Punishment and Reward in Parental Discipline for

Children Aged 5 to 6 Years: Prevalence and

Groups at Risk
Meinou H. C. Theunissen, PhD; Anton G. C. Vogels, PhD; Sijmen A. Reijneveld, MD PhD
From the TNO (Netherlands Organisation of Applied Scientific Research) Child Health (Drs Theunissen, Vogels, and Reijneveld), Leiden; and
Department of Health Sciences, University Medical Center Groningen (Dr Reijneveld), University of Groningen, Groningen, the Netherlands
The authors have no conflicts of interest to disclose.
Address correspondence to Meinou H.C. Theunissen, PhD, TNO Child Health, PO Box 3005, 2301 DA Leiden, the Netherlands (e-mail:
Meinou.Theunissen@tno.nl).
Received for publication January 20, 2014; accepted June 30, 2014.

ABSTRACT
OBJECTIVE: In this study we examined the use and predictors of

that spanking was more likely in families in which the mothers

have low and medium levels of education and in families of nonDutch ethnicity. Other punishment practices (eg, time-outs, verbal reprimands, and holding) were more likely in families of
Dutch ethnicity. Granting privileges was more likely in families
of non-Dutch ethnicity, who lived in large cities, whose income
was below the poverty level, in unemployed families, and in
small families. Cuddling and complimenting were more likely
in families with a high maternal educational level, in families
of Dutch ethnicity, and in small families.
CONCLUSIONS: These findings show the importance of considering social and economic factors when identifying and supporting parents with parenting/rearing challenges.

different discipline practices by parents of children aged 5 to 6

years.
METHODS: We obtained cross-sectional data for a nationally
representative Dutch sample of children aged 5 to 6 years within
the setting of routine well-child visits provided to the entire population. A total of 1630 children participated (response rate,
84%). Before the visit, parents completed a questionnaire with
questions about their approach to discipline (punishment and rewards). Chi-square tests and logistic regression analyses were
used to examine associations between discipline practices and
child, parent, and family factors.
RESULTS: Parental punishment prevalence was 21.9% for
spanking and 80.3% for other punishment practices, such as
time-outs. The prevalence of rewards as a discipline strategy
was 32.2% for granting privileges and 86.3% for cuddling/complimenting. Multivariate logistic regression analyses showed

KEYWORDS: children; discipline; parenting practices

ACADEMIC PEDIATRICS 2015;15:96102

WHATS NEW

either punishment or reward practices. Punishment means

parental practices that aim to eliminate undesired behaviors.
Examples are time-outs, removing privileges, yelling, and
spanking. Yelling and spanking have been described as aversive strategies by the American Academy of Pediatrics5
because of the harmful effects.3,4,6 However, the results of
high-quality well controlled longitudinal studies indicate a
trivial to very small but significant association between
spanking and negative outcomes.7 Rewarding means
parental practices that aim to strengthen desired behaviors.
Examples are cuddling, complimenting, or granting privileges (watching television, sweets, etc).
Effective and efficient parenting support might benefit
from information about the prevalence of different discipline
practices. Studies of discipline practices have focused mainly
on corporal punishment. These studies showed that parents
particularly use corporal punishment, such as spanking, in
children aged 2 to 3 years,8 in first born children,9 in children
with a difficult temperament,9 and in boys rather than
girls.10,11
Turning to parental and family characteristics, evidence
shows that younger parents,814 lower socioeconomic
status, more parental stress,9 and marital status

The discipline strategies spanking (to punish) and

granting privileges (to reward) were more frequently
used in families characterized by a number of indicators
of societal adversity such as low income, low educational level, immigrant status, and unemployment.

GOOD PARENTING IS pivotal for the health and development of children.14 An important aspect of parenting is the
approach to disciplining children. The American Academy
of Pediatrics Committee on Psychosocial Aspects of Child
and Family states that an effective discipline strategy must
contain 3 elements: 1) a learning environment characterized
by positive, supportive parentchild relationships, 2)
proactive teaching and strengthening desired behaviors, and
3) reactive practices (time-out, removal of privileges) and
punishment (eg, verbal reprimands) for decreasing or
eliminating undesired behaviors. The second issue entails
rewarding, which is also embedded in the wider array of
techniques to modify child behavior.5 Parents might use
various discipline approaches: spanking or cuddling, for
example. Generally, these approaches can be classified as
ACADEMIC PEDIATRICS
Copyright 2015 by Academic Pediatric Association

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PUNISHMENT AND REWARD IN PARENTAL DISCIPLINE

(unmarried)13,15 were associated with more frequent harsh

disciplining. A fair amount of evidence suggests that
African American parents used corporal punishment more
often than Caucasian parents in the United States.6,9,11,13
Little evidence has been obtained about discipline
practices other than corporal punishment. We found 2
studies that investigated child, parent, and family factors
associated with the use of other punishment practices for
young children (435 months13 and 1219 months12). The
first study showed that parent frustration was associated
with more use of toy removal, time-outs, and explaining.
Parental ethnicity (Spanish-speaking Hispanic ethnicity
compared with Caucasian parents in the United States)
was associated with less use of toy removal and timeouts.13 The second study showed that marital status, income,
and education were not predictors of any discipline practices
such as verbal communication, removing privileges, timeout, or ignoring.12 Studies of reward as a discipline strategy
are entirely lacking.
The main aim of this study was to investigate the prevalence and predictors (child, parent, and family factors) of
different discipline practices in parents of children aged 5
to 6 years. We oversampled ethnic minorities to make a
proper assessment of the associations with ethnicity.

METHODS
Data were collected between October 2002 and May 2003
within the framework of the routine preventive health assessments that are provided regularly to all Dutch children.
The local Medical Ethics Committee of Leiden University
Medical Center approved the study. Informed consent was
not necessary; the data were anonymized before being provided to the research institute. Anonymized data can be provided by TNO to researchers on request.
SAMPLE
The sample was obtained in a 2-stage procedure. In the
first stage, a random sample of 15 Dutch Child Healthcare
Services was taken from a total of 40 services. In the second,
each Child Healthcare Service provided a random sample of
approximately 100 children for the age group 5 to 6 years
(second year of elementary school). Child Healthcare Services in 2 large cities were each asked to provide an additional sample of 200 children from the largest ethnic
minority groups in the Netherlands: Moroccan, Turkish,
Surinam, and Antillean. Of the parents of 1939 children (5
and 6 years old) who were eligible, 1630 participated
(response rate, 84%). We excluded parents of children
with incomplete parent-reported data, which resulted in a
sample of 1399 parents of children (5 and 6 years old).
Representativeness of the Dutch population was assessed
by comparing our figures with national figures of Statistics
Netherlands. The sample was representative of the total
sample and representative of the Dutch population in terms
of age, gender, and ethnicity.
PROCEDURE
A questionnaire was mailed to parents along with the standard invitation for the preventive health assessment routinely

97

offered to all Dutch children. This questionnaire included

questions about discipline practices. The completed questionnaire was returned to the Child Healthcare Physician
(CHP) in a sealed envelope. The CHP forwarded the envelopes to the research institute without opening them.
The CHP then took a routine history and physically assessed each child. The CHP recorded the background characteristics of the child and family: ethnicity, child age and
gender, maternal and paternal educational level and age,
employment status, family composition, family size, family income, and urbanization. The country of birth of the
parents was taken as the determinant of ethnic status.
The educational level of each parent was the highest degree obtained by that parent. Education level was defined
as low (primary school, up to 8 years of education), medium (secondary school, up to 12 years), and high (higher
vocational education and university; more than 12 years).
Employment was defined as having at least one parent
working. Family composition focused on the number of
parents in the family (2 parents or 1 parent). Family size
focused on the number of children in the family (1 child,
2 children, $3 children). Family income was categorized
as below/at poverty level (<1200 Euros earned each
month) or higher ($1200 Euros earned each month). Urbanization was categorized as small/rural town
(<250,000 inhabitants) or large city ($250,000 inhabitants). All data were anonymized before being sent to the
research institute.
QUESTIONNAIRE
Data about discipline practices were obtained with 2 questions in the questionnaire. Parents were asked to indicate
practices they generally used to punish or reward their child.
The first question was: which discipline practices do you
apply if your child needs to be punished? Parents had the
following answer options: spanking (ie, slapping), holding,
time-out, sending out of the room/separating, standing in
the corner, withholding something (sweets, for instance), verbal reprimands (ie, firm words), or other. The second question
was which discipline practices do you generally apply to
reward your child? Parents had the following answer options: cuddling, sweets, presents, staying up longer, watching
television, promise of an outing, complimenting, or other.
Parents were allowed to give multiple answers to each question. Each answer option will be referred to herein as an
item.
ANALYSES
To classify the punishment and rewarding practices
mentioned in the questionnaire, a homogeneity analysis by
means of alternating least squares was conducted. Items
with a discrimination value > 0.30 on the resulting dimensions were grouped as separate disciplining strategies. The
analyses resulted in the punishment dimensions spanking
(a single item: spanking) and other punishment (items:
time-out, verbal reprimands, and holding), and the reward
dimensions cuddling/complimenting (items: cuddling
and complimenting) and granting privileges (items: giving
presents, watching television, and promise of an outing).

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THEUNISSEN ET AL

ACADEMIC PEDIATRICS

Items from each dimension were summed to create scales

(strategies). Each parent who answered the questionnaire
was classified as low or high on each strategy, using its median value as a cutoff point. We then assessed the prevalence
of each of the discipline strategies as identified.
Second, we assessed the associations between the 4 discipline strategies using chi-square tests. The effect size of a chisquare test can be described by a Cohen effect size index w.
Significant associations with an effect size of w $ 0.10 were
presented. Third, we assessed differences in child, parent, and
family characteristics for each strategy (eg, granting privileges: low or high) using chi-square tests and the Cohen effect

Table 1. Demographic Characteristics of the Participating Children

(N 1399)
Characteristic
Gender
Boy
Girl
Age, years
5
6
Family composition
Two-parent family
One-parent family
Other/unknown
Employment status
Unemployed
Employed
Unknown
Maternal educational level
Low
Medium
High
Unknown
Paternal educational level
Low
Medium
High
Unknown
Family size
One child
Two children
$3 children
Family income
Below poverty
Above poverty
Unknown
Urbanization
Rural/small town
Big city
Maternal age, years
<27
2733
$34
Unknown
Paternal age
<27
2733
$34
Unknown
Ethnicity
Dutch
Migrant
Unknown

size index w. Family and child background variables concerned those mentioned in the Procedure section.
Finally, we performed bivariate and multivariate logistic
regression analyses (forward selection method) to assess
which characteristics were related to the use of punishment
and reward strategies. Child, parent, and family characteristics were included as potential predictors.

RESULTS
DEMOGRAPHIC CHARACTERISTICS
Of all children, 23.4% were of non-Dutch ethnicity (ie,
at least 1 parent born outside the Netherlands). Further demographic information is presented in Table 1.

705
694

50.4
49.6

813
586

58.1
41.9

PREVALENCE OF PUNISHMENT AND REWARDS AS DISCIPLINE

STRATEGIES
Table 2 shows that most parents (78.1%) did not use
spanking as a general strategy to discipline their child.
Many parents (80.3%) used at least 1 of the other punishment practices such as time-out, verbal reprimands, or holding. Most of the parents (86.3%) used cuddling and

1253
121
25

89.6
8.6
1.8

Table 2. Frequency of Discrete Discipline Practices and Discipline

Strategies (N 1399)

65
1221
113

4.6
87.3
8.1

543
490
333
33

38.8
35.0
23.8
2.4

511
421
368
99

36.5
30.1
26.3
7.1

201
696
502

14.4
49.7
35.9

179
1035
185

12.8
74.0
13.2

1073
326

76.7
23.3

288
751
353
7

20.6
53.7
25.2
0.5

122
651
582
44

8.7
46.5
41.6
3.1

1057
327
15

75.6
23.4
1.1

Punishment practice
Spanking
Holding
Sending out of the room
Standing in the corner
Withholding something
Verbal reprimands
Other punishment strategies
Rewarding practice
Cuddling
Sweets
Presents
Staying up longer
Watching television
Promise of an outing
Complimenting
Other rewarding strategies
Discipline strategies
Spanking (01)
0
1
Other punishment (03)*
0
1
2
3
Cuddling/complimenting (02)
0
1
2
Granting privileges (03)
0
1
2
3

306
328
1044
75
1045
586
43

21.9
23.4
74.6
5.4
74.7
41.9
4.1

1271
290
312
202
120
177
1299
30

90.9
20.7
22.3
14.4
8.6
12.7
92.9
2.1

1093
306

78.1
21.9

275
809
306
9

19.7
57.8
21.9
0.6

36
156
1207

2.6
11.2
86.3

949
318
105
27

67.8
22.7
7.5
1.9

$Median

21.9%

22.5%

86.3%

32.2%

*Time-out, verbal reprimands, and holding.

Giving presents, watching television, and promise of an outing.

ACADEMIC PEDIATRICS

PUNISHMENT AND REWARD IN PARENTAL DISCIPLINE

99

Table 3. Prevalence of Punishment Strategies According to Child, Parent, and Family Characteristics (N 1399)
Spanking
$Median
Gender
Boy
Girl
Age, years
5
6
Family composition
Two-parent family
One-parent family
Employment status
Unemployed
Employed
Maternal educational level
Low
Medium
High
Paternal educational level
Low
Medium
High
Family size
One child
Two children
$3 Children
Family income
Below poverty
Above poverty
Urbanization
Rural/small town
Large city
Maternal age, years
<27
2733
$34
Paternal age
<27
2733
$34
Ethnicity
Dutch
Migrant

Other Punishments
Cohen w

$Median

0.04
165 (23.4%)
141 (20.3%)

Cohen w
0.05

173 (24.5%)
142 (20.5%)

188 (23.1%)
118 (20.1%)

0.04

200 (24.6%)
115 (19.6%)

0.06*

276 (22.0%)
28 (23.1%)

0.01

284 (22.7%)
24 (19.8%)

0.02

0.02
16 (24.6%)
262 (21.5%)

0.08**
5 (7.7%)
282 (23.1%)

0.14**
150 (27.6%)
103 (21.0%)
42 (12.6%)

0.09**
102 (18.8%)
135 (27.6%)
76 (22.8%)

0.07*
128 (25.0%)
81 (19.2%)
68 (18.5%)

0.07*
101 (19.8%)
97 (32.4%)
101 (27.4%)

0.02
43 (21.4%)
147 (21.2%)
116 (23.1%)

0.05
36 (17.9%)
157 (22.6%)
122 (24.3%)

0.07*
50 (27.9%)
210 (20.3%)

0.07*
29 (16.2%)
247 (23.9%)

0.08**
216 (20.1%)
90 (27.6%)

0.10**
267 (24.9%)
48 (14.7%)

0.07*
78 (27.1%)
150 (20.0%)
74 (21.0%)

0.05
53 (18.4%)
177 (23.6%)
84 (23.8%)

0.02
30 (24.6%)
142 (21.8%)
122 (21.0%)

0.01
28 (23.0%)
143 (22.0%)
135 (23.2%)

0.17**
191 (18.1%)
112 (34.3%)

0.19**
285 (27.0%)
28 (8.6%)

Cohen w: low 0.1, medium 0.3, and high 0.5. Unknown category of each variable is not included in the analyses.
*P < .05.
**P < .01.

compliments to reward their child. A sizable minority

(32.2%) used at least 1 of the practices of the strategy granting privileges such as giving presents, watching television,
and promise of an outing to discipline their child.
ASSOCIATIONS BETWEEN THE DISCIPLINE STRATEGIES
The rewarding strategy granting privileges was more
likely in parents who spanked (Cohen w 0.11; P < .01).
The strategy, other punishment was more likely in parents
who used the rewarding strategy cuddling and complimenting (Cohen w 0.13; P < .01). The strategy, other punishment was more likely in parents who spanked (Cohen
w 0.10; P < .01).
CHARACTERISTICS AFFECTING DISCIPLINE STRATEGIES:
BIVARIATE ANALYSES
Tables 3 and 4 present the characteristics associated with
punishment and rewards. Many characteristics were

significantly associated with a parental discipline

strategy, but most effect sizes were small (Cohen
w < 0.10). Only characteristics with a significant
relationship and a Cohen w > 0.10 were classified as
effects. Table 3 shows the characteristics associated with
punishment strategies. Spanking was more likely in families of non-Dutch ethnicity and with mothers with a low
education level. Other punishments practices (eg, timeout, verbal reprimands, and holding) were more likely in
families of Dutch ethnicity.
Table 4 shows the factors associated with rewarding
strategies. The strategy cuddling and complimenting
was more likely in families with a high maternal and
paternal educational level, with an income above poverty
level, living in small/rural towns, and of Dutch ethnicity.
The strategy granting privileges was more likely in families of non-Dutch ethnicity, with an income below

100

THEUNISSEN ET AL

ACADEMIC PEDIATRICS

Table 4. Prevalence of Reward Strategies According to Child, Parent, and Family Characteristics
Cuddling and Complimenting
$Median
Gender
Boy
Girl
Age, years
5
6
Family composition
Two-parent family
One-parent family
Employment status
Unemployed
Employed
Maternal educational level
Low
Medium
High
Paternal educational level
Low
Medium
High
Family size
One child
Two children
$ Children
Family income
Below poverty
Above poverty
Urbanization
Rural/small town
Large city
Maternal age
<27
2733
$34
Paternal age
<27
2733
$34
Ethnicity
Dutch
Migrant

Cohen w

Granting Privileges
$Median

0.04
599 (85.0%)
608 (87.6%)

0.02
234 (33.2%)
216 (31.l %)

0.02
697 (85.7%)
510 (87.0%)

0.01
266 (32.7%)
184 (31.4%)

0.02
1083 (86.4%)
101 (83.5%)

0.07*
393 (31.4%)
51 (42.1%)

0.10**
47 (72.3%)
1066 (87.3%)

0.07*
29 (44.6%)
373 (30.5%)

0.23**
417 (76.8%)
447 (91.2%)
314 (94.3%)

0.09**
200 (36.8%)
142 (29.0%)
93 (27.9%)

0.14**
414 (81.0%)
373 (88.6%)
338 (91.8%)

0.06
177 (34.6%)
119 (28.3%)
110 (29.9%)

0.07*
172 (85.6%)
616 (88.5%)
419 (83.5%)

0.11**
83 (41.3%)
235 (33.8%)
132 (26.3%)

0.12**
139 (77.7%)
923 (98.2%)

0.17**
93 (52.0%)
306 (29.6%)

0.14**
955 (89.0%)
252 (77.3%)

0.20**
290 (27.0%)
160 (49.1%)

0.08**
233 (80.9%)
663 (55.2%)
306 (86.7%)

0.10**
118 (41.0%)
234 (31.2%)
97 (27.5%)

0.06
98 (80.3%)
573 (88.0%)
503 (86.4%)

0.08*
48 (39.3%)
221 (33.9%)
163 (28.0%)

0.25**
964 (91.2%)
231 (70.6%)

Cohen w

0.24**
272 (25.7%)
172 (52.6%)

Cohen effect size index w: low 0.1, medium 0.3, and high 0.5. Unknown category of each variable is not included in the analyses.
*P < .05.
**P < .01.

poverty level, living in large cities, and in small families

(1 child).
CHARACTERISTICS AFFECTING DISCIPLINE STRATEGIES:
MULTIVARIATE ANALYSES
Table 5 presents the results of the stepwise logistic
regression analyses. In multivariate analyses, low and medium maternal educational level and non-Dutch ethnicity
were independently associated with the use of spanking.
Dutch ethnicity was independently associated with the
use of other punishment practices (eg, time-out, verbal reprimands, and holding).
High maternal educational level, Dutch ethnicity, and
small families (2 children as opposed to $3 children)
were independently associated with the use of cuddling
and complimenting. Non-Dutch ethnicity, living in large cities, an income below poverty level, employment, and small

family size (1 or 2 children as opposed to $3 children) were

independently associated with granting privileges.

DISCUSSION
The results of this study show that 22% of all parents of
children aged 5 to 6 years used spanking as a general strategy to punish their child. Most of the parents also used
other practices to punish their child, such as time-outs, verbal reprimands, and holding. As rewards, most parents
generally used the strategy cuddling and complimenting
rather than the strategy granting privileges. Parents who
used harsh punishment (spanking) were more likely to
use the rewarding strategy granting privileges. Parents
who used other punishments strategies were more likely
to use the rewarding strategy cuddling and complimenting. These associations between disciplining strategies

ACADEMIC PEDIATRICS

PUNISHMENT AND REWARD IN PARENTAL DISCIPLINE

101

Table 5. Associations of Background Characteristics With Discipline Strategies: Results of 4 Stepwise Logistic Regression Analyses
(N 1022)
Punishment

Ethnicity
Dutch
Migrant
Maternal educational level
Low
Medium
High
Family size
One child
Two children
$3 children
Urbanization
Rural/small town
Large city
Income
Below poverty
Above poverty
Employment status
Unemployed
Employed

Reward

Spanking

Other Punishment

Cuddling and
Complimenting

Granting Privileges

Reference (P < .01)

1.86 (1.312.64)

Reference (P < .01)

0.27 (0.160.44)

Reference (P < .01)

0.26 (0.180.40)

Reference (P < .01)

2.60 (1.803.74)

2.00 (1.323.02)
1.59 (1.042.42)
Reference (P < .01)

0.26 (0.140.47)
0.55 (0.291.05)
Reference (P < .01)
1.14 (0.632.06)
1.70 (1.112.61)
Reference (P < .05)

1.71 (1.102.65)
1.50 (1.102.06)
Reference (P < .05)
Reference (P < .05)
1.45 (1.012.07)
2.32 (1.373.94)
Reference (P < .01)
0.30 (0.130.72)
Reference (P < .01)

Data are presented as odds ratios (95% confidence interval).

might be interpreted as representing more general types of

disciplining strategies.
Characteristics closely associated with punishment strategies were ethnicity and maternal educational level. Characteristics closely associated with reward strategies were
ethnicity, maternal educational level, family size, urbanization, family income, and employment status.
CHILD, PARENT, AND FAMILY FACTORS AND DISCIPLINE
PRACTICES
We found that the strategies spanking (to punish) and
granting privileges (to reward) were more frequently
used in families characterized by a number of indicators
of societal adversity such as low income, low educational
level, immigrant status, and unemployment. Regalado
et al13 and Socolar et al12 found similar risk groups associated with spanking in the United States. Similar risk groups
were found for child maltreatment. Evidence shows that
groups at the highest risk for child maltreatment are immigrant and unemployed parents, in the Netherlands16 and
elsewhere.17 This might be because type of discipline strategy is an important risk factor for child maltreatment.
Discipline strategies might reflect a more general
parenting style and parenting skills. It seems likely that
aversive disciplining, for example, probably reflects a
more authoritative style.18 This style is more often found
in parents with low socioeconomic and immigrant status.
It is, however, also very likely that limited coping skills
are a relevant factor for the use of aversive parent strategies. Other factors that might explain the relation between
indicators of societal adversity and aversive parent strategies are cultural differences and living in an adverse situation that might lead to pressure and stress and, in turn, to
harsh discipline.

STRENGTHS AND LIMITATIONS

Our study had several strengths. The response rate was
high and the sample covered the entire Dutch population,
limiting the likelihood of selective response.
Some limitations should also be taken into account when
interpreting our findings. First, discipline practices were
assessed using self-report, which might lead to bias if parents give socially-acceptable responses. However, we
expect this effect to be small because parental responses
were collected anonymously, but we have almost certainly
underestimated the prevalence rates of practices like
spanking to some extent. Second, the context (ie, the situation, such as specific misbehavior of the child) of discipline strategies is an important factor and was not
assessed. Third, it might be that parents who spank are
over-represented in the nonresponse group, because parents are aware that spanking is not an approved method
of discipline. However, we expect this effect to be small
because the response rate was high (84%). The final limitation is that we did not measure the frequency with which
the discipline practices were used. For example, we asked
about which discipline practices do you generally apply if
your child needs to be punished? Additional research is
needed to obtain data about frequency, but it should be realized that such data are probably sensitive to various types of
information bias.
IMPLICATIONS
Because of the evidence of the harmful effect of aversive
disciplining, supporting parents in alternative discipline
styles is of great practical significance.3,6 Parents who
are struggling with the demands of child rearing might
be helped by a variety of parenting programs, such as the
Triple P-Positive Parenting Programme.19 Preventive,

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THEUNISSEN ET AL

primary, and secondary care can play important roles in

identifying this need and in facilitating access to services
that provide such parenting support. Because of the sensitive nature of this topic, improvements might be required in
professionals communication techniques.20
Moreover, our findings show that spanking is still prevalent in a large group of parents, with a preponderance of
risk factors in deprived settings. Preventive, primary, and
secondary care professionals should pay more attention
to these risk groups to eliminate the use of aversive discipline strategies and child abuse for these children.

ACKNOWLEDGMENT
Financial disclosure: The original research received financial support
from the Netherlands Organization for Health Research and Development
(ZonMw).

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