Health and well-being needs of Indigenous adolescents: a protocol for a scoping review of qualitative studies.

INTRODUCTION: Improving the health of Indigenous adolescents is central to addressing the health inequities faced by Indigenous peoples. To achieve this, it is critical to understand what is needed from the perspectives of Indigenous adolescents themselves. There have been many qualitative studies that capture the perspectives of Indigenous young people, but synthesis of these has been limited to date. METHODS AND ANALYSIS: This scoping review seeks to understand the specific health needs and priorities of Indigenous adolescents aged 10-24 years captured via qualitative studies conducted across Australia, Aotearoa New Zealand, Canada, the USA, Greenland and Sami populations (Norway and Sweden). A team of Indigenous and non-Indigenous researchers from these nations will systematically search PubMed (including the MEDLINE, PubMed Central and Bookshelf databases), CINAHL, Embase, Scopus, the Informit Indigenous and Health Collections, Google Scholar, Arctic Health, the Circumpolar Health Bibliographic Database, Native Health Database, iPortal and NZresearch.org, as well as specific websites and clearinghouses within each nation for qualitative studies. We will limit our search to articles published in any language during the preceding 5 years given that needs may have changed significantly over time. Two independent reviewers will identify relevant articles using a two-step process, with disagreements resolved by a third reviewer and the wider research group. Data will then be extracted from included articles using a standardised form, with descriptive synthesis focussing on key needs and priorities. This scoping review will be conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. ETHICS AND DISSEMINATION: Ethics approval was not required for this review. Findings will be disseminated via a peer-reviewed journal article and will inform a broader international collaboration for Indigenous adolescent health to develop evidence-based actions and solutions.

Oral health in the indigenous Sámi population in Norway - the dental health in the North study.

Objective: This study aims at presenting the feasibility of using the public oral health clinics in indigenous Sámi communities, as arena for a comprehensive data collection for population-based epidemiological oral health research among adults (age, 18-75 years) in a multi-ethnic setting.Material and methods: The study design was cross-sectional. The data collection was incorporated into the clinical procedure at six public dental clinics situated in the Administrative Area for the Sámi Language in Finnmark County, Northern Norway, during 2013-2014. Both clinical- and questionnaire-data were collected. The quality of clinical data was thoroughly calibrated and validated.Results: Altogether, 2235 people participated in the study gave a crude response rate at 88.7%. In the final data sample (n = 2034), 56.9% were female. We constructed three ethnic groups (Sámi, Mixed Sámi/Norwegian and Norwegian). Altogether, 67.7% reported Sámi or mixed Sámi ethnicity. The internal validity of the clinical data was found to be satisfactory when assessed by comprehensive quality procedure, calibration and reliability assessments.Conclusion: This study design and method assessments provide solid documentation that public dental clinics are suitable as arenas for data collection in epidemiological oral health studies in the Sámi population in this region.

Childhood violence and mental health among indigenous Sami and non-Sami populations in Norway: a SAMINOR 2 questionnaire study.

The main objectives of this study were to investigate the association between childhood violence and psychological distress and post-traumatic stress symptoms (PTS) among Sami and non-Sami adults, and to explore a possible mediating effect of childhood violence on any ethnic differences in mental health. This study is part of a larger questionnaire survey on health and living conditions in Mid- and Northern Norway (SAMINOR 2) which included 2116 Sami and 8674 non-Sami participants. A positive association between childhood violence and psychological distress and PTS in adulthood was found regardless of ethnicity. For women, childhood violence may have mediated some of the ethnic differences in psychological distress (53.2%) and PTS (31.4%). A similar pattern was found for men as to psychological distress (45.5%) and PTS (55.5%). The prevalence of psychological distress was significantly higher in the Sami than in the non-Sami group: 15.8% vs. 13.0% for women, and 11.4% vs. 8.0% for men. Likewise, PTS showed a higher prevalence in the Sami group, both for women (16.2% vs. 12.4%) and for men (12.2% vs. 9.1). CONCLUSION: A positive association between childhood violence and adult mental distress was found for both Sami and Norwegian adults. More mental problems were found among the Sami. Childhood violence may have mediated some of the ethnic differences.

Do Norwegian Sami and non-indigenous individuals understand questions about mental health similarly? A SAMINOR 2 study.

The Western culturally developed Hopkins Symptom Checklist (HSCL-10) is a self-report measure of mental distress widely used for both clinical and epidemiological purposes - also in the multiethnic epidemiological SAMINOR studies in Northern Norway, but without any proper cross-cultural validation. Our objective was to test invariance of the HSCL-10 measurements among Sami and the non-indigenous majority population in Northern Norway (participants in the SAMINOR 2 study) and whether the previously used HSCL-10 cut-off level (1.85) fits the Sami subgroups in the study. Participants belonged to Sami core, Sami affiliation, Sami background or majority Norwegian groups. The confirmatory factor analysis framework adapted for testing of measurement invariance showed no significant measurement invariance between the groups indicating that the HSCL-10 response scale predominantly was used in the same way and that significantly different meanings were not ascribed to the same set of questions. The cut-off criteria of 1.85 as indicative of psychological distress based on Norwegian data equal a score of 1.89, 1.94 and 1.91 in the Sami core, Sami affiliation and Sami background groups, respectively. Thus, the same cut-off criterion 1.85 may be safely used in all groups. However, one should still be looking for culture-specific expressions of mental stress.

Indigenous Values and Health Systems Stewardship in Circumpolar Countries.

Circumpolar regions, and the nations within which they reside, have recently gained international attention because of shared and pressing public policy issues such as climate change, resource development, endangered wildlife and sovereignty disputes. In a call for national and circumpolar action on shared areas of concern, the Arctic states health ministers recently met and signed a declaration that identified shared priorities for international cooperation. Among the areas for collaboration raised, the declaration highlighted the importance of enhancing intercultural understanding, promoting culturally appropriate health care delivery and strengthening circumpolar collaboration in culturally appropriate health care delivery. This paper responds to the opportunity for further study to fully understand indigenous values and contexts, and presents these as they may apply to a framework that will support international comparisons and systems improvements within circumpolar regions. We explored the value base of indigenous peoples and provide considerations on how these values might interface with national values, health systems values and value bases between indigenous nations particularly in the context of health system policy-making that is inevitably shared between indigenous communities and jurisdictional or federal governments. Through a mixed methods nominal consensus process, nine values were identified and described: humanity, cultural responsiveness, teaching, nourishment, community voice, kinship, respect, holism and empowerment.

Childhood violence and adult chronic pain among indigenous Sami and non-Sami populations in Norway: a SAMINOR 2 questionnaire study.

BACKGROUND: Internationally, studies have shown that childhood violence is associated with chronic pain in adulthood. However, to date, this relationship has not been examined in any indigenous population. OBJECTIVE: The main objectives of this study were to investigate the association between childhood violence and reported chronic pain, number of pain sites and the intensity of pain in adulthood in indigenous Sami and non-Sami adults, and to explore ethnic differences. DESIGN: The study is based on the SAMINOR 2 questionnaire study, a larger population-based, cross-sectional survey on health and living conditions in multiethnic areas with both Sami and non-Sami populations in Mid- and Northern Norway. Our study includes a total of 11,130 adult participants: 2,167 Sami respondents (19.5%) and 8,963 non-Sami respondents (80.5%). Chronic pain was estimated by reported pain located in various parts of the body. Childhood violence was measured by reported exposure of emotional, physical and/or sexual violence. RESULTS: Childhood violence was associated with adult chronic pain in several pain sites of the body regardless of ethnicity and gender. Childhood violence was also associated with increased number of chronic pain sites and higher pain intensity compared to those not exposed to childhood violence. However, among Sami men, this association was only significant for pain located in chest, hips/legs and back, and non-significant for increased number of chronic pain sites (adjusted model), and higher pain intensity. CONCLUSION: Respondents exposed to childhood violence reported more chronic pain in several parts of the body, increased number of chronic pain sites and more intense pain in adulthood than respondents reporting no childhood violence. However, among Sami men, this association was weaker and also not significant for increased number of chronic pain sites and higher pain intensity.

Ethical and methodological issues in research with Sami experiencing disability.

BACKGROUND: A study of disability among the indigenous Sami people in Norway presented a number of ethical and methodological challenges rarely addressed in the literature. OBJECTIVES: The main study was designed to examine and understand the everyday life, transitions between life stages and democratic participation of Norwegian Sami people experiencing disability. Hence, the purpose of this article is to increase the understanding of possible ethical and methodological issues in research within this field. The article describes and discusses ethical and methodological issues that arose when conducting our study and identifies some strategies for addressing issues like these. METHODS: The ethical and methodological issues addressed in the article are based on a qualitative study among indigenous Norwegian Sami people experiencing disability. The data in this study were collected through 31 semi-structured in-depth interviews with altogether 24 Sami people experiencing disability and 13 next of kin of Sami people experiencing disability (8 mothers, 2 fathers, 2 sister and 1 guardian). FINDINGS AND DISCUSSION: The researchers identified 4 main areas of ethical and methodological issues. We present these issues chronologically as they emerged in the research process: 1) concept of knowledge when designing the study, 2) gaining access, 3) data collection and 4) analysis and accountability. CONCLUSION: The knowledge generated from this study has the potential to benefit future health research, specifically of Norwegian Sami people experiencing disability, as well as health research concerning indigenous people in general, providing scientific-based insight into important ethical and methodological issues in research with indigenous people experiencing disability.

Approaching Etuaptmumk--introducing a consensus-based mixed method for health services research.

With the recognized need for health systems' improvements in the circumpolar and indigenous context, there has been a call to expand the research agenda across all sectors influencing wellness and to recognize academic and indigenous knowledge through the research process. Despite being recognized as a distinct body of knowledge in international forums and across indigenous groups, examples of methods and theories based on indigenous knowledge are not well documented in academic texts or peer-reviewed literature on health systems. This paper describes the use of a consensus-based, mixed method with indigenous knowledge by an experienced group of researchers and indigenous knowledge holders who collaborated on a study that explored indigenous values underlying health systems stewardship. The method is built on the principles of Etuaptmumk or two-eyed seeing, which aim to respond to and resolve the inherent conflicts between indigenous ways of knowing and the scientific inquiry that informs the evidence base in health care. Mixed methods' frameworks appear to provide a framing suitable for research questions that require data from indigenous knowledge sources and western knowledge. The nominal consensus method, as a western paradigm, was found to be responsive to embedding of indigenous knowledge and allowed space to express multiple perspectives and reach consensus on the question at hand. Further utilization and critical evaluation of this mixed methodology with indigenous knowledge are required.

Emotional, physical and sexual violence among Sami and non-Sami populations in Norway: The SAMINOR 2 questionnaire study.

AIMS: To assess the prevalence and investigate ethnic differences of emotional, physical and sexual violence among a population of both Sami and non-Sami in Norway. METHODS: Our study was based on the SAMINOR 2 study, a population-based survey on health and living conditions in multiethnic areas with both Sami and non-Sami populations in Central and Northern Norway. Our study includes a total of 11,296 participants: 2197 (19.4%) Sami respondents and 9099 (80.6 %) non-Sami respondents. RESULTS: Almost half of the Sami female respondents and one-third of the non-Sami female respondents reported any violence (any lifetime experience of violence). Sami women were more likely to report emotional, physical and sexual violence than non-Sami women. More than one-third of the Sami men compared with less than a quarter of non-Sami men reported having experienced any violence in their life. Sami men were more likely to report emotional and physical violence than non-Sami men. However, ethnicity was not significantly different regarding sexual violence experienced among men. Violence was typically reported to have occurred in childhood. Sami participants were more likely to report having experienced violence in the past 12 months. For all types of violence, the perpetrator was typically known to the victim. CONCLUSIONS: Regardless of gender, Sami respondents were more likely to report interpersonal violence. The prevalence of any violence was substantial in both ethnic groups and for both genders; it was highest among Sami women.

Ethnic discrimination and health: the relationship between experienced ethnic discrimination and multiple health domains in Norway's rural Sami population.

OBJECTIVE: Self-reported ethnic discrimination has been associated with a range of health outcomes. This study builds on previous efforts to investigate the prevalence of self-reported ethnic discrimination in the indigenous (Sami) population, and how such discrimination may be associated with key health indicators. STUDY DESIGN: The study relies on data from the 2003/2004 (n=4,389) population-based study of adults (aged 36-79 years) in 24 rural municipalities of Central and North Norway (the SAMINOR study). Self-reported ethnic discrimination was measured using the question: "Have you ever experienced discrimination due to your ethnic background?" Health indicators included questions regarding cardiovascular disease, diabetes, chronic muscle pain, metabolic syndrome and obesity. Logistic regression was applied to examine the relationship between self-reported ethnic discrimination and health outcomes. RESULTS: The study finds that for Sami people living in minority areas, self-reported ethnic discrimination is associated with all the negative health indicators included in the study. CONCLUSION: We conclude that ethnic discrimination affects a wide range of health outcomes. Our findings highlight the importance of ensuring freedom from discrimination for the Sami people of Norway.

Prevalence of self-reported stomach symptoms after consuming milk among indigenous Sami and non-Sami in Northern- and Mid-Norway - the SAMINOR study.

OBJECTIVE: The main purpose of this work was to identify the prevalence of self-reported stomach symptoms after consuming milk among Sami and non-Sami adults. STUDY DESIGN: A cross-sectional population-based study (the SAMINOR study). Data were collected by self-administrated questionnaires. METHOD: SAMINOR is a population-based study of health and living conditions conducted in 24 municipalities in Northern Norway during 2003 and 2004. The present study included 15,546 individuals aged between 36 and 79, whose ethnicity was categorized as Sami (33.4%), Kven (7.3%) and Norwegian majority population (57.2%). RESULTS: Sami respondents had a higher prevalence of self-reported stomach symptoms after consuming milk than the Norwegian majority population. The reporting was highest among Sami females (27.1%). Consumption of milk and dairy products (yoghurt and cheese) was high among all the ethnic groups. However, significantly more Sami than non-Sami never (or rarely) consume milk or cheese, and individuals who reported stomach symptoms after consuming milk had an significant lower intake of dairy products than those not reporting stomach symptoms after consuming dairy products. Sami reported general abdominal pain more often than the majority population. The adjusted models show a significant effect of Sami ethnicity in both men and women on self-reported stomach symptoms after consuming milk. In females, the odds ratio (OR)=1.77 (p=0.001) and in males OR=1.64 (p=0.001). CONCLUSION: Our study shows that the Sami population reported more stomach symptoms after consuming milk, suggesting a higher prevalence of milk intolerance among the Sami population than the Norwegian majority population.

A population-based study on health and living conditions in areas with mixed Sami and Norwegian settlements - the SAMINOR 2 questionnaire study.

OBJECTIVES: To describe the method, data collection procedure and participation in The Population-based Study on Health and Living Conditions in Areas with both Sami and Norwegian Settlements - the SAMINOR 2 questionnaire study. STUDY DESIGN: Cross-sectional and semi-longitudinal. METHODS: In 2012, all inhabitants aged 18-69 and living in selected municipalities with both Sami and Norwegian settlements in Mid and Northern Norway were posted an invitation to participate in a questionnaire survey covering several topics related to health and living conditions. The geographical area was similar to the area where the SAMINOR 1 study was conducted in 2003/2004 with the exception of one additional municipality. Participants could alternatively use a web-based questionnaire with identical question and answer categories as the posted paper version. RESULTS: In total, 11,600 (27%) participated (16% used the web-based questionnaire), with a higher participation rate among those over 50 (37% for women and 32% for men). Some geographical variation in participation rates was found. In addition, for those invited who also participated in the SAMINOR 1 study, we found that the participation rates increased with the level of education and income, while there was little difference in participation rates across ethnic groups. CONCLUSION: The knowledge generated from future theme-specific research utilizing the SAMINOR 2 database has the potential to benefit the general population in this geographical area of Norway, and the Sami people in particular, by providing knowledge-based insight into the health and living conditions of the multi-ethnic population in these parts of Norway.

Marginalisation and cardiovascular disease among rural Sami in Northern Norway: a population-based cross-sectional study.

BACKGROUND: Like other indigenous peoples, the Sami have been exposed to the huge pressures of colonisation, rapid modernisation and subsequent marginalisation. Previous studies among indigenous peoples show that colonialism, rapid modernisation and marginalisation is accompanied by increased stress, an unhealthy cardiovascular risk factor profile and disease burden. Updated data on the general burden of cardiovascular disease among the Sami is lacking. The primary objective of this study was to assess the relationship between marginalisation and self-reported lifetime cardiovascular disease (CVD) by minority/majority status in the rural Sami population of Norway. METHODS: A cross-sectional population-based study (the SAMINOR study) was carried out in 2003-2004. The overall participation rate was 60.9% and a total of 4027 Sami individuals aged 36-79 years were included in the analyses. Data was collected by self-administrated questionnaires and a clinical examination. RESULTS: The logistic regression showed that marginalised Sami living in Norwegian dominated areas were more than twice as likely to report CVD as non-marginalised Sami living in Sami majority areas (OR 2.10, 95% CI: 1.40-3.14). No sex difference was found in the effects of marginalisation on self-reported life-time cardiovascular disease. Moderate to no intermediate effects were seen after including established CVD risk factors. CONCLUSIONS: This study showed that marginalised Sami living in Norwegian dominated areas were more than twice as likely as non-marginalised Sami from Sami majority areas to report lifetime cardiovascular disease (CVD). Moderate to no intermediate effects were seen after including established CVD risk factors, which suggest little difference in lifestyle related factors. Chronic stress exposure following marginalisation may however be a plausible explanation for some of the observed excess of CVD.

Acculturation and self-rated health among Arctic indigenous peoples: a population-based cross-sectional study.

BACKGROUND: Acculturation is for indigenous peoples related to the process of colonisation over centuries as well as the on-going social transition experienced in the Arctic today. Changing living conditions and lifestyle affect health in numerous ways in Arctic indigenous populations. Self-rated health (SRH) is a relevant variable in primary health care and in general public health assessments and monitoring. Exploring the relationship between acculturation and SRH in indigenous populations having experienced great societal and cultural change is thus of great importance. METHODS: The principal method in the Survey of Living Conditions in the Arctic (SLiCA) was standardised face-to-face interviews using a questionnaire. Very high overall participation rates of 83% were obtained in Greenland and Alaska, whilst a more conventional rate of 57% was achieved in Norway. Acculturation was conceptualised as certain traditional subsistence activities being of lesser importance for people's ethnic identity, and poorer spoken indigenous language ability (SILA). Acculturation was included in six separate gender- and country-specific ordinal logistic regressions to assess qualitative effects on SRH. RESULTS: Multivariable analyses showed that acculturation significantly predicted poorer SRH in Greenland. 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 generated an OR of 1.59 in men (p=0.03). In Alaska, no evidence of acculturation effects was detected among Iñupiaq men. Among Iñupiaq women, an increased subsistence score represented an increased odds of 73% (p=0.026) for reporting poorer SRH. No significant effects of acculturation on SRH were detected in Norway. CONCLUSIONS: This study shows that aggregate acculturation is a strong risk factor for poorer SRH among the Kalaallit of Greenland and female Iñupiat of Alaska, but our cross-sectional study design does not allow any conclusion with regard to causality. Limitations with regard to wording, categorisations, assumed cultural differences in the conceptualisation of SRH, and confounding effects of health care use, SES and discrimination, make it difficult to appropriately assess how strong this effect is though.

Ethnic discrimination and psychological distress: a study of Sami and non-Sami populations in Norway.

The prevalence of psychological distress and its association with ethnic discrimination was examined among 13,703 participants (36 to 79 years of age) in a population-based study of health and living conditions in areas with indigenous Sami, Kven (descendants of Finnish immigrants), and Ethnic Norwegian populations (the SAMINOR study). Sami and Kven males reported greater levels of stress than Ethnic Norwegians. Ethnic discrimination was strongly associated with elevated levels of psychological distress. Results suggest that ethnic discrimination is a major potential risk factor for poor mental health, and may contribute to ethnicity-related differences in mental health between Sami and non-Sami populations.

Ethnicity, self-reported health, discrimination and socio-economic status: a study of Sami and non-Sami Norwegian populations.

OBJECTIVES: Investigate the association between ethnicity, social factors and self-reported health conditions of Sami and non-Sami Norwegian populations. STUDY DESIGN: Cross-sectional questionnaire. METHODS: SAMINOR is a population-based study of health and living conditions that was conducted in 24 municipalities in northern Norway during 2003 and 2004. The present study included 12,265 individuals aged between 36 and 79, whose ethnicity was categorized as Sami (33.1%), Kven (7.8%) and Norwegian majority population (59.1%). RESULTS: Sami respondents reported inferior health conditions in comparison to the Norwegian majority population. The most unsatisfactory conditions were reported by Sami females living outside the defined Sami area (with greater integration and assimilation) (p<0.05). Females typically reported less favourable health conditions than did males. Health inequalities varied by age and were more apparent in persons aged in their mid-50s or above. Across ethnic groups, respondents with the highest education and household income were healthier than others. Furthermore, those reporting to have been frequently discriminated against were more likely to report poorer health than those who did not; the odds ratios (95% CI) was found to be 2.88 (1.92-4.32) for women and 1.61 (1.08-2.42) for men. When discrimination was included in the logistical model, the increased risk of poor self-reported health decreased to non-significance for Sami respondents. The estimated risk decreased further when the socio-economic status was taken into account. CONCLUSIONS: The findings of this study suggest that self-reported ethnic discrimination combined with low socio-economic status contributes to inequalities in self-reported health when Sami and Norwegian majority population are compared.

Ethnic discrimination and bullying in the Sami and non-Sami populations in Norway: the SAMINOR study.

OBJECTIVES: To investigate the prevalence of self-reported experiences of ethnic discrimination and bullying among Sami and non-Sami adults. STUDY DESIGN: Cross-sectional, questionnaire-based survey. METHODS: SAMINOR is a population-based study of health and living conditions that was administered in 2003-2004 in 24 different Norwegian and Sami populated municipalities within central and northern Norway. This analysis was based on 12,265 men and women aged 36-79 years. Ethnic distribution was Sami (33.1%), Kvens (7.8%) and the ethnic Norwegian majority (59.1%). RESULTS: Overall, Sami and Kven respondents reported more ethnic discrimination and bullying in general than ethnic Norwegians (p < 0.001). The reporting was highest among the younger participants (p < 0.001). Men reported more ethnic discrimination than women, while women reported more bullying. Respondents with the strongest Sami affiliation reported higher levels of ethnic discrimination outside the Sami Language Act's district, while respondents with weak Sami affiliation, Kvens and ethnic Norwegians, reported higher levels inside this district. Among the respondents that reported bullying previously, the most common type was discriminating remarks and the most common location was public schools. For those who reported bullying in the past year, the most common types were gossiping and discriminating remarks, and the most common locations were at work and in the local community. Two out of three of those reporting ethnic discrimination, independent of ethnicity, also reported bullying. CONCLUSIONS: The findings from this study show that the Sami and Kven population more often experience bullying and ethnic discrimination than ethnic Norwegians. These results are consistent with experiences from other minority and marginalized groups that experienced colonization. More research is needed to understand the role bullying and ethnic discrimination play in the wellbeing and health of the Sami and Kven population.

Population based study of health and living conditions in areas with both Sámi and Norwegian populations--the SAMINOR study.

OBJECTIVES: The overall aim of the SAMINOR project was to study health and diseases in relation to living conditions among the Sámi population and to compare these with the Norwegian population in the same area. This article provides an overview of the background of the study and a description of the methods employed for the data collection. We give sample characteristics and elaborate on different definitions of ethnicity. STUDY DESIGN: Cross-sectional, population-based study, including questionnaires, a clinical examination and analyses of blood samples. METHODS: All individuals 30 or 36 to 79 years of age who were living in defined municipalities or specified local areas with a known Sámi population were invited to a cardiovascular screening program. The data were collected during 2003-2004. The questionnaires focused on living conditions, health, Sámi traditions and ethnicity. The eligible population consisted of 27,987 individuals and 16,865 (60.6%) participated by answering at least one questionnaire. Analyses were restricted to the 36 to 79 year-old age group which had 16,538 participants. The screening program comprised a blood sample, measurements of blood pressure, height, weight, and waist and hip ratio. Different definitions of Sámi ethnicity were explored. RESULTS: Of the sample, 35.6% reported Sámi background, and 13.2% reported that they, their parents and their grandparents had Sámi as their domestic language. This stringent definition of Sámi produced clearer differences between Sámi and Norwegians, as shown for some measures of socioeconomic status. CONCLUSIONS: The findings that are related to more strict definitions of Sámi ethnicity have important implications for the interpretation of earlier works and for future studies.