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Health Equity and Diverse Populations

Health is influenced by many intersecting factors. According to Health Canada,1 the determinants of health include a range of personal, social, economic and environmental factors that determine the health of individuals and the population. 

this is an image of an icon of health equity


Gambling, Gaming & Technology Use
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Health Equity and Diverse Populations

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
  • gender
  • culture
  • race/racism.

The social determinants of health refer to certain social and economic factors that fall within the wider determinants of health and relate to one’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.1 

When health-related differences between individuals and groups are socially produced, they become health inequities. 2, 3, 4 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”.5 

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 and those experiencing poverty, older adults, and Indigenous populations are more vulnerable to gambling problems (for a series of plain-language evidence summaries related to gambling, poverty, and homelessness, please see http://learn.problemgambling.ca/eip/poverty) yet show comparatively low rates of seeking professional treatment.6 Health inequities should therefore be considered when screening, assessing and providing care to clients who engage in problem gambling.6 

Achieving health equity means to reduce or eliminate the health inequities that exist in the population and to enable people to reach their fullest health potential.2 Access to quality health care and education, and improvements to physical and social settings, contribute to promoting and attaining health equity.2

Using a lens of health equity, this webpage highlights 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 that 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. 

Women

What does the evidence say?

Given the likelihood of gender differences, health equity is an important principle in relation to women who may have gambling problems. Research on understanding gambling and problem gambling has often focused on men.7, 8, 9 In recent years, several studies have emerged 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.7 Similar participation rates were found, for example, in a 2017 Ontario survey, with 68.7% of adult women and 69.7% of adult men reporting any gambling participation in the past year.10 According to the same Ontario survey, 1.0% of women reported having gambling problems in the past year, compared to 1.5% of men.10 In Canada, the prevalence was found to be 1.4% of women aged 15 years and older.11 

Although rates of problem gambling and harms vary in the international literature, overall rates of problem gambling for women seem to be increasing more rapidly than for men.12, 7 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 as a way of coping.12, 13, 7 Studies have also noted that women typically gamble on electronic
gaming machines and other non-strategic games; however, there is also an increase in younger women who gamble on a wider range of gambling activities.14, 7, 8  

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”.14, 12, 8, 9 

Women with gambling problems are more likely than men to report experiencing trauma either in childhood or adulthood.15, 14, 12, 7 Women with problem gambling also report experiencing co-occurring anxiety and depression, personality disorders, psychological distress and suicidality16, 15  with some research reporting that women experience these concurrent disorders more commonly than men.14, 12, 17 

Putting 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 http://learn.problemgambling.ca/eip/trauma-informed-care). This can facilitate provision of coordinated care for co-occurring disorders and problem gambling.7, 8 It may also be effective to screen for problem gambling in other healthcare settings, as clients may seek treatment for their co-occurring disorders or trauma first.7 

It is important to work with clients to reduce or eliminate barriers to problem gambling treatment, such as access to services, wait times, cost, lack of information and stigma.18 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.18, 19 

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,20 although there is a need for more evidence and best practice guidelines for women are lacking. 18 

One study in particular looked at CBT in 19 adult women with problem gambling and found that it was effective for raising self-esteem and for reducing gambling frequency and duration, money spent, and anxiety and depression symptoms.21 At a six-month follow-up post-treatment, 89% of women no longer met the criteria for a gambling disorder. The same study suggests promise in delivering CBT sessions to women clients that address topics such as financial limit setting, alternative activity planning, correcting cognitive misconceptions about gambling, problem solving, assertiveness training and relapse prevention.21 

Indigenous populations 

What does the evidence say?

Health equity is an important principle in relation to Indigenous communities realizing their full health potential. Indigenous Peoples in Canada (First Nations, Métis and Inuit communities) are more likely to experience problem gambling compared to the general population.22, 23 It has been estimated that 10% to 20% of Indigenous populations in Canada will experience problem gambling in their lifetime.24 

A study that surveyed urban Indigenous people living in the Prairie provinces reported a combined rate of problem and pathological gambling of 27%.25 Nearly 90% 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.26, 27 

Numerous factors may contribute to the risk of problem gambling for Indigenous people,24, 28, 27 including:
  • stress related to, for example, 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% of a large urban sample reported the belief that the harms of gambling outweigh the benefits.28

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.

Putting the evidence into practice

Treatment considerations may also vary across Indigenous communities. At present, treatment seeking and service uptake for problem gambling among Indigenous people appears to be low.25 

More research is needed to understand the impacts of gambling for Indigenous communities and best practices for 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.28In particular, Indigenous women who exhibit problem gambling may need greater supports to help heal from social traumas they have experienced.30 

Incarcerated populations 

What does the evidence say? 

People incarcerated by the criminal justice system, including detained and sentenced persons, experience many health inequalities.31 Therefore, health equity is an important principle for this diverse population that experience high rates of problem gambling.  

There are a wide range of problem gambling rates (i.e., ranging from 5.9% to 73%) among men and  women prison populations.32 Studies from countries such as Canada, Australia, New Zealand, Germany, the United Kingdom, and United States consistently show that incarcerated populations report significantly higher rates of problem gambling compared to general populations.33, 34, 35, 36, 37, 38 Although generally prohibited, gambling activities are common in prison settings.36 Prisoners and prison staff recognize that gambling can harm relationships inside prison.39

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% met the criteria for a gambling disorder; 65% of people with severe problem gambling and 20% of people with moderate problem gambling in the sample indicated that their offending was related to their gambling.36 Young male prisoners with a gambling disorder may also show elevated rates of other psychiatric diagnoses.40 

More research is needed on problem gambling among incarcerated women,33, 32 Indigenous people,41 and older persons42 to fully understand different needs and appropriate action for treatment. Furthermore, low numbers seek help for gambling problems either prior to or during incarceration,33 reflecting the need to further address barriers to treatment among marginalized populations.

Putting the evidence into practice

Brief screens 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.43 Providing early assessment and treatment could help reduce problem gambling, its negative health-related impacts, and problem gambling-related recidivism among incarcerated populations.32 

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.32 

Resources for clinicians

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

References

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​L​ast updated: March 31st, 2020

This information is intended to help clinicians in their use of evidence-informed practice (EIP) when screening, assessing, and treating clients with behavioural addiction(s). Evidence-informed practice, sometimes called evidence-based practice, is a client-centred approach to clinical decision making. It’s a way to solve problems by integrating the best available research evidence with the clinician’s experience, the client’s preferences and values, and the organizational and cultural context.1,2,3,4