Within Alaska there are some 47.000 Inuit [6]. Approximately 30% of these are Iñupiat [6-8] inhabiting the northern and western coasts as far south as Norton Sound [6]. Greenland is home to about 57.000 people, of which approximately 90% are Kalaallit (Greenlanders). The majority of Greenland’s population is situated on the south-central west coast. Only 3500 live on the east coast and less than 1000 are located in the far north. Kalaallisut (the Greenlandic language) is closely related to the Iñupiaq language spoken by Iñupiat in Alaska [9]. The traditional Sami settlement area (Sápmi) in Norway stretches from Finnmark in the north to Engerdal in Hedmark County in the south. No reliable or updated demographic record on the Sami exists. Though suffering from grave deficiencies, estimates of the total number of Sami in Norway usually vary between 40.000 and 50.000 [10].

The Iñupiat, Kalaallit and the Sami share a common, though independently unique, history of colonialism and have throughout history been victims of state and church driven forced assimilation [11-14]. Forced assimilation has resulted in loss or extensive change of traditional practices, native languages, and norms and beliefs [2]. As part of this process, concentration of the populations in large settlements provided most circumpolar indigenous peoples with schooling, health care, housing, water, sanitation, and imported foods and consumer products [14-16]. The post-World War II years in the Arctic were characterised by an intensification of social and cultural change [14]. In Greenland, Alaska, and Norway an increasing urbanisation has taken place [14] and mining, industrial fishing and the discovery of oil transformed – to a varying degree – the economies [17]. In 2005 only 17% of the Greenlandic population lived in villages [9]. In the post-war period in Norway and Alaska, outmigration from rural to urban areas has also been considerable [18,19]. Today the transition from hunting and small scale fishing to a mixed cash/harvest economy is seen all across the Arctic [16]. Subsistence and traditional foods is still a significant contributor to cultural identity and social cohesion among the Inuit and Sami [14,20,21], but unemployment is a problem in many Inuit communities which affects subsistence as this requires costly equipment such as guns, ammunition, snowmobile, and petrol [14,22-24]. The role of subsistence is also affected by access to the resources traditionally harvested being reduced by climate change, pollution, and an increasing number of regulations and import bans [16,20,22,23,25].

Changes in living conditions and lifestyle following this development affect health in numerous ways [16]. The life expectancy of the Inuit and the Sami has dramatically improved since 1950 [26-28], but the general health status of the Inuit is still inferior when compared with their respective state’s majority populations; this disparity has often been attributed to the Inuit’s relatively poorer socioeconomic status (SES) [16]. Few general health discrepancies between Sami and ethnic Norwegians are detected today. This is largely explained by little inter-ethnic variation in SES parameters [28].

The changes in occupational patterns are associated with increased acculturative stress, decreased physical activity and change in diet [16]. A number of studies on Inuit populations report a transition from the traditional and protein rich diet, to a diet of unhealthy store-bought foods thus making the Inuit susceptible to a variety of life-style diseases such as diabetes and cardiovascular disease [29]. High prevalence rates of obesity [30], and changes in diet [31] are also found in the Sami population in Norway. The effects of acculturation on chronic life-style diseases are evident in other populations and immigrant groups too [32].

Acculturative stress may be perceived as a response to life events associated with intercultural contact. To deal with various stressors, individuals will adopt different coping strategies eventually leading to some form of adaptation, of which integration may be the most health beneficial and marginalisation the least advantageous in terms of mental health [33]. The mental health effects of the various adaptations are very much debated [34]. A relationship between marginalisation and depression/anxiety was found in a study among rural Sami adolescent males [35]. Similarly, in Greenland it was found that better mental health status was associated with growing up in a town and being fully bilingual, as opposed to growing up in a small village and only speaking Greenlandic [36]. Spein et al. [37] found that more assimilated Sami adolescents reported more smoking and drinking compared with less assimilated Sami peers. Wolsko et al. found that among Alaska Yup’ik, higher levels of acculturation was associated with greater psychosocial stress, less happiness, and greater use of drugs and alcohol [38,39]. Wexler reports a relationship between loss of traditional knowledge, alcohol abuse, and low education attainment among Iñupiat in Northwest Alaska [24].

The direction of the associations in the many studies on health and acculturation is of course related to the fact that acculturation is context sensitive and that it has been operationalized differently in relation to a variety of health outcomes. Although numerous studies have explored how acculturation is related to various health outcomes, it still remains unclear how acculturation may be related to self-rated health (SRH) [40]. As summarised by Hansen et al. [41], even after a variety of physical, sociodemographic and psychosocial health status indices are controlled for [42], SRH significantly predicts mortality, and morbidity and subsequent use of health services [43]. In sum, SRH conceptually functions as a composite measure of mental and physical health [40], and becomes thus a relevant variable in primary health care and in general public health assessments and monitoring [44]. Exploring the relationship between acculturation and SRH in indigenous populations having experienced great societal and cultural change is thus of great importance.

The principal method in SLiCA was standardised face-to-face interviews using a questionnaire, which may be accessed on the project website [45]. The SLiCA target population was indigenous individuals aged 16 years and older (≥15 in Greenland) residing in traditional settlement regions. Data collection in Alaska and Greenland took place from January 2002 to February 2003 and from December 2003 to August 2006, respectively. In Norway the majority of the material was collected between June 2006 and June 2008 and a smaller amount (n=67) in 2003. Very high overall participation rates of 83% were obtained in Greenland and Alaska, whilst a more conventional rate of 57% was achieved in Norway. More detailed descriptions of the material, methods, and methodological issues in SLiCA are published elsewhere [46].

Self-rated health was measured by the question: How would you describe your health in general: Excellent, Very good, Good, Fair, or Poor? The labelling of categories varied somewhat in Greenland, i.e. Very good, Good, Fair, Poor, Very poor. In Norway and Alaska the variable was in the analyses coded: 0) Excellent, 1) Very good, 2) Good/Fair/Poor. In Greenland SRH was coded: 0) Very good, 1) Good, 2) Fair/Poor/Very Poor.

Established as essential Inuit and Sami culture values and identity markers, 12 standardised ordered categorical variables (G1: a, b, c, d, f, g, h, i, k, l, n, o) [45] measuring the importance (0=Very important through 3=Not at all important) of certain traditional subsistence activities, was chosen to measure acculturation. The items were selected in advance as they were considered relevant in all three countries. A score ranging from 0 through 36 was produced by adding the 12 variables, from which respective score averages were generated. Thus, a one unit increase in score average gave an approximation of the average effect of a one unit increase in all 12 variables. An increased score average indicated stronger acculturation, i.e. the activities were of lesser importance to a person’s Sami or Inuit cultural identity. Observations providing information from less than 9 variables in the score were coded as missing.

The linear acculturation scales have been criticised [47-49] and are replaced by models [50] attempting to explore the multidirectional nature of acculturation by incorporating possible adaptations such as integration and assimilation (see discussion). SLiCA was not exclusively and specifically designed for conducting multidimensional acculturation studies; we thus had to settle for a conventional scale-based analysis. We have nevertheless addressed much of the criticism by scrutinising the 12 subsistence variables in three country/region-specific exploratory factor analyses [51], all of which convincingly pointed to a one-factor solution that systematically presented strong factor loadings (≥0.57), overall low unique item variance (<0.6), and large sized overall Kaiser-Meyer-Olkin test results (≥0.87) (data not shown). We thus considered scale analysis to be an appropriate substitute.

Additionally, spoken indigenous language ability (SILA) was included in the regression model (see below) as language represents an integral part of a person’s cultural identity [11]. In the analyses, SILA was dichotomised due to small sample sizes; and as distributions differed, the variable was dichotomised differently. The question was: How would you rate your ability to speak Inuit/Sami? In Norway and Greenland the recoding was: 0) Very well, 1) Relatively well/With effort/A few words/Not at all. In Alaska the variable was dichotomised into: 0) Very well/Relatively well 1) With effort/A few words/Not at all.

Housing condition was not included in the regression models in Norway. Overall the standard of living is high in Norway and no variation was therefore observed in the variable. In Alaska and Greenland a score was generated by adding 9 variables measuring standard of housing. This score was further categorised based on its distribution. Worsening standard of housing is illustrated with an increased score. Living in a town or village was not included in the analyses of data from Norway as all participants are by definition rural. However, we included herein living in Finnmark or not, as prior studies [52] have shown that a north–south-based health gradient is relevant to account for in Norway.

The crude distributions of SRH by the included variables are presented in Table ​Table2.2. A close to significant relationship between poorer SRH and an increased subsistence score was observed among men in Alaska (p=0.08) and Greenland (0.07). In Greenland, a significant relationship and a similar trend was observed between SRH and SILA for both men (p=0.02) and women (p=0.04), while a somewhat reversed relationship was detected in Alaska (p<0.01).

Multivariable analyses are displayed in Table ​Table3.3. Acculturation significantly predicted poorer SRH in Greenland, and the relative effects of acculturation were stronger for men than for women, though this modification of effects was not significant (data not shown). An increased subsistence score gave an OR of 2.32 (P<0.001) for reporting poorer SRH among Greenlandic men, while an increased score for Greenlandic women generated an OR of 1.71 (P=0.01). Poorer SILA produced an OR of 1.59 in men (p=0.03) and 1.43 in women (p=0.07). In Alaska, no evidence of acculturation effects was detected among Iñupiaq men. Among Iñupiaq women, an increased score represented an increased odds of 73% (p=0.026) for reporting poorer SRH. No significant effects of acculturation were detected in Norway. However, SILA was close to significant (p=0.068) among Sami men, thus suggesting a substantial effect of acculturation on SRH (OR=1.74).

The observed relationship between acculturation and SRH may perhaps be explained by the aforementioned effects of colonialism and modernisation. A more sedentary lifestyle with increasing consumption of store-bought foods is a plausible explanation. Also, acculturative stress and related poor health behaviours such as alcohol and substance abuse are contributing factors. Extensive research has demonstrated that acculturation can have both negative and protective effects depending on the outcome of interest. Therefore, a relationship between acculturation and SRH gives a good indication of the overall effects of acculturation on composite health among the Sami, Iñupiat and Kalaallit.

That we could not observe a significant relationship between acculturation and SRH among the Sami may be because of the relatively early governmental focus on nation-wide equality in health care access in Norway. Financially, the Norwegian state contributed more to the reconstruction of health care infrastructure in Finnmark than elsewhere in the immediate post-war years, from which the rather large Sami population in the county have benefited from. The subsequent large scale regionalization of higher education in Norway in the 1970s also helped along the education of Sami-speaking physicians and other professionals needed in health care and other industries in Sami settlement areas [56]. This development may also explain the relatively high SES among the Sami today. However, the observed effect of SILA in Sami men was close to significant and may not be disregarded as random sampling variation. Language ability has shown to be a good indicator of acculturation in previous studies (see for example Bjerregaard et al. [36]) and among Kalaallit men in this study. Lack of indigenous language can indicate a reduced possibility of inclusion in the indigenous culture, or perhaps an orientation away from it. This includes adaptation to majority customs such as alcohol use [2].

Prior studies argue that Inuit men have to a greater extent than women experienced more problems integrating into the modern society; Inuit women have for example adapted more comfortably to higher education and wage employment [24,57]. This development is also observed among Sami women [58]. Though we found higher education levels among women in this study, we did not find any evidence suggesting stronger effects of acculturation in men, as did not Bjerregaard et al. [36] in their study on acculturation and mental health.

That we could not find a relationship between acculturation and SRH among Iñupiaq men may be because our operationalization of acculturation measured the phenomenon poorly in this stratum; acculturation is a multidimensional concept and our linear approach may thus have been unable to measure true acculturation effects among these men (see below). Also, considering the p-values of about 20%, we may because of relatively small numbers in the strata of Iñupiaq men, have been unable to pick up on potential true effects.

Important to note is that the involved populations differ greatly in terms of the legal framework conveying indigenous autonomy and self-determination [59-62], thus generating discrepancies between the countries with regard to the premise for developing and securing culture, languages, and land and subsistence rights. Also, the Sami are in minority in most municipalities in Sápmi (apart from the municipalities of Karasjok, Kautokeino and Nesseby), while the Iñupiat and Kalaallit are in majority in their regions. The degree and pace of acculturation is of course affected by such demographic incentives. Differences in autonomy and self-determination may of course also affect the impact of acculturation and, subsequently the observed effects of acculturation on health in these populations. However, the self-governing arrangements in the Arctic are of comparatively recent date; further comparative studies must be executed to better understand the significance of the various political arrangements for human development [63], and health.