressure[END_REF], we still found that 14.1% of the population had unknown hypertension.

The prevalence of diabetes in our population (7.1%) was lower than that reported in other studies in Spain [START_REF] Valdés | Evolución de la prevalencia de la diabetes tipo 2 en población adulta española[END_REF], which can be attributed to differences in methodology and diagnostic criteria.

Overall, we found that the prevalence of CVRF increases with age, with the exception of smoking, which was more frequent in those younger than 50 years, and low HDL-c concentrations, which were not correlated with age. The rates of hypercholesterolaemia (in men) and hypertriglyceridaemia were reduced from the age of 60 and 70 years, respectively. A low educational level was associated, after adjustment for sex and age, with a higher prevalence of CVRF (including smoking, obesity, abdominal obesity and hypertriglyceridaemia), and a higher consumption of cardiovascular drugs. Our data are consistent with other studies indicating the association between low socio-cultural status, a key factor in determining behavioural patterns [START_REF] Lantz | Socioeconomic factors, health behaviors, and mortality. Results from a nationally representative prospective study of US adults[END_REF], and obesity [START_REF] Regidor | Influencia a lo largo de la vida de las circunstancias socioeconómicas, de la inactividad física y de la obesidad sobre la prevalencia de síndrome metabólico[END_REF], smoking [START_REF] Businelle | Mechanisms linking socioeconomic status to smoking cessation: a structural equation modeling approach[END_REF], and other risk factors such as dyslipidaemia [START_REF] Kanjilal | Socioeconomic status and trends in disparities in 4 major risk factors for cardiovascular disease among US adults, 1971-2002[END_REF].

Our study has certain limitations. The characteristics of our population (urban, lower-middle socioeconomic status) do not permit the results to be extrapolated to other populations. However, the fact that the study involved a large random sample of the Nor does the local nature of the study diminish the significance of the results. Among the methodological limitations, we should note that we did not use a validated interview to categorize physical activity. The relationship of CVRF with the level of studies is limited by the existence of only two educational groups and the absence of other socioeconomic variables. The prevalence of previously unknown hypertension was calculated based on repeated measures of blood pressure made on a single day, which does not comply with the recommended diagnostic protocol. The prevalence of diabetes, calculated from an isolated fasting measurement of glucose and a personal history of a diagnosis of diabetes or the use of antidiabetic medication, may be underestimated because we did not perform an active search for cases by means of an oral glucose tolerance test. Furthermore, since there is a large short-term intraindividual variability in fasting plasma glucose, studies like ours that make a single determination of blood sugar tend to overestimate the prevalence of type 2 diabetes [START_REF] Selvin | Short-term variability in measures of glycemia and implications for the classification of diabetes[END_REF], which can be attenuated by the underestimation of the real prevalence of diabetes. Finally, methodological heterogeneity in diagnostic criteria and age groups hinder comparison of our results with other epidemiological studies.

In summary, we found a high prevalence of obesity, dyslipidaemia and hypertension in our environment. The high rates of smoking and a sedentary lifestyle in young women raise fears for a large increase in cardiovascular morbidity and mortality in this subgroup in the near future. The low educational level was associated with a higher prevalence of CVRF, especially smoking, obesity and dyslipidaemia. The high prevalence of classical CVRF or risk factors linked to obesity and its inadequate control represents a challenge for the health care system and requires implementation without delay of training programs and preventive measures, as well as active public health counselling, which should focus especially on the population with a lower socio-cultural level.

INTRODUCTION

  Cardiovascular diseases (CVD) are the main cause of mortality in Spain, accounting

  100-125 mg/dL (5.6-6.9 mmol/L), both inclusive. Dysglycaemia was defined as the presence of IFG or diabetes.Dyslipidaemia was considered to be present if there was a prior diagnosis of this process, if the patient was taking lipid-lowering drugs, or if the analytical concentrations of total cholesterol ≥ 200 mg/dL (5.2 mmol/L), LDL-c ≥ 160 mg/dL (4.1 mmol/L), high density lipoprotein cholesterol (HDL-c) <40 mg/dL (1.0 mmol/L) in men or <50 mg/dL (1.3 mmol/L) in women, or the triglycerides ≥ 200 mg/dL (2.3 mmol/L).Cardiovascular disease was considered to be a previous history of ischaemic heart disease (myocardial infarction, acute coronary syndrome, angina, or coronary revascularization), cerebrovascular disease (stroke, transient ischaemic attack) or peripheral arterial disease (intermittent claudication, revascularization or lower limb amputation, or abdominal aortic aneurysm).

  patterns, largely determined by socioeconomic and cultural factors, are critical in health indicators

  the high participation rate both contribute strength to the results.

  Kuhn Gonzalez M, Linares Castro L, Martos Cerezuela I, Mestre Reoyo G, Muñoz Villalba JC, Paniagua Gomez F, Perez Juncosa F, Reyes Alcazar P, Rodríguez Lago JA, Rodriguez Rivera MR, Sanchez Perez R, Sacristan Visquert E, Taboada Gonzalez F.

  The characteristics of the sample, overall and by sex, are shown in Table1.subjects performed a heart-healthy physical activity (walking at least 150 minutes weekly).

	F o r
	P
	e
	e r
	R
	e
	v i e
	w
	O n l
	y

Table 1 .

 1 Characteristics of the study population overall and by gender.

	Total	Male	Female	P

Anand SS; INTERHEART Study Investigators. Obesity and the risk of myocardial

Acknowledgments. We thank the doctors and nurses of the Ciudad Jardin Health Centre for their cooperation in the IMAP study: Anton Cortés M, Fernandez Tapia ML, Ginel

Funding. This study was undertaken with finance from the Consejeria de Salud Junta de Andalucia (nº exp. 283/06) (IMAP study)

Conflict of interest: None declared


Walker Ia
email: isabeauwalker@mac.com

I A Walker

Dr M W Newton

Improving surgical safety globally: pulse oximetry and the WHO Guidelines for Safe Surgery

Keywords: child < Airway, Developing World, quality improvement < Outcomes, General anesthesia

Access to safe surgery should be considered as part of the basic human right for health, but unfortunately this ideal is far from being reached in many lowincome countries. Pulse oximetry is recommended as a minimum standard of monitoring by all anesthesia organizations that have set standards, yet around 78,000 operating theaters worldwide lack this essential monitor. The WHO Safe Surgery Saves Lives Program has identified evidence-based guidelines for safe surgery that are applicable in any setting, and the Global Pulse Oximetry Program will help to improve access to pulse oximetry in countries where it is not available. However, these initiatives are just a start; capacity, infrastructure, trained healthcare providers and access to essential drugs and equipment for anesthesia and surgery need to become a public health priority in many lowincome countries. recently, through the use of simulation and with a better understanding of human factors, further improvements can be expected [START_REF] Gaba | Anaesthesiology as a model for patient safety in healthcare[END_REF]. In the USA, anesthesia-related mortality for surgical in-patients was estimated to be 1:2700 in 1948-52, and is currently estimated to be 1: 122,000 -1: 200 000 (2,3).

However, these advances in anesthesia safety have not been realized globally. A recent paper describing pediatric anesthesia in Benin documents a perioperative cardiac arrest rate of 1:64 anesthetics (62% mortality) (4). Reports from sub-Saharan Africa describe anesthesia mortality ranging from 1:133 to 1:1900 for adult and pediatric practice, similar to that seen in high-income countries more than fifty years ago [START_REF] Walker | Anaesthesia in developing countries -a risk for patients[END_REF]. How can access to safe anesthesia and surgery become a reality for all populations in the 21 st Century?

One of the primary challenges to improving outcomes from anesthesia and surgery is access to timely surgical care delivered by adequately trained and resourced healthcare providers. This should be recognized as part of the basic human right to health, but this ideal is far from being realized [START_REF] Ozgediz | The "Other" Neglected Diseases in Global Public Health: Surgical Conditions in Sub-Saharan Africa[END_REF][START_REF] Editors | A crucial role for surgery in reaching the UN Millennium Development Goals[END_REF]. Of the estimated 234 million surgical procedures that are performed each year, 74% procedures occur in high-and middle-healthcare expenditure countries (representing 30% of the world's population), 23% in low-healthcare expenditure countries (35% of the world's population) and 3.5% occur in poor-healthcare expenditure countries (35% of the [START_REF] Weiser | An estimation of the global volume of surgery: a modelling strategy based on available data[END_REF]. Africa suffers disproportionately, with 25% of the global burden of disease and only 2% of the global health workforce [START_REF]Working together for health[END_REF].

A recent survey describes the situation for pediatric surgery in southwest Uganda [START_REF] Walker | Paediatric surgery and anaesthesia in south-western Uganda: a cross-sectional survey[END_REF]. The pediatric surgical rate was 3% of that seen in England, and most surgery related to emergency procedures for burns, trauma and infectious complications.

Presentation for elective surgery for congenital abnormalities was considerably delayed, and many emergency patients were referred from rural hospitals to regional hospitals for surgery due to lack of essential resources. Such patients are likely to present a significant challenge to both surgeon and anesthesia provider. The surgical workforce was 5% of that in England (no specialist pediatric surgeons); the specialist anesthesiology workforce 1% of that in England, and 20% of anesthesia providers had no formal training at all ('trained on job'). Essential supplies such as oxygen, basic airway equipment, electricity and running water were not always available and none of the hospitals in the region reached WHO standards for essential surgery. Although Uganda is used as an example, the shortfall in infrastructure, supplies, workforce and volume of surgical activity is typical of many low-and middle-income countries [START_REF] Kushner | Addressing the Millennium Development Goals From a Surgical Perspective. Essential Surgery and Anesthesia in 8 Low-and Middle-Income Countries[END_REF][START_REF] Dubowitz | Global Anesthesia Workforce Crisis: A Preliminary Survey Revealing Shortages Contributing to Undesirable Outcomes and Unsafe Practices[END_REF][START_REF] Hodges | Paediatric anaesthesia in developing countries[END_REF]. Anesthesia and surgical providers need the tools of their trade, and poor anesthesia outcomes described in these circumstances should not surprise us (4).

Placing complex patients in the hands of inadequately trained and poorly resourced anesthesia providers undergoing surgery with inexperienced clinicians would likely be associated with high mortality anywhere. So how do we improve the situation? Limited health expenditure is the greatest barrier to improving the outcomes from healthcare. In Uganda, for example, the per capita government expenditure on health is $20 (compared to $2446 in the UK), and many families are required to make out of pocket contributions for their own healthcare. A recent survey of district hospitals in Africa identified a per capita expenditure on surgery of only $0.05 -$0.14, most of this relating to obstetric care [START_REF] Kruk | Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey[END_REF]. International donor organizations tend to focus public health policies on infectious diseases, malaria and HIV, but a shift of emphasis towards surgical care is long overdue. Surgical diseases are thought to account for 11% of the global burden of disease, whilst diseases such as HIV, malaria and tuberculosis account for only 1.3% of the global burden of disease [START_REF] Ozgediz | The "Other" Neglected Diseases in Global Public Health: Surgical Conditions in Sub-Saharan Africa[END_REF]. Injuries are responsible for more deaths of African children over five than HIV, malaria and tuberculosis combined. Essential surgical care can be achieved with similar cost effectiveness to childhood vaccination programs. In addition improving the facilities for surgical care may have the added benefit of strengthening health systems for the delivery of primary care. These factors need to be addressed as a priority [START_REF] Editors | A crucial role for surgery in reaching the UN Millennium Development Goals[END_REF][START_REF] Luboga | Increasing Access to Surgical Services in Sub-Saharan Africa: Priorities for National and International Agencies Recommended by the Bellagio Essential Surgery Group[END_REF].

Although resources are the greatest barrier to safe care, there is much that can be done to make sure that existing resources are used efficiently, in particular by ensuring that care is planned and delivered by individuals who are working well as a team. The adverse events from surgery constitute a significant public health concern. Major complications feature in 3%-22% of inpatient surgical procedures, with a death rate of 0.4%-10%, depending on the setting. Worldwide, an estimated 7 million patients suffer postoperative surgical complications annually, and 1 million patients die [START_REF]Guidelines for Safe Surgery: 2009: Safe Surgery Saves Lives[END_REF].

Evidence-based interventions to improve surgical safety were considered by the SSSL team led by surgeon and public health physician Atul Gawande. An international consortium including representatives from surgery, anesthesia, nursing, infection control and quality improvement convened to write evidence-based guidelines and identify a core set of safety standards that could be applied in all countries and in all settings [START_REF]Guidelines for Safe Surgery: 2009: Safe Surgery Saves Lives[END_REF]. The most common complications during and after surgery that were considered included unanticipated hemorrhage, surgical site infections, anesthesia complications or incorrect site surgery. Many complications were considered preventable by good communication and teamwork. The Surgical Safety Checklist was designed to facilitate implementation of the WHO Guidelines for Safe Surgery, and focuses on critical points during the patient's journey through theatre, prior to induction (Sign in), prior to incision (Time out) and at the end of surgery (Sign out).

The 19-point checklist includes key elements that contribute to surgical safety such as checking cross-match of blood for surgery, anesthesia equipment, the appropriate administration of antibiotics, whilst facilitating communication within the surgical team, one of the essential 'human factors' elements so often neglected in surgical care. The SSSL team investigated the impact of the Checklist in eight hospitals worldwide, four in high-income settings (USA, Canada, England, and New Zealand) and four in middle-and low-income settings (India, Jordan, Philippines and Tanzania [START_REF] Haynes | A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population[END_REF]. Data were collected prospectively from consecutively enrolled patients, 3733 before and 3955 after the introduction of the checklist. The overall mortality rate was reduced from 1.5% to 0.8% (p=0.003) and in-patient complications from 11.0% to 7% (p<0.001). Similar reductions in morbidity and mortality were noted after urgent surgery [START_REF] Weiser | Effect of a 19-item surgical safety checklist during urgent operations in a global patient population[END_REF]. The checklist was launched in June 2008, and since then, more than 25 countries have introduced the checklist on a national scale. Local modification of the checklist to suit pediatric practice is encouraged and specific guidance is available on the Safe Surgery website http://www.safesurg.org [START_REF] Safesurg | A website for information on how to reduce surgical deaths in surgical care globally[END_REF].

Further evaluation of the impact of the checklist from national studies is awaited, but one of the principle effects appears to be improved communication and team working, as predicted from the earlier pilot work [START_REF] Sewell | Use of the WHO surgical safety checklist in trauma and orthopaedic patients[END_REF][START_REF] Lingard | Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication[END_REF]. Improved teamwork with team training has recently been shown to have a striking effect on surgical mortality [START_REF] Neily | Association between implementation of a medical team training program and surgical mortality[END_REF]. Improved teamwork may be of particular relevance in low-income countries where professional hierarchies remain significant. The surgeon may be the only qualified doctor on site, and on occasion, non-medical anesthetists may feel cajoled into providing anesthesia when they do not feel adequately trained or resourced to do so [START_REF] Dobson | Training the trainers[END_REF]. Improved teamwork and routine use of the checklist may raise the professional standing of surgical nursing, and support the use standard safety checks, for example patient identification bands, surgical marking and swab, needle and instrument counts.

It is essential that surgeons and anesthesiologists support the principles of the checklist to overcome the practical challenges to its introduction [START_REF] Vats | Practical challenges of introducing WHO surgical checklist: UK pilot experience[END_REF]. One of the checks required during the Sign in phase of the checklist is that a functioning pulse oximeter is on the patient prior to anesthesia. This item stands out as the single piece of equipment mandated by the WHO Checklist. Why is it there?

During the development of the checklist, anesthesiologists from the expert group expressed the view that without universal pulse oximetry, the dramatic improvements in patient safety that followed the introduction of pulse oximetry into high-income countries in the mid-1980's would not be achieved in low-and middle-income counties, even with the use of the checklist [START_REF] Merry | Extending the WHO 'Safe Surgery Saves Lives' project through Global Oximetry[END_REF]. Although it could be argued that other monitoring modalities such as capnography are just as important, the expert group took the view that given the simplicity and reliability of the technology, pulse oximetry should be made available anywhere where general anesthesia or sedation is administered and should be a greater priority than all other anesthesia monitors. There are 58 countries that have established national standards of anesthesia monitoring, and all include the use of oximetry [START_REF] Funk | Global operating theatre distribution and pulse oximetry supply: an estimation from reported data[END_REF]. Pulse oximetry has been included as a minimum level of monitoring for anesthesia in all settings internationally [START_REF] Merry | International Standards for a Safe Practice of Anesthesia 2010[END_REF]. However, recent data suggests that around 78,000 operating theatres worldwide are not equipped with pulse oximeters, thus affecting surgical safety for millions of patients in middle-and low-income countries [START_REF] Funk | Global operating theatre distribution and pulse oximetry supply: an estimation from reported data[END_REF].

Following the publication of the Surgical Checklist, the WHO recognized the need to start a process to ensure the availability of pulse oximeters everywhere in the world where surgery is performed. This initiative is known as the Global Pulse Oximetry Project [START_REF] Merry | Extending the WHO 'Safe Surgery Saves Lives' project through Global Oximetry[END_REF]. The current work has been informed by a project undertaken by the Philippines, India and Vietnam [START_REF] Walker | Global oximetry: an international anaesthesia quality improvement project[END_REF]. This quality improvement project identified enthusiastic take up of the monitoring and training by anesthesia providers, many of whom had never used a pulse oximeter. There was evidence of learning and change of practice that was sustained over a period of time.

Education about both the WHO Checklist and the use of pulse oximetry is an important component of the Global Pulse Oximetry Project and a pilot evaluation of the checklist with pulse oximetry is planned. A procurement exercise has been followed by the WFSA to select a high quality, robust, low cost pulse oximeter meeting specifications for austere environments. Together with partners from the WHO, Harvard School of Public Health, AAGBI and Smile Train, the WFSA will use donor funds to start shipment of pulse oximeters to areas of need identified in lowand middle-income countries in early 2011 (contact GPOP@anaesthesiolgists.org for further information).

Although the Global Pulse Oximetry Project and the WHO Checklist are major steps on the road to improve anesthesia and surgical care in middle-and lowincome countries, there are further questions that should be addressed. For instance, 'task shifting' is required as a pragmatic response to the shortage of healthcare workers. The optimal duration and method of training is unknown, and outcomes from training programs should be addressed. It would be helpful to develop accredited regional training programs, similar to that achieved by the Pan African College of Surgeons for East, Central, and Southern Africa, and the role of international partnerships should be investigated. An international standard for anesthesia machines suited to low-income countries is currently under development, and the design of equipment specifically suited to these environments is required (and could offer manufacturers new market opportunities). Anesthesia techniques suited to high-income countries may not be appropriate in all settings, and outcomes using different techniques should be investigated. For instance, ketamine-based anesthesia without intubation may offer improved outcomes in some poorly resourced settings [START_REF] Walker | Paediatric surgery and anaesthesia in south-western Uganda: a cross-sectional survey[END_REF].

There are also some major hurdles that must be addressed to improve the very high anesthesia mortality rates reported. Positive incentives are required to encourage trained providers to stay in-country, for instance development of postgraduate training programs, access to housing, salaries, and continuous professional development programs. International partnerships may be helpful in this context. Quality improvement initiatives can be successful in resourcepoor settings, but they require attention to basic infrastructure if improvements are to be maintained (29). Fewer than 30% of countries have a national blood transfusion service, and lack of blood for emergency surgery is a frequent problem (30). Essentials such as water, electricity, oxygen and basic airway equipment are often not available and emergency surgery may be delayed when patients have to buy antibiotics, sutures or surgical gloves [START_REF] Kushner | Addressing the Millennium Development Goals From a Surgical Perspective. Essential Surgery and Anesthesia in 8 Low-and Middle-Income Countries[END_REF]31). Political buy in to the standards described by the WHO Guidelines for Safe Surgery at local, regional, national and international level is vital so that these critical limitations in surgical resources can be addressed. The public health challenges in providing safe surgical services are considerable, but essential surgical care has been neglected for too long. Widespread adoption of the WHO Surgical Safety Checklist and pulse oximetry should go a long way to improving surgical safety, but this is only the start of the journey.

  improved considerably in recent years in the wake of advances in technology, the development of new drugs, improvements in training, adoption of standards, guidelines and incident monitoring. More

  WHO Patient Safety initiative was established in 2004, led by Sir Liam Donaldson, then Chief Medical Officer in England. The second WHO Global Patient Safety Challenge "Safe Surgery Saves Lives" (SSSL) was launched in 2008 in acknowledgement of the fact that the global volume of surgery is significant and that

10 World

 10 Federation of Societies of Anaesthesiologists (WFSA) and Association of Anesthetists of Great Britain and Ireland (AAGBI) with an industry collaborator GE Healthcare, where 80 oximeters were introduced into different hospitals in Uganda,

  M, Lee P, Habiyakare C et al. Improving quality in resource poor settings: observational study from rural Rwanda BMJ 2009; 339: b3488 30. Bosenberg AT. Pediatric anesthesia in developing countries. Current Opinion in Anaesthesiology 2007; 20: 204-10.) 31. Hodges SC, Mijumbi C, Okello M et al. Anaesthesia services in developing countries: defining the problems. Anaesthesia 2007; 62: 4-11


Keywords: Parents/parenting, Self regulation, Preschool Social Development

The present study demonstrated that a more differentiated view of positive parenting practices is necessary in the study of children's acquisition of self-regulation. Here, the unique contributions of maternal warmth and responsiveness to distress to children's self-regulation were tested in a sample of 102 German mothers and their kindergarten children (51 girls and 51 boys). Behavior regulation and internalization of rules of conduct were examined as specific components of children's self-regulation. As expected, maternal warmth was positively related to the child's behavior regulation. Responsiveness to distress was positively linked to the child's internalization of rules of conduct. No significant interactions between maternal parenting and either the child's gender or effortful control were found. The results are discussed with regard to the unique functions that different parenting practices have for children's self-regulation.

Parenting practice and children's self-regulation 1 Linking maternal warmth and responsiveness to children's self-regulation Learning to effectively self-regulate one's own behavior in accordance with social standards is critical to children's development. In the literature, various parenting practices that promote this process have been identified (e.g., [START_REF] Chen | Parental warmth, control, and indulgence and their relations to adjustment in Chinese children: A longitudinal study[END_REF][START_REF] Friedlmeier | Emotion regulation in early childhood: A crosscultural comparison between German and Japanese toddlers[END_REF][START_REF] Jones | The specificity of maternal parenting behavior and child adjustment difficulties: A study of inner-city African American families[END_REF]. There is a growing body of empirical evidence that details the extent to which a specific parenting practice has a unique effect on a specific developmental outcome (see e.g., [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF][START_REF] Jones | The specificity of maternal parenting behavior and child adjustment difficulties: A study of inner-city African American families[END_REF][START_REF] Mize | Mothers' social coaching, mother-child relationship style, and children's peer competence: Is the medium the message[END_REF]. However, studies reporting functionally different effects involving positive parenting practices in non-American samples are scarce. Moreover, it has been pointed out that considerable differences exist between the US and European cultures, for instance, regarding parents' naïve theories of child development and socialization goals (Harkness, Super, & van Tiejen, 2000;[START_REF] Keller | Cultural models, socialization goals, and parenting ethnotheories: A multicultural analysis[END_REF]. Therefore, the purpose of the present study was to clarify the association of two aspects of positive parenting with two types of children's selfregulation in a German sample of kindergarten children. Positive parenting includes behaviors such as support, nurturance, and warm and appropriate discipline which promote a positive parent-child relationship (e.g., [START_REF] Tildesley | The development of children's intentions to use alcohol: Direct and indirect effects of parent alcohol use and parenting behaviors[END_REF]. Specifically, we investigated maternal warmth and responsiveness to distress in relation to children's behavior regulation in a delay task and children's internalization of rules of conduct. Moreover, the effects of children's gender and temperament on the relations between positive parenting and children's self-regulation were investigated as previous research has shown that children's characteristics moderate relations between parenting and developmental outcomes (e.g., [START_REF] Bates | Interaction of temperamentl resistance to control and restrictive parenting in the development of externalizing behavior[END_REF][START_REF] Eisenberg | Parental socialization of children's dysregulated expression of emotion and externalizing problem[END_REF]. So far however, most of these studies have focused on the development of externalizing problem behavior.

Self-Regulation

Self-regulation is a broad concept that focuses on an individual's motivation and ability to modify his or her emotion and behavior to achieve goals [START_REF] Kopp | Antecedents of self-regulation: A developmental perspective[END_REF][START_REF] Mcclelland | Links between behavioral regulation and preschoolers' literacy, vocabulary, and math skills[END_REF]Trommsdorff, 2009a). As a superordinate construct, self-regulation includes narrower constructs, such as the regulation of behavior (e.g., [START_REF] Kopp | Self-regulation in normal and atypical development[END_REF] and the internalization of rules of conduct (e.g., Kochanska, DeVet, Goldman, Murray, & Putnam, 1994). Behavior regulation is defined as the ability to express or control one's impulses, motor responses, and other behavior [START_REF] Wong | Behavioral control and resiliency in the onset of alcohol and illicit drug use: A prospective study from preschool to adolescence[END_REF]. Behavior regulation in children progressively shifts from external to internal processes [START_REF] Kopp | Antecedents of self-regulation: A developmental perspective[END_REF]McClelland, Ponitz, Messersmith, & Tominey, in press). During development children become increasingly aware of social standards. They learn to take a more active role in the self-regulation process and to regulate their behavior more independently of parental monitoring and intervention [START_REF] Kochanska | Children's conscience and self-regulation[END_REF]. Internalization involves adopting rules and norms, so that acting according to social standards is motivated not only by external consequences but increasingly by internalized rules [START_REF] Grusec | Impact of parental discipline methods on the child`s internalization of values: A reconceptualization of current points of view[END_REF]. The development of behavior regulation proceeds on an observable level of concrete behaviors, whereas internalization implies the acquisition of conscience.

Socialization of Self-Regulation

Psychologists have identified children's self-regulation as an important socialization goal of parents (e.g., [START_REF] Grusec | New directions in analyses of parenting contributions to children's acquisition of values[END_REF][START_REF] Maccoby | Socialization in the context of the family: Parentchild interaction[END_REF].

Typically, such socialization efforts begin in early childhood, when children become increasingly aware of the expectations of their social environment through parental rulesetting. For almost 30 years, research on parenting with regard to child outcomes was dominated by [START_REF] Baumrind | Current patterns of parental authority[END_REF] classification of parenting styles. A parenting style refers to a constellation of attitudes toward a child that is fairly constant over time and in a variety of contexts [START_REF] Collins | Contemporary research on parenting: The case of nature and nurture[END_REF][START_REF] Darling | Parenting style as context: An integrative model[END_REF][START_REF] Maccoby | Socialization in the context of the family: Parentchild interaction[END_REF]. However, [START_REF] Darling | Parenting style as context: An integrative model[END_REF] argue that for an understanding of the processes through which parenting influences child outcomes, one needs to differentiate between parenting style (e.g., authoritative or authoritarian) and parenting practices (e.g., warmth, responsiveness, control). Individual parenting practices that often have been grouped together for research purposes can serve different functions for children's developmental outcomes [START_REF] Maccoby | Parenting and its effects on children: On reading and misreading behavior genetics[END_REF][START_REF] Porter | A comparative study of child temperament and parenting in Beijing, China and the western United States[END_REF]. Specific parenting practices are used by parents to help children achieve particular socialization goals [START_REF] Darling | Parenting style as context: An integrative model[END_REF][START_REF] Mize | Mothers' social coaching, mother-child relationship style, and children's peer competence: Is the medium the message[END_REF]. They operate in circumscribed socialization domains, such as self-regulation, directly affect child behaviors (e.g., the ability to resist temptations), and have an impact on parent's socialization efforts [START_REF] Mize | Mothers' social coaching, mother-child relationship style, and children's peer competence: Is the medium the message[END_REF]. According to the specific developmental outcome in question, different parenting practices need to be investigated [START_REF] Darling | Parenting style as context: An integrative model[END_REF][START_REF] Grusec | Socialization in the family[END_REF]. [START_REF] Stewart | A critical look at parenting research from the mainstream: Problems uncovered while adapting Western research to non-Western cultures[END_REF] stated, "Instead of describing parenting characteristics by using typologies, an alternative approach is to dismantle typologies into their component parts" (p. 381; cf. also [START_REF] Darling | Parenting style as context: An integrative model[END_REF]. Nonetheless, many studies take a global approach to positive parenting, in which different positive parenting practices are grouped together [START_REF] Goldberg | Confidence in protection: Arguments for a narrow definition of attachment[END_REF][START_REF] Porter | A comparative study of child temperament and parenting in Beijing, China and the western United States[END_REF]. In particular, two aspects of positive parenting, warmth and responsiveness to distress, have often been treated as one, because their characteristics and their functions for child development seem to be very similar. Research, however, demonstrated a wide variability in warm and responsive parenting (e.g., [START_REF] Cahill | Theory of mind, self-worth and the mother-child relationship[END_REF]. MacDonald (1992) suggested that warmth and responsiveness to distress are not generally associated (such as that the level of warmth influences the effects of responsiveness and vice versa). [START_REF] Mize | Mothers' social coaching, mother-child relationship style, and children's peer competence: Is the medium the message[END_REF] found support for functionally different effects of these different aspects of parenting: responsive parenting (i.e., warmth, synchrony) accounted for unique variance in teacher ratings of children's social skills and aggression. Recently, a study by [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF] has provided further evidence that warmth and responsiveness to distress are two distinct features of positive parenting. These features require different skills and resources from parents. Moreover, they serve different functions in children's development. Parental warmth is characterized by high degrees of affection, spontaneous expressions of positive emotions in parent-child interactions, and frequent praise of the child, as expressed by behaviors such as kissing and hugging the child [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF][START_REF] Macdonald | Warmth as a developmental construct: An evolutionary analysis[END_REF]. As distinguished from warmth, responsiveness to distress focuses on parental reactions when a child is upset. Positive parental responsiveness to distress involves supportive reactions: for example, comforting or helping the child when he or she is facing an upsetting situation [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF].

Warmth and children's behavior regulation. By frequently engaging their children in interactions involving positive emotions, love, and praise of the child, parents facilitate children's ability and motivation for behavior regulation. For instance, a parent consistently expressing love and affection induces positive mood in the child. The child in turn is willing to control impulses and behaviors in order to continue the positive and satisfying parent-child interactions [START_REF] Grusec | Socialization in the family[END_REF]. Thus, parental warmth might be particularly related to children's development of behavior regulation. Studies have consistently demonstrated positive links between parental warmth and children's behavior regulation as assessed by parents' reports (e.g., [START_REF] Colman | Early predictors of self-regulation in middle childhood[END_REF]. In a recent study by [START_REF] Jennings | Understanding of self and maternal warmth predict later self-regulation in toddlers[END_REF], a positive relation between maternal warmth and behavior regulation in toddlers was observed. Other studies (e.g., [START_REF] Eisenberg | Relations among positive parenting, children`s effortful control, and externalizing problems: A three-wave longitudinal study[END_REF][START_REF] Jones | The specificity of maternal parenting behavior and child adjustment difficulties: A study of inner-city African American families[END_REF][START_REF] Russell | Positive parenting and boys' and girls' misbehavior during a home observation[END_REF] have shown that parental warmth was related to low levels of externalizing problems in children, and that high levels of behavior regulation were likewise associated with the absence of externalizing problems in childhood and adolescence [START_REF] Wong | Behavioral control and resiliency in the onset of alcohol and illicit drug use: A prospective study from preschool to adolescence[END_REF]. Thus, parental warmth is expected to be positively related to behavior regulation. .

Responsiveness to distress and children's internalization of rules of conduct.

The process of internalization is accompanied by children's experience of and coping with negative emotions, for instance, when being scolded for some mischief. Parents' active strategies affect how a child copes with these experiences. Responsive strategies help a child to acquire and to internalize social rules and standards (e.g., [START_REF] Kochanska | The emergence and development of conscience in toddlerhood and early childhood[END_REF] thus enhancing a child's motivation and ability to comply with parental demands and to internalize rules of conduct [START_REF] Karreman | Parenting and selfregulation in preschoolers: A meta-analysis[END_REF][START_REF] Kochanska | Mother-child mutually responsive orientation and conscience development: From toddler to early school age[END_REF]. According to [START_REF] Maccoby | Socialization in the context of the family: Parentchild interaction[END_REF], responsive parenting practices facilitate children's understanding of principles of cause and effect. These practices influence how open children are to parental socialization efforts and how willingly they learn to make appropriate choices [START_REF] Grusec | Impact of parental discipline methods on the child`s internalization of values: A reconceptualization of current points of view[END_REF]. Parental responsiveness thus facilitates children's motivation to meet situational demands. Further evidence is provided by a study examining the role of early versus ongoing maternal responsiveness in predicting cognitive and social development in full-term and preterm children [START_REF] Landry | Does early responsive parenting have a special importance for children's development or is consistency across early childhood necessary[END_REF]. The results of this study showed that children's internalization is fostered when parents demonstrate consistent patterns of responsiveness to their children's emotional needs throughout infancy and early childhood. Correspondingly, we expected that responsiveness to distress is positively related to internalization of rules of conduct.

Child's Gender and Effortful Control

Previous studies (e.g., [START_REF] Bates | Interaction of temperamentl resistance to control and restrictive parenting in the development of externalizing behavior[END_REF][START_REF] Blair | Maternal and child contributions to cortisol response to emotional arousal in young children from low-income, rural communities[END_REF][START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF][START_REF] Eisenberg | Effortful control and its socioemotional consequences[END_REF][START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF][START_REF] Kochanska | Maternal reports of conscience development and temperament in young children[END_REF] have shown that gender and effortful control are relevant in the development of children's selfregulation. Several studies revealed gender differences in children's and adolescents' selfregulation: Overall, girls have, compared to boys, stronger self-regulation skills [START_REF] Duckworth | Self-discipline gives girls the edge: Gender in self-discipline, grades, and achievement test scores[END_REF][START_REF] Matthews | Early gender differences in self-regulation and academic achievement[END_REF][START_REF] Raffaelli | Developmental stability and change in self-regulation from childhood to adolescence[END_REF].

However, these findings appear to be unique in to North-American samples and may not apply to other cultures, especially when observational measures of self-regulation are used (McClelland et al., in press). Some studies investigating gender as a moderating link between parenting and self-regulation revealed mixed and inconsistent findings (e.g., [START_REF] Colman | Early predictors of self-regulation in middle childhood[END_REF][START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF]. [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF] found that the child's gender, for instance, moderated the relationship between maternal responsiveness to distress and emotion regulation. The associations were obtained only for boys but not for girls. In contrast, in a study by [START_REF] Colman | Early predictors of self-regulation in middle childhood[END_REF] child gender did not moderate the effects of parenting on later self-regulation.

Generally, effortful control has been defined as the competence to inhibit a dominant response and/or to activate a subdominant response [START_REF] Rothbart | Temperament[END_REF]). Children's individual differences in effortful control may lead to different reactions to parenting. As a result, a child is more or less susceptible to parent behaviors [START_REF] Belsky | Differential susceptibility to rearing influence: An evolutionary hypothesis and some evidence[END_REF]. Additionally, child protective factors such as effortful control may buffer the consequence of negative parenting [START_REF] Bates | Temperament, parenting, and socialization[END_REF][START_REF] Rothbart | Temperament[END_REF]. Consistent with this view, effortful control has previously been identified as a moderator of the relation between parenting and children's self-regulation (e.g., [START_REF] Lengua | Anxiousness, frustration, and effortful control as moderators of the relation between parenting and adjustment in middle-childhood[END_REF][START_REF] Xu | Temperament, harsh and indulgent parenting, and Chinese children's proactive and reactive aggression[END_REF]. A high level of effortful control in children, for example, reduced the risk of externalizing problems in a family context of corporal punishment [START_REF] Lengua | Anxiousness, frustration, and effortful control as moderators of the relation between parenting and adjustment in middle-childhood[END_REF].

Study Aim

Although, there is a growing body of evidence for incremental effects of different parenting dimensions in the prediction of different child outcomes (e.g., [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF][START_REF] Mize | Mothers' social coaching, mother-child relationship style, and children's peer competence: Is the medium the message[END_REF][START_REF] Pettit | Antecedents and behavior-problem outcomes of parental monitoring and psychological control in early adolescence[END_REF]Reitz, Dekovic, & Meijer, 2006) the specific functions of different parenting practices for children's selfregulation need to be untangled in more detail, especially in non-American samples. In the present study, we expected that maternal warmth and responsiveness to distress would uniquely contribute to various self-regulation skills in kindergarten children. Maternal warmth was hypothesized to be positively related to the child's behavior regulation. Furthermore, we expected that maternal responsiveness to distress would correlate positively with the child's internalization of rules of conduct. In addition, we expected that the children's gender and effortful control would interact with parenting behavior (i.e., maternal warmth and responsiveness to distress) in predicting self-regulation skills: Stronger associations were expected for girls compared to boys and for children with higher levels of effortful control in comparison to children with lower effortful control. Mother's level of education served as a control variable as research has found links between family demographic variables (i.e., parental education) and the factors of interest in the current study (e.g., [START_REF] Connell | The impact of childcare and parent-child interactions on school readiness and social skills development for low-income African American children[END_REF][START_REF] Evans | Self-regulation and the income-achievement gap[END_REF][START_REF] Howse | Motivation and selfregulation as predictors of achievement in economically disadvantaged young children[END_REF].

Method

Participants

Participants consisted of 102 mother-child dyads (50 percent girls; 4-years 5 months to 6-years 5-months, M = 66 months). The mothers reported no evidence of any general medical disorder; for six children, a delay in language development was reported. The families were recruited from public kindergartens. The recruitment procedure included an information letter about the study that was distributed through kindergartens in ConstanceKonstanz, a town in the south of Germany. Approximately, 700 mothers received a letter. Mothers (n = 149) who agreed to participate were contacted by phone; 117 mother-child dyads finally attended the study. Fifteen participants had missing data, yielding the final sample size of 102 dyads.

Participants were primarily of middle-class socioeconomic status. All families came from a European cultural background. The majority of children lived in a two-parent household (80%). Twenty-six children (25%) were living in one-child-families, 61 (60%) had one sibling, and 15 (15%) had two or more siblings. All mothers had at least 12 years of schooling.

Using ICSED-97 (Organization for Economic Co-operation and Development, 1999) to indicate mother's level of education, 69 mothers (68%) in the sample had completed the first stage of tertiary education (i.e., BA or MA). Sixty-two mothers (61%) were currently employed, half of these working full-time.

Procedures

The mothers and children visited the laboratory of the Developmental and Cross-During the first session, a delay task (explained in greater detail below) was conducted by a trained female graduate student in Psychology. In a separate room, the mothers individually completed questionnaires on parenting practices, children's internalization of rules of conduct, and temperament. During the second session, the mothers answered an additional questionnaire on parenting practices. At the end of each session, the mothers and children received small presents. All mothers signed an informed letter of consent before participating in the study.

Measures

Measures that had not been previously used for German samples were translated by two German speakers fluent in both German and English. Divergent translations were checked and corrected.

Maternal warmth. The Child-Rearing Practices Report Q-Sort (CRPR Q-Sort; [START_REF] Block | The Child-Rearing Practices Report (CRPR): A set of Q-items for the description of parental socialization attitudes and values[END_REF], modified by Roberts, 1989[START_REF] Roberts | The socialization of emotion expression: Relations with prosocial behavior and competence in five samples[END_REF] measures parents' attitudes, behaviors and feelings about their children using 99 item-cards, each with statements such as, "I express affection by hugging, kissing and holding my child." and "My child and I have warm, intimate times together." Mothers were asked to evaluate their parenting behavior by sorting the cards into 9 piles, each containing 11 cards, according to the degree to which the items were descriptive of their parenting behavior (ranging from 1, "These cards are most undescriptive", to 9, "These cards are most descriptive"). The CRPR Q-Sort items that asked directly about maternal responsiveness to distress (n = 9) were deleted prior to analyses in order to avoid interference between the two variables. A criterion sort of warmth was used on the basis of independent ratings from six experts (see [START_REF] Roberts | Criterion sortings for warmth and control for the Child Rearing Practices Q-Sort[END_REF]. Correlations between mothers' individual ratings and this criterion sort were computed. The correlation coefficient can range from -1.00 (low warmth) to 1.00 (high warmth).

Maternal responsiveness to distress. The Coping with Children's Negative Emotion Scale (CCNES; [START_REF] Fabes | The Coping with Children's Negative Emotions Scale (CCNES): Psychometric properties and relations with children's emotional competence[END_REF]) is a self-report instrument consisting of six subscales that represent different parental responses to children's negative emotions. The questionnaire includes 12 hypothetical situations of common emotionally evocative events that young children often experience (for example, a bicycle accident or being rejected by a friend). The mothers answered questions about each situation on a 7-point scale (from 1, "very unlikely", to 7, "very likely"), indicating the probability that they would respond to the situation in the explained manner. Each question represents a typical response pattern for one of the six subscales: emotion-focused reactions, problemfocused reactions, expressive encouragement, distress reactions, punitive reactions, and minimization reactions. Studies have shown that the CCNES is a valid and reliable instrument to assess parental responsiveness to children's distress [START_REF] Fabes | The Coping with Children's Negative Emotions Scale (CCNES): Psychometric properties and relations with children's emotional competence[END_REF][START_REF] Gentzler | Parent-child emotional communication and children's coping in middle childhood[END_REF]. In the present study, Cronbach's aAlphas ranging from .70 to .86 for the six subscales were found. These are consistent with the results of other studies [START_REF] Coutu | Validation de la version francaise du questionnaire Coping with Children's Negative Emotions Scale -CCNES [Validation of the French version of the Coping with Children's Negative Emotions Scale -CCNES[END_REF][START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF].

Following [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF], a total score for responsiveness to distress was derived by averaging the six subscales (reversing the distress reactions, punitive reactions, and minimization reactions subscales).

Assessment of behavior regulation. The behavior regulation of the children was observed using the Snack Delay task of the Laboratory Temperament Assessment Battery -Preschool Version (Lab-TAB; [START_REF] Goldsmith | The Laboratory Temperament Assessment Battery (Preschool Version 0.5)[END_REF]. The procedure was videotaped. The children were offered candy under the constraint that they were to wait with their hands in their laps until a bell rang before eating the candy. The procedure was introduced with a practice trial. Six trials followed with different pause lengths, varying between 0 and 30 seconds (5s, 10s, no pause, 20s, no pause, and 30s). To judge whether the child violated the given rule before the experimenter rang the bell (i.e., by reaching for the candy), two previously trained raters coded the video for each trial (with 0 = no and 1 = yes). Overall possible scores ranged from zero to six. For analyses, the variable was recoded, with zero corresponding to low behavior regulation and six to a high level of behavior regulation. Inter-rater reliability, computed for 30% of the cases, was good (κ = .87).

Assessment of internalization of rules of conduct. The Maternal Reports of Conscience

Development (MRCD; [START_REF] Kochanska | Maternal reports of conscience development and temperament in young children[END_REF] was used as a parent-report instrument to measure each child's internalization of rules of conduct. The original instrument consists of 100 items. The response format is a 7-point scale ranging from 1 ("extremely untrue, not at all characteristic") to 7 ("extremely true, very characteristic"). The MRCD was used in an abridged version, because the questionnaires for this study were administered as part of a larger set of questionnaires relevant to other research questions. The items (n = 43) forming the factor "active moral regulation" were given to the mothers as a questionnaire according to the original sequence of items. This factor consists of four scales: confession (e.g., "My child will spontaneously admit fault or wrongdoing, either verbally or nonverbally."), reparation (e.g., "My child seems relieved when given an opportunity to repair a damage s/he has caused."), concern about others' transgressions (e.g., "My child gets upset when a guest breaks a household rule."), and internalized conduct (e.g., "My child clearly hesitates before doing something forbidden, even when alone."). The observed Cronbach's aAlphas, ranging from .74 to .87, were comparable to those of an American sample reported by [START_REF] Kochanska | Maternal reports of conscience development and temperament in young children[END_REF]. The scales were averaged to form a single active moral regulation score (Cronbach's aAlpha = .76).

Assessment of effortful control. The Children's Behavior Questionnaire (CBQ; Rothbart, Ahadi, Hershey, & Fischer, 2001) was used to measure each child's level of effortful control.

Mothers completed the CBQ short form, consisting of 94 items. In this parent-report measure, the mother indicates whether a statement about her child is true on a 7-point scale (from 1, "extremely untrue of your child", to 7, "extremely true of your child"). The instrument includes 15 scales that can be aggregated to three temperamental dimensions: effortful control, negative affectivity, and surgency. For our study, we adopted the factor solution of [START_REF] Rothbart | Investigations of temperament at three to seven years: The Children's Behavior Questionnaire[END_REF] to derive the factor for effortful control. As in [START_REF] Kochanska | Maternal reports of conscience development and temperament in young children[END_REF], all items were checked for any face resemblance to items relevant to internalization of rules, in order to avoid interference between these variables. Three items were consequently deleted. The scales "inhibitory control" ("My child approaches sites, it has been told, that they are dangerous, slowly and carefully."), "attentional focusing" ("When drawing or coloring in a book, my child shows strong concentration."), "low intensity pleasure" ("My child enjoys gentle rhythmic activities, such as rocking or swaying."), and "perceptual sensitivity" ("My child seems to listen to even quiet sounds.") were averaged. The resulting Cronbach's aAlpha (.60) was lower than the Cronbach's aAlpha (.74) reported by [START_REF] Putnam | Development of short and very short forms from the Children's Behavior Questionnaire[END_REF] for the very short form. The deletion of items did not alter reliability.

Results

Preliminary Analyses

The obtained correlation coefficients for maternal warmth were transformed using Fisher's r to z procedure to enable their use in data analysis (a common procedure when using Q-sort measures; e.g., [START_REF] Roberts | The socialization of emotion expression: Relations with prosocial behavior and competence in five samples[END_REF][START_REF] Cassibba | Attachment and play in childcare centers: Reliability and validity of the attachment Q-sort for mothers and professional caregivers in Italy[END_REF][START_REF] Roberts | The socialization of emotion expression: Relations with prosocial behavior and competence in five samples[END_REF]. This was done to adjust the distribution by converting Pearson's r to the normally distributed variable z. Maternal warmth was relatively high in the sample. The scores for maternal responsiveness to distress were comparable to the means reported by [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF]: mothers perceived themselves to be highly responsive when confronted with their children's distress. Mothers also reported high scores for their children's internalization of rules of conduct and effortful control. The means were comparable to those reported in other studies (e.g., [START_REF] Kochanska | Maternal reports of conscience development and temperament in young children[END_REF][START_REF] Komsi | Continuity of temperament from infancy to middle childhood[END_REF]. The children's observed behavior regulation ranged from low ("0") to high ("6"). Table 1 shows means and standard deviations of all variables.

T-tests of two independent groups revealed a significant effect of the child's gender only on his or her internalization of rules of conduct, t (100) = -2.12, p < .05, η 2 = .04.

Mothers reported a higher level of internalization of rules of conduct for girls (M = 4.82, SD = 0.56) than for boys (M = 4.52, SD = 0.82). Pearson correlations yielded no significant relations between the age of the child, the level of effortful control, and any predictor or outcome variable, respectively. However, mother's level of education was significantly and positively related to her warmth. Therefore, mother's level of education was entered in further hypotheses testing. The correlations are presented in Table 2.

Overview of Analyses

The hypotheses were tested with hierarchical regression analyses. Behavior regulation and the internalization of rules of conduct served as dependent (outcome) variables. The first block included mother's level of education and the child's gender (or effortful control, respectively). The second block included maternal parenting variables. Because maternal warmth and responsiveness to distress were positively and significantly correlated (see also [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF], we entered both variables together in the second block to test the unique effects of maternal warmth and responsiveness to distress on the child outcome variables. Furthermore, we also tested whether maternal warmth and responsiveness to distress interacted with the child's gender or effortful control to predict any of the child's outcome variables, respectively. The interaction terms were entered in a separate third block.

The variables were centered before the interaction terms were computed [START_REF] Cohen | Applied multiple regression/correlation analyses for the behavioral sciences[END_REF].

Predicting Children's Behavior Regulation

First, we examined relations between parenting and children's behavior regulation.

Consistent with our hypothesis, maternal warmth was a significant predictor of higher levels of behavior regulation, independent of any contribution of maternal responsiveness to distress.

Neither of the child variables (gender and effortful control) nor the mother's level of education reached significance in predicting the child's behavior regulation. There were no significant interactions between the child's gender (effortful control, respectively) and the parenting variables, although the interaction between the child's effortful control and maternal responsiveness to distress approached significance (p = .06). The results are presented in Tables 3 and4.

Predicting Children's Internalization of Rules of Conduct

The prediction of children's internalization of rules of conduct was considered next.

Analyses yielded significant main effects for the child's gender and mother's responsiveness to distress. Girls showed a higher level of internalization than boys. Consistent with our hypothesis, maternal responsiveness and children's internalization of rules of conduct were significantly and positively associated, whereas maternal warmth was not a significant predictor. Again, there was no significant effect of mother's level of education. There were no significant interaction between the child's gender and responsiveness to distress, however the gGender xX mMaternal wWarmth interaction was marginally significant (p = .08). A summary of results is presented in Table 5.

Table 6 shows the results of the regression analysis involving the child's effortful control as predictor. Mother's responsiveness to distress was again predictive of the child's level of internalization. The analysis yielded no main effects for mother's level of education, maternal warmth, and the child's effortful control. Again, no significant interaction between the child's effortful control and responsiveness to distress was found. For maternal warmth, there was a significant interaction with the child's effortful control. Please note, however, that contrary to the previously presented results, the full regression equation of this analysis did not reach significance.

In summary, consistent with our hypotheses, maternal warmth significantly predicted behavior regulation, over and above the influence of maternal responsiveness to distress. In contrast, the child's gender and effortful control were not significant predictors or moderators in the prediction of behavior regulation. As expected, maternal responsiveness to distress significantly and positively predicted the child's internalization of rules of conduct when controlling for maternal warmth. The child's gender was also a significant predictor: girls showed higher levels of internalization than boys as reported by mothers. There were no significant interaction effects in the prediction of internalization. Mother's level of education did not reach significance, neither in the prediction of the child's behavior regulation nor in the prediction of internalization.

Discussion

The purpose of the present study was to specify the function of distinct positive parenting practices -maternal warmth and responsiveness to distress -in children's selfregulation (behavior regulation and internalization of rules of conduct) and to extendt previous findings (e.g., [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF] to a different population (i.e., a non-American sample). The results were consistent with our expectations, and confirmed the necessity of a separate examination of maternal warmth and responsiveness to distress in regard to child outcomes [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF]. In line with previous findings (e.g., [START_REF] Colman | Early predictors of self-regulation in middle childhood[END_REF][START_REF] Jennings | Understanding of self and maternal warmth predict later self-regulation in toddlers[END_REF][START_REF] Karreman | Parenting and selfregulation in preschoolers: A meta-analysis[END_REF], maternal warmth was positively related to children's behavior regulation, whereas responsiveness to distress was positively associated with children's internalization of rules of conduct. Both parenting practices exerted their specific effects on child outcomes independently.

The present study extends previous work (e.g., [START_REF] Darling | Parenting style as context: An integrative model[END_REF][START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF][START_REF] Mize | Mothers' social coaching, mother-child relationship style, and children's peer competence: Is the medium the message[END_REF] on functionally different effects of different parenting dimensions. [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF] found evidence in favour of positive links between maternal warmth, children's emotion regulation, and peer group acceptance. Our study demonstrated thatmaternal warmth is also important for children's behavior regulation. In early childhood, behavior regulation begins to develop within child-caregiver interaction (McClelland et al., in press). Warm and supportive parenting, including positive emotional expressions (e.g., hugging), provides the emotional climate for the development of behavior regulation. Maternal warmth fosters a child's willingness to control his or her impulses and behaviors according to given rules, in order to continue the positive parent-child-interactions [START_REF] Jennings | Understanding of self and maternal warmth predict later self-regulation in toddlers[END_REF]. Part of the explanation is that maternal warmth promotes a child's enjoyment of interactions with the mother [START_REF] Kochanska | Mother-child and fatherchild mutually responsive orientation in the first 2 years and children's outcomes at preschool age: Mechanisms of influence[END_REF]. Furthermore, the results illustrate that mother's responsiveness to distress specifically enhances children's motivation and ability to internalize rules of conduct. Internalization implies refraining from prohibited actions even when not under surveillance [START_REF] Grusec | Impact of parental discipline methods on the child`s internalization of values: A reconceptualization of current points of view[END_REF][START_REF] Kochanska | Maternal reports of conscience development and temperament in young children[END_REF]. A child caught in misbehavior may experience negative emotions, for example when she or he is scolded by the parent. The parent's responsive reactions to the expression of negative emotions, even though the parent is currently upset about the child's misbehavior, facilitate the child's emotion regulation [START_REF] Bugental | Acquisition of the algorithms of social life: A domain-based approach[END_REF][START_REF] Roberts | Parents' responses to the emotional distress of their children: Relations with children's competence[END_REF]. These links, however, may also be of more indirect nature. Since maternal responsiveness to distress is positively associated with a child's emotion regulation [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF], a child of a responsive mother is more motivated and better able to regulate his or her emotion during discipline situations and, thus, is more attentive to parental messages [START_REF] Grusec | Socialization in the family[END_REF].

Contrary to our expectations, we found no significant interaction effects of parenting variables and the child's gender or effortful control in the prediction of behavior regulation or in the prediction of internalization of rules of conduct. In contrast, other studies reported clear gender differences. For example, [START_REF] Russell | Positive parenting and boys' and girls' misbehavior during a home observation[END_REF] reported significant relation between warmth and rates of misbehavior in girls but not in boys whereas [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF] reported a significant positive association between maternal warmth and child peer acceptance in boys only. This pattern of results suggests that the mother's parenting practices impact boys' and girls' development differently [START_REF] Colman | Early predictors of self-regulation in middle childhood[END_REF]. However, recently it has been suggested that gender differences may be unique to North American samples and to parent-or teacher-rated measures. No significant gender differences were found, for example, in Taiwanese, South Korean, and Chinese samples when using a direct measure of behavior regulation (McClelland et al., in press). This possibility is consistent with our findings as we found gender differences only regarding parents' reports (mothers reported higher levels of internalization for girls than for boys) but not in the direct measure of behavior regulation. However, the lack of significant moderating effects in our study may as well be a consequence of the difficulty finding moderator effects in field studies [START_REF] Mcclelland | Statistical difficulties of detacting interactions and moderator effects[END_REF].

Although mother's level of education was statistically controlled in our study, the characteristics of the sample (e.g., socio-economic background), and hence the kind of observed and reported behavior need to be taken into account when interpreting the present findings. Mothers in the sample tended to show higher levels of warmth than in other studies, due to sample characteristics. Maybe, the importance of warm parenting arises primarily in samples with higher economic backgrounds. These mothers may be more sensitive to their children's abilities and capable of adapting their parenting to their children's developmental skills than mothers with less economic resources [START_REF] Bakermans-Kranenburg | Differences in attachment security between African-American and white children: Ethnicity or socio-economic status?[END_REF].

Similarly, the moderate correlation between maternal warmth and responsiveness to distress may be explained by measurement constraints. Both, maternal warmth and responsiveness to distress, were assessed through mothers' self-reports. However, the use of parental reports in the assessment of these constructs and the finding of a positive relation between warmth and responsiveness to distress is consistent with prior research (e.g., [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF]. Therefore, the level of warmth might influence the effects of responsiveness, and vice versa. An alternative explanation of the shared variance between warmth and responsiveness is suggested by [START_REF] Macdonald | Warmth as a developmental construct: An evolutionary analysis[END_REF], who claims that warmth and responsiveness to distress are linked in Western cultures, but not universally. It This explanation points to the necessity to integrate the role of culture into the study of parenting and development [START_REF] Trommsdorff | Development of emotions as organized by culture[END_REF](Trommsdorff, , 2009b)). These limitations aside, the results still demonstrate unique contributions ofthat warmth and responsiveness to distress make unique contributions toconcerning different developmental domains. Theise results highlights the importance of disentangling parenting typologies or styles into their distinct components [START_REF] Mize | Mothers' social coaching, mother-child relationship style, and children's peer competence: Is the medium the message[END_REF][START_REF] Stewart | A critical look at parenting research from the mainstream: Problems uncovered while adapting Western research to non-Western cultures[END_REF]. Warmth and responsiveness operate in different socialization domains and serve different functions for child development [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF][START_REF] Grusec | Socialization in the family[END_REF][START_REF] Roberts | Parents' responses to the emotional distress of their children: Relations with children's competence[END_REF].

Several limitations of the present study should be noted. The study included crosssectional data only. Although we are aware of the discussion of bidirectionality in the socialization of children [START_REF] Collins | Contemporary research on parenting: The case of nature and nurture[END_REF][START_REF] Grusec | The development of moral behaviour and conscience from socialization perspective[END_REF][START_REF] Karreman | Parenting and selfregulation in preschoolers: A meta-analysis[END_REF][START_REF] Trommsdorff | Parent-child relations in cross-cultural perspective[END_REF], no interpretation about the direction of effects nor about long-term effects in the relationships between various aspects of positive parenting and selfregulation can be drawn from the present study. However, this criticism also applies to many studies where results have been interpreted to suggest that parenting influences self-regulation [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF][START_REF] Dennis | Emotional self-regulation in preschoolers: The interplay of child approach activity, parenting, and control capacities[END_REF][START_REF] Eiden | Children`s internalization of rules of conduct: Role of parenting in alcoholic families[END_REF]. Further studies should include longitudinal data to determine the direction of the relations between positive parenting practices and child self-regulation. Additionally, our sample was not socioeconomically diverse, and it is possible that sample characteristics (e.g., mother's socioeconomic and educational background) may function as possible moderators of the connection between parenting and self-regulation [START_REF] Paulussen-Hoogeboom | Child negative emotionality and parenting from infancy to preschool: A metaanalytic review[END_REF]. For a better understanding of potential moderator effects, more variation in sample characteristics is needed.

In conclusion, the pattern of results we obtained is consistent with the hypothesis that maternal warmth and responsiveness to distress are distinct positive parenting practices. Each makes unique contributions in the development of different aspects of self-regulation in kindergarten children. We therefore second the proposal of [START_REF] Davidov | Untangling the links of parental responsiveness to distress and warmth to child outcomes[END_REF] that, contrary to the common practice of grouping warmth and responsiveness to distress together, these features of positive parenting are not interchangeable. However, further research is needed to untangle the different pathways through which various parenting practices uniquely contribute to children's different developmental outcomes. Other closely related parenting practices, like control, should be further studied as well to avoid oversimplification of complex interactions. This type of research has definite concrete applications: for early family intervention programs, for promoting parents' understanding of the specificity of the relationship between various parenting practices and their psychological meaning for different developmental outcomes. Note. a Dummy coded (boys = 0; girls = 1). * p < .05.

The full regression equation was significant: F (6, 94) = 2.24, p < .05. The full model explained 6.9% of the variance (Adjusted R 2 = .069). Note. a Dummy coded (boys = 0; girls = 1). + p < .10. * p < .05.

The full regression equation was significant: F (6, 94) = 2.70, p < .05. The full model explained 9.3% of the variance (Adjusted R 2 = .093). The full regression equation did not reach significance: F (6, 94) = 1.83, p = .10.

Table 1

 1 Descriptive Statistics(N = 101)

	Measure	M	SD	Range

a Fisher`s z-scores.

Table 2

 2 Intercorrelations between Mother's Positive Parenting Practices, Mother's Level ofEducation, Child Age, Self-regulation, and Temperament

	N = 102

** p < .01. * p < .05.

Table 3

 3 Regression Analysis Predicting the Child's Behavior Regulation with Gender as Moderator

	Dependent Variable: Child's Behavior Regulation
	B	SE(B)	β

Table 4

 4 Regression Analysis Predicting the Child's Behavior Regulation with Effortful Control as ModeratorNote. + p < .10. * p < .05.The full regression equation was significant: F (6, 94) = 2.45, p < .05. The full model explained 8% of the variance (Adjusted R 2 = .080).Regression Analysis Predicting the Child's Internalization of Rules of Conduct with Gender as Moderator

	Dependent Variable: Child's Behavior Regulation
	B	SE(B)	β

Table 6

 6 Regression Analysis Predicting the Child's Internalization of Rules of Conduct with Effortful Control as Moderator

	Dependent Variable: Child's Internalization of Rules of Conduct
	B	SE(B)	β

+ p < .10. * p < .05.

Social Development