THE CO-CREATION OF BEHAVIOUR CHANGE RESOURCES FOR PEOPLE WHO GAMBLE AND AFFECTED OTHERS

Abstract

The aim of this project was to identify the range of change strategies used for gambling harm reduction and to create resources on implementing these strategies in real-life situations. The resources for gambling were developed using cocreation with experts with lived experience.

Over a two-stage data mining and review process, we developed four sets of resources:
1. For people who gamble on a variety of gambling forms and who want to reduce or stop gambling, or to reduce gambling harm (3 booklets).
2. For families, friends, and other people who are affected by gambling harm because of someone else’s gambling and who want to focus on reducing their own gambling harm (3 booklets).
3. For families, friends, and other people who want to support a person who gambles in reducing their gambling or gambling harm (3 booklets).
4. For people who gamble specifically on EGMs and want to maintain low-risk gambling (1 booklet). The resources reflect a wide range of lived experiences contextualised to New Zealand. They contain detailed practical instructions on implementing change strategies in a variety of gambling-related situations. The resources can be further customised for distinct population groups and/or translated to other languages. The resources are highly engaging in their professionally designed paper-based format but have a potential to be converted in a variety of different modalities.

Full text

THE CO-CREATION OF
BEHAVIOUR CHANGE
RESOURCES FOR PEOPLE
WHO GAMBLE AND
AFFECTED OTHERS
University of Auckland
Authors: Simone Rodda (PhD), Natalia Booth (MPh), Rimke Bijker (PhD),
Severi Luoto (PhD), Jason Landon (PhD),Dan Lubman (AMPhD)andNicki
Dowling (PhD)
August2021

Acknowledgements
This project was funded by the Ministry of Health, Aotearoa New
Zealand. We are thankful to the Ministry for their support on this
innovativeproject.
The authors gratefully acknowledge assistance from our wider
research team including Alesha Wells, Shirleen Prasad, Anna
Aucamp, Jennifer Park, and Jessica McKean.
This project could not have been possible without the many
hundreds of gamblers and their families who provided their
valuable time. Thank you to all the anonymous and brave people
whose stories were taken from forums and websites in the first
phase of this study.
About the authors
This project is part of a series of studies on change strategies that are grounded in real world experience.
Dr Simone Rodda is the lead investigator on these projects and is a senior lecturer at the University of
Auckland. Enquiries related tothis project can be directed to s.rodda@auckland.ac.nz
Conflict of interest declaration:The authors declare no conflict of interest in relation to this report or
project.
The authors accept full responsibility for the conduct of the study and the presentation of the results
contained herein.
Ethical approval to undertake this workwas granted by the University of Auckland Human Participants
Ethics Committee (019791).
Citing this work
Rodda, S.N., Booth, N., Bijker, R., Luoto, S., Landon, J. Lubman, D. I., Dowling. N. A. (2021). The co-creation of
behaviour change resources for people who gamble and affected others. Ministry of Health, New Zealand.

Table of
Contents
ORIENTATION TO THE PROJECT
INTRODUCTION TO SELF-
MANAGEMENT AND THE PROJECT
CO-CREATION OF CHANGE
STRATEGIES BOOKLETS
STAGE 1: INITIAL DEVELOPMENT
STAGE 2: EXPERT EVALUATION
FUTURE DIRECTIONS
03
07
10
12
16
25

EXECUTIVE SUMMARY
The Change Strategies Project led by Dr. Simone
Rodda at the University of Auckland specialises in
developing self-help interventions. All areas of
behaviour change (e.g., gambling, alcohol, internet,
pornography, gaming, loot boxes, caffeine, sugar, and
overeating) have a common pattern: people use
similar behaviour change strategies, i.e., self-directed
cognitive and behavioural actions, to reduce or stop
the consumption or to reduce harm from
consumption.
A significant proportion of gambling harm in New
Zealand falls on people at low to moderate severity
of harm. This is a group of population that is most
likely to benefit from change strategies considering
that 1) there is no specific treatment available to
them, 2) they are more likely to use self-help than
formal treatment, and 3) self-help has been found to
be effective in facilitating behaviour change.
The aim of this project was to identify the range of
change strategies used for gambling harm
reduction and to create resources on implementing
these strategies in real-life situations. The
resources for gambling were developed using co-
creation with experts with lived experience.
Over a two-stage data mining and review process, we
developed four sets of resources:
1. For people who gamble on a variety of gambling
forms and who want to reduce or stop gambling, or to
reduce gambling harm (3 booklets).
2. For families, friends, and other people who are
affected by gambling harm because of someone
else’s gambling and who want to focus on reducing
their own gambling harm (3 booklets).
3. For families, friends, and other people who want to
support a person who gambles in reducing their
gambling or gambling harm (3 booklets).
4. For people who gamble specifically on EGMs and
want to maintain low-risk gambling (1 booklet).
The resources reflect a wide range of lived
experiences contextualised to New Zealand. They
contain detailed practical instructions on
implementing change strategies in a variety of
gambling-related situations. The resources can be
further customised for distinct population groups
and/or translated to other languages. The resources
are highly engaging in their professionally designed
paper-based format but have a potential to be
converted in a variety of different modalities.
Recommendations for future research:
Test which strategies work for what type of an
end-user in what conditions and in what
combination with other strategies.
Further tailoring by end-user characteristics via
development of an online assessment tool.
Test different modalities of delivery including
online or via a smartphone app.
Use of the resources as a preventative
intervention coupled with community action (e.g.,
educational workshops on gambling harm
prevention for a community).
Integration of the resources with financial
industry initiatives (e.g., blocking of payments to
gambling operators].
Investigation of integration of the resources into a
stepped care approach (e.g., support for clients
and clinicians in post-treatment care and self-
management).

03
The Change Strategies Project was established to
support individuals in their recovery from harm
related to addictive behaviours. The project covers
a range of areas, including – but not limited to –
gambling, alcohol use, internet, gaming, loot boxes,
social media, pornography, caffeine, and sugar. The
rationale behind the Change Strategies Project is
that harm of addictive behaviours can be reduced by
improving individuals’ skills and competence and by
empowering them to make their own decisions.
People who engage in addictive behaviours often try
to recognise and address harms on their own. Many
people recover from addictions through what is
termed “natural recovery” by using multiple self-help
or self-management strategies (1-3). Such “change
strategies” are cognitive and behavioural actions
that aim to reduce addictive behaviours or the harm
from the addictive behaviours. They can be taken
with or without formal support.
The Change Strategies Project aims to facilitate this
behavioural change process by a multi-step process:
Understand and classify the change strategies
used by people to reduce addictive behaviours
and/or address harm specific to different
addictive behaviours.
Orientationto the project
Introduction About
the Change
Strategies Project
Develop foundations for acceptable, low-cost
interventions and conduct a preliminary
evaluation of their efficacy.
Test the interventions and tailor them to different
groups within the population.
The majority of population harm from addictive
behaviours is attributable to people who experience
low to moderate harm, whereas a much smaller
percentage of the population experiences severe
harm.
Seen from a public health perspective, reducing
harm on a larger scale will have a substantial effect
on the population as a whole (4). Furthermore,
people who have more severe addictions often have
complex comorbidities and may require more
intensive interventions, often guided by
professionals such as GPs, psychiatrists, or
psychologists (5, 6).As such, the Change Strategies
Project’s interventions are primarily targeted at
those at low and moderate risk of harm. However,
people experiencing more severe harm may still
benefit from the Change Strategies interventions as
they are developed in a manner which enables
integration into other behaviour change treatments
as well.
Gambling harm is a major public health issue impacting whole
of communities.

04
The Mental Health and Addiction Inquiry (7) has
recently identified the need for a more inclusive
mental health and addiction system for Aotearoa
New Zealand (7). The inquiry reported a substantial
gap in service options for those with less severe
needs, even when individuals are experiencing
considerable harm. This broad gap is magnified in
secondary prevention and treatment efforts,
whereby those at low and moderate risk almost
never come into contact with the service system. The
gap in service options is highly apparent for people
experiencing gambling-related harm.
Gambling-related harm has been identified as a
major public health issue (4). Prevalence studies
estimate that around 0.2-0.5% of the New Zealand
population experiences problem gambling (based on
a score of 8 or higher on the Problem Gambling
Severity Index), with a further 3.1-4.6% and 1.5-1.8%
being at low or moderate risk, respectively (8, 9).
Low- and moderate-risk gambling contributes to
approximately 82% of gambling-related harm in New
Zealand (10), with a large amount of gambling
expenditure spent on electronic gaming machines
(EGMs, also known as pokies) (11). Gambling-related
harm may not be experienced solely by the people
who gamble but may extend to others who are
connected to them, such as their families, whānau,
friends, colleagues, and the wider community (12). In
fact, estimates suggest that six times more
individuals are impacted by gambling harms than
there are problem gamblers (13).
Initiatives to reduce gambling-related harm have to a
great extent focused on educating gamblers of the
potential risks associated with losing control
alongside messaging that encourages gamblers to
engage in “responsible gambling” to minimise harm
and to stay in control (14, 15).
Orientationto the project
Furthermore, there have been multiple campaigns to
draw people at low and moderate risk of gambling-
related harm into treatment.However, the uptake of
these programs remains low (1, 3), possibly because
the types of services currently on offer are not
attractive to many low- or moderate-risk gamblers.
Similarly, using advertising and promotion to
encourage affected families to connect to services
has had little effect, and the current rate of help-
seeking by families is even lower than that of
gamblers (4, 16, 17).
The importance of
this project
More tools, support, and guidance for self-help and
self-care are needed to support people who gamble
and their family members in their recovery from
gambling harms. As noted by the Mental Health and
Addiction Inquiry, it is essential that the tens of
thousands of people not currently receiving support
should not result in diverting funding away from
specialist services – rather, focus should be
redirected at addressing gaps in the current service
system (7).
The Change Strategies Project intends to fill this gap
by creating resources that are affordable, have a low
threshold for implementation, and appeal to various
groups of people who experience gambling-related
harm or want to support those people who do
experience such harm.
More options are needed
that are appealing,
affordable and accessible to
people harmed by gambling

05
Co-creation of public health interventions is gaining
popularity in the field of public health. In contrast to
the more traditional interventions developed using a
top-down approach, co-creation utilises the
collective knowledge of researchers and the
intended target population, i.e., the end-users, to
develop interventions (18).
Through a process of co-creation interventions can
be tailored to the needs and preferences of the
target population, thereby enhancing acceptability
and uptake of the interventions (19).
For example, trials in which informative resources
were created by consulting and engaging end-users
showed that the resources became more relevant,
with the readability and comprehension of the
information being superior to information created
using a more traditional top-down approach (20).
The study we conducted involved several phases of
co-creation, and the input of end-users was used in
multiple ways to enhance the acceptability and
uptake of the resources intended to support
gambling-harm reduction.
Orientationto the project
Co-creation of
resources to support
gambling-harm
reduction

06
This report focusses on a study that was conducted
to create a set of resources that could be used
independently as self-help or as an addition to formal
treatment to reduce gambling harm. More
specifically, the report describes the activities and
results related to the co-creation of a set of
booklets with strategies on how to help (a) people
who gamble reduce or stop gambling; (b) families
and friends affected by another person’s gambling
harm; and (c) such affected others support the
person who gambles in reducing or stopping
gambling.
There are many different gambling activities that
people commonly engage in in New Zealand, such as
pokies, online gambling, casinos, and sports betting.
The abovementioned change strategy booklets that
were co-created are general in nature – that is, the
strategies are intended to support gambling harm
reduction regardless of the type of gambling.
However, gambling may be associated with various
challenges and opportunities specific to a certain
type of gambling. Thus, people who engage in a
certain type of gambling may benefit from specific
early-intervention resources. In addition to the
general resources to reduce gambling harm, we also
co-created a change strategy booklet as an early
intervention to serve people who are at a risk of
experiencing gambling harm from pokies. The
process and results of the co-creation of the low-risk
pokies booklet are presented in a separate section of
the report (see section 2.2.4).
This report will detail the phases of co-creation,
provide an overview of key points discussed by the
end-users, and offer recommendations for future
research in the field of gambling harm reduction.
Orientationto the project
PART ONE provides background information on self-
management to reduce gambling harm. A distinction
is made between self-management for (i)
People who gamble (ii)Affected others who want to
help themselves or those who gamble (iii) Users of
pokies. Furthermore, this part of the report will
highlight concerns and specific gaps in care related
to gambling harm reduction.
PART TWO expands on the co-creation of the set of
change strategies booklets. The co-creation was in
stages, each consisting of various research activities.
Stage I: Initial development.
International online sources were used to gather
real-life experiences on strategies to reduce
gambling or gambling harm. These data on behaviour
change strategies coming from real-life people were
then analysed, integrated with relevant academic
research, and organised to form coherent strategy
packages. The output of combined stage I research
activities was provisional content on each of the
individual strategies.
Stage II: Expert review. Experts reviewed the
content from stage I using a web survey with ratings
and open questions. The expert feedback was
integrated with the content. The outputs of the
integration process were co-created booklet sets
with behaviour change strategies aimed at various
groups of end-users: 1) people who gamble, 2)
affected others, 3) support persons. In addition to
the booklet sets aimed at abovementioned end-user
groups, stage I and stage II activities were executed
specifically to develop an early intervention for
reducing risk associated with pokies gambling.
PART THREE elaborates on possible future
directions needed to reduce gambling harm, based
on feedback from the consulted end-users. It is
positioned within a framework of findings from other
research in the field of gambling.
About this report
NOTE:Experts in this studyare people who gamble, affected
others (who want to help themselves), and support persons
(who want to help a person who gambles), but also
professionals who support any of these groups and who may
use the resources to supplement the services they provide as
standard care.

07
The majority of individuals experiencing gambling
harms do not seek psychological treatment (1, 21,
22). In fact, about a third of people with gambling
problems are thought to recover without
professional oversight, a phenomenon which has
been historically viewed as natural recovery (1).
Natural recovery is characterised by activities
directed at reducing gambling behaviours. These
activities are typically referred to as behaviour
change (or self-help) strategies. Recent research
suggests that a broad range of self-help resources
and strategies are frequently employed by
individuals to help themselves overcome gambling
harms (23-26).
SELF-MANAGEMENT OF GAMBLING
Behaviour change strategies are the first and most
widely used type of help among people who
experience gambling harms (26). Using these
strategies can help regulate gambling (23, 26),
including reducing the time or money spent
gambling (9). Triggers to using behaviour change
strategies include a realisation that gambling has
fundamentally changed the person (27), resulted in
negative emotions (26), or concerns that the
gambling will worsen.
Part 1. Introduction to self-management
PART ONE: Self-
management
strategies to reduce
gambling harm
Studies show that the most commonly used
strategies to reduce gambling harm include stimulus
control, new activities, professional or social support,
remembering negative aspects, reflecting on future
possible consequences, budgeting, tracking
gambling spend, thinking how money could be better
spent, limiting access to money for gambling, and
avoidance of venues, people, and places (23, 24, 26,
28, 29). However, a plethora of other change
strategies has been identified from online forums for
problem gambling (25).
In the most comprehensive study to date (29), our
team extended previous work to identify the
difference in frequency of use and helpfulness of
behaviour change strategies. Almost 500 people who
gamble evaluated 99 gambling-harm reduction
strategies. Interestingly, the findings revealed that
the most frequently used strategies were not
necessarily considered the most helpful.
Furthermore, on average, strategies were considered
only moderately helpful. These findings indicate a
need to provide guidance to effectively implement
strategies.
Currently, in New Zealand, information on behaviour
change strategies is available through websites such
as the HPA Choice Not Chance site which describes a
selection of strategies and some limited information
on how to implement them. These strategies,
however, are broad and not based on empirical
evidence, nor are they validated by consumer
experience of helpfulness. Moreover, there is no
accompanying guidance on how to implement these
strategies.
Change strategies are used by all gamblers to self-regulate
gambling involvement

08
Part 1. Introduction to self-management
SELF-MANAGEMENT FOR AFFECTED OTHERS
Previous work from our team indicates that family
members want to help themselves and often also the
person who gambles (30). Affected others, including
whānau and friends, can use various approaches to
address gambling, such as a family-focused, a
gambler-focused, or a blended approach (31).
A family-focused self-management approach aims
to support the family members of people with
gambling problems to respond or recover with or
without the involvement of the gambler. We found
that 28% of family members wanted a family-
focused approach that was most frequently about
improving the quality of the relationship, getting
information on support options, and managing the
impact of gambling (30).
Gambler-focused approaches are those that aim to
educate, advise, or counsel family members so that
they are better able to support the gambler in
recognising a problem, seeking help, and thereby
changing their gambling behaviours (32). In our
previous study, 50% of family members requested
gambler-focused options, such as advice and support
on getting the person who gambles to change,
supporting their behaviour change, and facilitating
their treatment seeking. Family members also
requested a blended approach (22%) (e.g., how to
support the person who gambles and how to deal
with the negative impacts). The 2016 Health and
Lifestyles Survey (33) conducted in New Zealand
reported that only approximately half of families and
whānau knew what they could do to help a person
with a gambling problem.
SELF-MANAGEMENT RELATED TO USE OF POKIES
Pokies venues have been the subject of extensive
research for more than 20 years. It is now well
established that the density and location of pokies
venues is associated with increased uptake of
gambling and associated gambling harm (34, 35).
Pokies venues are reported to be attractive to
gamblers (especially women, shift-workers, and older
people) as they provide a sense of safety, early and
late opening hours, and reduced-price meals and
drinks (36-38).
New Zealand gaming venues also play host to the
modern gaming machines that allow rapid play (a bet
every six seconds), with potential losses of up to
$1,500 per hour (based on a maximum bet of $2.50
per spin). This continuous form of gambling has been
linked to a loss of control, the development of
gambling harms, and exceeding personal limits (39,
40).
In recent years, our team has conducted multiple
studies on reducing risk associated with pokies
gambling. Among this work was a novel study
seeking to identify how people who play the pokies
stick to their monetary limits (41). The findings
showed that nine out of ten people who gamble had
at least one strategy in place for sticking to their
monetary limit in the venue. A follow-up study
indicated that without setting a limit, there was a
high risk of busts to occur, with spending ranging up
to $1,500 per bust (42).
Our work further shows that those who do set limits
frequently set them in excess of what is considered
safe according to gambling guidelines (41). Other
work that has been released recently set out to
determine low-risk gambling limits, such as the
amount of money and time spent with gambling per
month or per year that can be considered safe in the
sense that it does not result in increased odds for
experiencing gambling-related harms (43-45). It
should be noted that none of this work has been
operationalised to provide guidance to gamblers on
how to implement limits and stick to them
Implementation guidelines
are needed that address the
myriad of barriers for low
risk pokies gambling

09
Part 1. Introduction to self-management
Significant gaps in
the health system
can mean gambling
harm is not
addressed.
The co-creation of
resources for
gamblers and
affected others
offers a new
approach to
responding to
gambling harm.
Concerns related to
gambling harm
reduction in New
Zealand
Addressing significant gaps in the health system
The above information indicates that people who gamble in
AotearoaNew Zealand are not equipped with the full range of strategies
they can use to limit gambling-related harm. Available information
relating to limit-setting for gamblers in New Zealand is not based on
evidence, and information tends to be general rather than specific.
Furthermore, little information is available on how family members
manage or recover from gambling harms without formal treatment.
Significant gap
There is a significant gap in delivery of treatments and support to
people at a low to moderate risk of gambling, particularly as these
people rarely come into contact with the treatment system.
Support for sticking to limits
There is currently limited information for people who gamble on
how to stick to limits in gambling venues.
Affected others need support
There is limited information on the specific strategies that affected
others can use to limit the impact of harms on themselves.
Limited information on how to support others
There is limited information on the specific strategies that affected
others can use to support others to reduce gambling.
Listen and learn
There are a million and one stories online describing exactly how
gambling harms can be reduced. There is a need to listen and
synthesise these voices.
01
02
03
04
05
Although behaviour change strategies have been identified for gambling
harms, these have not yet been developed into resources for potential
end-users using a bottom-up and tailored approach. Such resources are
very much needed, especially for Māori, Pasifika, and Asian peoples who
are unwilling or unable to access face-to-face treatment.

10
To address the concerns and gaps identified above,
our project was executed in two stages in which we
conducted a series of foundational activities that
served to develop change strategies to reduce
gambling-related harm. Consistent with the Mental
Health and Addiction inquiry (7), we developed the
resources through a process of co-creation.
In this process, there was a strong commitment to
listening to the voices of people impacted by
gambling harms. The process places the end-user in
the beginning, middle, and end of the foundational
research. As such, the resulting resources do not just
reflect input from the end-users, but they are
grounded in the actual lived experience of end-users.
By definition, people are experts in their own lived
experience. Therefore, we will use the term “expert”
when referring to the potential end-users who
participated in the research activities of stage II. Our
research activities were performed in two stages
with several steps.
Stage I: Initial development (seeTable 1)
1. Content scraping. This activity aimed to identify
end-user content from websites focussing on the use
of change strategies to reduce gambling or gambling
harm. The identified content was targeted at three
areas, namely, gambling overall, affected others, and
low-risk gambling in pokies venues.
2. Content analysis. Content analysis of the
extracted end-user content was performed to create
strategies for behaviour change.
3. Data organisation. Data on behaviour change
strategies from real-life people was integrated with
evidence from relevant scientific literature.
Part 2. Co-creation of change strategies booklets
4. Review preparation. The lived experience and
associated evidence on change strategies was
synthesised into provisional content for each of the
strategies, which was presented in a format that
could be easily assessed by end-users.
Stage II: Expert review (see Table 2)
1. Web survey. A web survey with Māori, Pacific,
Asian, and Pākehā experts was conducted to assess
the relevance of the content for a New Zealand
setting.
2. Integration of expert feedback and provisional
content. Feedback on how to improve the content
(e.g., possible barriers to implementation of the
strategies, solutions to barriers, cultural
competence) was integrated with the content from
stage II to co-create sets of behaviour change
booklets grounded in lived experience.
3. Co-creation of low-risk pokies booklet. A
separate booklet was created as an early
intervention for reducing risk associated with pokies
gambling.
PART TWO: Co-
creation of change
strategies booklets
Resources were developed
through co-creation involving
multiple phases and methods

11
Part 2. Co-creation of change strategies booklets
ACTIVITY
METHODS
OUTPUT
1. Content scraping
Data mining real-life experiences
targeted at three groups of end-
users (i) People who gamble (ii)
Affected others (iii) People who
play the pokies
Three large datasets with real-life
data specific to each group of end-
users
2. Content analysis Thematic analysis which utilised
terminology of the original data A collection of strategy groupings
3. Data organisation
Scientific literature search to
supplement strategies with
evidenced-based information where
relevant and to structure strategies
into phases of behaviour change
Ten sets of behaviour change
strategies, organised by area
4. Review preparation Development of templates to
present strategies
Provisional content on each of the
strategies
Table 1: Stage 1 Initial development
Table 2: Stage 1 Expert review
ACTIVITY
METHODS
OUTPUT
5. Web survey
Mixed-methods web survey with
ratings and open questions;
snowball sampling and purposeful
targeting of
Māori, Pasifika, and Asian end-
users
Qualitative and quantitative
feedback on content for people who
gamble, content for affected others,
content for support persons, and
content for low-risk pokies gambling
6. Key findings summary
Descriptive analysis of ratings;
informal analysis of themes in the
feedback
Directions for key areas of
improvement
7. Integration of expert feedback
and provisional content
Thematic analysis of feedback
organised into strategy-specific
checklists; team discussions for
final decisions on how to integrate
the feedback
Three sets of behaviour change
strategies resources to reduce
gambling-related harm
8. Co-creation of a low-risk pokies
resource
Similar to methods used in Activity
6 and 7
A resource of behaviour change
strategies to reduce gambling-
related harm specific for those who
play the pokies

12
Stage I entailed a process of data mining real-life
experiences, content analysis, organising data into
behaviour change strategies, and synthesising the
content into a format that could easily be assessed
by end-users. Behaviour change strategies were
defined as actions, both cognitive and behavioural,
that were undertaken by people who gamble and
affected others to reduce gambling and/or gambling
harm.
CONTENT SCRAPING
Content scraping, also referred to as data mining, is a
particularly useful tool in behaviour change research.
It leverages the massive amount of naturally
occurring data in online forums and message
boards to understand how change happens in real-
world settings. Data mining was targeted at three
specific areas: gambling overall, affected others
(including those providing support for people who
want to reduce gambling behaviour), and low-risk
gambling in pokies venues.
For the purposes of the current study, we used one
existing dataset focussing on people who gamble,
which was collated as a part of a previous project
(25). A new dataset was created focussing on
affected others, of which the findings were recently
published (46). Another dataset was generated
specifically on strategies for staying in control with
pokies gambling (not published).
Part 2.Stage I: Initial development
Stage I: Initial
development
For all datasets, a rigorous search strategy was
used to collect a pool of international sources
across each of the searches. This search strategy
was based on a method developed in earlier research
investigating behaviour change strategies for
reducing gambling, internet usage, gaming and
pornography, sugar, and caffeine consumption, as
described previously (25, 47-49). Briefly, open-
access gambling forums were identified and
searched using combinations of search terms
describing indicators of harm, target audience, and
the method of change.
The forums were: Gambling Helpline (New Zealand),
Gambling Help Online Community Forum (Australia),
Gambling Therapy (UK), GamCare (UK), Gamtalk
(Canada), and Psych forums (USA). This search was
supplemented with a depersonalised search in
Google. Potential sources were assessed against the
following inclusion criteria: (1) focused on gambling
and/or gambling harm; (2) were from the perspective
of gamblers or affected others or were directed
towards gamblers or affected others; (3) included at
least three behaviour change strategies; (4) were
published in the last five years prior to the search;
and (5) were written in English. Sources were
excluded if they were advertising, promoting, or
encouraging gambling.

13
Part 2.Stage I: Initial development
CONTENT ANALYSIS
We used thematic analysis (50, 51) to sort the data
into meaningful strategy groupings while maintaining
original quotes, which could be used for the
development of resources. Groupings reflected
strategies that were discussed multiple times or
strategies on which there was a range of views. Each
extract (i.e., quote) was given a code that captured
the essence of the strategy and represented patterns
in the data. Definitions for the codes were inductive
and reflected the included data while also being
informed by existing change strategies research to
allow for consistency across the field (Rodda, Bagot
(29). The analysis was an iterative process in which
codes and strategy groupings continued to be
developed.
Importantly, a bottom-up approach was used to
preserve natural language and terminology used by
end-users in the original web content (52). The
findings, therefore, represented strategies that
people who gamble and affected others naturally use
to reduce gambling and/or gambling-related harm
and how they implement these strategies in real-
world settings. As a part of the analysis, notes were
taken in an excel database to indicate the overall
idea described in the online source and whether the
source reflected real-life experience from end-users
such as people who gamble, affected others, and
people who play the pokies, or advice provided by
someone in a professional role.
DATA ORGANISATION
Scientific literature was consulted to organise the
data. Firstly, a literature search was undertaken
against each of the identified strategies. The aim of
the search was to identify the mechanisms of
behaviour change that underpinned the strategies
and, where available, these mechanisms were
summarised to function as a background for the
strategies.
Where relevant, we supplemented strategies from
the real-life data with evidence-based information.
For instance, the dataset on affected others showed
the effects of stress and the need for stress
management. However, clear instructions on stress
management and how to implement it was lacking in
the data. Scientific literature confirmed being
affected by another person’s gambling as a stressful
life experience and, in turn, provides knowledge on
how to cope with this type of stress (53). After
reviewing the literature, this information was
selectively integrated in the strategy. Likewise, we
supplemented the strategy with information on
mindfulness and relaxation techniques as these are
indicated by existing literature as effective stress
management tools (54).
Secondly, scientific literature was used to structure
the strategies into phases of behaviour change
according to a behaviour change framework (i.e.,
the Health Action Process Approach, Schwarzer,
Lippke (55)). This framework incorporates various
stages, involving thinking about change, getting
ready for change, and taking action to achieve and
maintain change.
In line with the framework, the strategy groupings
from our data were divided into four different sets of
strategies:
Pre-decisional phase strategies, which included a
range of motivational strategies that help to form
an intention to change behaviour.
Post-decisional phase strategies, which included
strategies focused on planning for the behaviour
change.
Actional phase strategies, which included
strategies that enact actual behaviour change.
A post-actional phase strategy, which focused on
evaluation of a previous behaviour change
attempt with an aim to decide on the next action.

14
Part 2.Stage I: Initial development
DATA ORGANISATION cont..
Based on evidence from literature and team
discussions, we decided to split the strategies from
the affected others data set into two groups: (1)
strategies aimed at reducing harm experienced by
gambling from another person, that is, harm
experienced by others such as whānau, family,
friends, and colleagues (henceforth simply referred
to as “affected others”), and (2) strategies targeted
at those individuals, such as whānau, family, friends
(henceforth referred to as “support persons”), who
wish to support a person who gambles to reduce or
quit gambling.
As a result, the strategies were organised into nine
sets, covering strategies for each stage of behaviour
change (i.e., pre-decisional, post-decisional, and
actional) and by target group of end-users (i.e.,
people who gamble, affected others, and support
persons).
Strategies for staying in control in one specific
gambling context, namely pokies, were organised
into a separate resource. Based on our previous
work (56) we decided to group these strategies into
four categories based on the best timing of
implementation (before, during and after gambling).
These were joined together to form iterative steps
instead of themes. Table 3 provides an overview of
the ten sets of behaviour change strategies.
REVIEW PREPARATION
To enable the expert evaluation of strategies for
behaviour change, the data on behaviour change
strategies had to be collated into a format which
maintained the authenticity of the original data on
real-life experiences and was easy to assess by
potential end-users. The output of the combined
stage I research activities was therefore developed
into provisional content on each of the individual
strategies. Thematic analysis (50, 51) was adapted to
join quotes from the original data together and
present them as a narrative on each strategy. As
such, the content was principally a collation of
quotes organised coherently and intended for
dissemination to a lay audience rather than a report
intended for academic distribution.
We then developed templates that were used to
present the content. The design of these templates
was informed by feedback from end-users on
previously created guidelines to support behaviour
change (57-59) and feedback from the project team
(Landon, Lubman, Dowling) on various drafts.
Templates contained multiple elements including (i)
introduction, (ii) scientific background, (iii) details on
implementation, (iv) practical steps, (v) illustrative
quotes, and (iv) activities and visual elements.
Images were important to provide breaks between
text, reinforce messages, and improve the overall
readability of the content.

15
Resources were developed
through co-creation involving
multiple phases and methods
SET
SUB-SET
DESCRIPTION
Gambling harm reduction Get motivated
(20 pages, 6 strategies)
Pre-decisional strategies that aim to
increase behavioural intention to
reduce or limit gambling.
Barrier busters
(27 pages, 7 strategies)
Post-decisional strategies that
prompt people to plan to prevent
relapse.
Take action
(61 pages, 19 strategies)
Actional strategies that can be used
directly to reduce gambling or
gambling harm.
Help for families Goal setting
(17 pages, 5 strategies)
Pre-decisional strategies to resolve
ambivalence and create a
behavioural intention to address
gambling harm caused by some
else.
Barriers
(15 pages, 4 strategies)
Post-decisional strategies that
prompt people to plan to adhere to
new behaviour (i.e., reducing
gambling harm).
Take action
(38 pages, 11 strategies)
Actional strategies for gambling
harm reduction that can be used by
affected others with or without
involvement of the person who
gambles.
Be a support person Nudge
(14 pages, 4 strategies)
Pre-decisional strategies that
prompt realisation in the person
who gambles and strategies that
help the support person to set their
own goals.
Maintain change
(15 pages, 4 strategies)
Post-decisional strategies that
prompt planning on how to continue
supporting the person who gambles
long-term.
Give a helping hand
(29 pages, 8 strategies)
Actional strategies that can be used
to support the person who gambles
in implement gambling reduction
strategies.
Pokies guidelines
A “how-to” guideline on sticking to
limits at the pokies
(18 pages)
Strategies grouped under four
“steps” to be implemented
successively. The steps cover: (i)
strategies to be used for limit
setting, (ii) strategies to be used for
session planning, (iii) strategies to
be used at the moment of
gambling, (iv) strategies to be used
for discontinuing a gambling
session.
Table 3: Overview of the behaviour change strategy sets
Part 2.Stage I: Initial development

16
The provisional content from stage I was based on
data from international sources. As such, an essential
aim of stage II research activities was adapting the
content to fit the New Zealand context. This was
done by recruiting potential end-users, i.e., lived-
experience experts and professional experts, to
assess the content through a web-based survey. A
mixed-methods approach was used in which experts
rated the content and provided qualitative feedback.
The expert feedback was then integrated with the
content to form a co-created set of booklets aimed
at reducing gambling-related harm. Expert
feedback leading to the co-creation of a low-risk
pokies booklet will be discussed separately.
WEB SURVEY
Initially, we planned to have focus-group discussions
with experts to receive feedback on the provisional
content which could then be integrated to create
resources for gambling harm reduction. However, in
face of a growing COVID-19 pandemic, this plan had
to be adapted to assure safety to participating
experts and public health as a whole. Instead, a web
survey was designed to collect feedback on the
content from a large group of experts. We
purposefully targeted Māori, Pasifika, and Asian
peoples via a targeted recruitment campaign, though
the majority of the experts who responded to the
survey were Pākehā, the proportion of targeted
groups was similar or above the proportion of this
group in general population (for detailed
demographic information, see section “Meet the
experts” below). An additional benefit of the web
survey was that it enabled us to recruit a nation-wide
sample of experts.
Stage II: Expert
evaluation
RECRUITMENT PROCESS
We recruited individuals who were deemed experts
based on having lived or professional experience.
Thus, experts were people who gamble, affected
others, support persons, and professionals
interested in supporting any of these groups.
Recruitment of experts occurred via snowball
sampling, and free and paid advertising from a range
of different sources between January – April 2021.
The recruitment avenues included (a) paper posters
on notice boards in local supermarkets, libraries,
gyms, and other community spaces in Western,
Eastern, and Southern suburbs of Auckland that have
higher Māori, Pasifika, and Asian populations; (b) the
University of Auckland research study recruitment
page; (c) eleven gambling health promotion and
culturally specific services; and (d) social media
including Facebook, Instagram, Twitter, Neighbourly,
and Reddit.
Experts were able to choose the number of content
categories they wanted to review, up to a maximum
of 12 strategies. Experts received a $15 gift card for
reviewing three strategies, $30 for six reviews, $45
for nine reviews, and $60 for twelve reviews. For the
low-risk pokies content, experts received a $30
dollar gift card to review all steps in the set.
Part 2.Stage II: Expert evaluation

17
Part 2.Stage II: Expert evaluation
REVIEW PROCESS
The evaluation of the experts was conducted via a
mixed methods approach. Experts were asked to
provide ratings on their impressions of the content
on the following parameters: 1) readability and
comprehension, 2) helpfulness, and 3) overall
satisfaction. The low-risk pokies content was rated on
two additional parameters: 4) correctness and
relevance, and 5) potential to reduce gambling harm.
Overall satisfaction was measured using a 5-star
rating system (similar to online reviews), whereas the
other parameters were measured using a 5-point
Likert scale. For each of the parameters, more points
(or stars) corresponded to a more favourable rating.
The remaining questions were open questions
pertaining to potential barriers to putting the
strategies in practice and to providing specific
improvements to the content.
MEET THE EXPERTS
We recruited a total of 426 experts from across New
Zealand who evaluated the stage I strategies. Among
the overall recruited sample, 53% of the experts
were female and 46% male; all were aged between 18
and 72 years; and 20% identified as Māori, 7% as
Pasifika, 20% as Asian.
The total number of experts reviewing the stage I
strategies differed across the strategy sets:
One or more of the 31 strategies targeted at
people who gamble were assessed by 75 people
who had lived experience of having gambled in the
past or present or who were a professional with
interest in gambling harm reduction.
One or more of the 19 strategies targeted at
affected others were evaluated by 73 people who
reported knowing people who gamble, having
experienced or witnessed gambling impact on
families, or who were a professional with interest
in gambling harm reduction.
One or more of the 14 strategies targeted at
support persons were assessed by 63 people who
were willing to help someone who might be
developing (or have developed) a gambling
problem or by a professional.
All four steps of the strategies targeted at low-
risk pokies users were assessed by 215 people
who gambled on pokies in the past or present or
by a professional interested in gambling harm
reduction. See section "summary of findings" for
the description of expert feedback on, and
integration of, this feedback with the provisional
content related to low-risk pokies gambling.
A companion technical report provides a detailed
overview of expert characteristics, by target group of
the strategy sets.

18
Part 2.Stage II: Expert evaluation
SUMMARY OF KEY FINDINGS
The following sections summarise the ratings on
each of the parameters by target group of the
strategies. The ratings were also analysed by expert
characteristic (i.e. by role, gender, age group,
ethnicity, education level, knowledge of strategies,
gambling spending in a typical month, problem
gambler status according to PGSI, own gambling
experience, relation to person who gambles, and
severity of experienced gambling harm). The results
of these findings are detailed in the companion
technical report. A qualitative content analysis was
conducted to highlight key feedback to the open
questions that may have contributed to the ratings.
This analysis was then taken into account when
revising the resources subsequent to the stage II
expert review.
EXPERT FEEDBACK ON CONTENT TARGETED AT
PEOPLE WHO GAMBLE
Experts completed on average 6.8 reviews (SD =
4.8), resulting in each strategy being reviewed
between 13 and 19 times. Overall satisfaction with the
content for people who gamble was rated as high by
the majority of experts (high, 73%; neutral, 19%; and
low, 8%), as were the readability and comprehension
of the content (high, 86%, neutral 10%, and low, 4%)
and the perceived helpfulness of the content (high,
76%; neutral, 17%; and low, 7%).
Overall satisfaction was rated as high by 56–87% of
experts on pre-decisional phase strategies and by
59–88% of experts on post-decisional phase
strategies. Most variation in rating was seen in the
actional phase strategies. Experts were least
satisfied with the Consumption planning strategy
(high, 40%; neutral, 53%; and low, 7%) and most
satisfied with the Cash control and finances strategy
(high, 93%; neutral, 7%; and low, 0%).
In general, strategies with lower overall satisfaction
ratings also received lower ratings on perceived
helpfulness, but not necessarily on comprehension
and readability of the content. Comments on pre-
decisional phase and post-decisional phase
strategies often referred to the need for actional
strategies.
Further analysis of the quantitative data showed that
all parameters had significant differences in ratings
by gender, ethnicity, and gambling spending.
Significant differences were also seen in overall
satisfaction ratings by education and problem
gambler status, in readability and comprehension
ratings by age and education, and in helpfulness
ratings by gender and knowledge of strategies.
Appendix C shows the associations between expert
characteristics and ratings on overall satisfaction,
readability and comprehension, and perceived
helpfulness.
By using a mixed-methods approach, qualitative
feedback could be linked to ratings and be utilised
to identify key directions for improvement. For
instance, although the majority of experts provided
high ratings on the content, experts with lower-level
education less commonly provided high ratings on
satisfaction, comprehension, and readability
(compared to experts with higher-level education).
Key feedback identified from these experts revealed
a need for support with the implementation of the
strategies. Experts also suggested to incorporate
further encouraging language and to simplify certain
sections of the text to make the content more
digestible. Furthermore, there appeared to be a
pattern in comments by experts who might
experience more harm: those who reported higher
spending in a typical month and those with an at-risk
problem gambler often provided comments stating
that certain strategies would not work for problem
gamblers or that there is a need to tailor strategies
by severity of experienced gambling harm.
Other key feedback related to tailoring of the
strategies to people of different ethnic
backgrounds. For instance, Māori experts commonly
provided comments suggesting incorporation of te
reo Māori and to add content specific to Māori,
including references to culturally competent or
community-based support (e.g., marae-based
services). Asian experts on the other hand commonly
discussed the need for translation of resources and
support from people with the same ethnicity or who
speak the same language.

19
Part 2.Stage II: Expert evaluation
EXPERT FEEDBACK ON CONTENT TARGETED AT
AFFECTED OTHERS
Experts completed on average 6.8 reviews (SD = 4.7),
resulting in each strategy being reviewed between
23 and 28 times. High ratings were given by the
majority of experts on overall satisfaction (high, 74%;
neutral, 21%; and low, 5%), readability and
comprehension (high, 92%, neutral 6%, and low, 2%)
and perceived helpfulness (high, 84%; neutral, 13%;
and low, 3%).
Overall satisfaction was rated as high by between
67–80% of experts on pre-decisional phase
strategies, by 60–86% of experts on post-decisional
phase strategies, and by 56–86% of experts on
actional phase strategies. The least favourable
satisfaction rating was for the Get some distance
strategy (high, 56%; neutral, 32%; and low, 12%),
whereas the most favourable was for the Seek social
support strategy (high, 86%; neutral, 14%; and low,
0%).
Overall comprehension and readability were rated
as high for over 80% of all strategies, except for
the strategy Block busters (high, 76%; neutral, 16%;
and low, 4%). All strategies received high ratings
from experts in over 64% of reviews.
Further analysis of the quantitative data showed that
all three parameters had significant differences in
ratings by gender. Additionally, overall satisfaction
ratings showed significant differences by age.
Comprehension and readability ratings differed by
ethnicity and by relation to the person who gambles.
The companion technical report shows the
associations between expert characteristics and
ratings on overall satisfaction, readability and
comprehension, and perceived helpfulness.
Key feedback identified from the experts showed
interesting patterns. For instance, Māori experts
provided suggestions related to the incorporation of
te reo Māori. Asian experts on the other hand
provided an abundance of specific examples related
to cultural norms and values that were considered
helpful or unhelpful when putting the strategy into
practice.
Another commonality across the feedback was that
some answers to the questions were provided from
the perspective of a person who gambles. Thus, it
may have been unclear to experts that strategies
were aimed to support affected others instead of
directly supporting people who gamble.
Alternatively, responses may have been provided
from this perspective because the majority of
experts had past or present experiences with
gambling themselves despite identifying as “affected
other” in the survey. Furthermore, a wide variety of
novel barriers and solutions emerged from the
feedback which had not been described in the stage I
strategies.
Experts also noted that, to be effective, some
strategies should be implemented concurrently. For
example, Hidden barriers to coping was discussed in
relation to Professional advice so that mental health
issues identified using the former strategy could be
addressed with the latter.
Experts ratings indicated
high satisfaction with the
content. Seeking social
support was the most
highly rated strategy.

20
Part 2.Stage II: Expert evaluation
EXPERT FEEDBACK ON CONTENT TARGETED AT
SUPPORT PERSONS
Experts completed on average 7.2 reviews (SD =
4.6), with each strategy being reviewed between 28
and 35 times. Most experts provided high ratings for
overall satisfaction (high, 84%; neutral, 13%; and low,
3%).
The majority of experts also provided high ratings
for readability and comprehension (high, 94%;
neutral, 4%; and low, 2%) and helpfulness (high,
89%; neutral, 9%; and low, 2%). Between 75–85% of
experts reported high overall satisfaction on pre-
decisional phase strategies, between 77–90% on
post-decisional phase strategies, and between 74–
93% on actional phase strategies. The content with
the lowest and highest overall satisfaction rating
were both actional phase strategies, namely Sticking
to gambling limits (high, 74%; neutral, 20%; and low,
6%), and Cravings and urges (high, 93%; neutral, 7%;
and low, 0%).
Ratings on readability and comprehension of the
content were over 82% for all strategies. Ratings on
helpfulness of the content were over 77% for all
strategies.
Further analysis of the quantitative data showed that
ratings on two parameters were different by
subgroups of experts. Specifically, overall
satisfaction was significantly different by role (i.e.,
lived experience or professional), ethnicity,
education level, and own gambling experience, while
helpfulness was significantly different by ethnicity,
own gambling experience, and knowledge of the
strategy. An analysis of demographic associations
with comprehension and readability yielded no
significant results. The companion technical report
shows the associations between expert
characteristics and ratings on overall satisfaction,
readability and comprehension, and perceived
helpfulness.
Qualitative feedback showed similar trends to what
was seen in responses to content for affected others.
In particular, the importance of whānau and marae-
based support was central to feedback from many
Māori experts.
Likewise, family was a recurring topic in feedback
from Asian experts, although this was often
discussed in relation to a lack of open discussion
about gambling, which created a barrier to
implementation of strategies.
Analogous to the findings from the feedback on
affected others, experts came up with a whole range
of additional barriers and solutions that were not
covered in the stage I strategies for support persons.
Furthermore, experts suggested that strategies
could be implemented conjointly to increase
effectiveness. An example was pairing Cravings and
urges with Social network because it would be a huge
burden for an affected other to support the person
who gambles for a prolonged period of time without
sharing responsibilities between other support
persons.
The importance of whānau
and marae-based support
was central to feedback
from many Māori experts.

21
Part 2.Stage II: Expert evaluation
INTEGRATION OF EXPERT FEEDBACK AND STAGE I
CONTENT INTO STAGE II BOOKLETS
All feedback was organised in strategy-specific
checklists which summarised the expert comments
by themes and provided key quotes illustrative of the
theme. Key feedback focussed on a wide range of
themes, which are listed and explained in the
companion technical report. The checklists were
then used to address the feedback and integrate
experts’ comments, requests, and suggestions into
sets of stage II booklets with behaviour change
strategies. Decisions on how to integrate the
feedback were made through discussion within the
project team (NB, SL, RB, SR). This process entailed
incorporating examples and quotes provided by the
experts and addressing other suggestions and
feedback (including some new information that the
project team had to retrieve from other sources
based on the experts’ feedback and suggestions).
The following sections provide a general description
of how the behaviour change booklets were co-
created based on the themes in the feedback. The
checklists (see technical report) provide a detailed
overview of the themes, illustrative quotes, and a
description of how key feedback was addressed for
each strategy.
TAILORING STRATEGY SELECTION
Each booklet contains an introduction, a foreword,
and a decision-tree diagram, which is supportive of
the introduction and foreword. These are included in
the first three pages of each booklet. They were
added in response to expert feedback on tailoring the
resources. Specifically, the introduction to each
booklet was written to explain the phases of
behaviour change and make end-users aware of
which phase they are currently in. This awareness
will result in a better match of end-users to suitable
strategies according to the phase of behaviour
change that the end-user is in.As often addressed by
experts, there is no one-size-fits-all strategy. The
foreword in each booklet emphasises that users can
create a personalised suite of strategies in line with
their individual needs, preferences, beliefs, and
situation.
The decision-tree diagram provides an overview of
all available strategies per each target
group thereby enabling quick selection of
strategies as well as serving as a table of contents
for each booklet. Another purpose of the decision-
tree diagram was to address comments about
connectedness of strategies. For example, experts
noted that the Internal reasons for gambling strategy
and External reasons for gambling strategy seemed
to be interconnected and supplementary to one
another, with some suggesting that the strategies
could be merged. However, merging the strategies
would be in contradiction with the frequently
mentioned expert comment of strategies being too
long and wordy. Therefore, the decision-tree diagram
was depicted in a manner that grouped certain
strategies together as part of a sub-set, such as the
sub-set on Self-discovery which covers strategies on
reasons for gambling.
TARGET AUDIENCE
We ensured that the target audience was clarified for
each strategy because experts had noted that it was
not always clear who would benefit from the
strategy. The target group for strategies was
stipulated in the strategy description, and, when
certain examples or elements of the strategy were
specific to a subgroup of people who gamble, the
target group was also clarified in the corresponding
section. The comments revealed that in the Help for
families and friends and Be a support person booklets,
it was sometimes unclear whether strategies were
targeted at the gambler or the affected others.
To clear up any confusion, the forewords in these
booklets now clearly delineate the target group of
each booklet. An additional concern pointed out by
experts was that the term “family” was not inclusive
enough, as the booklets were also aimed at other
people affected by gambling and potential support
persons outside the family. The text was reviewed
and the term “family” was alternated throughout
with “friends”, “whānau”, or a combination of these
words and “family”.

22
Part 2.Stage II: Expert evaluation
REAL LIFE EXAMPLES AND QUOTES
Troubleshooting tables were incorporated
throughout the booklets to integrate real-life barriers
or obstacles that experts thought might hamper
implementation of the strategies. Troubleshooting
tables were added to the majority of strategies in the
booklets for affected others and support persons as
the mentioned barriers were numerous and divergent.
Some examples of barriers and solutions provided by
the experts on the strategies targeted at people who
gamble were closely related to the information in the
stage I strategies, which is why these examples were
often integrated in the text or added as quotes rather
than as separate troubleshooting tables.
An abundance of additional quotes was infused into
all of the booklets to cover a wide range of feedback.
For instance, experts expressed appreciation of quotes
and called for more real-life stories and relatable
examples. Furthermore, experts discussed that
motivational and inspirational quotes could help to
improve the tone of the text, and to address frequently
mentioned barriers such as lack of motivation, shame,
and honesty with oneself.
Experts also requested and provided examples that
were specific to certain people or situations. In
addition, experts often talked about the importance of
whānau and their experiences with enlisting the help of
others, including whānau and social contact more
generally.
CONTENT STRUCTURE AND READABILITY
The stage I strategies were originally divided into
several sections. The first two sections were brief and
served as an introduction and an explanation of the
strategy in light of scientific literature. The remaining
sections reflected the narrative that was primarily
based on end-user data extracted in stage I. As experts
commented that the research section included
information that was too scholarly and may be off-
putting to end-users, the research section was merged
with the introduction for each strategy. Additionally,
the section was edited to remove any terms that may
be considered jargon or incomprehensible to lay
people.
The remaining sections were also carefully reviewed
and rephrased where necessary to enhance
comprehension and readability, as comments indicated
that the overall text of some strategies was too
complicated or wordy.
Throughout the booklets, we added visual elements
and reformatted the text in response to expert
suggestions and requests. Visual elements included
activities that end-users could engage in, such as
drawing mind-maps, finishing checklists, transferring
examples to personal situations, adding their own
insights in open spaces for notes, and engaging with
pictograms that indicated discovery tasks.
Furthermore, textboxes displayed as notepads were
added at the end of certain strategies to offer
suggestions on next steps and other information
(including other strategies) that end-users could read
to complement the strategy. Reformatting was done by
presenting some information in tables or as bullet
points and inserting more breaks in the body text in
the form of quotes or pictures.
CULTURAL AND LOCAL COMPETENCE
Multiple measures were undertaken to increase the
local and cultural competence of the strategies. Firstly,
we incorporated a large variety of expert-provided
examples that were specific to the New Zealand
context. Secondly, te reo Māori was integrated into the
booklets by means of key phrases and commonly used
words (e.g., bilingual booklet titles and strategy names,
incorporation of terms such as whānau, marae, aroha,
and tamariki). We also increased the focus on whānau,
family, and cultural values, which were important to
Māori, Pasifika, and Asian experts. We further provided
examples of cultural activities, such as waka ama and
tai chi, that could help to reduce gambling-related
harm through their physical, cultural, and social
elements. Furthermore, at the end of the actional
booklets, a page was added with contact details of
national and culturally competent support services.
Finally, after all the expert feedback was integrated,
the booklets received a final read-over from a Māori
and Pasifika expert to assure correctness and
appropriateness of the booklets to people from these
ethnic backgrounds.

23
Part 2.Stage II: Expert evaluation
CO-CREATION OF LOW RISK POKIES RESOURCES
As part of this project, we also developed content
targeted at low-risk pokies users. The low-risk pokies
content focused on strategies that could support
people staying in control while gambling on pokies.
The strategies included limit setting (time and
money) and actions that an end-user could
implement just before a gambling session (e.g.,
session planning), during (e.g., having breaks to
prevent going into a zone), and straight after a
session (e.g., how to stop a session and not to return
to unwanted gambling).
The used methods in preparing the low-risk pokies
resources were similar to those used in the co-
creation of the other resources. Different to the
provisional content targeted at people who gamble,
affected others, and support persons, the low-risk
pokies content was relatively short. As the content
consisted of strategies which were organised into
four logical steps based on the recommended order
of engagement, experts were asked to provide
feedback on all four steps.
KEY FINDINGS FROM EXPERT REVIEW
In total, 215 experts evaluated the low-risk pokies
content, including 201 people with lived experience
and 14 professionals. Experts were 94 females and
121 males; the average age was 36.1 years (SD =
12.9), range 18-77. The sample included 145 Pākehā,
45 Māori, 9 Pasifika, 25 Asian, and 18 people of other
ethnicity, with some experts identifying with more
than one ethnicity.
Experts rated the proposed low-risk pokies
statements as easy to read and understand (high,
89%; neutral, 9%; and low, 3%) and helpful (high,
75%; neutral, 17%; and low, 8%). Overall satisfaction
with the content was acceptable (high, 67%; neutral,
22%; and low, 11%). Experts thought the content was
correct and contained relevant information (high,
88%; neutral, 9%; and low, 3%). A total of 75% of
experts reported that the content as a whole could
reduce pokies-related harm. Experts were more
satisfied with the content in Step 3 (in the venue)
and Step 4 (knowing when to walk away) than Step 1
(setting a limit) and Step 2 (pre-pokies prep).
Step 1 and Step 2 were briefer than the other steps
because there was less content from online sources.
More information was requested on how to
implement financial elements of these steps as well
as how to manage financial barriers to
implementation.
Ratings were significantly different by subgroups of
experts and the qualitative feedback from the
experts may, to some extent, explain these findings.
For example, younger experts were more satisfied
with the content than older experts. Older experts
expressed strong anti-gambling attitudes and they
were less accepting of strategies that in their view
‘encouraged gambling’. Younger experts envisioned
computer-based delivery to reduce the amount of
content. This would make the content more
accessible when needed (e.g., in the venue).
Asian experts were more satisfied with the content
than Māori experts. Māori experts indicated a
preference for the integration of te reo Māori as well
as more involvement of whānau in setting and
sticking to limits.
People with higher education were more satisfied
with the content than people with lower education.
People with lower education indicated a preference
for less words and more graphics and pictorial
representation of content. There was also a
preference for more explanation on how to set
annual limits and calculation of monthly and session
expenditure.
Experts who had poor-to-fair knowledge of
strategies for sticking to limits were more satisfied
with the than people who had fair-to-good
knowledge. People who had more pre-existing
knowledge of the strategies told us about barriers
that impeded successful implementation. Barriers
ranged from not being able to calculate an annual
limit to not having accountability or commitment to
the limit. There were also barriers associated with
budgeting, organisation, and planning skills. These
barriers were present across every step and almost
all strategies within the guidelines.

24
Part 2.Stage II: Expert evaluation
Experts also differed in their ratings as a function of
their monthly spending and gambling problem status.
Gamblers who spent less than $100 a month and non-
problem gamblers were more satisfied with the
content than people who spent more than $100 per
month and people at moderate risk or problem
gamblers. High-spend gamblers wanted more
information on how expenditure was related to levels
of gambling risk. There was a perception that very low
limits would be ignored by high-spend gamblers
because they were perceived as not realistic. There
was a view that the content would not be helpful for
people who had gambling problems. There was a
perception that people with problems should not be
gambling at all and instead should seek professional
help.
ASSEMBLY OF CO-CREATED LOW-RISK POKIES
RESOURCES
Our response to expert review for the low-risk pokies
content was more extensive than for other target
groups as we needed to integrate a great amount of
feedback provided in the review as well as restructure
the presentation of the content so that it was less
wordy and more engaging. This was done by changing
the overall look and feel from a 10-page text-based
document with five illustrations to a 30-page
infographic. The infographic now contains activities,
illustrations of key points, images, and pictures to
increase engagement. Other areas of development are
summarised below.
The target group for the low-risk pokies booklet was
clearly articulated at the outset of the stage I expert
review. Experts indicated that the resource was most
suitable for people with low-risk gambling problems
and for use to prevent problems from developing.
Where problems do develop for those who gamble at
the pokies, the low-risk pokies booklet now contains a
clear message that the best course of action is to stop
pokies gambling and use the Take control of gambling
booklets for regaining control.
Experts’ recommendations were added to every step of
the booklet to identify and address common barriers to
implementation. New content was added on the pros
and cons of limits, calculation of risk, and how pokies
work. Other content on the link between session,
month, and annual limits was also included in the
booklet.
Winning and losing was identified by the experts as a
major barrier to sticking to gambling limits. Winning
and losing most often affected the implementation of
in-venue strategies as well as the ability to walk away
when the limit was reached. More content was added
on winning and losing and how it affects sticking to
limits. The bulk of this added content focused on
ending the session because experts said this is where
winning and losing had the most influence on
behaviour.
In the provisional content, self-control and willpower
were included in Step 3 (i.e., In-venue). Experts told us
that self-control and willpower were needed for every
step but the emphasis should be in Step 4 (i.e.,
Walking away). Experts said that using self-control and
willpower in early steps meant there was very little
remaining at the end of a gambling episode, making it
extremely difficult to complete Step 4. Content was
added that informed end-users of the need to focus
self-control and willpower on sticking to limits and that
the most important timing was at the end of the
session.
Experts suggested placing greater focus on the
influence of alcohol and drug use on gambling. Content
was added on the impact of alcohol and drug use
before gambling which could lead end-users to
abandon pre-pokies prep. Content was also added to
Step 3 (i.e., In-venue) where experts told us that
drinking and gambling did not mix and was best
avoided.
Te reo Māori was included as key phrases throughout
the booklet and the colour scheme and images were
change to be more aligned with Kaupapa Māori. We
also included a greater focus on whānau and family
which were important to Māori, Pasifika, and Asian
experts. For example, we included ways to get family
involved in the calculation of the annual limit as well as
involvement of other gamblers in the family.

25
In PART TWO, we summarised the process of co-
creating resources to reduce gambling harm and
highlighted key feedback provided by experts. In
PART THREE, we discuss where to go from here. We
point out what further research is required for
determining the effectiveness of the resources and
tailoring them to individual end-users. Furthermore,
we provide recommendations on support of financial
management and for dissemination of the resources
in the community or as integrated with other
services.
DETERMINE EFFECTIVENESS
The result of our project was a co-created set of
resources to reduce gambling-related harm. The
rationale behind the process of co-creation was that
by grounding the resources in the actual lived
experience of end-users, this would enhance the
acceptability, uptake, and perceived helpfulness of
the resources. The next step would be to
understand which strategies are effective to which
end-users and in what situations.
In the current study, experts suggested to combine
strategies for them to be more effective. Other
research on people who gamble found that a
combination of up to ten or more strategies was used
to mitigate different scenarios (29). An example of
such a combination was coupling strategies on
avoiding gambling, getting busy with alternative
activities, reducing access to cash, and getting more
support from others. Evaluation of the change
strategies resources should therefore consider the
likelihood that strategies need to be used in
combinations to be effective.
Part 3. Future directions
Further research should aim to determine the
effectiveness of the co-created resources by testing
them in single-component (i.e., one strategy) and
multifaceted interventions (i.e., combination of
strategies) using robust approaches.Key outcomes
could include perceived helpfulness, adherence to
strategies, and reduction in experienced gambling-
related harm over a set time period.
ENSURE TAILORING OF RESOURCES
Literature indicates that tailored interventions lead
to more favourable outcomes compared to non-
tailored interventions (60-62). In our project, we
aimed to tailor the resources to the end-users on a
group level (i.e., people in New Zealand who either
gamble, are affected others, support persons, or who
play at the pokies) which required an approach of co-
creation which heavily relied on the input of these
end-users.Stage I research activities led to content
derived from international sources; this content was
not specific to people who experience gambling-
related harm in the New Zealand context.The expert
review in stage II addressed this gap as experts
provided feedback to enhance the relevance to end-
users in the local context.
PART THREE:
Future directions

26
Part 3. Future directions
ENSURE TAILORING OF RESOURCES cont..
Additionally, a specific question was asked at stage II
of the co-creation process to elicit feedback on
cultural competence of the stage I content.
Incorporating the expert suggestions and examples
that were given in response received high priority
during the assembly of the stage II booklets. Yet
enhanced local and cultural relevance does not
assure that each of the many strategies covered in
the booklets is relevant to individual end-users. As
frequently remarked by the experts, certain
strategies will be more suitable for certain end-
users, which may be dependent on factors like
severity of experienced gambling harm, cultural
background, and personal preferences.
After the stage II review, we included content (i.e., an
introduction, foreword, and decision-tree diagram)
with explicit prompts that encourage people to
create a personalised suite of strategies best fitting
their situation. The booklets also explain general
phases of behaviour change, while specific strategies
emphasise which type of end-users they are most
suitable for, where appropriate. As such, end-users
can more easily assess which strategies are suitable
for them, and the co-created resources therefore
support easy identification and access to suitable
strategies.
Although the booklets are designed in a way that
supports end-users in choosing strategies which are
suitable for them, more precise tailoring to the
individual was beyond the scope of the current
project. To tailor the resources on an individual
level, findings from the effectiveness study as
proposed above can be developed into an
assessment tool which can ensure that strategies
address relevant harm and are delivered at the
right time. Such an assessment tool could take into
account personal characteristics of end-users, such
as readiness to change, severity of gambling or
gambling harm, preference for change strategies,
and what worked in the past. For affected others,
assessment could additionally consider risk of
further harm or family violence and if they want to be
a support person as well.
For those who want to be a support person, an
assessment tool may take into account their
relationship to the person who gambles (e.g., family
member, friend, partner), whether the support
person gambles themselves, and if the support
person has access to a wider social network to share
the burden of support. For people playing at the
pokies, assessment would most likely include
questions on ability to maintain control and the
motivation to gamble (e.g., conditioning, escape,
impulsivity).
INVESTIGATE ONLINE DELIVERY
An important next step in our project would be to
investigate online delivery of the resources. It is
now expected that gambling treatment is accessible
online (63, 64). Yet availability of online delivery of
self-directed interventions directed at gambling
problems has lagged behind in comparison with
other mental health interventions (65).
Benefits of online services are increased accessibility
and convenience, discreetness, flexibility with time
management, and easy linkage to other services and
information (64, 66, 67). Furthermore, online delivery
can include podcasts and video content for
conveying personal stories and implementation
information, as was repeatedly requested by end-
users in the stage II expert review. Likewise, visual
storytelling using Māori visual art could enhance
connection with the content. An additional benefit of
online delivery is that it supports tailoring of the
interventions (61).
Once an assessment tool has been developed,
tailoring the resources from this project to the
individual may be achieved by including an
assessment-based algorithm which matches the
most suitable strategies for each unique end-user
(68). Online delivery could also support the
modification of the resources into a more precise
brief intervention. While all of the strategies are
currently accessible to all end-users, it would be
possible to customise content online and via an app
so that it is relevant to each end-user, for instance to
those who self-exclude from gambling or those who
do sports betting.

27
Part 3. Future directions
SUPPORT FOR FINANCIAL MANAGEMENT
Expert feedback in stage II of this project indicated
that some facets of financial management were
beyond individual control and that there is a need for
regulations and financial management tools to
reduce gambling harm. Major barriers to
implementing strategies related to financial
management were lack of financial literacy and
easy circumvention of safety measures to limit
access to money (e.g., withdrawal limits, breaking
own rules, deceiving oneself and others).
Government and industry initiatives can reduce the
gamblers’ burden to self-regulate. For instance, the
UK government has recently changed regulations so
that gambling operators can no longer accept credit
cards (69), thereby restricting gamblers’ easy access
to cash and potential debt. In New Zealand, Kiwibank
identifies customers spending large sums on
offshore gambling websites and offers these
customers the option to block payments to these
websites (70).
Experts in our study expressed a preference for non-
individual and non-psychological solutions such as
regulations on credit card use and payment blocks.
Furthermore, experts suggested more creative
solutions such as marae-based financial literacy
workshops, which might be more readily accepted by
community-orientated peoples from Māori, Pasifika,
and Asian backgrounds. Additional research is
warranted to identify what type of regulations and
initiatives are considered relevant and acceptable by
end-users.
DISSEMINATION AS EARLY INTERVENTION
The unique features of the Be a support person series
of booklets allow for them to be positioned as a
community-based early intervention.
Expert feedback in stage II indicated that the
resources could be used to:
Increase community awareness of gambling as a
health issue (e.g., that gambling can be addictive),
Change social norms around gambling stigma that
impede help seeking (e.g., to be non-judgmental),
Help people detect signs of gambling harm in
others early (e.g., by understanding that
depression can be a result of gambling),
Take measures that may prevent future gambling
harm (e.g., not exposing children to gambling).
Experts, therefore, advocated widespread
dissemination of the resources in the community.
They also suggested marae- or church-based
training sessions led by community leaders or
peers.
The expert feedback regarding the significance of
community-based dissemination is in line with
current evidence. For example, involving others and
providing social support can help both the person
who gambles and affected others (71, 72).
Furthermore, framing interventions as training or
personal development has been suggested as a
useful tool to engage a new cohort of people who
gamble and affected others (73). The nature of the
resources is well suited for group training which may
be preferred by some over formal treatment. Group
training has previously been tested for Pasifika
peoples in a similar strategies-based intervention for
sugar reduction and the findings showed group
training to be a well-accepted tool for dissemination
(59).

28
Part 3. Future directions
DISSEMINATION AS EARLY INTERVENTION cont..
In our study, financial illiteracy was noted as a crucial
barrier by many experts who gamble and who identified
as affected other. Only 61% of New Zealanders have
sufficient financial literacy, making New Zealand the
lowest ranking of OECD countries (74). Therefore, a
training package of these resources should cover
implementation of behaviour change strategies in
combination with capacity-building focussed on
increasing financial literacy. Research shows that 79%
of Māori and Pasifika peoples learn their financial skills
from their families, friends, and communities (74). As
such, group-based training might be particularly
suitable for these groups as it can build capacity in
entire communities.
INVESTIGATEOPTIONS FOR SERVICE INTEGRATION
Experts in our study often referred to the potential
need for additional guidance from a professional,
especially to initiate behaviour change, during
moments of crisis, or when underlying issues are
persistent. These findings highlight that there may be
important opportunities in integrating the behaviour
change resources in a variety of settings. For
instance, the resources may be integrated with primary
care services as primary care health professionals are
in an ideal position to deliver low-intensity treatments
to people with less severe gambling harms and their
family members due to their increased access to these
groups of people.
Additionally, the resources could be used as part of
stepped care, where they are supportive of a care
trajectory to help someone regain control over their
situation and maintain behaviour change independent
of professional help. The resources can function as
tools for the clients that complement in-person
support sessions and support adherence to treatment.
Literature shows that self-help interventions benefit
from having some in-person interaction (65). Thus, the
resources could also be part of an intervention that
involves low-intensity support from a peer or a
counsellor. This would entail training peers or
counsellors in the different types of behaviour change
strategies and on options for implementation.
The resources may
be integrated with
primary care
services as primary
care health
professionals are in
an ideal position to
deliver low-intensity
treatments to people
with less severe
gambling harms and
their family members
due to their
increased access to
these at risk groups.

29
Conclusion
The Change Strategy Project aims to develop
resources and programmes that support self-
management of addictive behaviours. This project is
a fine example of how resources can be developed
that are grounded in lived experience and are,
therefore, more relevant to people impacted by
gambling harm. The co-creation process developed
for this project is a first in its co-creation of a
comprehensive series of resources which involved
the end-user being in every aspect of the project.
We were able to demonstrate that robust research
methodology could be applied to large amounts of
naturally occurring data to generate a testable set of
content related to behaviour change. Detailed input
into the content was provided by hundreds of expert
reviewers (i.e., professionals and people harmed by
gambling) located across Aotearoa New Zealand.
This data was blended through a rigorous data
synthesis process to create ten different booklets
which truly represent the lived experience of
addressing gambling harm.
We see this project as a major step forward towards
supporting all aspects of self-management but
there is still some way to travel. Critically, the
resultant resources need to be subject to evaluation
to identify for who, when and where strategies are
effective as well as their optimal combination.
Furthermore, our project has developed new
resources for family and whānau who are at risk of
harm due to another persons’ gambling and it is
essential to evaluate the effectiveness of these
resources. This is especially important as the
gambling-related harm experienced by these groups
can be enormous. Many family also want to be a
support person but may also be affected themselves
and thus have a double burden.
To our knowledge, the resources to support someone
with a gambling problem over the longer term are
the first of their kind. The current study hints at the
feasibility of a population level approach given
interest in our study as indicated by ease of
recruitment. Similarly, interest was strong in the
additional resources developed specifically for
pokies gambling. This co-creation process
highlighted a need to improve financial literacy
especially in relation to setting a spending limit and
sticking to it.
Research over the past 20 years indicates that most
people self-manage gambling problems with varying
levels of success. We know that all gamblers engage
in change strategies either to self-regulate
frequency or expenditure or to repair a pattern of
overconsumption. Investing resources in supporting
autonomy and skills enhancement has the potential
to intervene early and prevent gambling harm from
becoming debilitating. The current project
addressed this by co-creating resources that reflect
real world conditions. These resources are ready for
further tailoring and evaluation in Aotearoa New
Zealand.

30
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Change Strategies Project examines behaviour
change from the perspective of the consumer. It uses
innovative data analysis techniques to synthesise
large naturally occurring data to give information
back to communities.
Our work spans behavioural addictions including
gambling, gaming, pornography as well as sugar,
caffeine and alcohol.We also do work focused
onenhancing the stepped care model with multiple
projects focused on e-mental health and new
methods of intervention delivery.
Change Strategies
Project
changestrategies.ac.nz
www.changestrategies.ac.nz
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