Health Equity and Diverse Populations


Health is influenced by many intersecting factors. According to Health Canada (2019), the determinants of health include a range of personal, social, economic and environmental factors that influence the health of individuals and the population.

These determinants of health include the following:

The social determinants of health refer to certain social and economic factors that fall within the wider determinants of health and relate to a person’s place in society (e.g., income, education and employment) (Health Canada, 2019). For groups such as Indigenous populations, racialized communities and people who identify as LGBT2SQ+, experiences involving racism, discrimination and histories of trauma are important social determinants of health (Health Canada, 2019).

When health-related differences between individuals and groups are socially produced, they become health inequities (Braveman, 2014; Srivastava, 2007; Whitehead, 1992). A World Health Organization resource refers to health inequities as differences in health that “are systematic, socially produced (and therefore [able to be changed]) and unfair” (Whitehead & Dahlgren, 2006).

Health inequities play a role in the development and maintenance of many health-related issues, including problem gambling. For instance, some population groups, including low-income groups, those experiencing poverty, older adults and Indigenous populations, are more vulnerable to gambling problems yet show comparatively low rates of seeking professional treatment (Raylu & Oei, 2004). Health inequities should therefore be considered when screening, assessing and providing care to clients who engage in problem gambling.

Achieving health equity means reducing or eliminating the health inequities that exist in the population and enabling people to reach their fullest health potential (Braveman, 2014). Access to quality health care and education, as well as improvements to physical and social settings, contribute to promoting and attaining health equity (Braveman, 2014).

This webpage uses a health equity lens to highlight the latest evidence and practice considerations regarding problem gambling in relation to the following populations: women, Indigenous populations and those who are incarcerated. This information is based on an evidence review and was also reviewed by experts in the field of problem gambling. Mental health and substance use service providers will be especially interested in how the evidence can be put into practice.

What does the evidence say?


Given the likelihood of gender differences, health equity is an important principle when considering women who may have gambling problems. Research on understanding gambling and problem gambling has often focused on men (McCarthy et al., 2019; Merkouris et al., 2016; Saboia Martins et al., 2002). Several studies have emerged in recent years that highlight the need for gender-specific considerations in problem gambling treatment.

Some international literature suggests that rates of gambling participation for women are similar to those of men (McCarthy et al., 2019). For example, similar participation rates were found in a 2017 Ontario survey, where 68.7 per cent of adult women and 69.7 per cent of adult men reported gambling participation in the past year (Ialomiteanu et al., 2018). According to the same Ontario survey, 1.0 per cent of women reported having gambling problems in the past year, compared to 1.5 per cent of men. Similarly, in Canada, 1.4 per cent of women aged 15 years and older reported having gambling problems in the past year (Afifi et al., 2010).

Although rates of problem gambling and associated harms vary in the international literature, overall rates of problem gambling for women seem to be increasing more rapidly than for men (Echeburú et al., 2011; McCarthy et al., 2019). In addition to gambling for fun or to win money, women report being motivated to gamble when feeling stressed, depressed, bored or lonely, and potentially use gambling as a way of coping (Echeburú et al., 2011; Grant et al., 2012; McCarthy et al., 2019). Studies have also noted that women typically gamble on electronic gaming machines and other non-strategic games; however, the number of younger women who participate in a wider range of gambling activities is also increasing (Delfabbro et al., 2018; McCarthy et al., 2019; Merkouris et al., 2016).

While more research in this area is needed, some studies show that women with problem gambling start to participate in gambling later in life (Echeburú et al., 2011) and typically develop problems more rapidly than men. This rapid development is called “telescoping” (Delfabbro et al., 2018; Echeburú et al., 2011; Merkouris et al., 2016; Saboia Martins et al., 2002).

Women with gambling problems are more likely than men to report experiencing trauma either in childhood or adulthood (Boughton & Falenchuk, 2007; Delfabbro et al., 2018; Echeburú et al., 2011; Merkouris et al., 2016). Women with problem gambling also report experiencing co-occurring anxiety and depression, personality disorders, psychological distress and suicidality (Afifi et al., 2010b; Boughton & Falenchuk, 2007), with some research reporting that women experience these concurrent disorders more commonly than men (Delfabbro et al., 2018; Echeburú et al., 2011; Merkouris et al., 2016).

Indigenous populations

Health equity is an important principle in relation to Indigenous communities realizing their full health potential. Indigenous Peoples in Canada (i.e., First Nations, Métis and Inuit communities) are more likely to experience problem gambling compared to the general population (Dowling et al., 2006; Belanger et al., 2017). It has been estimated that 10 per cent to 20 per cent of Indigenous populations in Canada will experience problem gambling in their lifetime (Breen & Gainsbury, 2013).

A study that surveyed urban Indigenous people living in the Prairie provinces reported a combined rate of problem and pathological gambling of 27 per cent (Williams et al., 2016). Nearly 90 per cent of participants in that same study reported past-year gambling activities, with the highest levels of participation reported for electronic gambling machines, lottery tickets and instant win tickets. Bingo is also popular in some Indigenous communities, including some northern communities (Bottorff et al., 2009; Gill et al., 2016).

Numerous factors may contribute to the risk of problem gambling for Indigenous people (Breen & Gainsbury, 2013; Currie et al., 2013; Gill et al., 2016), including:

While Indigenous people hold mixed opinions on whether gambling is harmful, 45 per cent of a large urban sample reported the belief that the harms of gambling outweigh the benefits (Currie et al., 2013).

Much more research is needed on the individual and community-level protective or resiliency factors associated with gambling among Indigenous communities. It is critical to recognize that Indigenous populations across Canada are diverse; therefore, risk and protective factors for problem gambling may vary greatly across communities.

Incarcerated populations

People incarcerated by the criminal justice system, including detained and sentenced persons, experience many health inequalities (World Health Organization, 2014). Therefore, health equity is an important principle for this diverse population that experiences high rates of problem gambling.

There is a wide range of problem gambling rates (i.e., ranging from 5.9 per cent to 73 per cent) among men and women prison populations (Banks et al., 2019). Studies from Canada, Australia, New Zealand, Germany, the United Kingdom and the United States consistently show that incarcerated populations report significantly higher rates of problem gambling compared to general populations (Abbott & McKenna, 2005; Abbott et al., 2005; Lahn, 2005; Turner et al., 2009; Turner et al., 2013; Zurhold et al., 2014). Gambling activities are common in prison settings, even though they are generally prohibited (Turner et al., 2009). Both incarcerated persons and prison staff recognize that gambling can harm relationships inside prison (McEvoy & Spirgen, 2012).

Incarcerated people with problem gambling also tend to report criminal behaviour related to gambling (e.g., theft to pay off debt). For example, a study of male federal offenders in Canada found that 9.4 per cent met the criteria for a gambling disorder.

Furthermore, 65 per cent of people with severe problem gambling and 20 per cent of people with moderate problem gambling indicated that their offending was related to their gambling (Turner et al., 2009). Young male prisoners with a gambling disorder may also show elevated rates of other psychiatric diagnoses (Widinghoff et al., 2019).

More research is needed on problem gambling among incarcerated women (Abbott & McKenna, 2005; Banks et al., 2019), Indigenous people (Riley et al., 2018) and older persons (Kerber et al., 2012) to fully understand different needs and appropriate action for treatment. Furthermore, few people seek help for gambling problems either prior to or during incarceration (Abbott & McKenna, 2005), reflecting the need to further address barriers to treatment among marginalized populations.

How do I put the evidence into practice?


When screening for problem gambling with a client who self-identify as a women, it is important to also screen for other mental health problems and any past or current trauma. (For more information on trauma-informed care and problem gambling, please see the trauma informed care EIP page.) This can facilitate the provision of coordinated care for co-occurring disorders and problem gambling (McCarthy et al., 2019; Merkouris et al., 2016). It may also be effective to screen for problem gambling in other healthcare settings, as clients may first seek treatment for their co-occurring disorders or trauma (McCarthy et al., 2019).

In addition, it is important to reduce or eliminate the barriers to problem gambling treatments, including access to services, wait times, cost, lack of information and stigma (Kaufman et al., 2017). Some of these barriers can be addressed by offering online or phone treatment options, increasing awareness of services available, training clinicians to be aware of the stigma and barriers faced by women, providing person-centred care, and providing women-only treatment options in a safe space (Kaufman et al., 2017; Piquette-Tomei et al., 2008).

Cognitive-behavioural therapy (CBT) is a time-limited form of psychotherapy that teaches clients to shift their thoughts and behaviours related to gambling and respond to their urges in healthier ways. CBT is currently considered an effective treatment for both men and women with problem gambling (Cowlishaw et al., 2012). However, there is a need for more evidence and best practice guidelines for women are lacking (Kaufman et al., 2017).

One specific study examined the outcome of CBT in 19 adult women with problem gambling and found that in addition to raising self-esteem, CBT was effective for reducing gambling frequency, gambling duration, money spent and associated anxiety and depression symptoms (Dowling et al., 2006). At a six-month follow-up post-treatment, 89 per cent of women no longer met the criteria for a gambling disorder. The same study suggests promise for delivering CBT sessions to female clients that address topics such as financial limit setting, alternative activity planning, correcting cognitive misconceptions about gambling, problem solving, assertiveness training and relapse prevention (Dowling et al., 2006).

Indigenous populations

Treatment considerations may vary across Indigenous communities. At present, treatment seeking and service uptake for problem gambling among Indigenous people appear to be low (Williams et al., 2016).

More research is needed to understand the impacts of gambling for Indigenous communities and to formulate best practices to address problem gambling. Important considerations when working with Indigenous people include the intergenerational trauma of colonization and lived experiences of racial discrimination that impact Indigenous communities. Development of anti-colonial/anti-racist policies will enhance services designed to assist with problem gambling among Indigenous peoples (Currie et al., 2013). In particular, Indigenous women who exhibit problem gambling may need greater supports to help heal from social traumas they have experienced (Hagen et al., 2013).

Incarcerated populations

Brief screenings for problem gambling may be particularly well suited for correctional settings as these tools can be used with minimal disruption to intake and assessment procedures (Cuadrado et al., 2012). Providing early assessment and treatment could help reduce problem gambling, its negative health-related impacts and problem gambling-related recidivism among incarcerated populations (Banks et al., 2019).

Treatment services specific to problem gambling for people in the correctional system are currently underdeveloped and should be a priority. Treatment programs could be a cost-effective approach to gambling-related crime reduction (Banks et al., 2019).

Additional resources

Resources are available to help you learn more about health equity principles and how they can be applied to your practice. Please note that these resources are not specific to problem gambling.


Abbott, M.W. & McKenna, B.G. (2005). Gambling and problem gambling among recently sentenced women in New Zealand prisons. Journal of Gambling Studies, 21 (4), 559–581. Available: Accessed March 31, 2020.

Abbott, M.W., McKenna, B.G. & Giles, L.C. (2005). Gambling and problem gambling among recently sentenced male prisoners in four New Zealand prisons. Journal of Gambling Studies, 21 (4), 537–558. Available: Accessed March 31, 2020.

Afifi, T.O., Cox, B.J., Martens, P.J., Sareen, J. & Enns, M.W. (2010a). The relation between types and frequency of gambling activities and problem gambling among women in Canada. In Canadian Journal of Psychiatry, 55. Available: Accessed March 31, 2020.

Afifi, T.O., Cox, B.J., Martens, P.J., Sareen, J. & Enns, M.W. (2010b). The relationship between problem gambling and mental and physical health correlates among a nationally representative sample of Canadian women. Canadian Journal of Public Health,101.

Banks, J., Waters, J., Andersson, C. & Olive, V. (2019). Prevalence of gambling disorder among prisoners: A systematic review. International Journal of Offender Therapy and Comparative Criminology. Available: Accessed March 31, 2020.

Belanger, Y.D. & Williams, R.J. (2012). Urban Aboriginal and First Nations perspectives on casinos and the First Nations gaming industry in Alberta, Canada. International Gambling Studies, 12 (1), 129–144. Available: Accessed March 31, 2020.

Belanger, Y.D., Williams, R.J. & Prusak, S.Y. (2017). Tracking the westernization of urban Aboriginal gambling in Canada’s Prairie Provinces. International Gambling Studies, 17 (1), 1–19. Available: Accessed March 31, 2020.

Bottorff, J.L., Carey, J., Mowatt, R., Varcoe, C., Johnson, J.L., Hutchinson, P. et al. (2009). Bingo halls and smoking: Perspectives of First Nations women. Health & Place, 15 (4), 1014–1021. Available: Accessed March 31, 2020.

Boughton, R. & Falenchuk, O. (2007). Vulnerability and comorbidity factors of female problem gambling. Journal of Gambling Studies, 23 (3), 323–334. Available: Accessed March 31, 2020.

Braveman, P. (2014). What are health disparities and health equity? We need to be clear. Public Health Reports (Washington, D.C.: 1974), 129 (Supplement 2), 5–8. Available: Accessed March 31, 2020.

Breen, H. & Gainsbury, S. (2013). Aboriginal gambling and problem gambling: A review. International Journal of Mental Health and Addiction, 11 (1), 75–96. Available: Accessed March 31, 2020.

Cowlishaw, S., Merkouris, S., Dowling, N., Anderson, C., Jackson, A. & Thomas, S. (2012). Psychological therapies for pathological and problem gambling. Cochrane Database of Systematic Reviews. Available: Accessed March 31, 2020.

Cuadrado, M. & Lieberman, L. (2012). Use of a short gambling screen with an arrestee population: A feasibility study. Journal of Gambling Studies, 28 (2), 193–205. Available: Accessed March 31, 2020.

Currie, C.L., Wild, T.C., Schopflocher, D.P., Laing, L., Veugelers, P. & Parlee, B. (2013). Racial discrimination, post traumatic stress, and gambling problems among urban Aboriginal adults in Canada. Journal of Gambling Studies, 29 (3), 393–415. Available: Accessed March 31, 2020.

Delfabbro, P., Thomas, A. & Armstrong, A. (2018). Gender differences in the presentation of observable risk indicators of problem gambling. Journal of Gambling Studies, 34 (1), 119–132. Available: Accessed March 31, 2020.

Dowling, N., Smith, D. & Thomas, T. (2006). Treatment of female pathological gambling: The efficacy of a cognitive-behavioural approach. Journal of Gambling Studies, 22 (4), 355–372. Available: Accessed March 31, 2020.

Echeburú, E., González-Ortega, I., de Corral, P. & Polo-López, R. (2011). Clinical gender differences among adult pathological gamblers seeking treatment. Journal of Gambling Studies, 27, 215–227. Available: Accessed March 31, 2020.

Gill, K.J., Heath, L.M., Derevensky, J. & Torrie, J. (2016). The social and psychological impacts of gambling in the Cree communities of northern Québec. Journal of Gambling Studies, 32 (2), 441–457. Available: Accessed March 31, 2020.

Grant, J.E., Chamberlain, S.R., Schreiber L. & Odlaug, B.L. (2012). Gender-related clinical and neurocognitive differences in individuals seeking treatment for pathological gambling. Journal of Psychiatric Research, 46 (9), 1206–1211. Available: Accessed March 31, 2020.

Hagen, B., Kalishuk, R.G., Currie, C., Solowoniuk, J. & Nixon, G. (2013). A big hole with the wind blowing through it: Aboriginal women’s experiences of trauma and problem gambling. International Gambling Studies, 13 (3), 356–370. Available: Accessed March 31, 2020.

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Ialomiteanu, A.R., Hamilton, H.A., Adlaf, E.M. & Mann, R.E. (2018). CAMH Monitor eReport 2017: Substance Use, Mental Health and Well-Being Among Ontario Adults. Available: Monitor/CAMH-Monitor-2015-eReport-Final-Web.pdf. Accessed March 31, 2020.

Kaufman, A., Jones Nielsen, J.D. & Bowden-Jones, H. (2017). Barriers to treatment for female problem gamblers: A UK perspective. Journal of Gambling Studies, 33, 975–991. Available: Accessed March 31, 2020.

Kerber, C.H., Hickey, K.L., Astroth, K.M. & Kim, M. (2012). Gambling behaviors and perceived health among incarcerated older adults. Journal of Psychosocial Nursing and Mental Health Services, 50 (8), 32–39. Available: Accessed March 31, 2020.

Lahn, J. (2005). Gambling among offenders: Results from an Australian survey. International Journal of Offender Therapy and Comparative Criminology, 49 (3), 343–355. Available: Accessed March 31, 2020.

McCarthy, S., Thomas, S.L., Bellringer, M.E. & Cassidy, R. (2019). Women and gambling-related harm: A narrative literature review and implications for research, policy, and practice. Harm Reduction Journal, 16 (1). Available: Accessed March 31, 2020.

McEvoy, A. & Spirgen, N. (2012). Gambling among prison inmates: Patterns and implications. Journal of Gambling Studies, 28 (1), 69–76. Available: Accessed March 31, 2020.

Merkouris, S.S., Thomas, S.A., Browning, C.J. & Dowling, N.A. (2016). Predictors of outcomes of psychological treatments for disordered gambling: A systematic review. Clinical Psychology Review, 48, 7–31. Available: Accessed March 31, 2020.

Merkouris, Stephanie S., Thomas, A.C., Shandley, K.A., Rodda, S.N., Oldenhof, E. & Dowling, N.A. (2016). An update on gender differences in the characteristics associated with problem gambling: A systematic review. Current Addiction Reports, 3 (3), 254–267. Available: Accessed March 31, 2020.

Piquette-Tomei, N., Norman, E., Dwyer, S.C. & McCaslin, E. (2008). Group therapy for women problem gamblers: A space of their own. Journal of Gambling Issues, 0 (22), 275–296. Available: Accessed March 31, 2020.

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Riley, B.J., Larsen, A., Battersby, M. & Harvey, P. (2018). Problem gambling among Australian male prisoners: Lifetime prevalence, help-seeking, and association with incarceration and aboriginality. International Journal of Offender Therapy and Comparative Criminology, 62 (11), 3447–3459. Available: Accessed March 31, 2020.

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Turner, N.E., Preston, D.L., Saunders, C., McAvoy, S. & Jain, U. (2009). The relationship of problem gambling to criminal behavior in a sample of Canadian male federal offenders. Journal of Gambling Studies, 25 (2), 153–169. Available: Accessed March 31, 2020.

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Widinghoff, C., Berge, J., Wallinius, M., Billstedt, E., Hofvander, B. & Håkansson, A. (2019). Gambling disorder in male violent offenders in the prison system: Psychiatric and substance-related comorbidity. Journal of Gambling Studies, 35 (2), 485–500. Available: Accessed March 31, 2020.

Williams, R.J., Belanger, Y.D. & Prusak, S.Y. (2016). Gambling and problem gambling among Canadian urban Aboriginals. Canadian Journal of Psychiatry, 61 (11), 724–731. Available: Accessed March 31, 2020.

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