This study was carried out between February and April 2021, amid lockdown due to the COVID-19 pandemic. A total of 601 individuals participated in this study by filling the online questionnaire. The sample was selected based on different demographic backgrounds from the five governorates of Lebanon (Beirut, Bekaa, Mount Lebanon, South Lebanon and North Lebanon) using a snowball technique. We contacted friends and family members to fill the online survey, then each participant was asked to forward the survey link to other friends and family members. Respondents were briefed about the topic, and the different aspects of the questionnaire before filling it out, while being assured of the confidentiality of their answers by one of the collaborators of this research project. Inclusion criteria included people above 18 years old living in Lebanon.
Minimal sample size calculation
According to the G-power software, and based on an effect size f2 = 2%, an alpha error of 5%, a power of 80%, and taking into consideration 20 factors to be entered in the multivariate analysis, the results showed that a minimal number of 395 was needed.
The questionnaire sent to the participants was in the Arabic language, which is the official language of Lebanon as well as the native language of all respondents. The questionnaire includes a sociodemographic section, and a scale-based section regarding different factors, as follows:
In this part of the questionnaire, participants were asked about their general sociodemographic data, including their age, gender, educational level, income, marital status, number of children, physical activity index and information about the household crowding index of the participants. The physical activity index was obtained by multiplying the daily activity intensity, frequency and duration ,whereas the household crowding index was calculated by dividing the number of persons living in the house by the number of rooms excluding the kitchen and bathrooms.
The following scales were used in the questionnaire:
This is a questionnaire consisting of 20 rated items, at a rate of 1 point per item. The SOGS scores are interpreted as follows: A score of 0 to 2 indicates no problem with gambling, a score of 3 or 4 indicates some problem with gambling, and a score of 5 or more indicates probable pathological gambling. The cutoff score of 5 has been discussed, especially in some countries like Australia, after very high prevalence rates (> 6%) were found using this cutoff. Thus, some studies propose a cut-off score of 10 making it possible to obtain prevalence rates similar to those found in the international literature. The sensitivity of this questionnaire is estimated at 99%. Its specificity is estimated at 83%, which results in a risk of false positives . (Cronbach’s alpha in this study = 0.947) The permission to use this questionnaire was obtained from Dr. Henry Lesieur and the South Oaks Foundation. The original SOGS was used with a lifetime-based measure.
The Alcohol Use Disorders Identification Test (AUDIT) was developed by the World Health Organization in 1982 as a simple way to assess alcohol consumption, drinking behaviors, and alcohol-related problems . It is a 10-item screening tool used to detect risky and harmful drinking patterns during the past 12 months. The answers are scored on a point system; a score of 8 or more is the threshold for identifying hazardous or harmful alcohol consumption . (Cronbach’s alpha in this study = 0.857).
The Fagerström Test for Nicotine Dependence, validated in Lebanon , is a standard instrument for assessing the intensity of physical addiction to nicotine. This test was designed to provide an ordinal measure of nicotine dependence related to cigarette smoking. It contains six items that evaluate the quantity of cigarette consumption, the compulsion to use, and dependence. In the scoring of the Fagerström Test for Nicotine Dependence, yes/no items are scored 0 or 1 and multiple-choice items are scored from 0 to 3. The items are summed to yield a total score of 0–10. The higher the total Fagerström score, the more intense is the patient's physical dependence to nicotine . (Cronbach’s alpha in this study = 0.628).
The Lebanese Waterpipe Dependence Scale-11 (LWDS-11) was used to assess waterpipe dependence . The LWDS-11 is composed of 11 items, measured on a 4-point Likert scale ranging from 0 to 3, and four subscales, which are described as physiological nicotine dependence (items 1–4), termination of dysphoric states or negative reinforcement (items 5 and 6), psychological craving (items 7–9), and positive reinforcement (items 10 and 11). The total score is reached by adding up the corresponding points and indicates the level of dependence. The LWDS-11 discriminated between mild, moderate, and heavy waterpipe smokers, based on a threshold score of 10 . (Cronbach’s alpha for the total scale in this study = 0.777).
This is an easy-to-use self-administered patient questionnaire used as a screening tool and severity measure for generalized anxiety disorder (GAD) . GAD-7 has seven items: (1) nervousness; (2) inability to stop worrying; (3) excessive worry; (4) restlessness; (5) difficulty in relaxing; (6) easy irritation; and (7) fear of something awful happening. The GAD-7 score is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of 'not at all', 'several days', 'more than half the days', and 'nearly every day', respectively, and adding together the scores of the seven questions. Scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate and severe GAD, respectively. When used as a screening tool, further evaluation is recommended when the score is 10 or greater. (Cronbach’s alpha for the total scale in this study = 0.939) . The GAD-7 is validated in the Arabic language in Lebanon .
The PHQ-9 (Patient Health Questionnaire-9) is a 9-question instrument given to patients in a primary care setting to screen for the presence and severity of depression according to DSM-4 criteria. This questionnaire takes less than 3 min to complete. Scores range from 0 to 27. In general, a total of 10 or above is suggestive of the presence of depression . (Cronbach’s alpha for the total scale in this study = 0.926). The PHQ-9 is validated in the Arabic language in Lebanon .
Translation procedure of the SOGS
Two independent certified translators performed the forward translation (from English to Arabic), and adapted it in a way that suits the Lebanese culture. Then, they reviewed, reconciled and harmonized this translation. The back-translation (From Arabic to English) was performed by two other independent certified translators, who were unaware of the intended concepts the questionnaire measures and were very fluent in English. Then, a committee of experts including healthcare professionals and both the forward and backward translators matched the back-translation with the original English questionnaire to detect inconsistencies and solve discrepancies between the two versions, and reached a consensus on all items to produce a pre-final version of the forward translation. This pre-final version was pilot tested on a small convenience sample of 12 people, to make sure that the translated questions retained the same meaning as the original questions, and ensure that there was no confusion regarding the translated items. The product of this process was the finalized forward translation.
The total sample was divided into two subsamples; sample 1 (n = 401) served to perform the factor analysis (FA), whereas sample 2 (n = 200) served for the confirmatory factor analysis. The FACTOR software was used to perform the FA, using the polychoric (tetrachoric) correlation and using the parallel analysis as a procedure for determining the number of factors/components. The varimax rotation was used to extract the items since the latter were not highly correlated. The Kaiser–Meyer–Olkin (KMO) and the Bartlett’s test of sphericity p-value were calculated to ensure model’s adequacy. Similarly, a confirmatory factor analysis was performed using the same software; the GFI and AGFI values were calculated (both are Chi-square-based calculations independent of degrees of freedom), with values ≥ 0.90 considered acceptable . In addition, the root mean square error of approximation (RMSEA) and the comparative fit index (CFI) were used as these are the most commonly used indices . Values of RMSEA of ≤ 0.06 indicate a good-fitting model, while CFI values > 0.90 indicate a reasonably good fit of the model . The SPSS software v.25 was used for the remaining statistical analysis. The Kuder-Richardson 20 (KR20; equivalent to the Cronbach’s alpha value) value was calculated to indicate the internal reliability of the SOGS scales’ items. Since the SOGS total score did not follow a normal distribution, as verified by the skewness and kurtosis values (outside the range of − 2 and + 2), we divided the total score into 3 categories as follows: no gambling problems (scores between 0 and 2), some gambling problems (scores 3 or 4) and probable pathological gambling (scores of 5 or more). The Chi-square and ANOVA tests were used to evaluate the associations between the SOGS categories and categorical variables and continuous variables respectively. A multinomial regression was conducted taking the SOGS categories as the dependent variable, to assess factors associated with having some gambling problems and probable pathological gambling compared to no gambling problems (taken as the reference group). Variables p < 0.2 in the bivariate analysis were taken as independent ones in the multivariate analysis model. Significance was set at p < 0.05.