Eliassen et al. BMC Public Health 2012, 12:948 http://www.biomedcentral.com/1471-2458/12/948 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 sum- marised by Hansen et al. [41], even after a variety of physical, sociodemographic and psychosocial health sta- tus indices are controlled for [42], SRH significantly pre- dicts 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 ac- culturation and SRH in indigenous populations having experienced great societal and cultural change is thus of great importance. Subsistence and traditional foods is a significant mar- ker of Inuit and Sami culture and identity [14,20,21]. Our study thus conceptualises acculturation as certain traditional subsistence activities being of lesser import- ance to people’s ethnic identity, and poorer spoken indi- genous language ability (SILA). Using data from the Survey of Living Conditions in the Arctic: Inuit, Sami, and the Indigenous Peoples of Chukotka (SLiCA), we explored how these activities and SILA were associated with SRH by gender among the Iñupiat of Alaska, Kalaallit of Greenland, and Sami of Norway. Methods SLiCA is an international research project on health and other aspects of the living conditions of indigenous peo- ples in Alaska, Canada, Greenland, Norway, Sweden, and Russia. 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 settle- ment 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 con- ventional rate of 57% was achieved in Norway. More Page 3 of 11 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 categor- ies 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 categor- ical variables (G1: a, b, c, d, f, g, h, i, k, l, n, o) [45] meas- uring the importance (0=Very important through 3=Not at all important) of certain traditional subsistence activ- ities, was chosen to measure acculturation. The items were selected in advance as they were considered rele- vant 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 ap- proximation 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 incorporat- ing possible adaptations such as integration and assimila- tion (see discussion). SLiCA was not exclusively and specifically designed for conducting multidimensional ac- culturation 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 solu- tion 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 ap- propriate 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 cul- tural identity [11]. In the analyses, SILA was dichoto- mised 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: