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:
- income and social status
- employment and working conditions
- education and literacy
- childhood experiences
- physical environments
- social supports and coping skills
- healthy behaviours
- access to health services
- biology and genetic endowment
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).
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:
- stress related to cultural and intergenerational trauma, grief and loss
- experiences of discrimination and racism
- mental illness
- substance use
- beliefs and traditions that may encourage gambling (e.g., beliefs about luck and skill in gambling)
- having friends and family that engage in gambling
- exposure and access to gambling activities
- reservation or remote location
- urban location.
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.
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).
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).
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).
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.
- DSM-V Cultural Formulation Interview
- Health Equity Impact Assessment (HEIA) – Ministry of Health, Ministry of Long-term Care
- Cultural Competence: Critical Self-Reflection on Our Practice when Working with Refugee Client (CAMH Webinar)
- Advancing Equity in Mental Health: An Action Framework - Canadian Mental Health Association Ontario
- Refugee Mental Health Project (CAMH)
- Health Inequalities in Canada Video (YouTube)
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