Journal of Cross-Cultural Psychology42(5) 699 –724© The Au.docx

Journal of Cross-Cultural Psychology
42(5) 699 –724
© The Author(s) 2011
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DOI: 10.1177/0022022110362750
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Articles
Pacific Islands Families
Study: The Association
of Infant Health Risk
Indicators and Acculturation
of Pacific Island Mothers
Living in New Zealand
Jim Borrows1, Maynard Williams1, Philip Schluter2,
Janis Paterson3, and S. Langitoto Helu4
Abstract
The Pacific Islands Families study follows a cohort of 1,398
Pacific infants born in Auckland,
New Zealand. This article examines associations between
maternal acculturation, measured by
an abbreviated version of the General Ethnicity Questionnaire,
and selected infant and maternal
health risk indicators. Findings reveal that those with strong
alignment to Pacific culture had
significantly better infant and maternal risk factor outcomes
than those with weak cultural

alignment. In terms of Berry’s classical acculturation model,
separators had the best infant and
maternal outcomes; integrators had reasonable infant and
maternal outcomes, while assimilators
and marginalisors appeared to have the poorest infant and
maternal outcomes. These findings
suggest that retaining strong cultural links for Pacific
immigrants is likely to have positive health
benefits.
Keywords
acculturation, infant health risk, Pacific health, culture and
health
Introduction and Background
People of Pacific ethnicities resident in New Zealand are
overrepresented in many adverse social
and health statistics. Pacific peoples generally fare worse than
the New Zealand population as a
whole in statistics relating to health, unemployment, housing,
crime, income, education, and nutri-
tion (Bathgate, Donnell, & Mitikulena, 1994; Cook, Didham, &
Khawaja, 1999). Despite the
1Faculty of Health and Environmental Sciences, AUT
University, Auckland, New Zealand
2School of Public Health and Psychosocial Studies, AUT
University, Auckland, New Zealand, and the University of
Queensland, School of Nursing and Midwifery, Australia
3School of Public Health and Psychosocial Studies, AUT
University, Auckland, New Zealand
4School of Population Health, Faculty of Medical and Health
Sciences, University of Auckland, New Zealand

Corresponding Author:
Jim Borrows, C/-Professor Philip Schluter, School of Public
Health and Psychosocial Studies, AUT University,
Private Bag 92006, Auckland, New Zealand.
Email: [email protected]
at Apollo Group - UOP on March 31,
2015jcc.sagepub.comDownloaded from
http://jcc.sagepub.com/
700 Journal of Cross-Cultural Psychology 42(5)
growth and employment opportunities in New Zealand, Pacific
people are more likely to be
living in poor circumstances with restricted access to higher
education, home ownership, and
access to functional amenities such as automobiles and
telephones. Such statistics have signifi-
cant consequences for Pacific families given that socioeconomic
disadvantage has been consistently
linked with negative health outcomes (Chen, 2004; Power,
2002).
Specifically, the raison d’etre for the Pacific Island Families
(PIF) Study, the health of Pacific
families, and especially their infants continues to be an issue of
major concern for New Zealanders.
The total neonatal death rate for Pacific infants at 4.7 per 1,000
live births is twice that of the rate
for New Zealanders of European ancestry but still less than the
5.0 of the indigenous Maori popu-
lation (New Zealand Health Information Service, 2006).
Similarly, Pacific infants have high
rates of hospitalization, particularly for respiratory illnesses
(Ministry of Health & Ministry of

Pacific Island Affairs, 2004), and present at hospital with
higher severity of illness than other
New Zealand children (Grant et al., 2001).
These negative infant statistics are somewhat perplexing,
especially in a country where pri-
mary health care services are available at low cost (free for pre-
schoolers) and emergency and
hospital care services, including birthing services, are provided
free of charge. Also, New Zealand
(Abel, Park, Tipene-Leach, Finau, & Lennan, 2001) and Pacific
ethnographies (Lukere & Jolly,
2002) show that neonatal and infant care practices are not
directly contradictory to accepted
Western infant care practices. In Pacific Island settings,
themselves changed by 200 years of
Western contact, the family is perceived as central in providing
traditional protocols for support
and advice to ensure infant well-being.
Explanation for the current Pacific child health circumstances is
likely driven by multiple
variables including the immigration process itself. Previous
research from the PIF study demon-
strated that acculturative orientation had a persistent association
with aspects of health status
and behaviour for cohort participants (e.g., Abbott & Williams,
2006; Low et al., 2005; Paterson,
Feehan, Butler, Williams, & Cowley-Malcolm, 2007), hence the
emphasis in this article on test-
ing the association between maternal acculturation and infant
and maternal health risk factors.
Culture, Health, and Acculturation
The interrelationship between culture and health, including
associated psychological processes,

has been a recurrent theme in the social science literature over
much of the last century (Helman,
2000; Sam, 2006a; Stroebe & Stroebe, 1995; U.S. Department
of Health and Human Services, 2001).
There is now acceptance in the medical and health professional
domains that culture should be
acknowledged as an important determinant of health status
(Corin, 1994; Snowden, 2005; Spector,
2002; U.S. Department of Health and Human Services, 2001)
and that concepts derived from
anthropologic and cross-cultural research may provide an
alternative framework for identifying
health issues that require resolution (Kleinman, Eisenberg, &
Good, 1978; Savage, 2000). In
particular, there is some agreement that many people from
minority cultures may not have faith
in, or necessarily benefit from, the medical interventions that
are being offered by the host soci-
ety (MacLachlan, 1997).
Also recognized is the importance of the interrelationship
between migration and health,
including seminal New Zealand/Pacific migration studies
(Stanhope & Prior, 1976), early inter-
national studies (Carballo, Divino, & Zeric, 1998; Ostbye,
Welby, Prior, Salmond, & Stokes,
1989), and more recent studies aimed at explaining the link
between migration and health (Sam,
2006a). That is, the realization that the well-being of a migrant
group is determined by interlink-
ing factors that relate to the society of origin, the migration
itself, and the society of resettlement.
All three sets of factors need to be considered if one seeks to
reduce or merely to understand the
level of health disorder in any immigrant group. Despite the
recognition of the importance of

Borrows et al. 701
culture and migration in determining health status and the
explanatory acculturation/health hypoth-
eses that this has generated (Carballo et al., 1998; Sam, 2006a),
there have been few empirical
attempts to link health with both migration and culture in
relation to other demographic, social,
and psychological factors operating in given communities in
New Zealand or international stud-
ies (Snowden, 2005). However, it is now clear that migration at
an individual level is a significant
life event for individuals impacting on subsequent health
behaviour and outcomes.
Closely related to culture and migration is the concept of
acculturation—that is, “culture change
that is initiated by the conjunction of two or more autonomous
culture systems” (Social Science
Research Council, 1954, as cited in Berry, Poortinga, Segall, &
Dasen, 2002, p. 350). The social
psychology literature is replete with alternative models of the
acculturative process, most of which
are multidimensional, involving numerous topics and factors
(Stanley, 2003). These multidimen-
sional topics range from those at the personal level, such as
personality qualities and psychological
adjustment (Ward & Leon, 2004), language retention and
community socialization, and external

acculturation drivers such as migration experience, micro- and
macro-societal policies, and
regional setting (Persky & Birman, 2005). Outside of these
models, but still incorporating multi-
dimensionality, are the two most common models of
acculturation theory: unidirectional and
bidirectional models of acculturation. Berry restated Redfield
and colleagues’ hypothesis that
acculturative adaptations lead to culture changes in either or
both of the migrating and host soci-
ety groups. He went on further to note that it is not inevitable
that intergroup contact proceeds
uniformly through sequential to ultimate assimilation as there
are many other ways of going
about it or indeed is potentially bidirectional and reciprocal
(Berry, 2006). Such insights gener-
ated by this bidirectional model challenges the ethnic melting-
pot assumptions and promotes
exploration and resolution of political sensitivities among
ethnicities (Flannery, Reise, & Jiajuan,
2001). These observations by Berry, Sam, and others, which
hint at multiple individual and group
acculturation strategies, have been complemented more recently
by Boski, who calls for the
development of a theoretical model of integration, a key
concept in the psychology of accultura-
tion, in which five meanings for this concept identified in the
existing literature are positioned as
in-depth directed layers of the bicultural psyche (Boski, 2008).
That is, the subtleties in the accul-
turation process at the group and individual level deserve
further and more detailed examination.
There are many studies that have examined acculturation
strategies in nondominant groups.
In most studies, preference for integration is expressed over

other acculturation strategies, although
notable exceptions with Turks both in Germany and in Canada,
and in Hispanic immigrant women
in the United States, have been cited (Ataca & Berry, 2002;
Berry, 2006; Jones, Bond, Gardner, &
Hernandez, 2002).
All these recent contributions that counter the assimilation and
melting-pot models could
be seen as underpinning Pacific community perspectives on
cultural maintenance within
New Zealand society. In New Zealand, there is widespread
official government dogma and minor-
ity community perception that cultural maintenance is important
to health outcomes and that
culturally specific information for minority groups on which to
base optimal policy and services
is necessary. The untested assumption is that such an approach
will lead to improved health and
social outcomes for Pacific peoples. An alternative “popular
hypothesis” in New Zealand would
more likely support international perspectives and studies cited
above that would expect more
positive health outcomes for those effectively embedded in
mainstream culture than for those
embedded in Pacific culture or those marginalized from both
cultures. This dominant cultural
and official “cultural maintenance” viewpoint is politically
persuasive in New Zealand and as a
result became the focus of refutation or support in terms of our
working hypothesis outlined as
the second aim for this study presented below.
Based on all these considerations, we applied Berry’s
acculturation model to the relationships
between acculturation and health, in this case operationalised as

poor outcomes for maternal and
infant health risk factors. Thus, in the context of understanding
the process and outcomes of
acculturation strategies adopted by Pacific families, this study
had two principal aims: namely,
to (a) investigate the association between mother and infant
health variables that might act as
infant risk indicators and adaptation to living in New Zealand
and (b) test the New Zealand view
that strong cultural alignment to the original Pacific culture is
associated with significantly better
outcomes in terms of maternal and infant health risk factors and
that weak cultural alignment is
associated with significantly poorer outcomes in terms of
maternal and infant health risk factors.
For reasons outlined in the Method section, an abbreviated
version of the General Ethnicity Ques-
tionnaire (GEQ; Tsai, Ying, & Lee, 2000) acculturation
measurement instrument was employed.
As a result, a secondary aim was to establish the validity and
reliability of the modified instrument.
Migration and Pacific People in Contemporary New Zealand
Society
To give a context to this study, it is necessary to describe the
place played in New Zealand’s
migration history by people of the Pacific Islands (as distinct

from indigenous Maori descent)
and their place in contemporary society. Polynesian settlement
of the Pacific was completed
around 1200-1300 AD when Te Ika o Maui (the mythical fish of
Maui), the North Island of
New Zealand, was the last Pacific archipelago to be discovered
and settled by the ancient Poly-
nesians (Prickett, 2001). These Polynesian ancestors became the
New Zealand indigenous Maori.
Major European settlement, and subsequent colonization,
commenced from the late 18th cen-
tury. Polynesian post-Maori contacts in the 18th and 19th
centuries were limited, and at the 1945
New Zealand Census of Population and Dwellings, only about
2,000 people were recorded as
being of Pacific origin.
A second great wave of Polynesian migration took place in the
relatively short period between
the 1950s and 1980s, when Pacific peoples arrived from the
islands of Samoa, Tonga, Cook Islands,
Niue, Fiji, and the Tokelaus. This modern Polynesian migration
was based principally on oppor-
tunity provided by largely economic imperatives in New
Zealand (Macpherson, Spoonley, & Anae,
2001) or economic sustainability of small island groups such as
the Tokelaus (Prior, Welby,
Ostbye, Salmond, & Stokes, 1987; Salmond, Joseph, Prior,
Stanley, & Wessen, 1985), supplemented
more recently by matters relating to renewing or continuing
links of kinship and family.
Currently, Pacific peoples are a very significant and growing
proportion of New Zealand’s
population. More than 6% (231,801 people) in New Zealand
were of Pacific ethnicity at the time

of the 2001 Census (Statistics New Zealand—Te Tari Tatau,
2002a), and Pacific people are pro-
jected to make up more than 8% of the population by 2021
(Statistics New Zealand—Te Tari
Tatau, 2005). The biggest concentration of Pacific people is in
Auckland, New Zealand’s largest
metropolitan area. Sixty percent of people of Pacific ethnicity
were born in New Zealand; of
those born overseas, 40% had arrived in New Zealand by 1981
and 30% between 1981 and 1990
(Statistics New Zealand—Te Tari Tatau, 2002a). This latest
migration of Pacific people influ-
ences the nature of both New Zealand and the home island
societies. For example, in the islands,
it is significant in terms of reducing the overall population and
in providing economic support to
home communities by way of individual and family remittances
to relatives. Table 1 illustrates
the large proportion of Pacific people residing in New Zealand
in relation to their respective home
island populations.
Since the migration wave of the late 20th century, Pacific
people have actively participated in
the New Zealand economy and society. In economic terms,
Pacific people have relatively high
labour force participation rates, particularly in the
manufacturing sector. This sector has declined
since the mid-1980s as a proportion of total employment but has
been offset with Pacific people
employment participation in the growing consumer service
industries (such as hotels, restaurants,
and retail) and the employment of younger people in more
skilled technical and professional

Borrows et al. 703
occupations (Statistics New Zealand—Te Tari Tatau, 2002b).
However, people of Pacific eth-
nicities remain underrepresented in managerial and professional
occupations yet overrepresented
in trades and elementary occupations. Overall current labour
force participation rates for people
of Pacific ethnicities are at 62.9%, lower than the national rate
of 68.5%, and unemployment
rates are at 6.9%, higher than the national rate of 3.7%
(Department of Labour—Te Tari Mahi,
2007). Maori rates for 2007 in labour force participation and
unemployment are 67.6% and 7.6%,
respectively. In terms of demography, Pacific people living in
New Zealand have a relatively
young age structure and a high fertility rate. While people of
Pacific ethnicities currently have a
lower life expectancy than the total population, it is higher than
that for the indigenous Maori
population (Cook et al., 1999). The Pacific population is
proportionately more likely than the
national population to be in the lower income bands, even after
age standardization. Employment
and income aside, the degree to which people of Pacific
ethnicity participate in New Zealand
society, and are hence not marginalized in ethnic group terms,
is illustrated in Figure 1, with the
number of births resulting from interethnic marriage between
three of the major four ethnic
groups in New Zealand. Interethnic marriage between the

Pacific and Asian ethnic groups is not
as common.
Geographically, Pacific peoples are principally resident in
major urban areas. Eighty-one per-
cent of peoples of Pacific ethnicities reside in the major urban
areas, including the Auckland
Region (66.0%), Wellington (12.4%), Christchurch (3.6%), and
Hamilton (1.9%). No other
New Zealand city, town, or district had more than 4,000
residents of Pacific ethnicity (Statistics
New Zealand—Te Tari Tatau, 2006a). Choice of residential
locations was driven by migration
history and economic imperatives mainly to low socioeconomic
status neighbourhoods that have
persisted along with maintenance of kinship and family ties
often irrespective of changes in
standard of living. There was no formal overt or covert official
state or local determination for
spatial distribution or segregation—unlike that experienced in
some migration histories elsewhere
(Musterd, Breebaart, & Ostendorf, 1998). Consequently, the
New Zealand location of Pacific
families remains concentrated in relatively deprived mixed-
ethnicity urban areas, with the major
concentrations in the sprawling central, western, and southern
suburbs of greater metropolitan
Auckland and in Wellington. At the 2006 New Zealand Census,
14% of the Auckland region’s
population was of Pacific descent, compared with European
(55%), Asian (18%), and Maori (11%).
In terms of the PIF study at recruitment, all participants in the
study were resident in the catch-
ment area for Middlemore Hospital, the principal birthing
hospital for the Counties Manukau

District Health Board (CMDHB). This catchment area is located
predominantly in Manukau City,
South Auckland. In 2005, just under half the CMDHB
population was made up of European and
other ethnicities (48%), with significant minorities being
Pacific (20%), Maori (17%), and Asian
(15%). More than a third (36%) of all Pacific people in New
Zealand live in CMDHB (2008).
Table 1. Pacific People in New Zealand (New Zealand 2001
Census) and Pacific Islands of Origin
(South Pacific Commission 2001 Estimate)
New Zealand Island of Origin PIF Cohort
Pacific Population Population Population
N % N N %
Samoan 115,017 48.6 170,900 647 52.9
Tongan 40,716 17.2 99,400 287 23.5
Cook Island Maori 52,569 22.2 19,300 229 18.7
Niuea n 20,148 8.5 5,400 59 4.8
The CMDHB area comprises a highly diversified community in
a country (New Zealand) that
by international standards ranks as a moderate to highly
diversified society, ranking equivalent to
the United States, ahead of Australia, and behind only Canada

and Israel. The authors of a recent
international study on immigrant youth claim that the “diversity
index” portrays the degree of
cultural pluralism present in society and reflects the potential
for interethnic and interlinguistic
contacts that people experience in a given society (Berry et al.,
2006). Pacific peoples live in a
positively oriented multicultural society with ample exposure to
other cultures, including the
majority culture, both in work and play, with a significant
degree of intermarriage with people of
European and indigenous Maori ancestry (Figure 1). Compared
with some migrant communities
elsewhere and some rural indigenous communities in New
Zealand (Maori) and Australia
(Australian Aborigines), people of Pacific ethnicities who
arrived in New Zealand as late
20th-century migrants have had relatively high involvement in
the New Zealand labour force,
have located in multi-ethnic urban (if poorer) areas, and have
significant social, sporting, and
cultural links with the wider New Zealand society. They provide
another cultural dimension
alongside indigenous urban Maori, Pakeha (New Zealanders of
European ancestry), and people
of Asian ethnicities in a rapidly evolving but largely empathetic
society that has a moderately
positive attitude toward the principles of multiculturalism and
integration as preferred accultura-
tion strategies (Sang & Ward, 2006).
Method
Participants
Data were gathered as part of the PIF study, a longitudinal
investigation of a cohort of 1,398

infants (22 pairs of twins) born at Middlemore Hospital,
CMDHB, South Auckland, New Zealand
during the year 2000. Middlemore Hospital was chosen as the
recruitment site as it has the largest
Figure 1. Pacific Children’s Live Births 2003: Distribution by
Ethnicity (Data From Statistics
New Zealand—Te Tari Tatau, 2004)
Borrows et al. 705
number of Pacific births in New Zealand and is representative
of the major Pacific ethnic groups
(Samoan, Cook Island Maori, and Tongan). It was estimated that
a cohort of 1,000 would provide
sufficient statistical power to detect moderate to large
differences after stratification for major
Pacific ethnic groups and other key variables. Eligibility
criteria included having at least one parent
who self-identified as being of Pacific ethnicity and a New
Zealand permanent resident. Thus,
non-Pacific mothers (including indigenous Maori) were eligible
for the study in cases where the
infant’s father was of Pacific descent. Detailed information
about the cohort and procedures is
described elsewhere (Paterson et al., 2006; Paterson et al.,
2008). All procedures and interview
protocols for the PIF study were granted ethical approval from
the National Ethics Committee.

PIF Study Instrument
A wide range of demographic, social, psychological, and health
information was gathered in
relation to the newborn infant and his or her parents at 6 weeks
postpartum using individual inter-
views of mothers conducted in their homes. Items elicited
details relating to household structure,
education and employment, ethnic and cultural identification,
length of residency in New Zealand,
language use and fluency, child health and development, infant
nutrition, infant sleeping, use of
health services (such as family planning and pregnancy),
childcare arrangements, parent child-
hood experiences, parental health and mental health, partner
relationships, family finances, housing,
transport, and church and leisure activities. In all, information
on 941 variables of interest was
gathered in the home interview, which lasted approximately 1.5
hours.
Acculturation Measure
Despite the importance of acculturation and its relevance for
policy makers in plural societies,
assessment of this concept remains problematic and no widely
accepted measurement methods
are available (Arends-Toth & van de Vijver, 2006). The
acculturation measure chosen for the
PIF study was an adaptation of the GEQ (Tsai et al., 2000). This
scale included elements consis-
tent with the current status of theory on the psychological
responses to acculturation (Arends-Toth &
van de Vijver, 2006; Berry, 2006; Cabassa, 2003). Moreover,
the GEQ embodies elements of
individual perceptions of characteristics of the island societies
of origin and the New Zealand
receiving society, it measured adoption and maintenance

strategies from a bidimensional perspec-
tive, and it has been widely applied internationally. Although
questioned more recently (Kang, 2006),
a bidimensional scale was chosen because:
Linear assimilation models continue to dominate public health
research despite the avail-
ability of more complex acculturation theories that propose
multidimensional frameworks,
reciprocal interactions between the individual and the
environment, and other accultura-
tive processes and . . . the rare use of multidimensional
acculturation measures and models
has inhibited a more comprehensive understanding of the
association between specific
components of acculturation and particular health outcomes.
(Abraído-Lanza, Armbrister,
Flórez, & Aguirre, 2006, p. 1)
With a demanding and lengthy study questionnaire, scales had
to be abbreviated and adapted
so that we would not lose participants in future measurement
waves. To suit the specific purposes
of the PIF study, the scale of Tsai et al. (2000) was further
abbreviated and adapted, thereby
developing the New Zealand (NZACCULT) and Pacific
(PIACCULT) versions of the GEQ
(Appendix). The original 38-item GEQ scale was reduced to 11
items on a pragmatic minimalist
basis but included key items reflecting five of the six specific
cultural dimensions identified by

Tsai et al. (2000) and reflected the two fundamental issues of
interest: (a) maintaining one’s heritage,
culture, and identity and (b) relative preference for having
contact with, and participating in,
the larger society (Berry, 2006). Also important in selecting
items was a concentration on items
that were likely to apply to the complete respondent population
(Van Nieuwenhuizen, Schene,
Koeter, & Huxley, 2001). Included were questions relating to
the specific cultural dimensions
of language, social affiliation, activities, exposure in daily
living, and food. The sixth dimension,
pride in culture, was excluded as it was considered that this
aspect was better accommodated
by other questions in the measure that reflected and
accommodated some aspects of this dimension.
Some specific items were excluded because they bore little
relevance to Pacific life in New Zealand,
for example listening to radio in a Pacific language, as such
services were not widely available
at that time. We thus excluded items that seemed from
knowledge of mainstream New Zealand
culture and New Zealand Pacific culture as having less
relevance (face validity) than for the
American/Chinese population for which the GEQ scale was
originally designed.
The scale was further adapted to include a small number of
items considered of particular
cultural relevance in New Zealand. Two questions relating to
social affiliation but not included
as such in the original GEQ scale were exploring issues relating

to contact with Pacific family
and relatives and attendance at church, both of which were
considered important in a Pacific con-
text in New Zealand society. Similarly, inclusion of sport as a
particular recreation was included
because of the perceived importance of Pacific youth
involvement in New Zealand sport and its
importance in the context of the wider New Zealand society.
The PIF study research group believed that measurement of
acculturation as used in cross-
cultural psychology, but distinct from qualitative
anthropologically and socially oriented cul tural
descriptions, was an important and relevant concept in the
context of the longitudinal study on
which we were embarking. This was an additional consideration
in adapting an existing validated
measure that included relevant domains and against which we
had an existing reference stan-
dard to compare. Because of project constraints, it was not
possible to pilot the measure we
developed against the longer version of the GEQ—hence the
inclusion in this article of the
retrospective reliability and validity comparisons. The measure
was developed to make it
appropriate and relevant to Pacific peoples and New Zealand
society as a whole and so as to
provide reasonable approximations of the acculturation process
for this population. Clear face
validity for this combined scale was revealed by both the pre-
study participant focus groups and
the advice received from the study’s Pacific Advisory Board—
this advice being integral to all
substantive decisions on study content. Subsequent results from
other PIF research (Abbott &
Williams, 2006; Low et al., 2005; Paterson et al., 2007)

demonstrated that the acculturation
variable measured from these scales was a persistently strong
associate for a range of health and
social indicators.
Assessment of Acculturation
This was undertaken using the classical adaptation and
acculturation strategies model des-
cribed by Berry (1980, 2003, 2006). The model describes four
distinct dimensions, with two
parts to each dimension depending on whether the acculturation
strategy is freely adopted by
the individual or minority group or imposed by the dominant
culture. The strategies are as
follows: (a) Separation (minority group or individual choice) or
segregation (dominant society
preference or force), (b) integration (minority group or
individual choice) or multiculturalism/
pluralism (dominant society preference or force), (c)
assimilation (minority group or indi-
vidual choice) or melting pot/pressure cooker (dominant society
preference or force), and
(d) marginalization/deculturation (minority group or individual
choice) or exclusion/ethnocide
(dominant society preference or force).
Borrows et al. 707
Selection of Maternal and Infant Risk Factors

To assess the association of acculturation and maternal and
infant risk factors likely to result in
poor infant health outcomes, a variety of relevant maternal and
infant variables that may provide
insights into such links were extracted from the extensive PIF
variable dictionary. The risk fac-
tors chosen and included for analyses were (a) maternal factors
considered to place the baby at
higher risk—namely, unplanned pregnancy, single mother
without partner, mother perpetrator of
severe interpartner violence, and mother clinically depressed
(Edinburgh Post-natal Depression
Score > 12), and (b) direct infant health risk factors likely to
result in poor long-term outcomes—
namely, small for gestational age, exposed to maternal smoking
in utero, exposed to alcohol in
utero, attended/admitted to hospital, not immunized at 6 weeks,
and not exclusively breastfed.
All factors were chosen taking into account known maternal and
infant risk factors for avoidable
morbidity and mortality (Ministry of Health & Ministry of
Pacific Island Affairs, 2004). Some
of the identified risk factors were included because they were
widely considered very important
by stakeholders in terms of Pacific health in New Zealand (e.g.,
single parents without partner
and maternal depression). The factor relating to maternal
perpetration rather than victimization
of severe intimate partner violence was included because an
earlier article from the study had
identified cultural alignment as significantly associated with
maternal perpetration of violence
but not victimization. Some infant health and health-related
variables were excluded, as they were
highly correlated with other variables (e.g., mother currently
smokes as compared to exposed to

maternal smoking in utero). Others were excluded because there
were too few cases. For exam-
ple, the APGAR score at birth was excluded because only 28
cases in the cohort met a clinically
significant low score (< 8 at 5 minutes post-birth), although it
has a demonstrated relationship
with longer term health outcomes, educational achievement, and
social stability (Oreopoulos,
Stabile, & Walld, 2007; Weinberger et al., 2000).
Statistical Analysis
Each of the respondents was individually scored on both the
NZACCULT and PIACCULT scales
and allocated to one of the categorical model classes dependent
on whether their individual score
fell above or below the median of the full group: namely, Low
New Zealand—High Pacific
(Separator), High New Zealand—High Pacific (Integrator), High
New Zealand—Low Pacific
(Assimilator), and Low New Zealand—Low Pacific
(Marginalisor). Subsequent analysis was
carried out in terms of this categorization.
To investigate, (a) aims and (b) all risk factors were
simultaneously associated with the 4-
leveled acculturation variable (taking separators as the
reference category) using a binomial
generalized estimating equation (GEE) model. Because the risk
factors are without natural order
and have different binary distributions, an unstructured
covariance matrix was adopted for the
GEE model. Two separate GEE models were run: (a) an
unadjusted model that consists of main
effects corresponding to the acculturation variable and risk
factors, and their interactions, and
(b) an adjusted model that consists of main effects

corresponding to the acculturation variable
and the risk factors, and their interactions, together with
selected sociodemographic variables:
mother’s age, ethnicity, highest educational qualification, and
household income. Estimated
marginal odds ratio (OR) means associated with the four-
levelled acculturation variable overall
risk factors were calculated and reported to provide a global
measure of the effect of acculturation.
The robust Huber-White sandwich estimator of variance was
used to calculate standard errors
and confidence intervals. GEE statistical analyses were
performed using Stata/IC 10.0 for Win-
dows (Stata Corp, College Station, TX, USA), and a
significance level of α = 0.05 was used to
determine statistical significance for all tests.
The NZACCULT and the PIACCULT were tested for reliability
(internal consistency) using
Cronbach’s α. Following Tsai et al. (2000), we analyzed aspects
of validity in two ways: First,
we measured the correlations between average cultural
orientation (as measured by the scales)
and a recognized standard index of acculturation (length of
residence in New Zealand); second,
the mean scores on each of the modified scale items were
calculated for participants who migrated
to New Zealand—less than 2 years ago, between 3 and 5 years,

between 6 and 10 years, more than
10 years, and in addition those who were born in New Zealand.
In line with Tsai et al. (2000), we predicted that if the
PIACCULT was a valid measure of
cultural orientation, then Pacific people who migrated recently
to New Zealand would report
(a) speaking a Pacific language more, (b) understanding a
Pacific language better, (c) being more
exposed to Pacific culture, (d) being more affiliated to Pacific
peoples, and (e) participating more
in Pacific activities than longer term migrants, who in turn
would report higher Pacific orienta-
tion than those born in New Zealand. Conversely, if the
NZACCULT measure was a valid
measure of orientation to New Zealand culture, New Zealand–
born Pacific people and those who
had been resident in New Zealand for a longer period would
report (a) speaking English more,
(b) understanding English better, (c) being more exposed to
New Zealand culture, (d) being more
affiliated to non-Pacific peoples, and (e) participating more in
New Zealand activities. Connected
line plots of mean scores of the 11 acculturation questions for
NZACCULT and PIACCULT
scales by years resident in New Zealand, together with a
superimposed lowess curve (a nonpara-
metric estimator of the mean function), were used to graphically
demonstrate this relationship.
Analysis of variance was used to statistically test these
suppositions, along with post hoc tests
including Tukey’s honestly significant difference multiple
comparison test and Welch’s robust
test of equality of means.
Results

In total, 1,708 mothers were identified, 1,657 invited to
participate, 1,590 (96%) consented to a
home visit, and of these, 1,477 (93%) were eligible for the PIF
study. Of those eligible, 1,376
(93%) mothers giving birth to 1,398 infants (22 pairs of twins)
of which 680 (49%) were female
participated at the 6-week interview. As non-Pacific mothers
were eligible if the child’s father
was Pacific, some 107 non-Pacific mothers and 1,269 Pacific
mothers participated at the 6-week
interview. Island-specific ethnic distributions in the cohort were
approximately representative of
the ethnic distribution and economic and social characteristics
of the main ethnic Pacific popu-
lation in New Zealand (Table 1). However, they do not reflect
the proportions of populations
from the islands of origin largely because Cook Island Maori,
Niueans, and Tokelauans, unlike
Samoans and Tongans, qualify automatically for New Zealand
citizenship.
Cultural Orientation
In total, 445 (35%) of the sample was categorized as separators,
231 (18%) as integrators, 342
(27%) as assimilators, and 242 (19%) as marginalisors. The
group was subdivided on a median
split-half, and the means, medians, and dispersions of the
PIACCULT and NZACCULT scales
(N = 1,258) were PIACCULT: M = 43.7, SD = 7.32; Median =
45.0; Interquartile range = 11; and
NZACCULT: M = 34.2, SD = 7.78; Median = 35.0; Interquartile
range = 12. Ethnic group dif-
ferences within the overall group in relation to cultural
alignment are outlined in Table 2.
All investigated risk factors were simultaneously associated

with the acculturation variable
using a binomial GEE model. Table 3 includes the percentage of
poor outcomes for each risk
factor and the unadjusted (OR) and associated 95% confidence
intervals (95% CI) for the
acculturation classifications derived from this model. Perusal of
Table 3 reveals considerable
heterogeneity in the estimated ORs between acculturation
classifications over the considered
Borrows et al. 709
risk factors. For example, compared to separators, the ORs
associated with infant exposure to
alcohol during pregnancy was 2.58 for integrators, 14.62 for
assimilators, and 6.98 for marginal-
isors. For infants born small for their gestational age, the
estimated ORs were 0.88 for integrators,
1.47 for assimilators, and 1.68 for marginalisors. In this GEE
model, the main effect variables
corresponding to acculturation and the risk factors were
significant (both p < .001), as was their
interaction (p < .001).
To provide a global measure of the effect of acculturation over
the 10 investigated risk fac-
tors, the estimated marginal OR means associated with the four-
levelled acculturation variable
was calculated and reported in Table 4. In the unadjusted
analysis, integrators, assimilators, and

marginalisors had significantly higher estimated marginal OR
means than separators (all p < .001).
Furthermore, assimilators and marginalisors had significantly
higher estimated marginal OR means
than integrators (p = .004 and .007, respectively), but no
significant difference was observed
between assimilator and marginalisor participants (p = .86).
When the GEE analysis was repeated with the addition of
selected sociodemographic vari-
ables, including mother’s age, ethnicity, highest educational
qualification, and household income,
there remained considerable heterogeneity in the estimated
adjusted OR between acculturation
classifications over the considered risk factors but some
dampening in their effect sizes com-
pared to the unadjusted ORs. This dampening can be seen in
Table 4, which also includes the
estimated marginal adjusted OR means associated with the four-
levelled acculturation variable.
Again, integrators, assimilators, and marginalisors had
significantly higher estimated marginal
adjusted OR means than separators (all p < .001). However,
assimilators and marginalisors had
estimated marginal adjusted OR means that were no longer
significantly higher than integrators
(p = .06 and .23, respectively). As before, there was no
significant difference in estimated mar-
ginal adjusted OR means between assimilators and marginalisor
participants (p = .50). In the
adjusted GEE analysis, there was a significance difference in
estimated risk factor ORs between
ethnic groups (p < .001), with Tongan mothers having an OR of
1.32 (95% CI: 1.15, 1.51), Cook
Island Maori mothers having an OR of 1.50 (95% CI: 1.29,
1.74), Niuean mothers having an OR

of 1.65 (95% CI: 1.32, 2.05), and other Pacific mothers having
an OR of 1.93 (95% CI: 1.48, 2.51)
compared to their Samoan counterparts. However, there was no
significant interaction between
the acculturation classifications and mother’s ethnicity (p =
.40), suggesting that the effect of
acculturation and ethnicity are independent important factors.
Reliability and Validity of the Acculturation Instruments
Cronbach’s α of 0.81 and 0.83 were obtained for the
NZACCULT and the PIACCULT scales,
respectively—values that are acceptable. The length of
residence in New Zealand was significantly
Table 2. Acculturation Classifications by Ethnicity
Acculturation Classifications
Separators Integrators Assimilators Marginalisors
Ethnicity N % N % N % N %
Samoan 304 47.4 151 23.5 125 19.5 62 9.7
Tongan 115 40.8 48 17.0 61 21.6 58 20.6
Cook Island 15 6.6 17 7.4 103 45.0 94 41.0
Niuean 4 6.8 10 16.9 26 44.1 19 32.2
Other 5 10.9 5 10.9 27 58.7 9 19.6
All 443 35.2 231 18.4 342 27.2 242 19.2
710

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Borrows et al. 711
correlated with average scores on the NZACCULT (r = 0.58)
and the PIACCULT (r = –0.45),
both p < .001. That is, the more oriented participants were to
New Zealand culture and the less
oriented they were to Pacific culture was correlated with the
number of years that they had
resided in New Zealand. However, PIACCULT and NZACCULT
scales are not strongly corre-
lated (r = –0.33). Analysis of variance by group supported the
predictions noted previously with
regard to the validity of the NZACCULT and PIACCULT
scales. It revealed significant differ-
ences among the five New Zealand residency groups for 9 of the
11 items on both the NZACCULT
and PIACCULT scales (Table 5). Generally, increasing mean
item values on the NZACCULT
scale were observed with increasing length of New Zealand
residency for migrants, with respon-
dents born in New Zealand exhibiting the highest item scores
(Figure 2a). A converse pattern
(Figure 2b) was observed for the PIACCULT scale. Church
attendance on the NZ scale and

Pacific sports participation on the Pacific scale failed to
discriminate significantly between the
five NZ residency groups. Larger effect sizes were observed for
speaking and understanding
language and being brought up and being familiar with the
relevant language and customs than
friendship and external social activities.
Discussion
The PIF study was designed to research issues of identified
relevance to the New Zealand Pacific
community. Community consultation undertaken to establish
relevant dimensions for the proto-
cols and advice received from our Pacific Advisory Board
reinforced the perspective that
maintenance of original Pacific culture was a relevant and
positive dimension to good health
outcomes in community perceptions.
The Association Between Mother and Infant Health Variables
The first aim of the study was to investigate the association
between mother and infant health
variables that might act as infant risk indicators and adaptation
to living in New Zealand. The
classical acculturation conceptual model (Berry, 1980) was
applied to achieve this aim. On the
basis of accumulated evidence in the literature, it would be
expected that those categorized as
integrators (high NZ, high PI) would have good or very good
health outcomes, separators (high
PI, low NZ) would have good or reasonable outcomes,
assimilators (low PI, high NZ) would
have reasonable outcomes, and marginalisors (low PI, low NZ)
would have poor outcomes.
Table 4. Estimated Marginal OR Means Associated With the

Four-Levelled Acculturation Variable
Over All 10 Risk Factors From Two Separate Binomial
Generalized Estimating Equation (GEE)
Regression Models
Separators Integrators Assimilators Marginalisors
GEE model ORa OR 95% CI OR 95% CI OR 95% CI
(i) Unadjusted 1.00 1.56 1.25, 1.94 2.39 1.98, 2.88 2.33 1.91,
2.83
(ii) Adjusted 1.00 1.53 1.23, 1.91 2.03 1.66, 2.48 1.84 1.50,
2.26
OR = Odds Ratio; CI = Confidence Interval.
(i) An unadjusted model that consists of main effects
corresponding to the acculturation variable and risk factors and
their interactions.
(ii) An adjusted model that consists of main effects
corresponding to the acculturation variable and the risk factors
and their interactions, together with selected sociodemographic
variables: mother’s age, ethnicity, highest educational
qualification, and household income.
a. Reference category.
Brought up NZ way
Familiar with NZ customs

Understanding of English
Have non-Pasifika friends
Friends speak English
Participate in NZ sports
Speak English
Have non-Pasifika contacts
Eat non-Pasifika food
See western-trained doctors
Non-Pasifika church attendees
1
2
3
4
5
M
e
a
n
a
c
c

u
lt
u
ra
ti
o
n
s
c
o
re
s
0-2 years 3-5 years 6-10 years >10 years NZ born
New Zealand residency
A
Table 5. Analysis of Variance Results Comparing Five New
Zealand Residency Groups (0 to 2 Years, 3
to 5 Years, 6 to 10 Years, > 10 Years and New Zealand Born)
on Item Scores of the PIACCULT
and NZACCULT Scales
Item F p Partial Eta-Squared
PIACCULT Scale
I was brought up the Pasifika way 69.8 < 0.001 0.181
I am familiar with Pasifika practices and customs 45.3 < 0.001
0.126

I can understand a Pasifika language well 61.8 < 0.001 0.164
I have several Pasifika friends 3.7 0.005 0.012
Most of my friends speak a Pasifika language 33.3 < 0.001
0.096
I participate in Pasifika sports and recreation 1.1 0.370 0.003
I speak a Pasifika language 120.2 < 0.001 0.276
I have contact with Pasifika families and relatives 8.1 < 0.001
0.025
I eat Pasifika food 17.6 < 0.001 0.053
I visit a traditional Pasifika healer . . . 13.2 < 0.001 0.040
I go to a church mostly attended by Pasifika people 27.1 <
0.001 0.079
NZACCULT Scale
I was brought up the NZ way 135.1 < 0.001 0.300
I am familiar with NZ practices and customs 105.1 < 0.001
0.250
I can understand English well 70.6 < 0.001 0.183
I have several non-Pasifika friends 61.0 < 0.001 0.162
Most of my friends speak English 79.2 < 0.001 0.201
I participate in NZ sports and recreation 27.6 < 0.001 0.080
I speak English 112.1 < 0.001 0.262
I have contact with non-Pasifika families and relatives 33.2 <
0.001 0.095
I eat non-Pasifika food 8.0 < 0.001 0.025
I visit Western-trained doctors 2.6 0.037 0.008
I go to a church mostly attended by non-Pasifika people 1.6
0.183 0.005
Figure 2a. Connected Line Plot Of Mean Scores of the 11
Acculturation Questions of NZACCULT
Scale for Participants Over the Years They Had Been Resident
in New Zealand (NZ), Together
with the Lowess Curve (Dashed Line)

Borrows et al. 713
Although our findings showed a clear direction for these
relationships, they were not in the
expected direction in terms of the majority of the existing
acculturation literature, although, as
indicated previously, there have been some exceptions (Ataca &
Berry, 2002; Berry, 2006;
Jones et al., 2002). The association between maintenance of
constructive health behaviours and
existence and maintenance of aspects of original society social
and cultural practices has also
been noted in the ethnocultural qualitative literature and the
paediatric and nursing literature
(Callister & Birkhead, 2002; Gurman & Becker, 2008). Several
studies have also documented
this apparent epidemiologic paradox, with better outcomes
occurring among disadvantaged
immigrant people (Liu, Chang, & Chou, 2008). However, unlike
this study, some of these stud-
ies focus their analysis on a single acculturation related factor,
such as length of residence
(Hawkins, Lamb, Cole, & Law, 2008) or ethnicity (Gould,
Madan, Qin, & Chavez, 2003),
rather than a validated or reliable measure of acculturation and
fail to adjust for important risk
factors and confounders.
Within this cohort, the marginalisor, assimilator, and integrator
groups had poorer outcomes
in terms of all the measured infant-related health risk factors

except for the risk factor, small for
gestational age. In this isolated case, the integrator group OR
was smaller than that for the refer-
ence separator group. Overall, our findings showed a clear
gradation of risk indicators from a
low-risk position held by the reference separator group to the
much-increased OR of each risk
factor for both the assimilator and the marginalisor groups, with
the assimilator and the margin-
alisor groups showing no significant difference.
As noted earlier, there was considerable heterogeneity in the
estimated OR between accul-
turation classifications over the considered risk factors.
However, in terms of the identified
maternal risk factors, three factors could be identified as having
greater risk ORs across the
acculturation categories other than the reference separator
group—namely, the mother being the
perpetrator of severe interpersonal violence, association with
maternal smoking in utero, and
Brought up Pasifika way
Familiar with Pasifika customs
Understand a Pasifika language well
Have Pasifika friends
Friends speak a Pasifika language
Participate in Pasifika sports
Speak a Pasifika langauage
Have Pasifika contacts

Eat Pasifika food
Visit Pasifika healers
Church mostly Pasifika
1
2
3
4
5
M
e
a
n
a
c
c
u
lt
u
ra
ti
o
n
s

c
o
re
s
0-2 years 3-5 years 6-10 years >10 years NZ born
New Zealand residency
B
Figure 2b. Connected Line Plot of Mean Scores of the 11
Acculturation Questions of PIACCULT for
Participants Over the Years They Are Resident in New Zealand
(NZ), Together with the Lowess Curve
(Dashed Line).
exposure to alcohol in utero. The latter two risk factors could be
recognized as negative adapta-
tion associated with undesirable but widespread socio/cultural
behaviours in the host society:
alcohol consumption by women is not considered appropriate
behaviour in traditional Pacific
societies but is sometimes linked to tolerated private and
sometimes aggressive male behaviours
(Ministry of Health: Sector Analysis, 1997). Similarly,
interpartner violence has been consis-

tently linked to excessive alcohol consumption (Leonard, 2000;
Paterson et al., 2007). Such
sociocultural behaviours appear to provide evidence of negative
adaptation of risk-taking host
society behaviours by all groups other than those who hold
strongly to traditional values and
behaviours in the new society. Conversely, it is possible that the
more private corporal health
factors such as birth control, breast feeding, and attitudes to
immunization are more deeply
imbedded psychological rather than recently adopted
sociocultural behaviours (Ward & Leon,
2004), which are subject to slower (less extreme) pace of
change. Detailed analysis of these is
beyond the scope of this article, as further research will be
required to clarify the complex relation-
ships between each of these identified risk factors within a
revised and more complex acculturation
model.
Is Strong Cultural Alignment to the Original Culture
Associated With Better Outcomes?
In terms of the second aim of the study, we found that when the
two dimensions of the accultura-
tion measure NZACCULT and PIACCULT were separately and
simultaneously considered, they
provided evidence to support the current Pacific cultural and
New Zealand official dogma. That
is, when Pacific cultural orientation is high, it has a protective
effect; however, this effect is
reduced in the presence of a high New Zealand orientation.
Existing empirical studies show that
at the time of migration, people are at special risk for adoption
of negative health risk practices
(Carballo & Nerukar, 2001; Prior et al., 1987; Salmond et al.,
1985), and at the time of birthing,

mothers are doubly at risk for maintenance or adoption of
negative health practices (Carballo &
Nerukar, 2001). The results presented in this article suggest that
there may be something protec-
tive in the process of maintaining original cultural habits
toward good health behaviours. For
example, it is logical to assume that responsible parenthood
would enhance prospects of success-
ful adaptation to the new society. Although the two high PI
orientation groups (separators and
integrators) did not differ significantly on the mean overall PI
scale, there was considerable het-
erogeneity between individual items. The separators scored
significantly higher than the integrators
on scale items relating to custom and active use of a Pacific
language, and these (especially
church attendance) are still important and relevant parts of
strong Pacific identity in New Zea-
land. These items measure traditional Pacific values and reflect
the strength of immediate family
bonds through which these young mothers traditionally obtain
crucial childbearing and child-
raising support. Pacific cultures have strong existing culturally
bound positive traditions toward
birthing and family welfares (Abel et al., 2001; Barclay,
Aiavao, Fenwick, & Papua, 2005). It
could be that those in the separator group have the full
advantage of strong family and commu-
nity associations within a culture of origin that enhances
responsible traditional behaviour and
allows consideration of selected new society behaviours that are
considered advantageous. In
this critical arena of maternal and infant risk, these findings
provide evidence of the benefit of
maintaining strong cultural ties especially where the transition
to the new societies systems is not

fully developed.
When the relationships were examined in light of selected
sociodemographic variables, there
was no significant difference in estimated marginal adjusted OR
means between assimilator and
marginalisor groups, except the extent to which the assimilators
report some negative health-
related practices such as smoking and alcohol consumption
during pregnancy. Although individual
Borrows et al. 715
socioeconomic status is accommodated in the adjusted analysis,
the majority of the PIF cohort
resides in South Auckland, which has a high proportion of the
most deprived economic areas as
outlined in the New Zealand Atlas of Socioeconomic Difference
(Crampton, Salmond, Kirkpatrick,
Scarborough, & Skelly, 2000). The extent to which the negative
health risk practices in the assi-
milator group are reflecting or dependent on this relatively
poorer socioeconomic setting within
the dominant subregional culture is an interesting question.
These communities, in themselves
multicultural, might also be considered marginalized in terms of
mainstream New Zealand social
culture. In this context, the different modes of acculturation
become different social determinants.
This article is a first step in exploring and providing some

evidence to refute the melting pot as
a preferred hypothesis.
Significant differences in estimated risk factors between ethnic
groups were found, with
Tongan, Cook Island Maori, Niuean, and other Pacific mothers
all having higher risk than their
Samoan counterparts and relatively different proportions in each
of the acculturation groups. The
larger numbers of the Samoan community could explain the
greater number of individuals in the
separator category than might be expected from comparable
studies. As is shown in Table 2,
Samoans made up 51% of the cohort and also had the highest
proportion of participants classi-
fied as separators. This also suggests that having strong and
numerous bonds to identify with
may have a protective influence in terms of positive health
outcomes in this particular New Zealand
setting. Where these bonds are weak (e.g., small numbers for
specific island ethnic group or for
those who choose assimilation or marginalized acculturation
strategies), some negative health
practices of the dominant society may be freely adopted. This
could explain why excess alcohol
consumption during pregnancy is characteristic of the
assimilators who are most closely tied to
negative cultural practices of the wider society but less strongly
associated with those in the
marginalisor category. The crude ethnic acculturation
differences are also partly explained by
the findings of the reliability/validity results. These confirm
that Pacific people who migrated
recently to New Zealand are less oriented to New Zealand
mainstream culture and those who
migrated to New Zealand less recently have had greater

opportunity for exposure to mainstream
New Zealand behaviour and lifestyle concepts (Figures 2a and
2b). The Cook Island and Niuean
participants in this study have a longer (if still relatively recent)
migration history than those of
Samoan and Tongan ethnicity. Hence, Cook Islands and Niuean
participants have greater pro-
portions in the integrator and marginalisor categories than is the
case for those from Samoa or
Tonga (Table 2). However, although the univariate analysis
provides support for the thesis that
the differences between acculturation groups is mediated by the
ethnic group differences, there
was no significant interaction between the acculturation
classifications and mothers’ ethnicity in
the adjusted GEE model. This suggests that the effects of
acculturation and ethnicity are inde-
pendent important factors.
The finding that separators are at lower risk run counter to
many of the studies that have exam-
ined acculturation strategies in nondominant cultural groups. In
most such studies, preferences
for integration are expressed over the other three strategies
(Berry, 2006). Integrative strategies
seem to be preferred at a societal level (Hjerm, 2000), but there
are subtleties (Arends-Toth &
van de Vijver, 2003), and exceptions have been found in
indigenous groups and in some cases in
lower socioeconomic immigrant groups in some settings, for
example Turks in Canada (Ataca &
Berry, 2002). This raises the question as to why preference for
integration in this cohort would
not be associated with the best outcomes given that most studies
in the acculturation literature
have produced results pointing in this direction. General

community and subregional social and
economic factors may be influencing the positive association
between adherence to traditional
culture and health outcomes with the relative collective
disadvantage of those who attempt to
adopt assimilation or an integration cultural strategy in the
setting of an economically deprived
area. That is, are the wider regional cultural examples and
imperatives themselves marginal to
the economically advantaged mainstream? This may mean that
assimilation and marginalisor
groups identified in this study are in fact themselves aligned
with the predominant subregional
economically deprived culture and share the negative prospects
and health outcomes of that
subregional culture. In this case, it is possible that
marginalization and assimilation are failed
outcomes of regional group rather than individual cultural
integration. These findings also under-
score the need for acculturation research to incorporate the
possibility of more than two cultures
or regional subcultures into the explanatory framework and to
examine the extent to which eth-
nocultural identities are contextually bound (Persky & Birman,
2005).
Aside from location in disadvantaged neighbourhoods, these

findings raise the question as to
whether New Zealand society limits the opportunities for
Pacific people to be exposed to ethnic
groups other than the range of minority Pacific ethnicities. That
is, is this an ethnic ghetto? As is
shown in the description of the place of Pacific people in
contemporary New Zealand society,
there is little doubt that opportunities for pursuing migration
strategies of choice have been avail-
able to Pacific communities. The PIF findings that the separator
group has better outcomes are
consistent with Sam (2006a), who found that immigrant youth
who preferred assimilation and
integration had a higher risk of engaging in health-
compromising behaviour, such as smoking
and drinking alcohol, than their peers who preferred separation.
It is also important to recognize
that these results are in line with the historical views of
acculturation scholars, including Berry
(2003), who points out that it is not inevitable that intergroup
contact will proceed uniformly
through a sequential process to ultimate assimilation. Flannery
et al. (2001) also noted that
insights generated by a bidirectional model hold the promise of
correcting melting-pot assump-
tions and promoting political sensitivities among ethnicities and
as such fit explicitly in terms of
the social determinants theories for explaining the epidemiology
of health outcomes.
Recent theory and research offers a deeper insight as to the
multidimensional nature of accul-
turation and its components than that incorporated in the
general model we and others have used.
As noted previously, it is possible that the advantages or
disadvantages of one or another mode

of acculturation may vary according to broad dimensions such
as sociocultural and psychologi-
cal adaptation (Ward & Leon, 2004), and in relation to the
domain or competence under study,
such as self-esteem, social competence, and behaviour and
skills and experience. However, most
significantly, advances in the theory of measurement of
acculturation and related cross-cultural
relationships (Boski, 2008) point out that integration, in terms
of Berry’s model of acculturative
attitudes or strategies, and as used for the framework for this
analysis, operates within a limited
concept of integration and in a sense is acultural and as such
might be interpreted as a measure of
double social identity. The abbreviated scales used for this
analysis (PIACCULT and NZACCULT)
were not designed to distinguish these sophisticated and
important contexts in measurement of
integration and acculturation—for example, (a) integration as a
cognitive-evaluative merger of
two cultural sets or (b) integration and functional (partial)
specialization in life’s public and pri-
vate domains (Boski, 2008). In terms of the former, the fact that
little differentiation in poor
outcomes for the assimilator and marginalisor groups suggests
that Boski’s value placement
concepts could hold true and that for some fully individually
and socially functioning individu-
als, values oriented toward single culture separation rather than
some overlapping entity may
prove preferable. In terms of the second of these integration
models, there is the possibility that
the individual responses to the two subscales were mediated by
an essentially private response to
the Pacific orientation in the context of language, families, and
way of life but an alternative

public response to the New Zealand orientation when
responding in the context of English being
widely used (and of necessity understood) in the context of
external employment and social and
public life in a multicultural city such as Auckland. This
concept of double response to identity
might partly explain why some questions with seemingly high
face validity proved problem
items in terms of the validity testing. In the context of the
private Pacific identity, sports is not
a separate identity concept being bound up with normal social,
community, and church life
Borrows et al. 717
(McGregor & McMath, 1993), whereas for a New Zealand–
oriented public response, the direc-
tion of response is very much affected by the part sport plays in
the context of mainstream life and
work and social exchanges.
Within New Zealand, culturally bound supportive services have
been developed over the last
decade—for example, dedicated Pacific support unit in
communities and hospitals. The efficacy
of such services remains the subject of debate, but these
initiatives show that central government
is focused on pursuing an effective public institutional and
societal strategy in areas of high ethnic
concentration and demand. Traditional island cultures also have

strong alternative community
and church ties that provide support and education around
childbirth (Barclay et al., 2005).
It is acknowledged that a more sensitive measure is needed to
elucidate the complex interac-
tion between the individual’s preferred cultural identity and the
accommodating multicultural
society that has evolved in New Zealand. That is, a society that
allows strong personal (internal)
maintenance of values derived from the original island societies
in family home and private life
domains, which are protective of mother and infant, while
functional specialization is enabled in
public life domains such as work, education, and civic society
(in this case, health services) from
the concern and service efforts provided by the host society.
The well-established services allow
ample opportunity for effective (if selective) participation in
most public life domains. Examina-
tion of these concepts in greater depth is beyond the scope of
this current article but will be
pursued in the future phases of the PIF longitudinal study.
Is the Abbreviated Version of the GEQ a Valid and Reliable
Instrument?
The ancillary aim for this study was to demonstrate that the
abbreviated version of the GEQ
adopted for use in the PIF longitudinal study was both a valid
and reliable instrument in the con-
text of the range of health and social outcomes that were of
principal interest for the PIF study.
Our confidence in the selection of items was borne out by the
psychometric analysis that showed
very good internal consistency of the resultant abbreviated New
Zealand (NZACCULT) and

Pacific (PIFACCULT) scales. The use of these scales was
justified in terms of testing our aims
and appropriate for ongoing use for Pacific people in this
longitudinal study and for similar epi-
demiological oriented studies in the future. To improve face
validity, the scale was adapted to
include a limited number of items assessing concepts considered
important and central to New
Zealand or Pacific culture. The analysis revealed that some of
these items did not contribute
significantly to the measure of cultural differentiation—hence,
we were sacrificing internal con-
sistency at the expense of content validity. Rather than remove
them from the scales, we left
them in place for they had different impacts in terms of the
respective PIACCULT and NZAC-
CULT scales and provided further insight into how the New
Zealand and Pacific cultures view
and accommodate such issues. In brief, these nondiscriminatory
items provide insights into some
of the differences in the Pacific versus New Zealand cultural
view in the context of New Zealand
society. They confirm that in a Pacific domain context, sport is
not a single distinguishable vari-
able in establishing Pacificness (McGregor & McMath, 1993);
conversely, in a New Zealand
domain context, church attendance is not a relevant variable as
the wider New Zealand society
and world view is more secularly oriented, with 65% of the New
Zealand population nominating
a religious affiliation as compared to 86% of Samoans and 90%
of Tongan people who were
affiliated with a religion (Statistics New Zealand—Te Tari
Tatau, 2006b).
Strengths of This Study

There are some specific strengths of this study that deserve
elucidation. First, the short but robust
acculturation measure used was constructed so that the cultural
orientation and change could be
described and its impact could be quantitatively measured for
inclusion in the ongoing explanatory
models for healthy child and family development. This approach
can be useful in the context of
the universal modelling rationale for this longitudinal study,
providing both insights for testing
and explanation of the results as is the case in this initial study
of the association of acculturation
and maternal and infant health risk indicators. Despite having
many salient features, including
the ability to accommodate and appropriately model correlated
binary data, GEE methods used
here have not readily been adopted by behavioural researchers
(Lee, Herzog, Meade, Webb, &
Brandon, 2007). The approach also fits a modern
epidemiological perspective for examining the
impacts of relevant social and health determinants, in this case
the mode of acculturation, and
serves to enrich the literature in terms of the place of
acculturation and acculturation strategies in
the context of the wider psychosocial and epidemiological
literature.

Second, although this is a birth cohort, the island-specific
ethnic distributions in the cohort are
approximately representative of the ethnic distribution of the
main ethnic Pacific population in
New Zealand. This is unexceptional as a great majority of the
Pacific population in New Zealand
is located in the wider Auckland metropolitan area but still
useful in terms of policy and planning
for areas such as ongoing refinement of antenatal and birthing
services and community health
promotion activities such as immunization strategy, nutrition
advice, and exercise programs.
Specific Limitations
There are four specific limitations of this study that need to be
recognized:
(a) Abbreviating the GEQ from a 38-item to 11-item scale was a
necessary requirement for the
PIF study to avoid lengthening an already long
multidisciplinary questionnaire. The resultant
bi-dimensional scales have proved robust and successful in the
context of a general measure of
acculturation for the epidemiological explanatory model used
here and can continue to be used in
this context. This is notwithstanding the limitations on the use
of the median split method outlined
in Arends-Toth and van de Vijver (2006), and the conclusions
of Kang (2006), that lack of indepen-
dence between ethnic and mainstream cultural orientations is
partially due to specific scale format
and that structural features commonly found in bi-dimensional
acculturation instruments cause
strong inverse associations between the two cultural
orientations. Our analyses have shown that the
PIACCULT and NZACCULT are not strongly correlated (–0.33)

and show a wide distribution of
the means between the NZACCULT and the PIACCULT scales.
This means that when responding
to the Pacific-oriented scale, the tendency was to a more
uniform and positive response than was the
case with the New Zealand scale but not for those mother
participants (≈40%) who were New
Zealand born. It is also clear that other than the expected trends
over time in relation to length
of residency in New Zealand, no obvious differential exists in
terms of the way in which the
New Zealand–born as compared with island-born participants
responded to the two questionnaires.
(b) A more important limitation in relation to the use of this
scale for this study is the inability
to apply it in the contexts of more recent, complex, and richer
acculturation models that have
aroused interest elsewhere. These include, for example, domain-
specific models (Arends-Toth &
van de Vijver, 2006, 2007; Tsai et al., 2000) and specialized
acculturation and integration con-
cepts such as cognitive-evaluative, functional specialization,
frame switching, and constructive
marginalization models as summarized by the five-level model
of the acculturation process pos-
tulated by Boski (2008). The approach adopted in the
measurement used in this study carries an
inherent risk that may remain fixed at the first level
(acculturation attitudes) rather than moving
on through cultural perception and evaluation to areas such as
functional specialization and per-
haps true multiculturalism, cultural heteronomy, and true
autonomy of self.
(c) The demonstrated difference in the means between the

acculturation groups other than the
separator group (Table 4), while significant, is probably
insufficient in practical clinical terms to
suggest that identification of at-risk individuals based solely on
the acculturation scale used in
Borrows et al. 719
this study would not be practical for direct clinical use in the
health and social services. How-
ever, these findings can be used to highlight the areas of cross-
cultural difference in perception
of, and potential use of, health services by individuals caught
between or outside cultures. It is
this issue that needs to be addressed in health promotion and
service terms so that the benefit or
use of such services can be optimized. In addition, these
findings suggest that cultural alignment
should be considered for inclusion in explanatory
epidemiological models and support the per-
spective that culture be given proper consideration in the
clinical decision-making process.
(d) Last, it is also important to recognize that this analysis is
constrained by the nature of limi-
tations common to longitudinal studies, with large
multidimensional questionnaires resulting in
lesser opportunity to drill down into multifaceted issues. This
approach limits the degree to
which the specific role of Pacific subcultures and their elements

can be elucidated. For example,
we were not able to investigate the impact of individual
attitudes on mode of acculturation at this
data collection point. Separator mothers may be inherently
group or community aligned rather
than more individually oriented and hence may be less likely to
engage in potentially risky
behaviour. We may be able to consider individual versus group
personality behavioural charac-
teristics of participants and the association with acculturation in
later phases of the study.
These findings provide support for the view that retaining and
enhancing strong cultural links
for Pacific immigrants is likely to have positive benefits. The
acculturation measure proved
robust and reliable as an overall measure. A clear association
was shown between mode of accul-
turation and the group of maternal and infant risk factors,
however this measure did not sufficiently
reveal which of the infant and maternal outcomes were
individually effective indicators of accul-
turation risk independent of the overall acculturation categories.
Also, such detailed relationships
may comprise a useful outcome only if the other subtleties of
the acculturation process pointed
to elsewhere in this article are properly accommodated. In
particular, those subtleties related to
attitudinal and behavioural responses in public and private
domains and attitudes and behaviours
in both the sociocultural and more personal psychological and
corporal health realms.
We acknowledge that it is not possible from this study to
determine whether in terms of recent
models of integrative acculturation strategies the findings

presented here are in fact indicators of
an effective New Zealand public integrative but not assimilative
(melting pot) strategy. These
findings raise questions about the stability of the relationships
between culture and health risk
factors; how reflections of disadvantage are maintained over
time; at what speed post-migration
changes take place; how these changes support, refute, or assist
in better explaining current migration/
acculturation and health hypotheses such as the “immigrant
health paradox” (Sam, 2006a); and
what factors influence this, especially in relation to
acculturative stress.
Further planned work in the longitudinal PIF study will
determine the durability of these find-
ings and explore in more depth aspects of cultural contact
between Pacific peoples and the wider
New Zealand society and examine this in terms of degree of
change, elements of the process that
lead to cultural alignment remaining static or the rate of change
over time, and ultimately the
relationship between the cultural alignment of the parent(s) and
the children in this birth and
family cohort. This could add a significant dimension to the
understanding of the modes of the
classical acculturation model (Berry, 2003; Sam, 2006b) and the
more recent explanatory models
of levels of integration in the acculturation process (Boski,
2008).
Conclusion
Most descriptions of the acculturative processes, particularly
exceptions to the assimilative norm
(Ataca & Berry, 2002), are generally cross-sectional in nature.
This initial analysis of acculturation

in the context of this large-scale longitudinal epidemiological
study (Paterson et al., 2008) pro-
vides a singular opportunity to explore these concepts over time
in greater depth. In spite of
current limitations, further research within the parent
longitudinal study offers ongoing opportu-
nity to unravel some of the nuances and impacts of cultural
alignment, in terms of historical recognized
models and modes of acculturation that are still rarely
considered in a traditional epidemiological
approach. This study, placing acculturation at the centre of
interest and analysis, provides an
interdisciplinary approach aimed at beginning the process of
filling this deficit. “And most
New Zealanders, whatever their cultural backgrounds, are good-
hearted, practical, commonsen-
sical and tolerant. Those qualities are part of the national
cultural capital that has in the past saved
the country from the worst excesses of chauvinism and racism
seen in other parts of the world.
They are as sound a basis as any for optimism about the
country’s future.” (King, 2003, p. 520)
Appendix
Pacific Island and New Zealand Acculturation Scales:
The PIACCULT (Pacific orientation)

I was brought up the Pasifika way
I am familiar with Pasifika practices and customs
I can understand a Pasifika language well
I have several Pasifika friends
Most of my friends speak a Pasifika language
I participate in Pasifika sports and recreation
I speak a Pasifika language
I have contact with Pasifika families and relatives
I eat Pasifika food
I visit a traditional Pasifika healer when I have an illness
I go to a church that is mostly attended by Pasifika people
The NZACCULT (New Zealand orientation)
I was brought up the NZ way
I am familiar with NZ practices and customs
I can understand English well
I have several non-Pasifika friends
Most of my friends speak English
I participate in NZ sports and recreation
I speak English
I have contact with non-Pasifika families and relatives
I eat non-Pasifika food
I visit Western-trained doctors when I have an illness
I go to a church that is mostly attended by non-Pasifika people
Note. These scales are scored in a 5-point Likert format: 1 =
strongly disagree, 2 = disagree, 3 =
neither disagree or agree, 4 = agree, and 5 = strongly agree.
Acknowledgements
The PIF Study is funded by grants awarded from the Foundation
for Research, Science & Technology, the
Health Research Council of New Zealand, and the Maurice &
Phyllis Paykel Trust. The authors gratefully
acknowledge the families who participated in the study as well

as other members of the research team. In
addition, we wish to express our thanks to the PIF Advisory
Board for their guidance and support.
Borrows et al. 721
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interests with
respect to the authorship and/or publication
of this article.
Financial Disclosure/Funding
The author(s) received no financial support for the research
and/or authorship of this article.
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