Identifying and prioritizing gaming workers’ health and safety concerns using mapping for data collection

Abstract

This research was prompted by the clinical presentation of workers from a variety of gaming occupations with injuries and illnesses and multiple health and safety concerns.
Using participatory action research principles, 51 gaming workers in Ontario and 20 gaming workers in Manitoba were consulted during a series of focus group sessions. Mapping exercises were used to survey the participants about their health concerns, perceived occupational hazards and the impact of working conditions on their personal lives. Participants were then asked to prioritize their concerns and make recommendations for improvements.
Gaming workers from both provinces identified similar health, hazard and psycho-social concerns. They prioritized the issues of stress, ergonomics, indoor air quality (including second-hand smoke and temperature), biological hazards, physical hazards and noise.
This study points to a need to more fully investigate and address health and safety issues in the gaming industry. It also demonstrates the effectiveness of a worker-driven, participatory consultation.

Full text

AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 39:42±51 (2001)
Identifying and Prioritizing Gaming
Workers' Health and Safety Concerns
Using Mapping for Data Collection
Margaret M. Keith, PhD cand.,
1
Beverley Cann,
2
James T. Brophy, BA,PhD cand.,
1
Deborah Hellyer, MD,FRCP(C),FCCP,CIME,
3
Margaret Day,
4
Shirley Egan,
5
Kathy Mayville,
3
and Andrew Watterson, PhD
6
Background This research was prompted by the clinical presentation of workers from a
variety of gaming occupations with injuries and illnesses and multiple health and safety
concerns.
Methods Using participatory action research principles, 51 gaming workers in Ontario
and 20 gaming workers in Manitoba were consulted during a series of focus group
sessions. Mapping exercises were used to survey the participants about their health
concerns, perceived occupational hazards and the impact of working conditions on their
personal lives. Participants were then asked to prioritize their concerns and make
recommendations for improvements.
Results Gaming workers from both provinces identi®ed similar health, hazard and
psycho-social concerns. They prioritized the issues of stress, ergonomics, indoor air
quality (including second-hand smoke and temperature), biological hazards, physical
hazards and noise.
Conclusions This study points to a need to more fully investigate and address health
and safety issues in the gaming industry. It also demonstrates the effectiveness of a
worker-driven, participatory consultation. Am. J. Ind. Med. 39:42±51, 2001.
ß2001 Wiley-Liss, Inc.
KEY WORDS: participatory action research; mapping; casino workers; gaming
workers; dealers; environmental tobacco smoke; stress; occupation; ergonomics
INTRODUCTION
The gaming industry in North America, once limited
mainly to large gambling centers in the United States such
as Las Vegas and Atlantic City, has exploded into the
Canadian economy. In the last 10 years, gambling in regu-
lated gaming facilities has been legalized in most provinces
and territories, setting the stage for booming growth in the
gaming industry. According to Statistics Canada, between
1992 and 1997 pro®ts to provincial governments from
gambling rose from 1.7 to 3.8 billion dollars and employ-
ment rose from 12,000 to 35,000 [Marshall, 1998]. Yet, in
spite of its growing workforce and enormous impact on the
economy, there has never been a systematic investigation of
occupational health and safety within the gaming industry.
This study was initiated in 1997 after inquiries and
patient contacts were made at the Occupational Health
1
Faculty of Health and Community Studies,DeMontfort University,Leicester, UK (currently
Visiting Researcher, Public Health and Occupational Health Effectiveness Group, University
of Stirling, Scotland)
2
Occupational Health Nurse, MFLOccupational Health Centre, Inc.
3
Occupational Health Clinics for Ontario Workers-Windsor, Windsor, Ontario,Can ada
4
Health and Safety Representative, Manitoba Government Employees Union, Winnipeg,
Manitoba, Canada
5
Health and Safety Representative, CAW Local 444
6
Public Healtha nd OccupationalHealth Effectiveness Group,University ofStirling, Stirling,
Scotland
Institution atwhi ch workwas performed: Occupational Health Clinics for OntarioWorkers
(OHCOW), Windsor Occupation al Health Information Service (WOHIS), MFL Occupation al
Health Centre, Inc. (MFL OHC), Manitoba Govern ment Employees Union (MGEU), CAW-
Canada : National Automobil e, Aerospace, Transportation an d General Workers Union of
Canada (CAW) Local 444.The participating organizations self-funded this study.
Consent and Approval: Every participant completed a signed consent form permitting the
authors to publishthe findings. No personal identifiers have been included in the manuscript.
Correspondence to: Margaret M. Keith, Occupational Heal th Clinics for Ontario
Workers, S arnia-Lambto n. 171 Kendall Street, Point Edwa rd, Ontario, Canada N7V 4G6.
E-mail: mkeith@ohcow.on.ca
Accepted1 August 2000
ß2001Wiley-Liss,Inc.

Clinics for Ontario Workers (OHCOW) in an Ontario
community. The center includes a diagnostic medical clinic,
occupational hygiene and ergonomic services and an af®li-
ated inquiries service. Clinic physicians diagnosed indivi-
dual gaming workers with dermatitis, respiratory disease,
negative reproductive outcomes, and a variety of muscu-
loskeletal injuries. Staff also received inquiries from gaming
workers requesting information about ergonomics in the
gaming environment, basic universal precautions for clean-
ing up blood and body ¯uid spills, insect infestation, and
potent cleaning agents. Gaming workers reported ringing in
the ears after working near noisy slot machines. Some had
personal security and harassment concerns. Drink servers
said they were required to wear skimpy uniforms which
were revealing and uncomfortable and made them feel
vulnerable to harassment. There were questions about the
possible respiratory and dermal sensitization to coin dust.
Many had complaints of respiratory, eye and throat irritation
which they attributed to second-hand smoke. When the
center's staff turned to the literature to ®nd answers, they
quickly discovered the scarcity of published research
available on the gaming work environment.
The Ontario clinic director contacted the MFL
Occupational Health Center (MFL OHC), in an area where
gaming facilities had been operating for a number of years,
and learned that they too had been approached by gaming
workers with health and safety concerns. Staff at both
centers recognized that there were overwhelming unmet
needs for occupational health and safety research for this
expanding industry that went far beyond their modest
resources. Yet they were still faced with the practical
questions of where and how to begin to address the many
health and safety concerns that were being raised by the
gaming workers. After a series of discussions, it was
proposed that the most valuable and manageable under-
taking would be to try to identify the most immediate health
and safety concerns of the gaming workers in the two
communities and to explore ideas for improvement. Thus, a
collective consultative process was launched. The occupa-
tional health centers in both communities struck a research
partnership with each other and with the unions representing
the gaming workersÐCAW-Canada: National Automobile,
Aerospace, Transportation and General Workers Union of
Canada (CAW) in Ontario and the Manitoba Government
Employees Union (MGEU) in Manitoba.
Background
The two Ontario gaming facilities involved in the study
were opened in 1994. At the time the study was conducted,
they had a combined employment of approximately 3,600.
There were two additional government-owned gaming faci-
lities in other cities. However, the gaming workers who were
represented in this study were, and remain, the only union-
ized gaming workers in the province. There were three
Manitoba facilities involved in the study. One was opened in
1989, followed by two more in 1993. When the study was
carried out, the three gaming sites together, which
represented all of the facilities operating in the province,
employed about 800 workers. All of the government-
operated gaming facilities in Manitoba are organized by the
Manitoba Government Employees Union.
Gaming Worker Occupational Health
and Safety Literature
A review of the recent literature revealed very few
scienti®c studies and reports regarding gaming workers'
health and safety: an incidence of pesticide exposure
resulting in solvent intolerance was investigated in a hotel
attached to a gaming facility [Cone and Sult, 1992]; gaming
workers were found to be exposed to greater levels of
environmental tobacco smoke than the general population in
a study carried out in a casino hotel in Atlantic City [Trout
and Decker, 1996]; higher levels of amines were found in
side-stream tobacco smoke than in main-stream smoke in a
study conducted in the gaming room of a club [Luceri et al.,
1993]; mutagenic activity was found in the samples
collected in the breathing zones of workers in a casino
where smoking was present [Kado et al., 1991]; casino
owners in Western Australia were sued by their employees
for failing to provide a smoke-free environment [Ragg,
1993]; a job satisfaction questionnaire was administered to
casino employees to identify any association with depres-
sion and aggression [Lapenz and Lester, 1997]; two studies
of casino card dealers found low job satisfaction [Frey and
Carns, 1988; Darcy and Lester, 1995]; another found no
increased stress [Posner et al., 1985]; and an investigation
into the gambling, drinking, smoking and other health risk
activities of gaming workers was recently published
[Shaffer et al., 1999]. None of the above literature fully
explores the potential occupational health and safety risks of
the gaming environment.
METHODS
Planning and Co-ordinating
As a ®rst step in the research, occupational health
center staff in Ontario and Manitoba met with several small
groups of gaming workers to gain insight into their health
and safety concerns and acquire a basic understanding of
gaming work processes. Informal visits were made to the
gaming facilities to observe the work directly. Then a 3-day
planning meeting was held with all the key players in the
research process: union health and safety representatives
and members from both unions; two university-based
research advisors; occupational health clinic staff, including
Mapping Gaming Workers' Health and Safety Concerns 43

a physician, two occupational health researchers, two
occupational health nurses, an industrial hygienist, an
ergonomist and administrative personnel. The research
team agreed upon the methodology to be utilized and
de®ned the goals of the project: to identify any workplace
health and safety concerns of workers in the Ontario and
Manitoba gaming facilities; determine three to ®ve priority
concerns for action and/or more in-depth study; assist
gaming workers in becoming more aware of their own
workplace health and safety issues. Here were no prede®ned
hypothesesÐthis was to be a general exploration of the
gaming work environment from the perspective of the
gaming workers themselves.
Participatory Action Research
The research team chose participatory action research
as the study approach for this project. In recent years,
participatory action research has gained wider acceptance
and has been used successfully in occupational health and
safety research [Israel et al., 1989, 1992; Wilkening, 1990;
Hugentobler et al., 1992; Laurell et al., 1992; Loewenson
et al., 1993; Dollard et al., 1997; Hagey, 1997]. Key
components of participatory action research are its acces-
sibility, consciousness-raising potential, action orientation
and ability to produce reliable information [Laurell et al.,
1992]. Participatory action research is useful in advancing
understanding of problems important to less powerful
groups in society [Dollard et al., 1997]. Due to the demon-
strated links between participation, control and health
status, the participatory action research process may be
considered health enhancing in and of itself as it places
control in the hands of the participants [Israel et al., 1992].
The assumption is that the research process and results will
effect change [Cornwall and Jewkes, 1995].
Rather than treating people as the subjects of study by
a detached and neutral researcher, participatory action
research engages researchers and subjects in a partnership.
Mergler [1987] discusses the value of incorporating work-
ers' needs and knowledge into scienti®c research. She
describes her experience with a formal institutional agree-
ment between university-based scientists at the University
of Quebec in Montreal and two major unions. Worker±
scientist interaction takes place at all stages of the
researchÐthe de®ning of the project, establishing of aims,
data collection methods, analysis, interpretation and writing
of conclusions and recommendations. This ``rapproche-
ment'' has resulted in a number of successful research
projects including a study of health and safety hazards in
slaughterhouses [Mergler et al., 1983], a study of women's
health in the ®sh-processing industry [Messing and Reveret,
1983], and a study of bank tellers' work activity and health
[Seifert et al., 1997]. Although on a smaller scale, the
research partnership and process for the gaming workers'
study incorporated many of the principles de®ned by the
Quebec partnership.
The group being studied, in this case gaming workers,
would govern all critical decisions in the research process
[Loewenson and Biocca, 1995]. No claim would be made
for the impartiality of the worker-researchers. Their knowl-
edge of the gaming work environment and the complexities
of the social dynamics existing in their own workplaces
(e.g., tensions between occupational groups) would provide
valuable background perspective. The research advisorsÐ
professionals, clinic staff and academicsÐwould advise on
such matters as appropriate study methods, research ethics,
and control measures.
Focus Groups
Having determined the gaming workers' research needs
to be primarily qualitative and being constrained by limited
resources, focus groups were deemed by the research team
to be the most ef®cient and effective means for gathering
data. Focus groups have been proven useful for obtaining
rich insight into the thoughts and feelings of target groups
about speci®c topics or issues and for gaining interpretation
[Morgan, 1998]. This ideally suited the project's goals.
For those engaged in participatory action research, such
qualitative research methods are particularly apt. At the root
of participatory action research is a critique of the dominant
quantitative research approachÐthat since quantitative
research utilizes only the so-called objective or hard data,
it excludes all knowledge that cannot be readily quanti®ed
[Loewenson et al., 1993]. Qualitative research, on the other
hand, can provide rich in-depth descriptions and under-
standing of people's subjective experience. The use of qua-
litative research in occupational health and safety can
provide insight and interpretation into workers' knowledge,
opinions, feelings and social dynamics that would be missed
by quantitative research alone [Needleman and Needleman,
1996].
In order to create a safe, encouraging focus group
environment where the participants would feel a sense of
trust, it was decided that the gaming workers on the research
team, would act as facilitators and that the focus group
sessions would be held away from the gaming site. A staff
observer and recorder would attend all focus group sessions.
Training Facilitators
The research team produced a focus group facilitators'
guide providing instructions and a set format for data
collection. This reduced the possibility of variances in
approach by the multiple facilitators and ensured a degree of
uniformity. A day-long training session, led by center staff,
was held for the facilitators. Facilitators were provided with
guidelines for ethical research conduct and ideas for dealing
44 Keith et al.

with potential group dynamics issues. Facilitators were
advised that their role would be to listen and animate dis-
cussion.
Recruiting Study Participants
To recruit volunteer study participants, CAW and
MGEU representatives wrote directly to all gaming workers
in the respective Ontario and Manitoba facilities. The
representatives also promoted the study by posting ¯yers
and providing information packages at work. Gaming wor-
kers who were interested in attending a focus group were
asked to submit a form. They were then organized into
appropriate groupings. Once participants were recruited,
focus groups were scheduled to accommodate gaming
workers' shift schedules. The average duration of each
session was 2.5 to 3 hours and the groups averaged about
four participants each.
Mapping
Mapping can be a powerful health and safety investi-
gative and assessment tool [Firth et al., 1997; O'Neill,
1997]. It can provide crucial evidence to support demands
for improvement [O'Neill, 1998]. The use of mapping in
health and safety research was ®rst validated in the 1960s
when the hazards identi®ed through the use of drawings by
workers at the Fiat plant in Italy were subsequently
supported by more traditional empirical research [Mujica,
1992]. Analysts of the Italian worker-based occupational
health research model, in exploring its applications
for North America, concluded that the use of ``risk maps''
could enhance occupational health prevention and raise
awareness among medical professionals [Reich and
Goldman, 1984].
There are a number of arguments for the use of mapping
in qualitative research, particularly in the area of health and
safety. Mapping is participatory. It encourages discussion
and analysis. It allows participants to see the inter-con-
nectedness of their health problems, workplaces and lives.
Brown [1995] argues that mapping helps to break from
the traditional, dif®cult to understand technical jargon used
by most medical and health and safety professionals.
Mapping utilizes workers' subjective experience and know-
ledge to paint detailed pictures of their working conditions
and interactions. Such data is more readily and universally
comprehended than most quantitative data, such as air
sampling results or epidemiological ®ndings. Moreover,
because of its use of images, color-coding, stickers and
symbols, mapping helps to overcome problems of literacy
and language differences [Gonzalez Arroyo et al., 1995].
This is an important consideration when, according to
Statistics Canada, more than one-third of Canadians are
only marginally literate [Hardwick, 1996].
The mapping exercises herein described, were utilized
in the focus group sessions to collect descriptive data regar-
ding the participants' perceptions of their own health, the
workplace hazards they face and the psycho-social impact
of their work on their personal lives. A chart was used to
help the gaming workers prioritize their issues and make
recommendations for remedial action.
This series has been used extensively by the occupa-
tional health centres to assist workers, in a wide range of
private and public sector industries, to identify and evaluate
health and safety issues.
Body mapping
Body mapping is a tool for eliciting subjective infor-
mation regarding the health problems (illnesses, injuries,
aches and pains, etc.) of workers. This exercise was carried
out collectively using large, simple images of the body
(front and back) which were posted on the wall. The gaming
workers were asked to place self-sticking dots on the body
map to indicate any health problems they were experien-
cing. They then reported to the group, one at a time, what
health problems their dots represented. This information
was recorded.
Hazard mapping
The gaming workers were asked to draw a rough
diagram of their work area or areas, on large sheets of paper
which were mounted on the wall. Some participants drew
individual mapsÐothers were done collectively. Collective
maps were encouraged when there was more than one
person from a particular work area or occupation. Partici-
pants were instructed to draw the physical layout of their
work areas, themselves, their co-workers and any hazards
which they believed exist. They were also asked to
categorize the hazards as biological, chemical, physical,
stress or work design, using color-coded, self-sticking
labels. They were then asked to describe their drawings to
the rest of the group. This information was recorded.
``Your World'' mapping
The ``Your World'' mapping exercise was designed to
bring out the psycho-social impact of work and its hazards
on the gaming workers' lives. A large sheet of paper, with a
small human ®gure drawn in the center, was ®xed to the
wall. Participants were asked to add symbols or words
around the human ®gure to represent any areas of their life
they believed were affected by their work. For example, the
effects of shiftwork on child care might be represented by
stick ®gures of children and a clock. Participants then exp-
lained their written comments and drawings to the group and
the information was recorded.
Mapping Gaming Workers' Health and Safety Concerns 45

Establishing priorities and
recommendations for remedial action
At the end of each exercise, the facilitators summar-
ized, and to some degree, synthesized the concerns and
descriptions from the participants. This allowed the facili-
tators to check back with the participants for accuracy and it
allowed the recorders to check that the recorded notes
re¯ected what the participants said.
Next, each focus group produced a wall chart recording
what participants identi®ed as priority problems, associated
causes and effects, and some creative solutions. Focus group
participants were each asked to identify one priority work-
place health and safety concern for action and/or more in-
depth study. The chosen priorities were to be based, not only
on their personal experience, but also on what they consi-
dered important to their co-workers.
Participants were then asked to cast three votes for their
top priority issues using self-sticking dots. This gave them
the opportunity to vote on, not only their top issue, but
other participants' issues as well. The ®nal stage of the
exercise entailed a discussion regarding possible remedies
or solutions.
Observing and Recording
Focus Groups
Occupational health centre staff functioned as observers
and recorders for each focus group. They provided clari-
®cation regarding the exercises, if needed, ensured the
research was being carried out in a sound manner and re-
corded all of the participants' pertinent comments. The
observers did not facilitate or participate. Any observations,
impressions, and feelings of the observers were also re-
corded. Following the sessions, there were short debrie®ng
meetings of the facilitators, observers, and recorders. This
provided an opportunity to discuss any dif®culties, to plan
the next sessions, and to share observations.
RESULTS
A total of 51 gaming workers in Ontario and 20 gaming
workers in Manitoba participated in 16 separate focus
groups. There were workers from each of the gaming faci-
lities operating in the two communities. Sixteen occupa-
tional groups within the gaming industry were represented,
however the dealers (17) and cleaners-porters (13) were
most heavily represented. The majority (46) had worked
at the gaming facilities between 1 and 5 years. There
were 36 women and 35 men; 26 were in the 21±30 age
range; 26 were in the 31±40 age range; 15 were in the
41±50 age range; three were in the 51±60 age range;
one did not specify age. There were 56 full-time, 13 part-
time and one casual employee. There were two self-
reported sexual orientation minority and six racial minority
participants.
Body Mapping Data
The body maps revealed concentrations of dots in the
lower back, shoulder, joint, neck and head areas. The dots
represented a wide range of health problems.
*Musculoskeletal pain in the shoulders, back, hips, feet,
ankles, knees, neck, elbows, wrists, hands, and ®ngers
was attributed to heavy lifting, manual handling of
coins, pushing heavy carts or trolleys, lifting buckets of
coins from below ¯oor level and stacking them on
trolleys (called ``coin pulls''), pushing and pulling
trolleys loaded with coins, wearing coin belts,
prolonged standing and walking (in some cases on
uneven surfaces such as cobblestone ¯ooring), having
to move furniture to clean while holding a mop or
broom in the other, (having been instructed never to set
the cleaning equipment down).
*They reported repetitive strain injuries, such as ten-
dinitis, carpal tunnel syndrome, stress fractures, and
epicondylitis believed to be caused by repetitive work,
such as dealing cards or using a computer key board,
andawkward posturesfrom poorlydesignedworkstations.
*There were general health complaints, such as head-
aches, irritability, fatigue, sleeplessness, and dizziness
which were largely attributed to stress, shiftwork, and
second-hand smoke.
*Some had hearing loss or ringing in the ears which they
believed resulted from working in close proximity to
the noisy slot machines.
*There were complaints of eye strain and discomfort
which were thought to be caused by ¯ashing or glaring
lights and/or second-hand smoke.
*Many described heat and cold-related problems from
unevenly controlled indoor temperatures, inappropriate
clothing requirements and uniforms, and outdoor travel
or activities.
*Upper and lower respiratory tract problems, such as
shortness of breath and sore throats, were believed to
be related to the poor indoor air quality and second-
hand smoke.
*There was a perceived increase in colds, ¯u, nausea,
and gastrointestinal problems which were attributed by
the gaming workers to their close contact with the
general public.
*There were cases of reproductive problems, such as
miscarriages that were thought to be related to poor
ergonomic design and second-hand smoke.
*Traumatic injuries, such as pinches, crushes, burns,
scalds and cuts had occurred reportedly from poorly
designed tools, equipment, and facilities.
46 Keith et al.

*There were reports of allergic reactions and skin
rashes, which the gaming workers attributed to coin
dust, insects, harsh cleaning agents, and other chemical
usage.
Hazard Mapping Data
The following are the hazards most frequently cited by
the gaming workers in each of the ®ve assigned categories:
physical; chemical; biological; work design; and stress
hazards.
In the physical hazards category, poor temperature
control was mentioned by all occupational groups. Some
of the comments related to temperature were linked with
in¯exibility in the dress code. Three groups identi®ed noise
from slot machines and customers as a hazard. Other
hazards categorized by the gaming workers included
equipment and machinery and heavy work.
The chemical hazard most vociferously noted in all
occupational groups was environmental tobacco smoke.
This was mentioned together with comments about poor
ventilation and generally poor air quality. Certain chemical
hazards were occupation speci®c, such as coin dust men-
tioned by cashiers and cleaning chemicals mentioned by
cleaners.
The biological hazards reported by all occupational
groups were mainly those associated with working in close
proximity to the public, that is, ``colds and ¯us,'' concern
about handling dirty money and chips, and being in contact
with human waste and other body ¯uids. Body ¯uids and
germs were also considered to be a cause of stress, along
with fear of disease transmission from needle-stick injury.
Work design hazards included poor building design,
poor ergonomics, repetition, standing, and working alone.
Material handling activities, particularly handling coins or
other heavy objects, such as chairs and stools, were men-
tioned in several groups. Other concerns included maneu-
vering through narrow spaces crowded with people, slot
machines and other furniture and poor work station layout
and design.
Three main workplace stress hazards emerged from the
occupational groups: relations with patrons (dealing with
behavior ranging from rude to violent); relations with
management (inconsistent rules, having no compassion);
and concerns about personal safety (walking to the car,
robbery). Other stressors mentioned included shift work and
short-staf®ng.
Not surprisingly, different occupational groups empha-
sized speci®c concerns. Some issues, such as second-hand
smoke, stress and harassment from patrons were almost
universal.
The dealers considered repetitive strain injuries to be
one of their greatest concerns. They also feared reprisal
from patrons who were losing money. They observed that
patrons, who were emotionally stimulated, many under the
in¯uence of alcohol or drugs, became aggressive, particu-
larly after losing money. They referred to Friday and
Saturday nights as ``Fight Nights,'' as agitated, intoxicated
patrons lost self-control. One dealer spoke of how grati®ed
he felt when a patron won a large amount of money, only to
face disapproval from his supervisor. Some workers spoke
of enjoying the excitement of the overall gaming atmo-
sphere.
The cleaners (porters) were concerned about ergo-
nomic issues (pushing, pulling and carrying equipment), use
of certain cleaning agents, noise and overcrowding, along
with concerns about biological hazards from body ¯uids,
and bacteria. They mentioned spills of blood, urine, and
vomit, particularly in the bathrooms. Some spoke of having
to dispose of containers of urine from beside the slot
machines. These were apparently left by patrons who were
unwilling to give up their place at a slot machine to use the
restroom. Porters also spoke of the harassment they exp-
erienced from some superstitious patrons while they were
sweeping around slot machinesÐthey were told angrily that
brooms brought bad luck and to ``get away'' from the area.
Workers in the slot machine department reported the
problems of noise and abuse from patrons. The overall
atmosphere was described as being very stressful. They
reported that the slot machines were very noisy, playing
tunes and ringing bells to attract patrons. Flashing lights,
re¯ective surfaces, and mirrored ceilings added to the
``super-charged'' environment. They also spoke of the
heavy penalty imposed by their employer if they were short
any money. They felt that the stressful environment and
demanding patrons made it dif®cult to concentrate and that
mistakes in making change were inevitable.
Participants from the security department reported
that prolonged standing and fear of patron violence were
important issues for them. They reported a number of
instances in which irate patrons tried to assault themÐfor
example, one security of®cer told of an incident in which a
patron attempted to run him over with his car.
Overcrowding, stress and poor ergonomics were among
the issues raised by the of®ce workers.
``Your World'' Mapping Data
The most frequently cited psycho-social problems were
the disruptions caused by shift work and scheduling, and the
impact of pain, illness and fatigue on the gaming workers'
daily lives.
They described the effects of shift work and scheduling
on their relationships with friends and family, childcare and
child rearing, leisure and social activities, weekend and
holiday activities, and community and church involvement.
Some reported a reduction in sexual activity, reproductive
problems, and marital break-ups.
Mapping Gaming Workers' Health and Safety Concerns 47

Pain, injuries, illness and fatigue affected their ability to
perform housework, participate in sports and other hobbies,
and tend to the needs of children and grandchildren.
A number of the participants spoke of how much they
liked their jobs. Yet they talked, almost without exception,
about the exhaustion or stress symptoms they experienced
after work. They spoke of mood, stress and irritability
problems. They reported problems with sleep and appetite.
A number discussed the need to be alone after returning
home from work, feeling unable to face family and friends.
Some feared for their job security.
Identi®ed Priorities
The top priority issues identi®ed by the participants in
Ontario were stress, indoor air quality (including second-
hand smoke and temperature), ergonomic hazards, biologi-
cal hazards, physical hazards, and training. Noise, which
was identi®ed as a serious problem by many of the partici-
pants, was viewed primarily as a cause of stress and was
thus included in the stress category, along with over-
crowding and harassment.
The top priority issues identi®ed by the participants in
Manitoba were indoor air quality, stress, ergonomics, noise,
patrons with infectious diseases, and temperature extremes.
Indoor air quality was a priority problem identi®ed by
all occupational groups and the facilitators. Ergonomics
followed closely. Stress and temperature extremes were
priorities for three groups, facilitators included.
Gaming Workers' Recommendations
for Remedial Action
The suggested solutions to combat stressful working
conditions were varied. Many focused on the need for better
management training especially in the so-called ``people
skills,'' standardizing management policies, consistent app-
lication of rules, developing and enforcing policies for
dealing with abusive or intoxicated patrons, educating pat-
rons, discontinuing the use of the security surveillance sys-
tems to evaluate workers, improving communication and the
relationship between workers and management, getting
management to listen to the workers, providing sensitivity
training regarding human rights issues, improving sche-
duling and rotating holidays and weekends, increasing
teamwork, and establishing a ``mental health and safety
committee.'' The gaming workers also suggested that stress
could be reduced by turning down the noise.
They suggested indoor air quality and second-hand
smoke problems could be alleviated by improving the
general ventilation system, maintaining comfortable tem-
peratures, providing ®ltered smoking tables, installing local
exhaust systems to capture locally generated contaminants
(e.g., coin dust), maintaining the HVAC system, carrying
out regular air testing, limiting or banning smoking, and
enforcing regulations regarding smoking in restricted areas.
They suggested ergonomic problems could be reduced
by instituting rotation of jobs, providing a massage therapist
or physiotherapist on site, providing an exercise area and
equipment on site, providing longer breaks and rest periods,
hiring additional staff to allow for team tasks and relief
persons, improving work station design, maintaining carts
and other equipment, providing or permitting more com-
fortable footwear, providing better carpet underlay, light-
weight adjustable carts, making coin banks more accessible,
providing chairs, stools, anti-fatigue mats, step-ups, and
lifting devices, removing unsafe equipment, such as the
``shuf¯e master'' which sets a pace of work which was
viewed as being too fast by the dealers, increasing work
space by widening aisles and limiting the number of patrons
in an area, improve the coin pull by having coins drop into
chutes under the ¯oor, providing ergonomically designed
tools and equipment, solicit worker input into work design.
Participant Evaluations
The response from participants to the focus group
content and format was overwhelmingly positive. Three
main themes came out of the comments. Participants were
pleased with the breadth and depth of the topics covered.
They appreciated the opportunity to be included and to be
heard. They were optimistic that positive change could
come about. Several participants expressed surprise in
learning that workers in other areas of the gaming facilities
and even in other job classi®cations were experiencing
similar problems. They said they felt less alone with their
own problems. Several responded that they felt the in-
volvement of workers in their own research was an effec-
tive, common sense strategy for making health and safety
improvements.
Follow-Up
In the winter of 1998, the results of the study were made
available to all of the gaming workers in both communities.
The two interim Ontario facilities were closed in the
summer of 1998 and a large permanent facility was opened,
adding approximately 1,500 employees to its workforce.
The gaming facilities in Manitoba were also restructuredÐ
one of the facilities was closed while the others were ex-
panded. Approximately 300 new jobs were created.
In the summer of 1999, the union health and safety
representatives from the facilities in both communities were
asked a series of follow-up questions to evaluate the status
of the health and safety concerns raised during the study.
They reported that a considerable number of improvements
recommended by the gaming workers had been implemen-
ted. They attributed this to the study.
48 Keith et al.

Summary of Response to
Follow-Up Inquiry
Ontario
Collective bargaining took place between the CAW and
the casino corporation within weeks of the release of the
study ®ndings. At the union's insistence, reference to the
gaming workers' research study was incorporated into
the language of the collective agreement and it was agreed
that the ®ndings were to be considered by the joint union-
management health and safety committee. According to the
union representative, the study's recommendations have
indeed been discussed during committee meetings and, in
many cases, recommendations have been implemented. For
instance, there have been numerous ergonomic improve-
ments in terms of work stations, practices and equipment;
control of unruly patron behavior is more consistent; and
increased labor relations personnel has improved interpreta-
tion and implementation of management policies.
Manitoba
Unlike Ontario, the union in Manitoba did not attempt
to include the study in its collective agreement. The
Manitoba union is, however, dealing with the ®ndings
through its joint union-management health and safety com-
mittee structure. According to the union health and safety
representative, the committees are indeed following up on
all areas of the survey and improvements have been made.
For example, cash carts have been introduced eliminating
the need for slot attendants to carry heavy amounts of cash;
cashiers have experienced less lifting in the bank area as a
result of ergonomic changes; and there has recently been an
assessment carried out regarding stress and harassment in a
process initiated by the new Lottery Board of Directors.
DISCUSSION
The main goal of this study was to gain greater
knowledge of the health and safety concerns and priorities
of gaming workers in order to provide direction for action
and further study. The research team is satis®ed that this
goal was accomplished. The research method chosen
provided discussion on many issues. The utilization of
mapping exercises to gather data, rather than the more
traditional survey methods, resulted in full and enthusiastic
participation, rich description and dialogue, and thoughtful,
strategic, collectively-formulated recommendations. The
participatory nature of the study created a sense of owner-
ship and empowerment among the gaming workers which
allowed them to con®dently and knowledgeably present the
®ndings to their joint union-management health and safety
committees for consideration and action.
Validity
Many of the main issues were repeated by individuals
within and across focus groups. Much of what was heard in
the focus groups had also been heard ``on the ground'' in the
gaming facilities, in health and safety committee meetings,
and in preparation meetings for the research project. The
non-gaming worker research team members, in visiting each
of the gaming facilities, also found consistencies between
the observable phenomena (such as work station design,
noise, equipment design and second-hand smoke) and the
data provided by the participants. Moreover, the similarity
between concerns voiced in Ontario and Manitoba was
striking. The consistency of the reports from two distinct
geographic locales, from multiple gaming facilities, and
across several occupational groups helps to support the
validity of the ®ndings.
Some of the gaming workers' concerns were also
validated by existing literature. Concerns about second-
hand smoke, for example, are corroborated by previously
published investigations which found increased levels of
environmental tobacco smoke in casino gaming areas [Trout
and Decker, 1996; Trout et al., 1998]. Literature on the
health risks of environmental tobacco smoke in the
hospitality industryÐbars and restaurantsÐis also relevant
for the gaming workers [Jarvis et al., 1992; Seigel, 1993;
Akbar-Kanzadeh, 1996; Bergman et al., 1996; Dimich-
Ward et al., 1998; Eisner et al., 1998].
It would be an onerous task to fully evaluate the gaming
workers' study ®ndings in terms of existing knowledge
because of the lack of literature speci®cally related to
gaming workers' health and safety. One might examine the
literature regarding occupations which are similar to those
found in the gaming industry. Or one might examine the
current literature regarding the known health effects of
conditions described by the gaming workers. For example,
there is ample literature supporting the gaming workers'
subjective experience regarding shiftwork and stress
[Harrington, 1994] and regarding the association between
stress and its effects on health [Martino, 1992].
CONCLUSION AND RECOMMENDATIONS
This study provides a snapshot of the gaming work
environment from the workers' own experience and per-
spective, making a valuable contribution to our understand-
ing of their concerns. The collaborative and participatory
nature of the study provided all involved with a rich learning
experience.
The authors encourage workers and researchers to
develop such partnerships in order to undertake participa-
tory action research in occupational health and safety, not
only in the gaming industry, but in others as well. It is our
contention that the research methodology used in the
Mapping Gaming Workers' Health and Safety Concerns 49

gaming workers' study, in particular the use of mapping for
data collection, is transferable to any number of other
industries and occupational settings and experimentation
with its use is encouraged.
Furthermore, the ®ndings clearly indicate that oppor-
tunities exist for further research into the health and safety
of gaming work, particularly in the identi®ed priority areas:
stress; indoor air quality and ergonomics and more speci-
®cally, environmental tobacco smoke; environmental and
patron-induced stress; musculoskeletal and repetitive strain
injuries. The study has proven to be of value in terms of
hypotheses generation. Although this study answers some
questions, it poses many more. For instance: does gaming
work present speci®c ergonomics challenges? Are there
ways of reducing stress in the gaming environment? Can
patron-generated violence and harassment be controlled?
Do gaming workers' cotinine levels differ pre- and post-
shift? Do unionized and non-unionized facilities differ in
terms of health and safety conditions?
This study provides evidence from which it can be
reasonably concluded that there are health and safety
concerns in the gaming environment requiring further
research and corrective action. The authors encourage, as
a responsible, proactive measure, an industry-wide evalua-
tion of the health and safety concerns in the identi®ed
priority areas.
ACKNOWLEDGMENTS
This was a participatory project. As such, there were
many individuals involved in all aspects of the study,
including the writing and editing of the report of the study
®ndings. The authors wish to acknowledge the following
contributors: Craig Axler, Lynn Bueckert, Judy Cook, Diane
Gagnon. We also thank the staff and representatives of the
participating organizations who undertook organizational
tasks: Mary Cook, Cathy Walker, Patricia Noonan, and
Perry Gilmore. The authors wish to thank especially the
gaming workers who helped to plan and/or facilitate
workshops: CAW members Ron Delmore, Pat Easter,
Thomas Hayes, Guy Levesque, Larry Patterson, Warren
Skyers, Flora Spada, Tenease White, Carol Wilson, and
Catherine Wilson; MGEU members Irene Demski, Robin
Drylick, Doug Peter and Terry Turcan. We also wish to
acknowledge the academic research consultants who lent
their experience and expertise to this project and/or to the
review of this article: Anne Forrest, Karen Messing, Kevin
Gorey, Dorothy Wigmore, Rory O'Neill.
REFERENCES
Akbar-Kanzadeh F, Greco TM. 1996. Health and social concerns of
restaurant/bar workers exposed to environmental tobacco smoke. Med
Law 87:122±132.
Bergman TA, Johnson DL, Boatright DT, et al. 1996. Occupational
exposure of nonsmoking nightclub musicians to environmental
tobacco smoke. Am Ind Hyg Assoc J 57:746±752.
Brown MP. 1995. Worker risk mapping: an education-for-action
approach. New Solutions Winter:22±30.
Cone E, Sult TA. 1992. Acquired intolerance to solvents following
pesticide/solvent exposure in a building: a new group of workers at risk
for multiple chemical sensitivities? Toxicol Ind Health 8(4):29±39.
Cornwall A, Jewkes R. 1995. What is Participatory Research? Soc Sci
Med 41(12):1667±1676.
Darcy P, Lester D. 1995. Job satisfaction in casino dealers. Psychol
Rep 77:642.
Dimich-Ward H, Lawson J, Chan-Yeung. 1998. Work shift changes in
lung function in bar workers exposed to environmental tobacco smoke.
Am J Respir Crit Care Med 157:A505.
Dollard MF, Heffernan PT, Wine®eld AH, Wine®eld HR. 1997.
Conducive production: how to produce a PAR worksite proposal. New
Solutions 7(2):58±69.
Eisner MD, Smith AK, Blanc PD. 1998. Bartenders' respiratory health
after establishment of smoke-free bars and taverns. JAMA
280(22):1909±1914.
Firth M, Brophy J, Keith M. 1997. Workplace roulette: gambling with
cancer. Toronto: Between the Lines.
Frey JH, Carns DE. 1988. Job satisfaction of casino card dealers.
Sociology and Social Research 72:159±164.
Gonzalez Arroyo M, Darling E, Szudy B. 1995. Risk mapping for
change: experience with electroplating shops. New Solutions Winter:
27±28.
Goodwin LD, Goodwin WL. 1984. Qualitative vs. quantitative
research or qualitative and quantitative research? Nurs Res 33(6):
378±380.
Hagey RS. 1997. Guest editorial: the use and abuse of participatory
action research. Chronic Diseases in Canada 18(1).
Hardwick C. 1996. International survey on adult literacy. Perspectives
on labour and income summer. Catalogue No. 89±545-XPE. Ottawa:
Statistics Canada.
Harrington JM. 1994. Shiftwork and health: a critical review of the
literature in working hours. Ann Acad Med Singapore 23(5):699±705.
Hugentobler MK, Israel BA, Shurman SJ. 1992. An action research
approach to workplace health: integrating methods. Health Education
Quarterly 19(1):55±76.
Israel BA, Schurman SJ, House JS. 1989. Action research on
occupational stress: involving workers as researchers. Int J Health
Serv 19(1):135±155.
Israel BA, Schurman SJ, Hugentobler M. 1992. Conducting action
research: relationships between organization members and researchers.
J Appl Behavioural Sci 28(1):74±101.
Jarvis MJ, Foulds J, Feyerabend C. 1992. Exposure to passive smoking
among bar staff. Br J Addict 87:111±113.
Kado NY, McCurdy SA, Tesluk SJ, Hammond SK, Hsieh DPH, Jones
J, Schenker MB. 1991. Measuring personal exposure to airborne
mutagens and nicotine in environmental tobacco smoke. Mutat Res
261(1):75±82.
Lapenz SK, Lester D. 1997. Job satisfaction in casino employees.
Percept Mot Skills 84:1258.
Laurell AS, Noriega M, Martinez S, Villegas J. 1992. Participatory
research on workers' health. Soc Sci Med 34(6):603±613.
50 Keith et al.

Loewenson R, Biocca M. 1995. Participatory approaches in occupa-
tional health research. Med Lav 86(3):263±271.
Loewenson R, Laurell AC, Hogstedt C. 1993. Participatory Appro-
aches in Occupational Health Research. A study prepared for IDRC
(Canada):9.
Luceri F, Pieraccini G, Moneti G, Dolara P. 1993. Primary aromatic
amines from side-stream cigarette smoke are common contaminants of
indoor air. Toxic Ind Health 9(3):405±413.
Marshall K. 1998. The gambling industry: raising the stakes. Statistics
Canada Catalogue No. 75-001-XPE, Perspectives Winter:7±11.
Martino VD. 1992. Occupational stress: a preventative approach.
Conditions of Work Digest 11(2):3±21.
Mergler D. 1987. Worker participation in occupational health research:
theory and practice. Intl J Health Serv 17(1):151±167.
Mergler D, et al. 1983. The Effects of Working Conditions on the
Health of Workers in Slaughterhouses. Report 047, Canadian Centre
for Occupational Health and Safety, Hamilton, Ontario.
Messing K, Reveret JP. 1983. Are women in female jobs for their
health? A study of working conditions and health effects in the ®sh-
processing industry in Quebec. Intl J Health Serv 13:635±647.
Morgan DL. 1998. The focus group guidebook. Thousand Oaks,
London & New Delhi: Sage Publications, 103 p.
Mujica J. 1992. Coloring the hazards: risk maps research and education
to ®ght health hazards. Am J Ind Med 22:767±770.
Needleman C, Needleman ML. 1996. Qualitative methods for
intervention research. Am J Ind Med 29:329±337.
O'Neill R. 1997. Mapping out work hazards. Hazards 60: Centrepages.
O'Neill R. 1998. Body of evidence. Hazards 61: Centrepages.
Posner I, Leitner LA, Lester D. 1985. Stress in casino ¯oor employees.
Psychol Rep 57:246.
Ragg M. 1993. Australia: passive smoking prosecution. Lancet 341,
January 16:167.
Reich MR, Goldman RH. 1984. Italian occupational health: concepts,
con¯icts, implications. Am J Pub Health 74(9):1031±1041.
Seifert B, Abraham HJ. 1982. Indoor air concentrations of benzene and
some other aromatic hydrocarbons. Ecotoxicol Environ Saf 6(2):
190±192.
Seifert AM, Messing K, Dumais L. 1997. Star wars and strategic
defense initiatives: work activity and health symptoms of unionized
bank tellers during work organization. Int J Health Serve 27(3):
455±477.
Seigel M. 1993. Involuntary smoking in the restaurant workplace.
JAMA 270:490±493.
Shaffer HJ, Vander Bilt J, Hall MN. 1999. Gambling, drinking,
smoking and other health risk activities among casino employees. Am
J Ind Med 36:365±378.
Trout D, Decker J. 1996. Health Hazard Evaluation Report No.
HETA-95-0375-2590, Bally's Park Place Casino Hotel, Atlantic
City, New Jersey. Cincinnati: Hazard Evaluations and Technical
Assistance Branch, NIOSH, U.S. Department of Health and Human
Services.
Trout D, Decker J, Mueller C, Bernert JT, Pirkle J. 1998. Exposure of
casino employees to environmental tobacco smoke. J Occ Env Med
40(3):270±276.
Wilkening W. 1990. In defense of health and well-being, work and
welfare. Papers from the Second Karlstad Symposium on Work, June
18±20:47±52.
Mapping Gaming Workers' Health and Safety Concerns 51