Assisting an Australian Aboriginal and Torres Strait Islander person with gambling problems: a Delphi study

Step 1: Panel formation

The aim was to recruit a minimum of 30 people to the panel, which is within the typical Delphi panel size of 15–60 experts [20], allowing for reliable consensus to be reached.

Twenty-two participants with experience in working with Aboriginal and Torres Strait Islander people with gambling problems completed all three rounds. The participants had an average age of 46.4 (SD 10.48) and 12 were female and ten male. They were from the following Australian states and territories: ACT (n = 1), NSW (n = 2), SA (n = 1), VIC (n = 7), NT (n = 2), QLD (n = 6), TAS (n = 1) and WA (n = 2). They worked in an Aboriginal gambling service (n = 7), a general gambling service (n = 5), a local health service (n = 4), a community service (n = 1), or other mental health setting (n = 3), or as a researcher (n = 4) (note: some may have worked in more than one service). Seven of the participants were Aboriginal and none were Torres Strait Islander. Three participants had experienced gambling problems themselves, while 10 had supported a family member and 11 a fellow community member who experienced gambling problems. The retention rate for participants completing all three rounds was 84.6% (26 participants completed Round 1).

Step 2: Literature search and survey development

The Round 1 survey included two types of questions – items from a previous international study to develop guidelines for assisting people with gambling problems in developed English-speaking Western countries [17] and items derived from a targeted literature search described below. The methodology of the study to develop the gambling guidelines for English-speaking Western countries is described in detail elsewhere [17]. Three hundred and forty-seven items from the previous survey that received a consensus rating of at least 50% were used in the Round 1 survey of this current study.

In line with other similar Delphi studies (e.g. [17, 21, 22]), the first 50 websites, 50 books and 50 journal articles were retrieved. The decision to examine the first 50 for each search term was based on a previous Delphi study that found that the quality of the resources declined rapidly after the first 50 [23]. After duplicates were removed, the remaining sources were reviewed for relevant information, as were any links appearing on the websites. Websites, articles and books were excluded if they did not contain information about how a member of the public can recognise and help an Aboriginal or Torres Strait Islander person who has gambling problems. A total of 24 websites, articles and books were included and used to develop the Round 1 survey. Figure 1 summarises the results of the literature search.

A working group, consisting of staff from Mental Health First Aid Australia, the University of Melbourne and an Aboriginal and Torres Strait Islander mental health first aid expert (who is Aboriginal) translated the results from the literature search into helping statements that were clear, actionable, and contained only one idea. These statements, plus the items from the recent Delphi study to develop guidelines for helping a person with gambling problems from a developed English-speaking Western country [17], were used to form the first of three questionnaires that were administered to the expert panel via SurveyMonkey.

In this study, a distinction was made between the subclinical symptoms of problem gambling and gambling disorder (a diagnosis). We use the term gambling problems, defined as gambling activities where the person struggles to limit the amount of time or money spent on gambling, leading to adverse consequences for the person, their family, or the community. This includes someone whose gambling problems are at a clinically diagnosable level [10]. This definition was used because it is not feasible or preferred that members of the public (e.g. family or friends) diagnose pathological or disordered gambling, and because the study sought to identify the signs of a range of gambling problems (from at risk gambling through to problem gambling). Also, if family, friends and co-workers can recognise, identify and address gambling problems earlier, severe gambling harms may be prevented.

Step 3: Data collection and analysis

Data were collected in a survey administered over three rounds between January and April 2016. In the survey, participants were asked to rate each of the helping statements, using a 5-point scale (‘essential’, ‘important’, ‘don’t know/depends’, ‘unimportant’ or ‘should not be included’), according to whether or not they thought the statement should be included in the guidelines. In Round 1, participants also could provide qualitative data in the form of suggestions for new helping statements. See Additional file 1 for copies of the three rounds of the survey.

These cut-off criteria were chosen by the working group because there was only one panel and lower cut-off percentages would have yielded too many statements, making the guidelines impractical to use.

The following criteria were used to determine whether the participants’ comments would be translated into new helping statements: (1) the idea was actionable and understandable, (2) it was not a repeat of an item in the first survey, and (3) it was within the scope of the project. This new content was translated into helping statements for the Round 2 survey. The Round 2 survey also included Round 1 items that needed to be re-rated. Participants were given a summary of Round 1 that included a list of the items that were endorsed and rejected, as well as the items that needed to be re-rated in Round 2. The summary included the panel percentages of each rating, as well as the specific panel member’s scores for each re-rated item. This allowed the participants to compare their ratings with the expert panel’s consensus rating and decide if they wanted to maintain or change their answer when re-rating an item.

The procedures for Rounds 2 and 3 were the same as Round 1 with several exceptions. Round 2 consisted of new items from the Round 1 comments. There was no opportunity for comments in Round 2 or Round 3, and if a re-rated item did not receive an ‘essential’ or ‘important’ rating by 90% or more of the panel, it was rejected. Round 3 only contained items introduced in Round 2 that needed to be re-rated, according to the above criteria.

Step 4: Guidelines development

The endorsed items were written into continuous prose to form the guidelines. The first author drafted the guidelines and the working group edited the draft to produce the final guidelines document. This document was presented to the expert participants for comment and final endorsement.

Guidelines development

The first author grouped items thematically under specific headings, re-writing them into continuous prose for ease of reading. As much as possible, original wording of the items was retained. Some examples and explanatory notes to clarify the advice were given, for example, the risk factors for gambling problems were included in the guidelines. The draft guidelines were then presented to participants for final comment, feedback and endorsement. All participants endorsed the guidelines without suggesting changes.

Comparison between these guidelines and the guidelines for people from English-speaking Western countries

Recently, guidelines for assisting a person with gambling problems from English-speaking Western countries have been published [17, 18]. There are some notable differences between these two sets of guidelines (see Additional file 3 for a comparison of the two sets of items). The Aboriginal and Torres Strait Islander guidelines include a section on the impact of culture on gambling problems. This section includes more general information about Aboriginal and Torres Strait Islander understanding of health and well-being, as well as specific social expectations that may impact on gambling problems. For instance, the expert panellists determined that the first aider should know about the Aboriginal and Torres Strait Islander expectation that one provides for their family and kin. It is important that the first aider know this because this cultural norm may mean that the effects of gambling are felt more widely throughout the community or that gambling harms are lessened, reducing the motivation to change [25].

Another difference is in the way the first aider should approach the person. In the guidelines for English-speaking Western countries, the first aider should “First state some positive things about the person and your relationship with them” and then “… talk about what behaviours you have noticed…”. This is a more direct approach than what is recommended if you are concerned about an Aboriginal or Torres Strait Islander person, where a ‘gentle’ and ‘gradual’ approach is recommended, including having a “yarn (discussion) about other topics to try to find some common ground for discussion” before introducing concerns about gambling.

The most notable difference between these guidelines and the guidelines for English-speaking Western countries is in the number of items related to money that were endorsed. The survey had items relating to financial warning signs (e.g. complaints about mounting debt) and financial strategies for reducing the impact of gambling (e.g. leaving cash at home when going gambling). Of the financial signs that were rated, 67% were endorsed in the previous survey, while only 41% were endorsed in the Aboriginal and Torres Strait Islander survey. It may be that because Aboriginal and Torres Strait Islander people experience economic disadvantage at higher rates than non-Indigenous people [26], some of the financial signs may be indicators of this general economic disadvantage rather than of gambling problems specifically. Furthermore, 80% per cent of the financial strategies to reduce the impact of gambling were endorsed in the survey for English-speaking Western countries as compared to only 25% for the Aboriginal and Torres Strait Islander survey. Examples of the financial strategies include leaving cash at home when going gambling and allowing someone else to temporarily manage accounts or money. A number of social factors may be responsible for these items not being endorsed in the Aboriginal and Torres Strait Islander study. Household overcrowding, particularly in rural and remote households, may mean that if money is left at home it may be used by others in the household [4, 27]. Also money is often seen as a shared resource rather than belonging to any one individual in the family or household [28, 29], making some of the items about giving someone else control over your money irrelevant. Finally, poor financial literacy for some Aboriginal and Torres Strait Islander people and limited access to financial services for rural and remote people [28] may mean some of these items are not applicable to some Aboriginal and Torres Strait Islander people, e.g. “Increases their usage of or acquires additional credit cards” as a warning sign for gambling problems.

This research has a few limitations. First, there is limited research that indicates what is most helpful for Aboriginal and Torres Strait Islander people with gambling problems; therefore, limiting the initial literature search. However, because participants could suggest missing helping actions, this limitation should be minimised. Another limitation is the possibility that some participants rated statements that were beyond their expertise, leading to an omission of useful items. Furthermore, participants were not able to discuss their comments with others. If panel members held biases or incorrect assumptions that were unchallenged because there was no opportunity for discussion, it is possible that key actions were omitted from the guidelines. The panel size for this research is another potential limitation – despite extensive recruitment only 22 people completed all three surveys. Akins, Tolson and Cole [30] found that “Panels of similarly trained experts (who possess a general understanding in the field of interest) provide effective and reliable utilization of a small sample from a limited number of experts (in this case 23) in a field of study to develop reliable criteria that inform judgment and support effective decision-making.” The use of only one panel of experts (professionals) could be seen as a limitation. However, a majority of the participants had experienced gambling problems in themselves, a family member or community member giving them ‘lived experience’ expertise as well. Finally, although it was the intent to recruit Torres Strait Islander people to the expert panel, we were unable to do this and this may limit the applicability of these guidelines to this population.

Future research to develop guidelines for helping Aboriginal and Torres Strait Islander family and community members affected by another person’s gambling would be beneficial. Also, research could evaluate the perceived usefulness of downloading and reading these guidelines, as has previously been done for other sets of mental health first aid guidelines by Hart and colleagues [31]. Furthermore, research could be conducted to validate the identified signs of gambling problems or the effectiveness of the actions suggested in the guidelines. Finally, any courses that are developed using these guidelines should be evaluated.