Eliassen et al. BMC Public Health 2012, 12:948 http://www.biomedcentral.com/1471-2458/12/948 Table 1 Crude distributions of variables by gender and country/region (Continued) Page 6 of 11 136 (26.7) 155 (30.5) 61 (12.0) 157 (28.4) 137 (24.8) 69 (12.5) 63 (22.3) 63 (22.3) 9 (3.2) 95 (25.1) 68 (17.9) 19 (5.0) - - - - 0-2 4-9 Missing a Fisher’s exact chi2 test on non-missing data only. b Two-sided t-test. poorer SRH in Greenland, and in Alaska among Iñupiaq women. 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 sub- stance abuse are contributing factors. Extensive research has demonstrated that acculturation can have both negative and protective effects depending on the outcome of inter- est. Therefore, a relationship between acculturation and SRH gives a good indication of the overall effects of accul- turation 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. Fi- nancially, 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 in- digenous language can indicate a reduced possibility of inclusion in the indigenous culture, or perhaps an orien- tation 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 integrat- ing into the modern society; Inuit women have for ex- ample 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 accul- turation 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 dif- fer greatly in terms of the legal framework conveying in- digenous autonomy and self-determination [59-62], thus generating discrepancies between the countries with re- gard 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 ma- jority in their regions. The degree and pace of accultur- ation 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 develop- ment [63], and health. Limitations An essential limitation in the study was that the re- sponse options in our dependent variable, SRH, differed in wording in Greenland (Very good through Very poor) compared with Norway and Alaska (Excellent through Poor). As the distance between the categories differed due to variation in wording [64], the frame of reference was unstandardized; the distributions of SRH are thus incomparable [65]. What still was possible, though, was to analyse the direction of the associations. Significant relationships and careful assessments of the overall strength of the associations gave a general impression of the overall effects of acculturation on SRH among the involved populations. Also, SILA was coded differently