This article is available in: PDF HTML  Reflections on Poverty, Homelessness, and Problem Gambling: Discoveries from a World Café

Journal Information
Journal ID (publisher-id): jgi
ISSN: 1910-7595
Publisher: Centre for Addiction and Mental Health
Article Information
Article Categories: Original Research
Publication date: September 2019
Publisher Id: jgi.2019.42.4
DOI: 10.4309/jgi.2019.42.4

Reflections on Poverty, Homelessness, and Problem Gambling: Discoveries from a World Café

Eden Hamilton Wright Princess Margaret Cancer Centre, Toronto, ON, Canada
Julia Woodhall-Melnik Department of Social Science, University of New Brunswick, St. John, NB, Canada
Sarah Hamilton-Wright MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, ON, Canada
Sara J.T. Guilcher Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
Aklilu Wendaferew Good Shepherd Ministries, Toronto, ON, Canada
Andrée Schuler MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, ON, Canada
Flora I. Matheson MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, ON, Canada

Abstract

Problem gambling is a hidden public health concern, especially among people who experience poverty and homelessness, with studies from North America showing a combined prevalence of lifetime problem and pathological gambling ranging from 29.8% to 58.2%. Service providers in the non-addiction sectors (e.g., housing and primary health care) have not traditionally screened their clients for problem gambling behaviours or concerns. In an effort to build multi-sector awareness and stimulate discussion about problem gambling, poverty, and homelessness, we invited practitioners from the social, health, and human services community and people with lived experience to join a knowledge translation and mobilization event in which we used the World Café method. The purpose of this paper is to summarize the knowledge generated about problem gambling, poverty, and homelessness from the perspectives of the World Café participants. We identified themes that align with quality of care espoused by the World Health Organization, Health Quality Ontario, and the Organisation for Economic Co-operation and Development. These themes include delivering care that is highly accessible to clients who are experiencing poverty in a one-stop shop that is timely and efficient, patient centred and equitable with respect to gender and sexual orientation, culturally sensitive, and trauma informed and that provides a therapeutic alliance and safe space to enhance well-being. Participants identified the need for a plain-language, accessible definition of problem gambling and the need to create awareness of the harm associated with problem gambling in targeted messages that engage clients, policy makers, and the general public.

Keywords: problem gambling, World Café, knowledge translation, quality of care, health and social services, community engagement

Résumé

Le jeu problématique est un problème de santé publique caché, en particulier chez les personnes en situation de pauvreté et d'itinérance, avec une prévalence combinée du jeu problématique et du jeu pathologique au cours de la vie allant de 29,8 à 58,2%, selon des études réalisées en Amérique du Nord. Les fournisseurs de services dans les secteurs non liés à la toxicomanie (p. ex., le logement et les soins de santé primaires) n’ont pas toujours soumis leurs clients à un dépistage de comportements ou de problèmes liés au jeu. Dans le but de sensibiliser les différents secteurs et de stimuler la discussion sur la dépendance au jeu, la pauvreté et l’itinérance, nous avons invité des praticiens de la communauté des services sociaux, de la santé et communautaires et des personnes ayant une vécue cette expérience à se joindre à un événement d’application des connaissances et de mobilisation, en nous fondant sur la méthode « World Café ». Le but de cet article est de résumer les connaissances générées sur le jeu problématique, la pauvreté et l’itinérance, du point de vue des participants au World Café. Nous avons relevé des thèmes correspondant à la qualité des soins préconisés par l’Organisation mondiale de la santé, Qualité des services de santé Ontario et l’Organisation de coopération et de développement économiques. Ces thèmes incluent la fourniture de soins 1) grandement accessibles pour les clients en situation de pauvreté, dans un guichet unique rapide et efficace 2) centrés sur le patient et équitables en ce qui concerne le genre et l’orientation sexuelle; 3) adaptés à la culture; 4) sensibles aux traumatismes; 5) offerts en alliance thérapeutique et 6) prodigués dans un espace sécuritaire pour améliorer le bien-être. Les participants ont relevé la nécessité de formuler une définition de la dépendance au jeu en termes simples et accessibles, ainsi que la nécessité de sensibiliser le public au préjudice associé au jeu problématique dans des messages ciblés qui engagent les clients, les décideurs et le grand public.

Introduction

Both problem gambling (Korn, 2000; Korn & Shaffer, 1999) and homelessness (Begin, Casavant, Chenier, & Dupuis, 1999; Echenberg & Jensen, 2008; Hwang, 2001; Rogers, Button, & Hume, 2005) are serious public health concerns. Several studies in the United Kingdom, the United States, and Canada have documented an association between problem gambling and homelessness (Crane et al., 2005; Gattis & Cunningham-Williams, 2011; Holdsworth, Tiyce, & Hing, 2012; Sharman, Dreyer, Clark, & Bowden-Jones, 2016). Research indicates that the combined prevalence of lifetime problem and pathological gambling ranges from 29.8% to 58.2% among people who are experiencing homelessness or using a community service (Lepage, Ladouceur, & Jacques, 2000; Matheson, Devotta, Wendaferew, & Pedersen, 2014; Nower, Eyrich-Garg, Pollio, & North, 2015). Studies also indicate that some subpopulations of those who are experiencing homelessness are at greater risk of developing problem gambling, such as veterans (Edens & Rosenheck, 2012), men (Matheson et al., 2014), and newly homeless adults aged 50 years and older (Crane et al., 2005).

The relationship between problem gambling and homelessness is complex. Studies find that multiple concerns associated with poverty, such as unemployment, bankruptcy, unaffordable rent, and eviction, contribute to the relationship between problem gambling and homelessness (Antonetti & Horn, 2001; Crane et al., 2005; Holdsworth et al., 2012; Williams, Rehm, & Stevens, 2011). Problem gambling is also associated with a variety of psychiatric conditions in persons who experience homelessness. In an analysis of survey data from 275 predominately African American individuals who were experiencing homelessness, Nower et al. (2015) found that problem gambling was associated with an increased risk of meeting diagnostic criteria for psychiatric disorders and substance dependency (see also Ferentzy, Skinner, & Matheson, 2013). The associations between problem gambling, mental health, poverty, and substance abuse illustrate the need to engage with diverse social and health service agencies to design interventions and services that are effective for persons who are experiencing homelessness and problem gambling (Guilcher et al., 2016).

Early speculation on the direction of the relationship between problem gambling and homelessness indicates bi-directionality (Sharman et al., 2016). An analysis of quantitative data with 72 persons who were experiencing homelessness in the United Kingdom indicates that problem gambling predominantly leads to homelessness. However, the authors note that some gambling behaviours develop after individuals become homeless (Sharman et al., 2016). Exploratory qualitative studies also found that problem gambling contributes to homelessness. For example, in their analysis of qualitative interviews with 18 homelessness service providers and 17 of their clients in Australia, Holdsworth et al. (2012) noted that gambling negatively affects financial security, relationships, and support networks.

Services for problem gambling screening, prevention, and treatment are scarce and prospective clients may be unfamiliar with gambling-focused services and/or dissatisfied with those that are available (Evans & Delfabbro, 2005; Guilcher et al., 2016; Hamilton-Wright et al., 2016; Pulford et al., 2009; Scull & Woolcock, 2005). Crane et al. (2005) identified a prevalence rate of 15% for problem gambling in newly homeless older adults in the United States, England, and Australia; however, the authors noted that few adults accessed support for gambling. A recent qualitative study that explored service access for men who experience problem and pathological gambling called for an expansion of services to address problem gambling. Specifically, researchers argued that there is a need for integrated services that address concurrent social and health needs such as housing, mental health, substance use, and poverty (Guilcher et al., 2016). Nower et al. (2015) recommended that agencies who serve people who are experiencing homelessness screen for problem gambling; however, this requires that agencies be equipped to provide access to population-appropriate services. Persons who experience homelessness are highly stigmatized and less likely to seek help for problem gambling behaviours or for associated financial, relationship, and health problems (Baxter, Salmon, Dufresne, Carasco-Lee, & Matheson, 2016; Holdsworth et al., 2012; Suurvali, Hodgins, Toneatto, & Cunningham, 2012).

This paper presents the findings from a unique community engagement event, the World Café, which gathered human, social, and health sector participants together to generate collective knowledge about problem gambling, poverty, and homelessness.

Gambling Services Considerations

Research on service delivery and service needs for problem gambling is scarce, more so for people who are experiencing poverty and homelessness. In a recent qualitative study (Pickering, Spoelma, Dawczyk, Gainsbury, & Blaszczynski, 2019), service users (n = 32) provided their perspectives on recovery. They viewed it as a continuous process, one through which service users can develop insight into the psychological and environmental factors that promote gambling. This insight enhances people’s sense of empowerment to overcome the addiction. The service users perceived that engagement in non-gambling activities, nurturing of social networks, stabilization of finances, and a concentrated focus on overall well-being were important aspects of recovery. An Australian study with clinicians and managers (n = 41) within the mental health service environment in Victoria identified barriers to gambling screening (Rodda, Manning, Dowling, Lee, & Lubman, 2018). These barriers included competing priorities, perceived importance of routine screening, lack of access to screening tools and resources, considerations of patient responsiveness, and the need for workforce training. Richard, Baghurst, Faragher, and Stotts (2017) reviewed the literature on the relation between sociocultural factors (e.g., race, ethnicity, culture) and gambling. They found little research in this area and much of it marked by inconsistent findings. The authors suggest that treatment approaches need to consider differences in net financial worth, cultural belief systems that enable gambling and negate help seeking because of perceptions of stigma, and acculturalization. In a review by Zakiniaeiz and Potenza (2018), the authors noted that the evidence on gender differences in gambling and help seeking is scant from the service delivery perspective. Some potential treatment considerations for gambling and substance misuse include gender differences in motivation to seek help and biological and sociocultural differences.

Priebe et al. (2012) spoke with 154 experts across 14 European countries from a variety of disciplines (physicians, allied health care providers, community service specialists, lawyers, and those with backgrounds in social science/policy). Using semi-structured interviews and case vignettes, the authors identified components of good practice in mental health services among socially marginalized groups, including outreach programs; integration, collaboration, and coordination of services to address the varied needs of these populations; and promotion of service awareness among potential service users and health care practitioners (also see Wieczorek & Dąbrowska, 2018). Aligned with these findings, Lewis, Black, and McMullen (2016) found that community service agencies are not equipped to address problem gambling. Training and improved provider cross-communication is necessary to enhance service coordination.

Wieczorek and Dąbrowska (2018) conducted qualitative interviews with 30 patients and 15 professionals in Poland. One focus of this research was to identify how people choose a gambling treatment facility. Findings indicated that choice was related to perceptions of ease of access (e.g., travel distance), quality and reputation of the clinic, assurances of anonymity, and patient knowledge of the treatment landscape. Factors that appeared to affect treatment included lack of availability of outpatient gambling treatment services, long wait lists, and groups that did not cater specifically to people who were experiencing a gambling disorder.

In an effort to mobilize knowledge from problem gambling research and stimulate discussion about connections between recovery services for problem gambling, poverty, and homelessness, we invited practitioners from the social, health, and human services community to join a World Café. The World Café is a specific type of knowledge translation and mobilization event that provides participants with a welcoming café-style environment (Brown and Isaacs, 2005). Participants engage in facilitated dialogue wherein conversations are constructed and reconstructed in order to move individual knowledge and experience toward collective knowledge and actionable solutions. This method allows participants to provide feedback and contribute their perspectives to research knowledge. The purpose of this paper is to summarize and mobilize the collective knowledge generated about problem gambling, poverty, and homelessness from the perspectives of the participants of the World Café.

Method

Ethics Statement

This study was part of a broader research grant that received ethics approval from the Research Ethics Board of St. Michael’s Hospital. Participants of the World Café signed an audio and visual consent form as required by the St. Michael’s Hospital Communications Department.

The World Café Method

The World Café (Brown et al., 2005) is modelled after appreciative inquiry, which emphasizes strength-based learning and mutual creativity, to move participants and facilitators as a collective group from discussions of questions to solutions that can produce actionable change (Cooperrider, Whitney, & Stavros, 2008; Emlet & Moceri, 2012). The World Café offers participants an informal, safe, and intimate setting for the exchange of ideas with the purpose of blending diverse knowledge and experience into learning. World Cafés are designed to move the conversations from the personal, to the collective and present moment, to the future (Brown et al., 2005).

The World Café aligns with the Knowledge Creation phase of the Knowledge to Action Framework wherein knowledge is tailored to create products, services, and tools that are useful for promoting change in a local context (Crane et al., 2005; Field, Booth, Ilott, & Gerrish, 2014). The World Café gathers participants into small groups seated together at café tables. These groups are invited and encouraged to engage in progressive rounds of conversations that inform larger interconnected conversations (Fouché & Light, 2011). In this way, intimate café table conversations form the stepping stones to thoughts on collective action (Fouché & Light, 2011). As Brown et al. (2005) suggests, the setting and structure of the conversations within the World Café method promote a natural progression in conversation from discussions of individual experience to deeper discussions on the subject matter. The ultimate goal is to move knowledge toward actionable solutions.

Participant Recruitment

This research was conducted in partnership with the Good Shepherd Ministries (GSM), a non-profit organization that provides shelter, addiction, and mental health services to men in Toronto, Canada. The research team worked with GSM to compile a list of 50 contacts from community and government agencies within the Greater Toronto and Hamilton areas in Ontario, Canada. An email invitation was sent to each of these participants and 18 persons agreed to participate in the World Café. In total, 14 of the 18 persons attended the café event. In addition, the staff invited participants with lived experience of gambling and precarious housing to participate. Two participants with lived experience attended the World Café, for a total of 16 participants. Ten different organizations represented the housing and shelter sectors, social services, gambling support services, family and community medicine, municipal government, and public health. Two of the organizations had more than one representative in attendance. The other organizations (n = 8) had one representative each. Two days prior to the event, we placed a reminder call to the participants. The participants themselves included service providers, clinicians, clients, and policy makers. Participants received a lunch and a gift bag as a token of appreciation.

The World Café Design

The World Café was designed in accordance with seven principles (Brown & Isaacs, 2005). The creation of a welcoming, café-style environment is integral to facilitating meaningful conversations among participants. The research team arranged five tables with colourful tablecloths topped with white paper tablecloths. Participants were encouraged to use these white paper tablecloths to write about and sketch their conversations, thoughts, and reflections. At the start of the World Café, participants engaged in an icebreaker activity and were provided with meals, drinks, and snacks throughout the day.

The World Café began with a short introductory presentation that described findings from a qualitative study conducted at GSM. In the study, the team explored client experiences of gambling, homelessness, health, and service delivery (barriers/facilitators, intervention points; Guilcher et al., 2016; Hamilton-Wright et al., 2016). The participants were then engaged in two rounds of conversation for each of the three questions that were developed for the World Café. After the participants discussed a question at one table, they were asked to travel to a new table to discuss the same question with different participants. The World Café facilitator (F.I.M.) asked that one person remain at each table to act as table host and share the essence of the previous conversation. Participants were asked to link ideas that they brought from their previous table conversations. At the end of each set of two rounds of conversation, all participants came together for what is referred to as a “harvest.” Brown et al. (2005) describe the harvest as a time for all participants to contemplate the essence of the small-table conversations through collective thinking. This process enables ideas and connections between ideas to become visible to participants and researchers.

The World Café method allows for the exchange of ideas, with collaboration and understanding at the heart of the exchange. From the table conversations to the group harvest, discussions were focused on sharing ideas for positive action. Participants were respectful of all points of view and demonstrated a clear understanding of the goal of the World Café, which is sharing personal perspectives to achieve collective action.

Participants with lived experience spoke openly about their experiences of homelessness and problem gambling, which deepened the conversations. Many service providers voiced that their own experiences in working with clients aligned with the perspectives shared by the two participants with lived experience. During the group harvest, there was recognition from all participants that the common themes derived from table conversations and group discussions were similar.

The research team and GSM staff co-developed the questions that were used for the World Café. These questions were based on the knowledge generated from a larger qualitative study, which found an unmet need for services for persons who concurrently experience problem gambling and homelessness (Guilcher et al., 2016; Hamilton-Wright et al., 2016). The questions (see Table 1) were designed to help the research team and our community partners to understand the current system responses for people who experience homelessness and poverty.

Table 1 Discovery World Café Questions

Data Collection: The World Café Event

The World Café was held in Toronto, Ontario, on November 24, 2014. Throughout all activities, the participants were encouraged by the facilitator to listen to one another and to collectively develop insights and look for themes in their conversations. The World Café method typically captures knowledge through tablecloth drawings or graphic recordings, which are collected during the table conversations and the harvest (Brown et al., 2005). The research team collected visual data from the tablecloths and seven scribes captured the table conversations. Table hosts and scribes were trained researchers, all versed in qualitative approaches to data collection and analysis. The lead researchers met with the table hosts to train them on the World Café approach and best practices in the collection of field notes and in facilitation. All handwritten notes were typed.

Analysis

The analysis focused exclusively on the scribed notes from table conversations and the group harvest, which were richer than the information captured on the tablecloths. We conducted thematic analysis by following the approach described by Aronson (1995) and Braun and Clarke (2006). Aronson (1995) suggested a pragmatic approach, which can be used to analyse direct quotes or paraphrased notes. First, analysts identify general patterns in the data. Each pattern is used to categorize the data. Patterns are then collapsed and synthesized into themes and subthemes from their similarities (Aronson, 1995; Braun & Clarke, 2006).

Four members of the research team (F.I.M., S.H.-W., J.W.-M., and E.H.W.) individually reviewed the data to identify recurrent patterns and collated it. The team members met prior to beginning the coding process and reviewed the patterns emerging. Then each team member reviewed the scribe notes and constructed initial codes. The team then met to review the proposed initial 13 codes and finalized these codes to provide a framework for later analysis. Collectively the research team reviewed, and categorized, the data into eight themes. Microsoft Excel was used to organize the data. As we did not audio-record the conversations, we used paraphrased examples of participants’ thoughts, as recorded by the scribes, in the findings. To enhance methodological rigour (Flick, von Kardorff, & Steinke, 2004; Maxwell, 2002), we incorporated investigator triangulation, having several observers (scribes) taking notes with different participants and using both the scribed table and harvest notes for coding and analysis. We member checked the data (to verify the emergent themes) with a co-author on the paper who is a service provider and World Café participant. Finally, during coding and analysis, team members met several times to verify common themes.

Results

Define Problem Gambling Behaviours

Participants thought that the use of the term “problem gambling” presented a barrier to client engagement with services. Given that gambling has been normalized as a legal activity in Ontario, participants were concerned that clients and their family members may under-report problem gambling or not recognize the harms associated with gambling because of this normalization. They felt that using language that would be familiar to clients was important in order to remove barriers to care.

We really need to use street language because it’s not going to work for them. The standard definition.

Clients with complex needs have to understand the complexity of their own issues. A street language that describes their behaviours and how it's disrupting their own lives.

Participants felt that health and social service staff could educate clients on harmful effects associated with problem gambling; this could help clients to self-identify potential harmful behaviours before they escalate into problems that are more serious. Participants suggested that service agencies adopt a “street” or “plain language” definition that reflects the harms associated with gambling rather than relying on a clinical definition.

Foster Therapeutic Relationships and Space

Participants felt it was important to have time to develop rapport with their clients. Rapport is necessary to build sustainable and trust-based relationships to enhance continuity of care. Participants noted that therapeutic spaces, with warm, inviting, and calming atmospheres, encouraged clients to access care and meaningfully engage with providers; such spaces also provided a setting where participants may feel comfortable talking about stigmatized behaviours, as described below from the scribe notes.

Services need to be more comfortable for people, especially for most people who are not used to an office setting, something to calm the mind.

Other features of therapeutic space that emerged from the data were acceptance of clients’ spirituality and pets, as well as integrated music therapy. Client-centred care, in which each client develops a care plan with his or her providers, was identified as an important part of the therapeutic relationship that allowed clients to prioritize their health needs.

Improve System Supports for Client-Centred Care

There was a common belief among participants that clients who experience problem gambling could receive high-quality, client-centred care despite existent systemic barriers. This idea was captured in the scribe notes during the table conversations.

I come from shelters, any type of issue comes up at the shelters, the population evolves over time, and the shelter workers have to gain more and more skills to respond to all of the needs.

Participants felt that unwelcoming practice settings and funding shortages within housing support services were detrimental to quality of care and accessibility of problem gambling services for clients who were experiencing poverty and homelessness. For example, job-related stress, burnout, and high staff turnover inhibited the foundation of long-term therapeutic relationships between providers and clients; such relationships promote service acquisition and adherence to care. There was a sense of frustration that excess administrative responsibilities (e.g., reporting and comprehensive intake assessments), amidst limited funding and human resources, impaired providers’ ability to engage with and fully support clients.

Train Service Providers to Screen for Problem Gambling

Training was viewed as essential to high-quality provision of care for clients facing poverty, homeless, and gambling concerns. According to participants, training would encompass prevention, screening, treatment approaches, and knowledge of existing resources to support people with gambling concerns, as captured in the scribe notes below.

That’s a good example because we have developed the capacity to help people with drug addictions and things like that, so we need to develop our capacity in terms of understanding what gambling is and how to conduct assessment of gambling, what are the resources that are out there. We see that it is a serious problem in the homeless population and if we don’t address it, we miss an opportunity to address an important problem.

Clients with complex needs also need insight and awareness into their needs, more funds for staff to learn how to meet needs of complex patients, clients need a street language that describes the behaviour that they understand and how it affects their lives.

Scribes captured the participants’ conversation on the value of training on screening for problem gambling among service providers in novel settings such as shelters, trusteeship programs, and medical settings.

…we have developed the capacity to help people with drug addictions, so we need to develop our capacity in terms of understanding what gambling is and how to conduct assessment of gambling. We see that it is a serious problem in the homeless population and if we don’t address it, we miss an opportunity to address an important problem.

In our agencies, the training is critical but we don’t really know what interventions we would do. The interventions are traditionally designed for the casino-going public.

Building capacity among service providers and agencies who frequently serve as the first point of contact for populations who are experiencing poverty could help to ensure that clients at risk of gambling-related harms are identified early. From the table conversation described below, this is especially important, as problem gambling is associated with poverty and homelessness.

Broaden the Service Delivery Model to Better Meet Client Needs

…they use a lot of technology in lots of other sectors but we use it in health care only to write notes a lot of the time. But there’s so much more technology that can be used but some clients can’t get five blocks to the hospital… if they are acutely ill, but you can link up with clients through a secure video conference system to bridge people instantaneously. Some people feel like it won’t be as personalized but once every three or four sessions the counsellor could go out in person and make those connections. They are doing it in Vancouver and they are a few steps ahead because they have much more of an acute problem.

Participants felt that the current approach to service delivery did not meet client needs and did not provide service accessibility at key times. They stated that clients often experience urges to gamble in the evening and on weekends, well outside the service delivery hours of operation. The World Café participants suggested that services could be provided outside normal business hours, such as evenings (e.g., 7pm to 11pm) and weekends, when people may be more at risk of gambling.

Rethink Silos and Geographically Dispersed Service Delivery Models

It is difficult to address gambling concerns among people who are experiencing poverty and homelessness when services are delivered in silos. For example, clients who need housing along with treatment for problem gambling had difficulty gaining access to these services through a single agency, as articulated in the scribe note below.

Gambling needs to be addressed in a holistic way, as well just like mental health and addiction, because if we don’t address all issues that people have, then they won’t adequately address their gambling either.

These silos make it extremely difficult to offer integrated care for clients with concurrent health and social needs. When services are dispersed geographically, people who face homelessness and poverty may have insufficient money to travel to services, even to those that address basic needs (e.g., food, clothing). According to participants, travel costs to geographically dispersed service agencies may discourage help seeking and create potentially insurmountable barriers and fatigue for people who face physical disability and mental health concerns. This concern was a collective concern of the participants and captured in the scribe notes below.

Having that team allows for a multiple point of entry into all sectors, so every door allows access to whatever the needs are.

In terms of developing capacity, the shelters are the gateway to help but transportation is a huge barrier, so sometimes agencies try to do everything in house so transportation doesn’t become an issue. So, in order to partner, you would need a fund to get people into places and then there’s capacity, you can send people out to deal with something and they could get distracted and drop off but if it’s in house, you may not get people dropping out.

World Café participants said that mobile clinics may provide an opportunity to reach out to clients where they are, whether it be in shelters, in social housing, or on the street. Multidisciplinary clinics were discussed as a way to meet the diverse needs of clients (e.g., housing, chronic care, dental care, problem gambling). Online services offer another alternative to clients who cannot reach a physical service location. Online service spaces may provide a greater degree of anonymity and confidentiality, especially for those who fear the stigma that goes along with the label of “problem gambler,” who experience social anxiety, or who may be wary of face-to-face interaction with providers.

Ensure Services Are Mindful of Trauma and Diverse Gender and Sexual Identities

According to the World Café participants, many people who engage in problematic gambling behaviours experienced early childhood trauma; thus services, regardless of focus (e.g., shelter, gambling), should be trauma informed and address gender and sexual identity, all of which play a role in whether people will seek services. For example, people identifying within LGBTQ2IA communities may differ in how they disclose their gambling and shelter concerns and how or if they seek help.

There was a discussion earlier about trauma being a factor, so you may need someone who focuses on trauma counselling, so having that multidisciplinary team is important.

Participants indicated that research that investigates the intersection of problem gambling, homelessness, sexual identity, and gender could identify specifics of service needs and patterns of help seeking, which in turn, could inform practice. Issues of trauma and the diversity of the population were discussed by the participants and captured as shown below in the scribe notes.

One of the agencies talked about the case workers and the responsibilities, and increasingly the requirement is that they are to know more and more about different things and then you have the gender differences, certain men and women would prefer to get information face-to-face so they can see the social cues and tone of voice because that’s their preferred form of getting information, so it’s that piece in terms of information (instead of the web). And clients with complex needs need a lot of resources, so more resources for general counselling, more therapeutic/psychosocial kinds of work but we don’t have the funding to go there…it’s not just about gambling but it’s also about risk-taking behaviour.

The World Café participants noted that it is important to recognize that there is an element of hope that is entwined with gambling. Participants felt that this was unique to problem gambling in comparison to other addictions. Hope, and its dissolution, was of concern to many participants and emerged in table conversations and in larger group discussion, as noted in the scribe note below.

I harken back to what someone mentioned this morning that gambling instils hope, so I don’t know if the other agencies can speak to that, if it’s a legitimate piece because in the homeless population it plays a role, so in order to motivate someone to set aside the gambling, so as a counsellor, you need to find what are the legitimate things that you can offer to the client that will substitute that hope for some other form of hope that’s more concrete.

If gambling is a source of hope for those who desire to escape poverty and homelessness, service providers need to find innovative ways to encourage clients who are seeking pathways out of poverty to stop or reduce their harmful gambling behaviours and find other sources of hope.

Enhance Awareness of the Connection Between Problem Gambling, Poverty, and Homelessness

Participants suggested that there is a need to enhance awareness about the harms associated with problem gambling among clients, policy makers and the public and that creating awareness of the high prevalence of problem gambling and gambling-related harms among people facing poverty and homelessness is especially important. In the table conversations, participants suggested that client educational resources could address the risks and consequences of problem gambling and post them in novel settings such as shelters and places that provide drop-in services, as noted in the scribe notes below.

Prepare pamphlets for easy access to websites that provide information about the programs available and the support they provide.

Targeted advertising campaigns that use traditional and social media could enhance the public’s awareness of problem gambling among those facing poverty and homelessness.

Prevention should be attacked the same way they got you – should be more in the media, pumping at you constantly [to counteract advertising that promotes a better life through gambling].

Advertising that counteracts media stories that glorify gambling, or that provide a more balanced assessment of gambling, are important to improve public awareness about gambling-related harms that can lead to poverty and homelessness. Participants felt that the government was doing little (and may not be sufficiently informed) to create awareness of the harms associated with gambling or in counteracting advertising that encourages gambling, especially among youth and those who are experiencing homelessness. As captured by one of the scribes:

If people higher up in government (municipal, provincial) don't know about these issues, they need to be informed.

Discussion

In this paper, we discuss the use of the World Café as a knowledge translation and mobilization approach. We asked social and health service providers and people with lived experience to discuss their perspectives on problem gambling, poverty, and homelessness. Several themes emerged from our analysis that indicate the need to alter and add to current services to better reach and assist persons who experience poverty and homelessness with problem gambling.

The World Health Organization (WHO), the Organisation for Economic Co-operation and Development, and Health Quality Ontario define quality of care as effective, efficient, cost-effective, accessible, timely, patient-centred, responsive, equitable, and safe (Health Quality Ontario, 2017; Kelley & Hurst, 2006; WHO, 2006). The findings of our study reflect these quality domains. For the service providers and persons with lived experience who participated in the World Café, high quality of care emerges from therapeutic relationships and meets the clients where they are most comfortable. This is in line with the principle of patient centricity, responsiveness, and equity of care (Horvath, 2000). Accessible, timely, and efficient services—delivered within a one-stop-shop model to meet the multiple needs of low-income and homeless clients—are preferred, rather than a service delivery model that is based on silos. Integrated services could reduce the cost of accessing care, which would promote both system efficiency and service accessibility for clients who experience homelessness, poverty, and problem gambling. Integration of gender, sexuality, and trauma-informed care into gambling and other addiction services would provide increased patient centricity and responsiveness in care. Equity of care and patient-centred services align with the therapeutic relationship predicated on promoting safety.

Therapeutic relationships are important to client engagement and re-engagement (Karver, Handelsman, Fields, & Bickman, 2006; Lambert & Barley, 2001), especially among people who experience significant stigmatization and marginalization (Baxter et al., 2016; Holdsworth et al., 2012). Smith, Thomas, and Jackson (2004) explored a number of process variables believed to influence counselling outcomes for people who were experiencing problem gambling. They found that the therapeutic relationship was the strongest predictor of gambling problem resolution. Guilcher et al. (2016) explored service needs among men at a downtown Toronto shelter who also experienced gambling concerns. Men preferred client-centred services through which they could be active contributors to decisions that affected their health and recovery from problem gambling. They also felt that treatment settings should be less clinical and more inviting and that integrated services would be more appropriate to address a variety of social and health needs, including problem gambling.

There are opportunities to develop community outreach programs that are person centred and to incorporate the principles of quality care to assist people who experience poverty, homelessness, and problem gambling. These programs could be modelled after pre-existing outreach programs, for example, programs developed to assist female sex workers with addictions recovery (Bowser, Ryan, Smith, & Lockett, 2008; Deering et al., 2011; Yahne, Miller, Irvin-Vitela, & Tonigan, 2002), elderly women struggling with alcohol addiction (Fredriksen, 1992), and youth who are homeless and/or struggling with addictions (Carmona, Slesnick, Guo, Murnan, & Brakenhoff, 2017; Hughes et al., 2013). Research suggests that recovery is enhanced when programs employ peer outreach workers and treatment is trauma informed with a lens on gender and sexual identity (Boughton & Falenchuk, 2007; Deering et al., 2011; Deren, Kang, Mino, & Guarino, 2012; Grant & Potenza, 2006; Latkin, 1998). This aligns with the recommendations from service providers and people with lived experience that emerged from the World Café. Future research should evaluate the efficacy of trauma-informed outreach programs, with a diverse gender and sexual identity lens, for persons who experience homelessness, poverty, and problem gambling.

Knowledge about populations who experience poverty and homelessness is still developing. Service delivery models often do not consider the context of poverty and homelessness in the care of people who are also experiencing problem gambling. Some of the findings of our paper align with previous research. Notably, integration and coordination of services is integral to ensure that people have easy access to services. Staff training will ensure an appropriate level of awareness of problem gambling in populations who are experiencing disadvantage, the integration of tools into practice, training on screening for problem gambling, cultural influences on problem gambling and treatment seeking, and recognition and training on the importance of a gender/sex-responsive approach to care (Lewis et al., 2016; Priebe et al., 2012; Wieczorek & Dąbrowska, 2018). Integration of services is especially important for those who lack financial security in order to minimize the need to travel to multiple service providers to meet the co-morbid health and social issues faced by people who are experiencing poverty and homelessness. As with previous research, we identified that long wait lists are deterrents to care (Wieczorek & Dąbrowska, 2018). From previous research, we know that recovery from problem gambling is enhanced when patients feel their own sense of empowerment (Pickering et al., 2019).

Our findings suggest that a street-level approach may be needed to enhance client care among people who are experiencing homelessness and poverty (e.g., defining problem gambling). The findings also suggest that trauma-informed care is integral to service provision, as many who experience poverty and homelessness along with addiction have histories of childhood sexual and physical abuse and neglect (Hamilton-Wright et al., 2016; Holdsworth & Tiyce, 2013; Holdsworth et al., 2012; Roberts et al., 2017). The latter finding suggests a need to foster therapeutic relationships and spaces especially for people who have experienced stigma related to gambling, homelessness, and poverty, spaces that embrace people’s spirituality and are pet friendly. Being mindful of gender and sexual identity—and how these characteristics can affect gambling, treatment seeking, and recovery—is an important aspect of therapeutic relationships and spaces. Offering help outside traditional service hours (evenings/weekends) would ensure that clients have support when they most need it and when they are more likely to feel urges to gamble. Participants also indicated that education to counteract the pervasive advertising campaigns that promote gambling is essential to improve public knowledge of gambling harms. Education also has to reach clients of social service agencies to inform them about the harms of gambling and resources for care.

A major feature of gambling addiction is the expectation of hope to alleviate financial insecurity for those who are experiencing poverty and/or homelessness. Service providers expressed being in a dilemma when supporting these clients; for example, taking away a source of hope for a better life by encouraging clients to stop gambling could be detrimental to their well-being. Other researchers also expressed this message of hope (Holdsworth et al., 2012; Sharman & D’Ardenne, 2018; Tiyce & Holdsworth, 2011), which has unique connotations for people living in poverty.

Strengths and Limitations

This research strongly benefitted from the participation of people with lived experience of poverty, homelessness, and problem gambling. Other participants represented a small number of service provider agencies from two urban cities in Ontario. Future research should engage more providers and people with lived experience from urban, suburban, and rural areas across Canada to augment what we discovered through the World Café. Despite the small number of participants in the current study, the findings suggest concrete ways to move forward to support service providers who do not traditionally provide care for people with problem gambling concerns.

Trained scribes sat at the café tables to take notes on the conversations between participants and to document the larger harvest discussions, in keeping with the design of the World Café. Researchers often audio tape more traditional qualitative methods such as focus groups. The World Café method encourages multiple intersecting conversations that culminate in the harvest, a discussion wherein the participants identify emergent themes from the conversations. In essence, the participants engage in knowledge synthesis together.

Conclusion

The project used a unique approach to co-create knowledge. To date only a few studies have used the World Café method to examine health and social issues (Broom, Brady, Kecskes, & Kildea, 2013; Emlet & Moceri, 2011; Fouché & Light, 2011; Kellehear & O’Connor, 2008; Stöckigt, Teut, & Witt, 2013; Teut et al., 2013). This project produced a variety of actionable recommendations to improve service quality and care for persons who concurrently experience problem gambling and poverty and/or homelessness. These recommendations include the use of street language to define problem gambling for clients and creating environments that foster therapeutic relationships and space. To enhance system supports for client-centred care, participants suggested additional funding and support for service providers themselves to reduce work-related stress. Participants also felt that it is important to remove silos in the service system and to create models of service delivery that are more responsive to client needs (e.g., mobile units to go to the client). They also recommended that training on how to screen, treat, and refer for problem gambling is needed to ensure that clients can access gambling treatment through any service and that services are responsive to diverse populations such as those who face trauma or who express non-traditional gender and sexual identities. Encompassing all of these suggestions is the need to enhance awareness of the connection between problem gambling, poverty, and homelessness more generally in our society.

The findings of the study align with the definitions of quality care espoused by the WHO, the Organisation for Economic Co-operation and Development, and Health Quality Ontario and thus can inform service delivery and practice in the area of problem gambling, homelessness, and poverty. Future studies should continue to look for innovative solutions to provide accessible, targeted, high-quality care to this population.

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Submitted February 15, 2019; accepted August 9, 2019. This article was peer reviewed. All URLs were available at the time of submission.

For correspondence: Flora I. Matheson, PhD, MAP Centre for Urban Health Solutions, St. Michael’s Hospital, 30 Bond Street, Toronto, ON M5B1W8., e-mail: mathesonf@smh.ca

Competing interests: None declared (all authors).

Ethics approval: Not required.

Acknowledgements: The MAP Centre for Urban Health Solutions is part of the Li Ka Shing Knowledge Institute of St. Michael’s Hospital. This study was funded by the Ontario Problem Gambling Research Centre. S.J.T.G. is supported by the Canadian Institutes for Health Research (CIHR) Embedded Clinician Scientist Award in Transitions in Care (2016-2020). The views expressed in this publication are the views of the authors and do not necessarily reflect those of the funders.

This event would not have been possible without the enthusiasm and genuine interest of the World Café participants. We are indebted to them for sharing their thoughts on service needs and solutions. We thank each of our table scribes for their contribution: Anita Mohan, Rafeya Shami, Eden Hamilton Wright, Fiona Park, Julia Woodhall-Melnik, Sarah Hamilton-Wright, and Kimberly Devotta.

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