Racial/ethnic differences in dyslipidemia patterns.

BACKGROUND: No studies have comprehensively examined the prevalence of dyslipidemia, a major risk factor for cardiovascular disease, among diverse racial/ethnic minority groups. The primary aim of this study was to identify racial/ethnic differences in dyslipidemia among minorities including Asian Americans (Asian Indian, Chinese, Filipino, Japanese, Korean, or Vietnamese), Mexican Americans, and blacks compared with non-Hispanic whites. METHODS AND RESULTS: Using a 3-year cross section (2008-2011), we identified 169 430 active primary care patients (35 years or older) from an outpatient healthcare organization in northern California. Age-standardized prevalence rates were calculated for 3 dyslipidemia subtypes: high triglycerides (fasting laboratory value ≥150 mg/dL), low levels of high-density lipoprotein cholesterol (fasting laboratory value <40 mg/dL [men] and <50 mg/dL [women]), and high levels of low-density lipoprotein cholesterol (fasting laboratory value ≥130 mg/dL or taking low-density lipoprotein-lowering agents). Odds ratios were calculated by multivariable logistic regression, with adjustment for patient characteristics (age, measured body mass index, smoking). Compared with non-Hispanic whites, every minority subgroup had an increased prevalence of high triglycerides except blacks. Most minority groups had an increased prevalence of low high-density lipoprotein cholesterol, except for Japanese and blacks. The prevalence of high low-density lipoprotein cholesterol was increased among Asian Indians, Filipinos, Japanese, and Vietnamese compared with non-Hispanic whites. CONCLUSIONS: Minority groups, except for blacks, were more likely to have high triglyceride/low high-density lipoprotein cholesterol dyslipidemia. Further research is needed to determine how racial/ethnic differences in dyslipidemia affect racial/ethnic differences in cardiovascular disease rates.

Binge Drinking and Perceived Neighborhood Characteristics Among Mexican Americans Residing on the U.S.-Mexico Border.

BACKGROUND: This study examines the association between perceived neighborhood violence, perceived neighborhood collective efficacy, and binge drinking among Mexican Americans residing on the U.S.-Mexico border. METHODS: Data were collected from a multistage cluster sample of adult Mexican Americans residing in the U.S.-Mexico border areas of California, Arizona, New Mexico, and Texas (N = 1,307). The survey weighted response rate was 67%. Face-to-face interviews lasting approximately 1 hour were conducted in respondents' homes in English or Spanish. Path analysis was used to test whether collective efficacy mediated the impact of perceived neighborhood violence on binge drinking. RESULTS: Among 30+-year-old women, perceived neighborhood collective efficacy mediated the effects of perceived neighborhood violence on binge drinking in a theoretically predicted way: Lower perceptions of violence predicted an increased perception of collective efficacy, which in turn, predicted less binge drinking. Direct effects of violence perceptions on binge were nonsignificant. Younger 18- to 29-year-old women showed a similar (but nonsignificant) pattern of effects. Perceived collective efficacy also mediated the effects of perceived violence on binge drinking among men, but in opposite ways for older and younger men. Older men showed the same mediating effect as older women, but the effect reversed among younger men due to a strong, positive relation between collective efficacy and binge drinking. There were also age differences in the direct effect of violence perceptions on binge drinking: Perceptions of violence predicted more binge drinking among young men, but less among older men. CONCLUSIONS: These results highlight the complexity of people's responses to neighborhood characteristics in regard to their drinking. Young men in particular seem to react very differently to perceptions of collective efficacy than other groups. However, among both men and women, collective efficacy may come to play an increasingly important protective role in health outcomes with age.

Disentangling contributions of bar attendance, drinking, and other factors to elevated acute alcohol problems on the U.S.-Mexico border.

BACKGROUND: Levels of drinking are unusually elevated among young adults on the U.S.-Mexico border, and this elevation can be largely explained by young border residents' unusually high frequency of bar attendance. However, this explanation complicates interpretation of high alcohol problem rates that have also been observed in this group. Because bar environments can lower the threshold for many types of problems, the extent to which elevated alcohol problems among young border residents can be attributed to drinking per se-versus this common drinking context-is not clear. METHODS: Data were collected from multistage cluster samples of adult Mexican Americans on and off the U.S.-Mexico border (current drinker N = 1,351). After developing structural models of acute alcohol problems, estimates were subjected to path decompositions to disentangle the common and distinct contributions of drinking and bar attendance to problem disparities on and off the border. Additionally, models were estimated under varying degrees of adjustment to gauge the sensitivity of the results to sociodemographic, social-cognitive, and environmental sources of confounding. RESULTS: Consistent with previous findings for both drinking and other problem measures, acute alcohol problems were particularly elevated among young adults on the border. This elevation was entirely explained by a single common pathway involving bar attendance frequency and drinking. Bar attendance did not predict acute alcohol problems independently of drinking, and its effect was not moderated by border proximity or age. The common indirect effect and its component effects (of border youth on bar attendance, of bar attendance on drinking, and of drinking on problems) were surprisingly robust to adjustment for confounding in all parts of the model (e.g., fully adjusted indirect effect: b = 0.11, SE = 0.04, p < 0.01). CONCLUSIONS: Bar attendance and associated increases in drinking play a key, unique role in the high levels of acute alcohol problems among the border's young adult population that cannot be entirely explained by sociodemographic or social-cognitive characteristics of young border residents, by contextual effects of bars on problems, or by broader neighborhood factors. Bar attendance in particular may represent an early modifiable risk factor that can be targeted to reduce alcohol problem disparities in the region.

Parental feeding practices and child weight status in Mexican American families: a longitudinal analysis.

BACKGROUND: Parental feeding practices are thought to influence children's weight status, through children's eating behavior and nutritional intake. However, because most studies have been cross-sectional, the direction of influence is unclear. Moreover, although obesity rates are high among Latino children, few studies of parental feeding practices have focused on this population. METHODS: This 2-year longitudinal study examined mutual influences over time between parental feeding practices and children's weight status, in Mexican American families with children 18 years old at baseline. Mothers (n = 322) and fathers (n = 182) reported on their feeding practices at baseline, 1-year follow-up, and 2-year follow-up. Weight status, defined by waist-height ratio (WHtR) and body mass index (BMI), was ascertained at all assessments. Cross-lagged panel models were used to examine the mutual influences of parental feeding practices and child weight status over time, controlling for covariates. RESULTS: Both mothers' and fathers' restriction of food predicted higher subsequent child weight status at Year 1, and for fathers this effect was also found at Year 2. Mothers' and fathers' pressure to eat predicted lower weight status among boys, but not girls, at Year 1. Child weight status also predicted some parental feeding practices: boys' heavier weight predicted mothers' less pressure to eat at Year 1, less use of food to control behavior at Year 2, and greater restriction at Year 2; and girls' heavier weight at Year 1 predicted fathers' less pressure to eat and less positive involvement in child eating at Year 2. CONCLUSIONS: This study provides longitudinal evidence that some parental feeding practices influence Mexican American children's weight status, and that children's weight status also influences some parental feeding practices. Feeding practices of both mothers and fathers were related to children's weight status, underscoring the importance of including fathers in research on parental feeding practices and child obesity.

Trajectories of Ethnic-Racial Identity and Autonomy Among Mexican-Origin Adolescent Mothers in the United States.

This study examined trajectories of ethnic-racial identity (ERI) and autonomy development among Mexican-origin adolescent females in the United States (N = 181; M(age) at Wave 1 = 16.80 years, SD = 1.00) as they transitioned through the first 5 years of parenthood. Trajectories of ERI and autonomy also were examined in relation to psychosocial functioning. Unconditional latent growth models indicated significant growth in autonomy, ERI resolution, and ERI affirmation from middle to late adolescence. Conditional latent growth models indicated that autonomy and ERI exploration growth trajectories were positively associated with psychosocial adjustment. Although adolescent mothers are experiencing transitions that are not normative during adolescence, they also engage in normative developmental processes, and their engagement in such processes is linked with better adjustment.

Acculturative and enculturative stress, depressive symptoms, and maternal warmth: examining within-person relations among Mexican-origin adolescent mothers.

Mexican-origin adolescent mothers face numerous social challenges during dual-cultural adaptation that are theorized to contribute to greater depressive symptoms. Alongside challenges, there are familial resources that may offer protection. As such, the current study examined the trajectories of depressive symptoms among 204 Mexican-origin adolescent mothers (M age = 16.80, SD = 1.00) across a 4-year period (third trimester of pregnancy, and 10, 24, and 36 months postpartum). Further, we examined the within-person relations of two unique sources of stress experienced during dual-cultural adaptation, acculturative and enculturative stress, and youths' depressive symptoms; we also tested whether adolescent mothers' perceptions of warmth from their own mothers emerged as protective. Adolescent mothers reported a decline in depressive symptoms after the transition to parenthood. Acculturative and enculturative stress emerged as significant positive within-person predictors of depressive symptoms. Maternal warmth emerged as a protective factor in the relation between enculturative stressors and depressive symptoms; however, for acculturative stressors, the protective effect of maternal warmth only emerged for US-born youth. Findings illustrate the multidimensionality of stress experienced during the cultural adaptation process and a potential mechanism for resilience among Mexican-origin adolescent mothers.

The association between personality traits and body mass index varies with nativity among individuals of Mexican origin.

Personality traits have been associated consistently with health-related outcomes, but less is known about how aspects of the sociocultural environment modify these associations. This study uses a sample of participants of Mexican origin (N = 1013) to test whether exposure to the United States, indexed by nativity (Mexicans living in Mexico, foreign-born Mexican Americans, and U.S.-born Mexican Americans), moderates the association between personality traits and body mass index (BMI). Higher Conscientiousness was associated with lower BMI, regardless of nativity. In contrast, the association between Neuroticism and BMI was moderated by exposure to the U.S.: Neuroticism was associated with higher BMI among U.S.-born Mexican Americans (partial r = .15) but not among Mexican participants (partial r = .00), an effect strongest and most robust for the impulsivity facet of Neuroticism. This finding suggests that with more exposure to the United States, those who are more emotionally impulsive are at greater risk for obesity. More broadly, these findings suggest that social and psychological vulnerabilities interact to contribute to health outcomes.

Exploring Mexican American adolescent romantic relationship profiles and adjustment.

Although Mexican Americans are the largest ethnic minority group in the nation, knowledge is limited regarding this population's adolescent romantic relationships. This study explored whether 12th grade Mexican Americans' (N = 218; 54% female) romantic relationship characteristics, cultural values, and gender created unique latent classes and if so, whether they were linked to adjustment. Latent class analyses suggested three profiles including, relatively speaking, higher, satisfactory, and lower quality romantic relationships. Regression analyses indicated these profiles had distinct associations with adjustment. Specifically, adolescents with higher and satisfactory quality romantic relationships reported greater future family expectations, higher self-esteem, and fewer externalizing symptoms than those with lower quality romantic relationships. Similarly, adolescents with higher quality romantic relationships reported greater academic self-efficacy and fewer sexual partners than those with lower quality romantic relationships. Overall, results suggested higher quality romantic relationships were most optimal for adjustment. Future research directions and implications are discussed.

Early adolescent temperament, parental monitoring, and substance use in Mexican-origin adolescents.

Previous studies suggest that temperamental dispositions are associated with substance use. However, most research supporting this association has relied on European American samples (Stautz & Cooper, 2013). We addressed this gap by evaluating the prospective relations between 5th grade temperament and 9th grade substance use in a longitudinal sample of Mexican-origin youth (N = 674). Effortful control and trait aggressiveness predicted 9th grade substance use, intentions, and expectations, even after controlling for 5th grade substance use. Additionally, we found an interaction between temperament and parental monitoring such that monitoring is a protective factor for early substance use primarily for youth with temperamental tendencies associated with risk for substance use (e.g., low effortful control and aggression). Results add to the growing literature demonstrating that early manifestations of self-control are related to consequential life outcomes.

Attempting to successfully straddle the cultural divide: Hopelessness model of bicultural stress, mental health, and caregiver connection for Mexican descent adolescents.

The present study extends the Hopelessness Model of Depression through: (a) investigating the applicability of bicultural stress as precipitant in this model, (b) expanding mental health outcomes in addition to depression (i.e., life satisfaction), and (c) examining the protective role that male and female caregiver connection may play in disrupting this model for Mexican descent adolescents. With a sample of 524 Mexican descent adolescents (46.9% male; 53.1% female; age range: 14-20; M = 16.23 years; SD = 1.10 years), 2 structural equation models were tested, The first model (Theoretical Model) sought to determine the relationship between bicultural stress, life satisfaction, and depressive symptoms with hopelessness as a mediator. The second model (Protective Factor Model) investigated both male and female caregiver connectedness as potential protective factors in the bicultural stress-mental health relationships. Both models were supported. In the Theoretical Model, hopelessness mediated the relationship between bicultural stress and the mental health variables (i.e., depression and life satisfaction). Additionally, in the Protective Factor Model, female caregiver connection moderated the relationships between bicultural stress and life satisfaction, highlighting that female caregiver connection is a protective factor in the bicultural stress-life satisfaction relationship. Findings will be discussed from a resilience perspective with recommendations of how practitioners can use these findings for mental health prevention and intervention purposes.

Persistent ischemic stroke disparities despite declining incidence in Mexican Americans.

OBJECTIVE: To determine trends in ischemic stroke incidence among Mexican Americans and non-Hispanic whites. METHODS: We performed population-based stroke surveillance from January 1, 2000 to December 31, 2010 in Corpus Christi, Texas. Ischemic stroke patients 45 years and older were ascertained from potential sources, and charts were abstracted. Neurologists validated cases based on source documentation blinded to ethnicity and age. Crude and age-, sex-, and ethnicity-adjusted annual incidence was calculated for first ever completed ischemic stroke. Poisson regression models were used to calculate adjusted ischemic stroke rates, rate ratios, and trends. RESULTS: There were 2,604 ischemic strokes in Mexican Americans and 2,042 in non-Hispanic whites. The rate ratios (Mexican American:non-Hispanic white) were 1.94 (95% confidence interval [CI] = 1.67-2.25), 1.50 (95% CI = 1.35-1.67), and 1.00 (95% CI = 0.90-1.11) among those aged 45 to 59, 60 to 74, and 75 years and older, respectively, and 1.34 (95% CI = 1.23-1.46) when adjusted for age. Ischemic stroke incidence declined during the study period by 35.9% (95% CI = 25.9-44.5). The decline was limited to those aged ≥60 years, and happened in both ethnic groups similarly (p > 0.10), implying that the disparities seen in the 45- to 74-year age group persist unabated. INTERPRETATION: Ischemic stroke incidence rates have declined dramatically in the past decade in both ethnic groups for those aged ≥60 years. However, the disparity between Mexican American and non-Hispanic white stroke rates persists in those <75 years of age. Although the decline in stroke is encouraging, additional prevention efforts targeting young Mexican Americans are warranted.

Cross-border policy effects on alcohol outcomes: drinking without thinking on the u.s.-Mexico border?

BACKGROUND: Rates of alcohol-related outcomes are sensitive to policy differences in politically distinct, adjacent territories. Factors that shape these cross-border effects, particularly when the policy differences are longstanding, remain poorly understood. We compared the ability of 2 classes of variables with theoretical relevance to the U.S.-Mexico border context-bar attendance and alcohol-related social-cognitive variables-to explain elevated drinking on the U.S. side of the border relative to other areas of the United States. METHODS: Data were collected from multistage cluster samples of adult Mexican Americans on and off the U.S.-Mexico border (current drinker N = 1,351). Structural equation models were used to test drinking context (frequency of bar attendance) and 6 different social-cognitive variables (including alcohol-related attitudes, norms, motives, and beliefs) as mediators of border effects on a composite drinking index. RESULTS: The border effect on drinking varied by age (with younger adults showing a stronger effect), consistent with previous findings and known risk factors in the region. Contrary to theoretical expectations, 6 different social-cognitive variables-despite relating strongly with drinking-were comparable in border and nonborder areas (within and across age) and played no role in elevated drinking on the border. Conversely, elevated drinking among border youth was mediated by bar attendance. This mediated moderation effect held after adjusting for potential sociodemographic and neighborhood-level confounders. CONCLUSIONS: Increased drinking among U.S.-Mexico border youth is explained by patterns of bar attendance, but not by more permissive alcohol-related social-cognitive variables in border areas: Border youth attend bars and drink more than their nonborder counterparts, despite having comparable alcohol-related beliefs, attitudes, norms, and motives for use. Alcohol's heightened availability and visibility on both sides of the border may create opportunities for border youth to drink that otherwise would not be considered.

Concentrations of the urinary pyrethroid metabolite 3-phenoxybenzoic acid in farm worker families in the MICASA study.

Indoor pesticide exposure is a growing concern, particularly from pyrethroids, a commonly used class of pesticides. Pyrethroid concentrations may be especially high in homes of immigrant farm worker families who often live in close proximity to agricultural fields, and are faced with poor housing conditions, causing higher pest infestation and more pesticide use. We investigate exposure of farm worker families to pyrethroids in a study of mothers and children living in Mendota, CA within the population-based Mexican Immigration to California: Agricultural Safety and Acculturation (MICASA) Study. We present pyrethroid exposure based on an ELISA analysis of urinary metabolite 3-phenoxybenzoic acid (3PBA) levels among 105 women and 103 children. The median urinary 3PBA levels (children=2.56 ug/g creatinine, mothers=1.46 ug/g creatinine) were higher than those reported in population based studies for the United States general population, but similar to or lower than studies with known high levels of pyrethroid exposure. A positive association was evident between poor housing conditions and the urinary metabolite levels, showing that poor housing conditions are a contributing factor to the higher levels of 3PBA seen in the urine of these farm worker families. Further research is warranted to fully investigate sources of exposure.

Perceived discrimination and ethnic affirmation: Anglo culture orientation as a moderator among mexican-origin adolescent mothers.

This study examined whether Anglo culture orientation modified the association between adolescents' perceived ethnic discrimination and ethnic identity affirmation over time in a sample of Mexican-origin adolescent mothers (N = 205, Mage  = 16.24 years). Results indicated that perceived ethnic discrimination was significantly associated with decreases in ethnic identity affirmation over time for adolescents reporting high Anglo culture orientation, but no relation existed for adolescents reporting low Anglo culture orientation. Findings suggest that a person-environment mismatch (i.e., between adolescents' perceptions of their connection to Anglo culture and the messages they receive from others regarding that connection in terms of perceived ethnic discrimination) may be detrimental to adolescents' development of positive feelings about their ethnicity.

Cultural socialization and ethnic pride among Mexican-origin adolescents during the transition to middle school.

The relation between cultural socialization and ethnic pride during the transition to middle school was examined for 674 fifth-grade students (50% boys; Mage = 10.4 years) of Mexican origin. The theoretical model guiding the study proposes that parent-child relationship quality is a resource in the transmission of cultural values from parent to child and that parental warmth promotes the child's positive response to cultural socialization. Results showed that mother and father cultural socialization predicted youth ethnic pride and that this relation was stronger when parents were high in warmth. The findings highlight the positive role parent cultural socialization may play in the development of adolescent ethnic pride. Furthermore, findings reveal the role of parent-child relationship quality in this process.

Self-socialization of gender in African American, Dominican immigrant, and Mexican immigrant toddlers.

This article advances a self-socialization perspective demonstrating that children's understanding of both gender categories represents an intergroup cognition that is foundational to the development of gender-stereotyped play. Children's (N = 212) gender category knowledge was assessed at 24 months and play was observed at 24 and 36 months. Higher levels of gender category knowledge and, more specifically, passing multiple measures of knowledge of both gender categories at 24 months was related to increases in play over time with gender-stereotyped toys (doll, truck), but not gender-stereotyped forms of play (nurturing, motion). In contrast to the long-standing focus on self-labeling, findings indicate the importance of intergroup cognitions in self-socialization processes and demonstrate the generalizability of these processes to a diverse sample.

Incidence of alcohol use disorders among Hispanic subgroups in the USA.

OBJECTIVE: Hispanics are the largest ethnic minority group in the USA and a fairly heterogeneous group. But this heterogeneity has usually been ignored by grouping them into a single category. The objective of this study is to challenge that practice by providing alcohol use disorders (AUD) incidence and risk estimates across Hispanic subgroups. METHODS: A subsample of Hispanics (n = 2371) and non-Hispanic whites (n = 7741) at risk for AUD who participated in the first and second wave of the National Epidemiological Survey on Alcohol and Related Conditions was analyzed. Weighted incidence for AUD was calculated across Hispanic subgroups. A weighted modified Poisson generalized linear model was used to estimate relative risks. RESULTS: Compared with non-Hispanic whites, Puerto Ricans have the highest AUD incidence (3.6%; 95% CI: 0.5, 6.7) followed by Mexican-Americans (2.5%; 95% CI: 1.5, 3.6), Other Hispanics (1.6%; 95% CI: 0.1, 3.1) and Cuban-Americans (0.6%; 95% CI: 0.1, 1.2). In contrast, weighted adjusted relative risk estimates for Mexican-Americans were (RR = 3.2; 95% CI: 1.7, 6.2) but for Puerto Ricans (RR = 2.2; 95% CI: 1.0, 5.0) it was somewhat attenuated but still significant (P = 0.049). No difference was found for Cuban-Americans or Other Hispanics. CONCLUSIONS: The annual incidence and risk for AUD varies greatly among Hispanic subgroups. Nonetheless, the practice of categorizing Hispanics as a homogenous ethnic group still continues. Our findings suggest that this practice is not only inappropriate, but also hinders a better understanding of AUD etiology, prevention, treatment and rehabilitation in the largest ethnic minority group in the USA.

Meaningful family relationships: neurocognitive buffers of adolescent risk taking.

Discordant development of brain regions responsible for cognitive control and reward processing may render adolescents susceptible to risk taking. Identifying ways to reduce this neural imbalance during adolescence can have important implications for risk taking and associated health outcomes. Accordingly, we sought to examine how a key family relationship-family obligation-can reduce this vulnerability. Forty-eight adolescents underwent an fMRI scan during which they completed a risk-taking and cognitive control task. Results suggest that adolescents with greater family obligation values show decreased activation in the ventral striatum when receiving monetary rewards and increased dorsolateral PFC activation during behavioral inhibition. Reduced ventral striatum activation correlated with less real-life risk-taking behavior and enhanced dorsolateral PFC activation correlated with better decision-making skills. Thus, family obligation may decrease reward sensitivity and enhance cognitive control, thereby reducing risk-taking behaviors.

Variants in ABCB1, TGFB1, and XRCC1 genes and susceptibility to viral hepatitis A infection in Mexican Americans.

UNLABELLED: Hepatitis A vaccination has dramatically reduced the incidence of hepatitis A virus (HAV) infection, but new infections continue to occur. To identify human genetic variants conferring a risk for HAV infection among the three major racial/ethnic populations in the United States, we assessed associations between 67 genetic variants (single nucleotide polymorphisms [SNPs]) among 31 candidate genes and serologic evidence of prior HAV infection using a population-based, cross-sectional study of 6,779 participants, including 2,619 non-Hispanic whites, 2,095 non-Hispanic blacks, and 2,065 Mexican Americans enrolled in phase 2 (1991-1994) of the Third National Health and Nutrition Examination Survey. Among the three racial/ethnic groups, the number (weighted frequency) of seropositivity for antibody to HAV was 958 (24.9%), 802 (39.2%), and 1540 (71.5%), respectively. No significant associations with any of the 67 SNPs were observed among non-Hispanic whites or non-Hispanic blacks. In contrast, among Mexican Americans, variants in two genes were found to be associated with an increased risk of HAV infection: TGFB1 rs1800469 (adjusted odds ratio [OR], 1.38; 95% confidence interval [CI], 1.14-1.68; P value adjusted for false discovery rate [FDR-P] = 0.017) and XRCC1 rs1799782 (OR, 1.57; 95% CI, 1.27-1.94; FDR-P = 0.0007). A decreased risk was found with ABCB1 rs1045642 (OR, 0.79; 95% CI, 0.71-0.89; FDR-P = 0.0007). CONCLUSION: Genetic variants in ABCB1, TGFB1, and XRCC1 appear to be associated with susceptibility to HAV infection among Mexican Americans. Replication studies involving larger population samples are warranted.

Perceptions of efficacy, expressed emotion, and the course of schizophrenia: the case of emotional overinvolvement.

Although it is clear that expressed emotion (EE) is associated with the course of schizophrenia, proposed models for this association have struggled to account for the relationship between the EE index of emotional overinvolvement (EOI) and relapse. To expand our understanding of the EOI-relapse association, we first attempted to replicate the finding that the EOI-relapse association is curvilinear among 55 Mexican-Americans with schizophrenia and their caregiving relatives. Second, we evaluated whether the caregivers' perception of their ill relative's efficacy may account for the EOI-relapse association. Our results comport with past findings with regard to the curvilinear nature of the EOI-relapse association among Mexican-Americans and suggest that EOI may only seem to be a risk factor of relapse because of its strong association with a true risk factor for relapse (i.e., caregivers' perception of their ill relative's efficacy).