Presented at the 6th International Gambling Conference in February 2016. Presented by Sari Castrén

1. 12.2.2016 1
Reliability of instruments measuring
at-risk and problem gambling
among young individuals:
A protocol of a systematic review
covering years 2009-2015
Castrén S, Edgren R, Alho H, Salonen AH
Internationl Gambling Conference 2016_Auckland_Castren

2. Gambling scene in Finland
Availability, accessibility and acceptability
12.2.2016 Internationl Gambling Conference 2016_Auckland_Castren 2
• Tripartite monopoly system
• Expenditure on gambling one of the
highest in Europe
• Approximately 20 000 slot machines
in kiosks, shops, bars, restaurants,
gas stations, shopping centres
• Young age, male gender, high net
income and risky alcohol
consumption, associated with
favorable gambling attitudes
• Advertising and marketing are
perceptible
Salonen AH, Castrén S, Raisamo S, Orford J, Alho H, Lahti T. Attitudes towards gambling in Finland: A cross sectional population
study. BMC Public Health 2014; 14, 982-.
Castren S, Murto A, Salonen AH. Rahapelimarkkinointi yhä aggressiivisempaa – unohtuivatko hyvät periaatteet? YP. Gambling
advertising in Finland. Yhteiskuntapolitiikka, YP 2014; 79 (4):438-443.

3. Finland in World gambling map
0
1
2
3
4
5
6
7 Australia
Belgium
Canada
Denmark
Estonia
Finland
France
Germany
GreatBritain
HongKong
Hungary
Iceland
Italy
Macau
Netherlands
NweZeland
N.Ireland
Norway
Singapore
SouthAfrica
SouthKorea
Sweden
Switzerland
UnitedStates
Percentages%
Standardized Problem Gambling Prevalence Rates
Source: Williams et al. 2012. The Population Prevalence of Problem Gambling: Methodological Influences, Standardized Rates, Jurisdictional
Differences, and Worldwide Trends 2012. Report prepared for the Ontario Problem Gambling Research Centre and The Ontario Ministry of Health
and Long Term Care.
Internationl Gambling Conference 2016_Auckland_Castren12.2.2016 3

4. Finnish gambling 2015
• Past-year population prevalence, Finns aged 15-74 yrs
– Any gambling 80%
– At-risk and problem gambling (SOGS = 1+) 18.3%
– Problem gambling (SOGS = 3+) 3.3%
– Probable PGs (SOGS =5+) 1.3%
• Gambling in 2011 and 2015
– Gambling increased among 18-24 & 65-74-year-olds
– Problem gambling among women increased
– ARPG increased
Salonen A. & Raisamo S. (2015) Suomalaisten rahapelaaminen 2015. Rahapelaaminen, rahapeliongelmat ja
rahapelaamiseen liittyvät asenteet ja mielipiteet 15–74-vuotiailla. [Finnish gambling 2015. Gambling, gambling
problems, and attitudes and opinions on gambling among Finns aged 15–74.] National Institute for Health and
Welfare (THL). Report 16/2015.
Internationl Gambling Conference 2016_Auckland_Castren12.2.2016 4

5. At-risk and problem gambling (ARPG) among
Finnish youth
 Measurement of youth ARPG
– Single questions
– SOGS-RA
– DSM-IV-MR-J
– SOGS & PGSI – instruments
developed for adults
 No validated scales/measures in
Finland for any context
12.2.2016 Internationl Gambling Conference 2016_Auckland_Castren 5

6. Background for the systematic review
• Continuing the existing reviews stating: There is a lack of
valid/reliable instruments to assess ARPG among youth
– Stichfield R. A critical review of adolescent problem gambling
assessment instruments. Int J Adolesc Med Health 2010;22:77-93.
– Blinn-Pike A, Worthy SL, Jonkman JN. Adolescent gambling: A review of
an emerging field of research. J Adolesc Health 2010: 47:223-236.
• Preliminary plan: a population study for Finnish youth
– to measure ARPG with the most reliable and valid instrument(s)
– utilize register data and longitudinal design
12.2.2016 Internationl Gambling Conference 2016_Auckland_Castren 6

7. Aims of the study
• to clarify which instruments measuring ARPG among
youth are the most reliable and valid for both
population-based and clinical studies in light of
reported estimates of internal consistency,
classification accuracy and psychometric properties.
• to identify the most suitable instruments presently
available and provide insight on what brances of the
field require further investigation.
12.2.2016 Internationl Gambling Conference 2016_Auckland_Castren 7

8. The team involved in the process
• Researchers (5) with expertise in
– Youth gambling
– Population studies and clinical studies
– Reliability and validity of gambling instruments
– Systematic reviews
– Academic writing
• Informatician (1)
– Data bases and searches
12.2.2016 Internationl Gambling Conference 2016_Auckland_Castren 8

9. Search strategy
• The data search was categorized using Cochraine handbook
guidelines (PICOS) for formulating review questions and
inclusion criteria.
– P = Patient, i.e. population
– I = Intervention, i.e. instrument
– C = Comparator, i.e. reference instrument
– O = Outcome, i.e. reliability.
• A structured electronic search was conducted Nov 2014
according to methods recommended in the PRISMA
statement in Medline, Pub Med, PsycInfo databases covering
articles between 2009-2014.
• Database searches were updated in November 2015.
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10. Eligibility criteria
• Articles written in English.
• Publications in peer/reviewed journals (also doctoral theses -
if the quality reached the standards).
• Population-based samples and clinical samples.
12.2.2016 Internationl Gambling Conference 2016_Auckland_Castren 10

11. Assessment of the articles
• Two researcher independently assessed all articles.
– Inclusion/exclusion criteria
– Quality assessment
• The joint probability of agreement between the
researchers were counted
• Disagreement in evaluation was resolved by discussion
and a third independent researcher were consulted
when needed.
12.2.2016 Internationl Gambling Conference 2016_Auckland_Castren 11

12. PHASE I
Exclusion criteria for the abstracts (n = 822)
1. Non-gambling related reseach topic
2. Sample age over 28 years of age
3. No gambling instrument employed
4. Case study, commentary, editorial or letter
5. Other (specification required)
The joint probability of agreement between the researchers
were 90% for the exclusion of based on the abstracts.
12.2.2016 Internationl Gambling Conference 2016_Auckland_Castren 12

13. PHASE II
Inclusion criteria for the full texts (n = 445)
P = Patient
– Less than 29 years of age
I = Intervention
– Instrument designed to evaluate youth gambling
C = Comparator (only used as additional information !)
– Reference instrument, measurement etc.
O= Outcome
– Instrument reliability reported
The joint probability of agreement between the researchers
were 92% for the inclusion based on full-text evaluation.
12.2.2016 Internationl Gambling Conference 2016_Auckland_Castren 13

14. Presentation of the article selection process
12.2.2016 Internationl Gambling Conference 2016_Auckland_Castren 14
Articles included
(n = 50)
Full texts read
(n = 445)
Articles included
(n = 42)
Excluded (n = 403)
•Inclusion/exclusion criteria
•P - No Findings for ˂29-year-olds (n = 151)
•I - No screening instrument (n = 187)
•O - No reliability assessment (n = 49)
•Other (n = 16)
Excluded (n = 377)
•No gambling (n = 294)
•No ˂29-year-olds (n = 6)
•No screen/instrument (n = 47)
•Other (n = 30)
Abstracts read
(n = 882)
Literature search (2009-2015)
•Medline (OVID) (n = 605)
•Pubmed (n = 554)
•PsycInfo (n = 65)
•Duplicates removed (n = 404)
Reference list search
•Potential articles (n = 20)
•Included (n = 8)

15. Quality assessment of included articles (n = 50)
• The revised Quality Assessment of Diagnostic Accuracy
Studies tool (QUADAS-2)
– The risk of bias of articles.
– The applicability of articles.
• QUADAS-2 was tailored for our review, tested on a
subsample of articles and modified to ensure unambiguous
assessment between researchers.
• An important change was omitting the evaluation of risk of
bias regarding reference standard, because both the index
test and reference standard (if measured) were applied
identically within a gambling context.
• Information pertaining to the reference standard was inferred
from the applicability assessment.
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16. Quality assessment: the revised QUADAS-2
12.2.2016 Internationl Gambling Conference 2016_Auckland_Castren 16
Risk of bias Applicability
Patient
selection
Index test Flow and
timing
Patient
selection
Index test Reference test
•Were
participants
selected
randomly?
•Was the
sample
representative
of the general
population?
•Were
inappropriate
exclusions
avoided?
Did the
conduct of the
test avoid
introducing
bias?
(e.g.time
restirictions,
instructions,
order of test
completion)
Were all
participants
included in the
analysis?
(e.g. were all
participants
included in the
analysis;
attrition rate,
drop outs,
inadequate
responses)
Does the
sample match
the review
question?
(e.g. is the
measure
developed for
youth)
Is the validity
of the index
test a
research
question of
the study?
(e.g. main
focus in
reliability or
something
else)
Is the reference
standard used to
make judgements
about the validity or
reliability of the index
test? (e.g.
money/time spent on
gambling)

17. RESULTS
Reliability estimates will be reported (Forthcoming)
• SOGS-RA (the South Oaks Gambling Screen Revised for
Adolescents)
• DSM-IV-J (the Diagnostic Statistical Manual IV adapted for
Juveniles)
• DSM-IV-MR-J (the Diagnostic Statistical Manual IV (Multiple
Response format) adapted for Juveniles)
• MAGS (the Massachusetts Gambling Screen)
• CAGI (the Canadian Adolescent Gambling Screen)¹
• GABSA (the Gambling Addictive Behaviour Scale for
Adolescents)
Both GAGI and MAGS were included to complement the reviews by Stichfield (2010) and Blinn-Pike et al. (2010)
¹GAGI - Unpublished report- not an article
²MAGS – not strictly an adolescent instrument
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18. Research group
Edgren R. BA Psych
Castren S. Ph.D.
Mäkelä M. MD, Ph.D.
Pörtfors P. M.Sc.
Alho H. MD, Ph.D.
Salonen AH. Ph.D.
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19. Thank you
Sari Castrén Ph.D.
Senior Researcher
Clinical psychologist
National Institute for Health and
Welfare, Tobacco, Gambling and
Addiction
Clinicum, Internal Medicine,
University of Helsinki and Helsinki
University Hospital Finland
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