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THE CO-DESIGN OF TWO E-MENTAL HEALTH
PROTOTYPES FOR MINIMISING GAMBLING HARM:
DEVELOPMENT AND EVALUATION
Final report
March 2022
Prepared for
Ministry of Health
PO Box 5013
Wellington
Simone Rodda
Bridgitte Thornley
Lisa Campbell
Stephanie Merkouris
Kathleen Bagot
Natalia Booth
Nicki Dowling
ii
ACKNOWLEDGEMENTS
This report reflects work undertaken over a 30-month period during the COVID-19 pandemic and we
acknowledge the technical work of Koda Web Design during such a difficult time. We also thank Dr Rimke
Bijker and Dr Severi Luoto for their contribution to the report preparation.
Thank you to the counsellors and people with lived experience who provided their time and thoughts into co-
designing the e-tools for gambling treatment services. We also acknowledge support from the Ministry of
Health and the funding that made this project possible. We are grateful to the cultural Māori and Pasifika
advisors, both professional and people with lived experience. Their input was tremendously important to
create the connection between the e-mental health tools and future users.
Suggested citation
Rodda, S.N., Thornley, B., Campbell, L., Merkouris, S., Bagot, K., Booth, N., and Dowling, N. (2022). The
co-design of two e-mental health prototypes for minimising gambling harm: Development and evaluation.
Ministry of Health, New Zealand (pp.1-160)
iii
GLOSSARY OF ABBREVIATIONS AND TERMS
CBT Cognitive Behavioural Therapy
DSM-5 Diagnostic and Statistical Manual of Mental Disorders version 5
GP General Practitioner
GSAS Gambling Symptom Severity Scale
MET Motivational Enhancement Therapy
MH Mental Health
MI Motivational Interviewing
PG-YBOC Yale Brown Obsessive Compulsive Scale adapted for Pathological Gambling
PGF Services Problem Gambling Foundation Services
PGSI Problem Gambling Severity Index
PMGH Preventing and Minimising Gambling Harm
PNF Personalised Normative Feedback
Note on terminology
The iterative nature of this research has meant that terminology changes across the report. This is an expected
and natural consequence of the co-design approach undertaken. While we started with terminology as used in
the academic literature, we then moved more to plain language that was reflective of service and consumer
need. As such, we have updated terminology for consistency purposes across the report, but this was not
possible for the various interview schedules and informant responses and presented quotes. For example, the
i-CBT prototype content initially was described as lessons and modules which through the co-design process
became topics with activities. Overview sections inclusive of the executive summary and
recommendations/conclusions are presented with the co-design terminology.
iv
1. EXECUTIVE SUMMARY
Gambling is a major public health issue in Aotearoa, New Zealand. A recent report by the New Zealand
Department of Internal Affairs found that annual gambling expenditure was around $2.4 billion in New
Zealand, with $895 million spent on poker machines alone (1). This very substantial expenditure on gambling
is associated with harm not only to those who gamble but their closest family members, whānau, and wider
communities (2). The impacts of gambling can range from financial and social harms through to deterioration
of cultural engagement, employment, inter-personal relationships, and well-being (3, 4). Gambling is
recognised as an addictive behaviour in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
alongside other addictive disorders (5). The international prevalence rate of problem gambling is around
2.3% in adults (6). There are a range of evidence-based treatments in New Zealand for addressing gambling-
related harm. A Cochrane review indicated that the optimal treatment for Gambling Disorder is Cognitive
Behavioural Therapy (CBT), and to a lesser extent motivational interviewing (7). New Zealand has a world-
class treatment system for individuals experiencing gambling harm. This system includes access to free
counselling, information and support through in-person, telephone, and internet options. There is growing
recognition, especially since the emergence of COVID-19, that e-mental health is a necessary requirement for
effective treatment delivery (8). E-mental health offers a broad array of benefits which include extended
reach, clinical efficacy, and cost-effectiveness. It can broaden the chances of establishing a connection
between expert gambling clinicians located in face-to-face services and people with a gambling problem (9).
Despite these benefits, e-mental health options are still emerging in the gambling field with just a handful of
studies investigating the integration of e-mental health and in-person treatment delivery.
Integrating e-mental health options into the New Zealand system will bring benefits to those working in
specialist gambling services and their clients. Ensuring risk minimisation from gambling is a shared goal of
the partnership between University of Auckland (UoA), PGF Services and Salvation Army Oasis. Our
partnership draws on academic, clinical, community and Kaupapa Māori experience and expertise. We work
closely with both those providing services, such as counsellors, and those with lived experience (i.e., clients)
to inform the development and evaluation of e-mental health options for within the current system.
Aims: This project was a collaboration between UoA, PGF Services and Salvation Army Oasis with
international partners Deakin University. The purpose of the project was to explore readiness, need and
preferences for e-mental health for in-person gambling treatment services and to co-design a prototype
screening tool and e-mental health program that could be integrated into service delivery as a blended service
delivery model.
The project commenced in 2019 and undertook five distinct phases of development over a 30-month period:
Phase I and II were exploratory and conducted to determine need and interest in e-health tools. Phase III
focused on responding to need and the development of two prototypes. Phase IV involved the release of a
screener prototype and collection of data from people with gambling problems. Phase V was an evaluation
involving clinicians and counsellors as to the overall helpfulness, utility and viability of the screener and i-
CBT for gamblers. This project was funded by the MOH in the 2019 funding round, providing important
support to meet these goals.
PHASE I: EXPLORING E-MENTAL HEALTH READINESS AND NEED
Phase 1 of the project involved exploring e-mental health readiness and need using five different components,
including a Steering Committee, e-mental health audit, and needs analysis survey.
v
Activity
Description
Timing
1. Grant awarded by
Ministry of
Health
MOH funded a partnership between UoA, PGF Services and
Salvation Army Oasis to explore e-mental health. Partners from
Deakin University in Australia provided clinical expertise. The
agreement was to focus on the identification of need and
development of one tool ($249,867).
Agreement
signed August
2019
2. Steering
Committee
Convened
A Steering Committee was convened with representation from
UoA, PGF Services, Salvation Army Oasis, MOH, Bi-cultural
Relationship lead at PGF Services, Deakin University, and
people with lived experience of gambling harm.
September -
October 2019
3. Priority areas
identified for e-
mental health by
Steering
Committee and
study
investigators
A desk-top audit of practices of gambling treatment services and
the need for e-mental health tools and protocols was conducted.
Priority areas were identified inclusive of (i) increase access to
clinical expertise located in gambling treatment services (ii)
enhance the treatment experience through the creation of a new
digital tool. Two preferred options were identified by the
Steering Committee, which included a screener with
personalised feedback that could be located on services’
websites and an internet-delivered CBT (i-CBT) program that
could be delivered as part of blended in-person treatment.
September -
October 2019
4. University of
Auckland and
Deakin
University
develop options
for e-mental
health
Researchers reviewed the literature to develop drafts of the
content and functionality of the screener and i-CBT program. Dr
Rodda led the development of the screener draft content and
functionality. Professor Nicki Dowling led the redevelopment of
content from an evidence-based self-directed program
(GAMBLINGLESS) so that it was tailored for a blended service
delivery approach.
October 2019
5. Service e-mental
health readiness,
needs and
preferences
determined
An online survey was conducted to determine readiness for e-
mental health options and current experiences of working with e-
mental health. The survey was completed by 47 service
providers and consumers of gambling services. The survey
results indicated the service providers had high levels of
readiness for e-mental health and were already engaged with a
range of different technology-based options for client contact
and treatment. There was broad support and readiness for the
screener and i-CBT, and participants preferred e-mental health
options that could be blended with in-person treatment. Services
also provided extensive input into how each prototype should be
customised so that it was specific to service needs.
October 2019
vi
PHASE II: CO-DESIGN HUI
Phase II of the project involved a co-design workshop aimed at customising the content and functionality of
the e-mental health prototypes for gambling. The workshop had the dual purpose of increasing readiness for
e-mental health and identifying the optimal content and functionality of these prototypes. Thematic analysis
was used to code extensive notes taken during the co-design hui so that these could inform later
customisation. Results from Phases I and II indicated that the partnership sought to develop an e-mental
health prototype that could attract a new cohort of treatment seekers and connect them with existing service
providers.
Activity
Description
Timing
Hui to develop
customised e-
mental health
screener and i-CBT
A co-design workshop with key stakeholders sought to extend the
findings of the needs analysis to understand in more detail
customisation considerations for the two e-mental health
prototypes. A series of interactive presentations were conducted,
followed by small and large group discussions. The workshop
involved 32 representatives inclusive of managers, counsellors,
cultural advisors, health promoters, academics, and consumers.
Extensive discussions were held on (i) the content and
functionality of the screener questions and personalised feedback
report (ii) i-CBT content and functionality, and (iii) blending of
the screener and i-CBT into service delivery.
Hui evaluation was overwhelmingly positive with attendees
indicating excitement and enthusiasm about e-mental health for
their service and practice. Attendees appreciated being able to
contribute to the process of customisation of tools so that they
were specific to the needs of services.
Mail outs to
attendees
November
2019
Held
December
2019
Data analysis
Feb/Mar 2020
PHASE III: PROTOTYPE DEVELOPMENT AND TESTING
Although project funding was for preparatory work for e-mental health and the development of one
prototype, results from Phases I and II indicated strong demand and justification for both a screener and i-
CBT in blended service delivery model. This led to the decision to develop two relatively low-cost prototypes
that were customised to the needs of services.
The first prototype was an online screener with a personalised report that could be placed on the websites of
gambling support services. A second prototype was i-CBT for gambling that could be delivered in
conjunction with face-to-face counselling. The i-CBT prototype provided tailored support that was
customised to meet the needs of people who access in-person support and demonstrated a move away from a
one size fits all approach.
vii
Activity
Description
Timing
Preparation of
prototype for
screener
Prototype development involved the collation of customisation
needs from Phases I and II. Customisation needs were changes to
assessment content and language, and presentation of and changes
to the prototype report so that it was motivational for clients and
normalised help seeking practices. Customisation needs also
related to screener integration into the service model to establish
new pathways into care.
The outcome was a screener that was completed by community
members and immediately provided a personalised report to them
of their gambling behaviours, motivation, strengths and help
seeking. Completion of the screener took approximately 10
minutes. Algorithms were developed to provide comparative
feedback with other people in New Zealand. The screener was
presented in English with Te Reo Māori headings and phrases. A
protocol was developed that captured the recommended response
to requests to discuss the screener results.
Content
development
March–
August 2020
Technical
development
July 2020-May
2021
Note COVID-
19 outbreak
occurred at
this time
Preparation of
prototype for i-
CBT
The i-CBT prototype development involved the collation of
customisation needs from Phases I and II. Customisation needs
were focused on functionality and counsellor-client
communication, as well as rendering content appropriate for
Aotearoa New Zealand. The outcome was an i-CBT prototype that
could be delivered in conjunction with in-person treatment.
The prototype was developed with three levels which reflected
three pathways: behavioural conditioning, escape (coping)
motives, and action (enhancement) motives. Each pathway
contained topics and each topic contained activities. There were
52 activities in total, with each activity taking around 10 minutes.
The activities in the i-CBT prototype included first and second
wave CBT activities (behavioural and cognitive), as well as
strategies adopted from third-wave CBT interventions (e.g.,
Acceptance and Commitment Therapy and Dialetical Behaviour
Therapy). The prototype prompted clients and counsellors to
select i-CBT activities during treatment planning and/or during
episodes of care. A website was developed, and interactive and
visual imagery included that represented people in New Zealand.
A communication loop was a feature that supported clients to
easily select activities for further discussion with their counsellor.
Self-paced professional development was provided to support
preparation for online delivery.
Content
development
August 2020 –
July 2021
Technical
development
Sept 2020-Oct
2021
Note COVID-
19 outbreak
occurred at
this time
viii
PHASE IV: SCREENER RELEASE AND PATTERNS OF ENGAGEMENT
The screener prototype was released on PGF Services and The Salvation Army Oasis’ websites in June 2021.
All full responses to the screener were extracted on 11 November 2021. In total, 772 unique records were
recorded during the first five months after the screener became operational. In Phase IV, these records were
analysed with reference to participant demographics and gambling severity to determine which community
members were using the screener.
Activity
Description
Timing
Screener prototype
release and patterns
of engagement
Of the 772 unique records, 270 people scored in the problem
gambling category of the PGSI (35%) and 185 scored in the
moderate-risk gambling category (24%). A further 18% were
classified in the low-risk gambling category and 23% were
classified in the non-problem gambling. One third of people
classified in the problem gambling category (32.3%) were
interested in discussing their results with a professional. Those in
the low-risk and moderate-risk gambling categories had low
interest in discussing their gambling screener results with a
professional (0.7% and 4.3%, respectively). Almost 16% of
participants were Māori with a further 4% Pacific and 3% Asian
culture. EGMs were the most engaged gambling activity by
people with problem gambling followed by lotto, casino and
wagering. People with problem gambling reported high
importance and readiness to change but low confidence to resist
an urge; whereas those at moderate risk reported average
importance and readiness but moderately high confidence to resist
an urge.
Of people who completed the screener, 13% expressed an interest
in help-seeking, including 32% of people with problem gambling.
In total, 71 (9%) participants requested to be contacted after
completing the screener. Of these, 6% were classified in the low-
risk gambling category, 7% in the moderate-risk gambling
category, and 85% in the problem gambling category.
June -
November
2021
PHASE V: SCREENER AND I-CBT EVALUATION
Gambling services’ collaborators and people with lived experience of gambling participated in interviews to
provide feedback on the screener after it had been operational for five months. Nine interviews were
conducted in November 2021 which were transcribed and analysed using thematic analysis. To evaluate the i-
CBT protocol, a survey with open-ended items was developed and administered to 21 service providers and
people with lived experience. The survey was administered in December 2021 and analysed using thematic
analysis.
ix
Activity
Description
Timing
Screener prototype
evaluation
An evaluation was conducted with nine service providers and
consumers who had been involved in the screener development.
The screener was perceived as helpful in providing an immediate
brief intervention that facilitated access to in-person treatment.
Multiple areas for improvement to the prototype were identified
including longer term assessment, dissemination to other services,
more interactivity and visual representation of scores, as well as
the inclusion of lived experience. Possible methods to increase
rate of engagement with in-person expertise included the option to
discuss results via chat or text and consider proactive follow-up of
all screener completers.
November
2021
i-CBT prototype
evaluation
An evaluation was conducted with 21 service providers and
consumers with lived experience of gambling harm. The i-CBT
prototype was deemed suitable for most clients because it was
easy to access and contained content that would be
complementary to in-person care. The content was considered
comprehensive but could be extended to include a greater focus on
family and community as well as a focus on internet gambling.
There were calls for other content including daily gratitude diaries
and self-monitoring. Delivery via the purpose-built website was
considered acceptable but there were requests for more interactive
elements and locally produced audio and visual content. The
customised method of activity selection should be continued but a
check list to guide treatment planning which recommends topics
and activities would be helpful. Self-paced professional
development in e-mental health was deemed helpful and this
should continue to be available for new staff.
December
2021
Study conclusions
Given the success of this project, the team strongly supports continued co-design of the next stage of e-
mental health tool development. Key areas of work include preparing the screener prototype for ongoing
service delivery and dissemination and testing the prototype with clients in services to offer further
refinement of content, interactivity, communication loop and client management functions. The current
project focused on the development of two prototypes and work is now needed to determine their impact on
gambling harm. Future priority areas include investigating who benefits from the screener and i-CBT and
how these can be integrated into services to provide seamless access to the enhanced suite of options.
Opportunities for growth identified in this study include a screener and i-CBT for whānau and family and the
provision of both tools in a range of different languages.
Our goal to incorporate e-mental health has not only resulted in two e-mental health prototypes that have the
potential to reduce gambling harm, but the project also provided a wealth of information to support future
refinements and additional options.
x
• Working collaboration across academic and community settings to address common goal, drawing on
experience and expertise to address key public health issue.
• Use of multiple methods, sequentially phased design ensured development and implementation was
based on what stakeholders needed and what they said would work.
• While initially funded to identify need and explore the development of one tool, we developed two
prototypes using the principles of co-design, demonstrating flexibility and focus on meeting stakeholder
needs. To ensure the success of the prototypes, the University of Auckland and Deakin University
provided in-kind support.
• An inclusive approach involving engagement from service providers and management to client-facing.
• Readiness of counsellors was established across multiple services in New Zealand.
• Data collected can be used for other tools and refining current practices.
• Uptake by clients and counsellors demonstrates that prototype development was successful.
• The screener has brought additional clients to the service. It identified those who have gambling
problems but are not proceeding to treatment options.
• Aotearoa New Zealand continues to provide world-class treatment with e-mental health options
supporting clients and providers. The adoption of these prototypes extended this care to provide greater
reach and service integration.
Recommendations for the screener prototype
Recommendations were based on broad findings from across each of the project phases. Priority screener
recommendations were to address prototype limitations in terms of interactivity and look and feel of the
assessment and personalised report. It is recommended that access pathways into service is further increased
to include text messaging, as well as support for self-help focused on treatment readiness and development of
strengths for gambling recovery. Once the prototype is ready for general release, services can work with
mental health and alcohol and other drug service partners to expand access to gambling screening and links
into gambling treatment services. Longer term follow-up evaluation is needed to determine the effectiveness
of the screener as a brief intervention, and this can be administered to catch relapse and facilitate easy access
to an expert clinician. Additional new screeners are warranted, especially a screener for affected others and
whānau impacted by gambling harm. A summary of key recommendations is listed below.
• Minor modifications are made to reduce the length of the screener gambling types and to increase the
focus on identification of strengths and values.
• The report structure is retained but can be enhanced to contain interactive elements, more graphical
representation of results and integration of more cultural and lived experience elements.
• Pathways into services are working well and can be further enhanced to include more low intensity
options like chat and text messaging.
• Additional data analysis on screener data is needed to identify the profile of those who register as having
problem gambling but do not request a discussion with a counsellor. This information can be used to
shape messaging and offer different ways to facilitate connections with service providers.
xi
• Self-help needs to be considered for the hundreds of people with low and moderate risk gambling who do
not have an interest in treatment. This self-help can be focused on improving self-confidence to resist a
gambling urge, improve treatment readiness and provide an easy way of making an initial connection
with an expert gambling clinician.
• The project was focused on development of the screener prototype but has not evaluated the usefulness or
impact of the screener on client outcomes. There is an urgent need to determine the impact of the screener
on gambling harm inclusive of expenditure and severity of harm.
Recommendations for the i-CBT prototype
Recommendations for i-CBT prototype were derived from the multiple needs analysis and evaluation
undertaken across the 30-month project. Priority i-CBT prototype recommendations were focused on
improvements to the interactivity of the program and the inclusion of counsellor videos and other content.
There was broad acceptance of the communication loop that linked clients and counsellors within the
website, and the view was that this would work well with in-person treatment. Enhancements to content were
recommended including more content on family and community involvement and cultural needs specific to
the New Zealand context. These enhancements could be made over time and in response to ongoing client
and counsellor suggestions.
The priority for i-CBT now is to test the feasibility and acceptability of i-CBT for reducing gambling harm.
Follow-up evaluation on the impact of usage patterns on gambling harm is needed inclusive of the
engagement with activity content, use of communication loop and retention in both in-person and i-CBT
treatment. Enhancements that would likely support effective client engagement with i-CBT include an
assessment tool to guide topic and activity selection and the inclusion of enhanced client tools to include
daily gratitude, capacity to record and save interactive elements from the program and better information and
guidance on how to navigate and get the most out of the program. At this time, it is recommended that i-CBT
remains a prototype until there has been a client evaluation. There was also a strong call to redevelop i-CBT
so that it could be delivered via an app which could follow-up from the client evaluation process.
In addition to the current i-CBT program, there were calls for i-CBT to improve treatment readiness for those
not yet willing to talk to a counsellor as well as i-CBT for those who were at low and moderate risk. There
were also requests for i-CBT for family and whānau that was gambler-focused (how to help someone with a
gambling problem) and family-focused (how to help yourself). A summary of key recommendations is listed
below.
• Minor modifications to existing content and expansion of new content that focuses on family and
community, strengths, and culture.
• The i-CBT module structure is retained including the communication loop. Minor modifications are
needed to the look and feel of the notes tab and client profile page.
• Counsellor facing management system needs to be established inclusive of the technical and operational
protocols for sending and receiving messages to clients through the website.
• Information and resources can help clients get the most out of i-CBT and should be available on the
website as well as hard copy resource that can be disseminated by counsellors. Website delivered
information can be via video content and involve counsellors to increase their presence in the site.
• To maximise client outcomes, the screener and i-CBT can be linked, and longer term follow up on client
outcomes evaluated included as part of the treatment protocol.
xii
• Longer term development needs include delivery via a smart phone app and extended client support via
lived experience and online community forums.
• Other i-CBT programs include the development of tailored options that meet the needs of different
profiles of gamblers. This includes self-help with counsellor support for those at low and moderate risk of
gambling problems and i-CBT treatment readiness for those experiencing gambling problems but not yet
ready to talk to a counsellor. Affected other and whānau based i-CBT is also warranted but extensive
development would be needed in terms of identifying the content of this program.
Knowledge dissemination
The team has been involved in extensive dissemination over the past 30 months, including to clinicians,
service providers and researchers across the mental health and addictions sector in New Zealand and
Australia. Completed dissemination activities undertaken by the team included:
• Rodda, S., Dowling, N., Thornley, B., Campbell, L., Merkouris, S. (December 2019) Presentation of the
needs analysis survey results to the gambling sector. Co-design Hui, Auckland.
• Thornley, B., Campbell, L., Rodda, S., Dowling, N., Merkouris, S., & Bagot, K., (September 2020) Co-
design of an e-health program for reducing gambling harm: An analysis of service provider needs.
Conference presentation at the Australian & New Zealand Addiction Conference.
• Helping gamblers to help themselves (May 2021). Article in the DAPAANZ provided journal - Addiction
Standard.
• Prasad, S. (2021) Responding to gambling problems in Asian communities: An exploratory study of
internet delivered self-help resources. Masters Dissertation, University of Auckland.
• Rodda, S. (September 2020). E-health and other client engagement using technology. Presented at the
National Gambling Training Forum Rotorua (50 service providers).
Elements of the current project were investigated as part of a Masters degree. Shirleen Prasad examined i-
CBT for Asian people as part of her Masters of Health Practice and work in Asian Family Services. Shirleen
reported strong interest by clients and counsellors in i-CBT for gambling and her findings indicated a need to
offer i-CBT in different languages.
Planned dissemination activities include preparation of two manuscripts for publication on (i) screener
prototype development and usage and (ii) i-CBT development and evaluation. We also plan to submit 2
abstracts to the International Gambling Conference in Auckland (2022). Finally, the team will also prepare a
summary of the project that can be disseminated to all relevant stakeholders inclusive of those who were
involved in various stages of this project.
xiii
2. Table of Contents
1. EXECUTIVE SUMMARY ........................................................................................................................ iv
3. BACKGROUND ......................................................................................................................................... 1
GAMBLING DISORDER ................................................................................................................................................. 1
PROBLEM GAMBLING PREVALENCE ............................................................................................................................ 1
AETIOLOGY OF PROBLEM GAMBLING ......................................................................................................................... 2
TREATMENT AND RECOVERY FROM PROBLEM GAMBLING .......................................................................................... 2
HELP-SEEKING AND ACCESS TO TREATMENT .............................................................................................................. 3
E-MENTAL HEALTH..................................................................................................................................................... 3
E-MENTAL HEALTH TREATMENT APPROACHES FOR GAMBLING .................................................................................. 4
1.7.1. Self-assessment with feedback ........................................................................................................... 4
1.7.2. Online self-directed interventions ..................................................................................................... 5
1.7.3. Blended treatment options ................................................................................................................. 7
SUMMARY OF CURRENT LITERATURE ......................................................................................................................... 8
CURRENT STUDY AIMS APPROACH .............................................................................................................................. 9
PROJECT RESEARCH QUESTIONS ............................................................................................................................... 9
SUMMARY OF METHODS ........................................................................................................................................... 9
2. PHASE I: Exploring e-mental health readiness and need ......................................................................... 11
SERVICE PROVIDER READINESS, PREFERENCES AND NEEDS ANALYSIS ................................................................... 11
1.12.1. Survey items .................................................................................................................................. 12
1.12.2. Procedure ...................................................................................................................................... 12
1.12.3. Analysis plan ................................................................................................................................. 12
1.12.4. Participant characteristics ............................................................................................................ 13
NEEDS ANALYSIS RESULTS ..................................................................................................................................... 14
1.13.1. Current use of e-mental health tools with clients .......................................................................... 15
1.13.2. Perceived benefits and disadvantages of e-mental health ............................................................ 15
1.13.3. Screener preferences ..................................................................................................................... 18
1.13.4. I-CBT needs and preferences ........................................................................................................ 22
1.13.5. Support needs for e-mental health work ....................................................................................... 24
4. PHASE II: Co-design hui .......................................................................................................................... 25
PARTICIPANTS IN THE CO-DESIGN HUI ...................................................................................................................... 25
SEMI-STRUCTURED GROUP INTERVIEW SCHEDULE ................................................................................................... 26
PROCEDURE AND MATERIALS ................................................................................................................................... 26
DATA COLLECTION AND ANALYSIS........................................................................................................................... 27
CO-DESIGN HUI – SCREENER PROTOTYPE ................................................................................................................. 27
CO-DESIGN HUI I-CBT PROTOTYPE PREFERENCES .................................................................................................... 32
POST-WORKSHOP EVALUATION ................................................................................................................................ 41
5. PHASE III: Prototype development and pilot testing ............................................................................... 45
SCREENER CUSTOMISATION...................................................................................................................................... 45
6.8.1. Prototype assessment items ............................................................................................................. 46
6.8.2. Prototype report needs .................................................................................................................... 50
6.8.3. Prototype report content ................................................................................................................. 51
6.8.4. Screener and service integration .................................................................................................... 54
I-CBT CUSTOMISATION AND PROTOTYPE ................................................................................................................. 56
6.9.1. i-CBT content preferences ............................................................................................................... 56
6.9.2. i-CBT functionality preferences ...................................................................................................... 57
6.9.3. i-CBT other considerations ............................................................................................................. 58
6.9.4. Prototype i-CBT and website .......................................................................................................... 59
I-CBT PROTOTYPE WEBSITE DEVELOPMENT ........................................................................................................... 64
xiv
PROFESSIONAL DEVELOPMENT FOR E-MENTAL HEALTH ......................................................................................... 71
6. PHASE IV: Screener release and patterns of engagement ........................................................................ 77
SCREENER IMPLEMENTATION ................................................................................................................................. 78
SCREENER PATTERNS OF CLIENT ENGAGEMENT ..................................................................................................... 79
6.13.1. Gambling severity ......................................................................................................................... 79
6.13.2. Sociodemographic characteristics ................................................................................................ 80
6.13.3. Engagement in gambling activities ............................................................................................... 81
6.13.4. Gambling frequency ...................................................................................................................... 82
6.13.5. Monthly gambling expenditure ..................................................................................................... 84
6.13.6. Impact of gambling ....................................................................................................................... 85
6.13.7. Perceived comparison with others ................................................................................................ 86
6.13.8. Level of importance, readiness, and confidence ........................................................................... 86
6.13.9. Motives for gambling .................................................................................................................... 87
6.13.10. Strengths that help control gambling .......................................................................................... 88
6.13.11. Interest in discussing screener results with a professional ......................................................... 89
7. PHASE V: Screener and i-CBT evaluation .............................................................................................. 90
EVALUATION OF SCREENER PROTOTYPE ................................................................................................................. 90
6.14.1. Potential screener impact ............................................................................................................. 91
6.14.2. Dissemination ................................................................................................................................ 95
6.14.3. Screener content ............................................................................................................................ 96
6.14.4. Enhanced engagement .................................................................................................................. 99
6.14.5. Pathways into services ................................................................................................................ 100
6.14.6. Administration ............................................................................................................................. 102
EVALUATION OF THE I-CBT PROTOTYPE .............................................................................................................. 106
6.15.1. i-CBT impact ............................................................................................................................... 107
6.15.2. i-CBT content .............................................................................................................................. 107
6.15.3. i-CBT delivery ............................................................................................................................. 109
6.15.4. i-CBT blending ............................................................................................................................ 111
6.15.5. i-CBT Administration .................................................................................................................. 112
6.15.6. i-CBT Service model ................................................................................................................... 114
8. Recommendations and conclusions ........................................................................................................ 115
SCREENER FINDINGS AND RECOMMENDATIONS .................................................................................................... 115
I-CBT FINDINGS AND RECOMMENDATIONS .......................................................................................................... 121
PROJECT CONCLUSION .......................................................................................................................................... 127
9. References ............................................................................................................................................... 129
10. Appendix A: Survey items for needs analysis .................................................................................... 137
11. Appendix B: Semi-structured group prompts at co-design hui ........................................................... 142
12. Appendix C: Screener semi-structured interview schedule ................................................................ 143
13. Appendix D: i-CBT for gambling prototype evaluation ..................................................................... 144
xv
LIST OF TABLES
Table 1. Participant demographics and expertise (n = 47) ........................................................................ 13
Table 2. Perception of working with e-mental health systems and tools (n = 41) ...................................... 14
Table 3. Clinical activities which clinicians currently use on the internet (n = 26)................................... 15
Table 4. Perceived benefits and disadvantages of e-mental health systems and services (n = 47) ............ 16
Table 5. Method of discussing assessment results (n, %) ........................................................................... 19
Table 6. Ranked preference for blended treatment model (n = 44) ............................................................ 22
Table 7. Preference for i-CBT for gambling accessibility .......................................................................... 22
Table 8. Preference for location of lesson content completion, n (%) ........................................................ 23
Table 9. Ranked preference for blended treatment model (n = 44) ............................................................ 24
Table 10. Support for e-mental health work (n = 51) ................................................................................. 24
Table 11. Co-design workshop participants ............................................................................................... 25
Table 12. Summary of Hui discussion on screener ..................................................................................... 28
Table 13. Summary of Hui discussion on i-CBT ......................................................................................... 32
Table 14. Co-design hui evaluation (n = 29) .............................................................................................. 42
Table 15. Summary of assessment customisation ....................................................................................... 45
Table 16. Gambling product consumption in the past 12 months ............................................................... 47
Table 17. Gambling symptoms measure adapted from PG-YBOCS ........................................................... 48
Table 18. Levels of importance, readiness, and confidence ....................................................................... 49
Table 19. Gambling motives measurement ................................................................................................. 49
Table 20. Strength categories containing 52 different strengths ................................................................ 50
Table 21. Screener customisation needs and outcomes .............................................................................. 50
Table 22. Screenshots of the screener report .............................................................................................. 52
Table 23. Pathways customisation needs and outcomes ............................................................................. 54
Table 24. i-CBT content needs and customisation ...................................................................................... 56
Table 25. i-CBT functionality needs and customisation ............................................................................. 57
Table 26. i-CBT other consideration customisation ................................................................................... 58
Table 27. Summary of (un)learn to gamble core topics and activities ....................................................... 61
Table 28. Summary of Escape Motives topics and activities ...................................................................... 62
Table 29. Summary of Action Motives topics and activities ....................................................................... 63
Table 30. Summary of website structure and functionality ......................................................................... 64
Table 31. Summary of engagement enhancement and communication loop .............................................. 70
Table 32. Summary of professional development for e-mental health ........................................................ 72
Table 33. PGSI scores for each item in the screening tool, completed by 722 participants (n,%) ............ 79
Table 34. Sociodemographic characteristics by PGSI categories (%) ....................................................... 80
Table 35. Engagement in gambling activities in the last 12 months per gambling activity (%)................. 81
Table 36. Number of gambling activities participants engaged in during the last 12 months (%) ............ 82
Table 37. Frequency of engagement in gambling in the last 12 months per gambling activity (%) .......... 83
Table 38. Number of days gambled in the last 30 days per gambling activity (M, SD) ............................. 83
Table 39. Spending in a typical month per gambling activity (M, SD) ....................................................... 84
Table 40. Spending in the last 30 days per gambling activity (M, SD)....................................................... 84
Table 41. Impact of gambling (%) .............................................................................................................. 85
Table 42. Perceived gambling frequency compared to other New Zealanders (%) ................................... 86
Table 43. Importance, readiness, and confidence to change gambling (%) ............................................... 87
Table 44. Motives for gambling (%) ........................................................................................................... 88
Table 45. Strengths identified by participants (%) ..................................................................................... 89
Table 46. Interest in discussing screener results with a professional (%) .................................................. 89
Table 47. Summary of qualitative evaluation of screener ........................................................................... 90
Table 48. Summary of evaluation of i-CBT prototype .............................................................................. 106
xvi
Table 49. Screener assessment findings and recommendations ............................................................... 116
Table 50. Screener report findings and recommendations ....................................................................... 117
Table 51. Screener prototype findings and recommendations – service integration ................................ 118
Table 52. Screener prototype findings and recommendations – other considerations ............................. 120
Table 53. i-CBT prototype findings and recommendations - content ....................................................... 122
Table 54. i-CBT prototype findings and recommendations – functionality and blending ........................ 123
Table 55. i-CBT prototype findings and recommendations – delivery considerations ............................. 124
Table 56. i-CBT prototype findings and recommendations – other considerations ................................. 126
LIST OF FIGURES
Figure 1. Frequency of preference for time spent on screener with personalised report........................... 18
Figure 2. Appropriate person to deliver email support .............................................................................. 19
Figure 3. Appropriate person to deliver chat support ................................................................................ 20
Figure 4. Appropriate person to deliver phone support ............................................................................. 20
Figure 5. Appropriate person to deliver text support ................................................................................. 21
Figure 6. Appropriate person to deliver in-person support ........................................................................ 21
Figure 7. Protocol for service response to the screener ............................................................................. 55
Figure 8 Motivational pathways for i-CBT Protocol .................................................................................. 60
Figure 9. Content and functionality of screener ......................................................................................... 77
Figure 10. Pathways from screener results into services ........................................................................... 77
Figure 11. PGF Services screener link ....................................................................................................... 78
Figure 12. Salvation Army Oasis screener link .......................................................................................... 79
1
3. BACKGROUND
Gambling has been a major growth industry during the last 30 years and it is estimated that 70% of New
Zealanders gambled at least once in the past year (10). This is comparable with international rates of
participation that average around 80% of populations that have legalised gambling opportunities (11, 12).
Increased availability of some forms of gambling, particularly electronic gaming machines (EGMs) and
casino table games, has been associated with a rise in gambling-related problems. In a number of
jurisdictions, including New Zealand, 15-30% of regular EGM participants experience gambling problems
(13).
Gambling disorder
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines gambling disorder as persistent
and recurrent engagement in problematic gambling behaviours, which leads to significant impairment and
disruption in many areas of life including personal and professional relationships. Previous DSM editions
(DSM-III and DSM-IV) referred to this condition as pathological gambling, and it was previously classified
as an impulse control disorder. Its reclassification now identifies gambling disorder as an addiction, alongside
alcohol and substance use disorders (5).
Gambling disorder is characterised by difficulties in controlling money and time spent gambling. These
difficulties often lead to adverse consequences for the gambler and/or others (14). The consequences of
gambling disorder are far-reaching and can include financial, legal, and occupational difficulties, family and
relationship breakdown, and intimate partner violence (15, 16). It has been estimated that up to six people are
negatively affected by someone else’s gambling (17).
Gambling disorder is highly comorbid with mental health disorders, such as mood, anxiety, alcohol, and drug
use disorders, impulse control disorders, and personality disorders (4, 18, 19). A systematic review has shown
that treatment-seeking samples of gamblers have high current rates of comorbid mood disorders (78.4%),
major depressive disorder (29.9%), anxiety disorders (17.6%), alcohol use disorders (21.2%), and substance
use disorders (non-alcohol) (7.0%) (19).
Public health frameworks often conceptualise gambling activity, and risks from gambling, as existing on a
spectrum (20). The term ‘problem gambling’ is utilised to describe gambling problems along a continuum of
harm, from gambling that results in no adverse consequences to problem gambling, which leads to adverse
consequences to the gambler, their friends, family, and community (21). The term ‘problem gambling’ will
be utilised throughout this report to refer to the most extreme end of the gambling risk as it is most commonly
used in the New Zealand context.
Problem gambling prevalence
The New Zealand National Gambling Study found that 0.7% of adults, as measured by the Problem
Gambling Severity Index (PGSI), met the past-year criteria for problem gambling and were experiencing
significant problems associated with their gambling (13). Another 1.8% of adults are at moderate risk with a
further 5% categorised as low-risk gamblers. Prevalence of moderate and problem gambling is particularly
high for Māori and Pasifika people (13). An increased risk of lifetime gambling problems was associated with
being male, identifying as being of Māori or Pasifika ethnicity, being aged 25-34, and living in a household
with five or more people. Other risk factors include residence in lower socioeconomic areas, lower
educational attainment, having paid employment, and living alone (13).
The Ministry of Health estimates that the effects of problem gambling in New Zealand result in a loss of
3,300-10,600 years of ‘quality of life’ per year, or $330 million to $1.06 billion per annum (22). The activity
2
most frequently associated with gambling-related harm is EGMs (4, 23, 24). Although the prevalence in the
community is relatively low, the burden of harm for gambling problems is comparable to other health-related
conditions, such as major depressive disorder, osteoarthritis, and alcohol misuse disorder, highlighting the
importance of developing appropriate prevention and interventions for this major public health issue (25).
Aetiology of problem gambling
There are various aetiological models which explain the development and maintenance of problem gambling.
These include learning theory, cognitive models, and the biopsychosocial model. Learning theory and the
cognitive model in part explains the development and maintenance of problem gambling but is limited as it
does not describe the whole experience. People with gambling problems differ with respect to a range of
characteristics including psychiatric comorbidities, preferred gambling activities, motivation(s) to gamble,
and personality traits such as impulsivity and self-control. In an effort to integrate this array of motivations
and behaviours, Blaszczynski and Nower (26) proposed a bio-psychosocial model. Referred to as the
‘pathways model’, it integrates the numerous biological, personality, developmental, cognitive, behavioural,
and ecological determinants of problem gambling. It was developed as a way to address heterogeneity in
problem gambling including factors such as psychiatric comorbidities, preferred gambling activities,
motivations to gamble, and personality traits (26).
The pathways model proposes three distinct pathways in the development and maintenance of problem
gambling. These pathways comprise (1) behaviourally conditioned gamblers, (2) emotionally vulnerable
gamblers, and (3) antisocial impulsivist gamblers (26). Pathway one is referred to as the core pathway. This is
because it includes components of all three pathways, including accessibility to gambling, classic and operant
conditioning, the development of cognitive schemas, and habituation. Some people develop gambling
problems solely because of the mechanisms described in pathway one. These gamblers are usually introduced
to gambling by chance and while they may experience depression or anxiety, it is a consequence rather than a
cause of excessive gambling (26).
Pathway two refers to those who have some kind of pre-existing vulnerability to gambling. Pathway two is
the same as pathway one with the addition of emotional vulnerability and biological vulnerability. When a
person who gambles is emotionally vulnerable, they may gamble as a response to their psychological distress
or to regulate their emotions. This pathway also suggests that the person who gambles may have a family
background of problem gambling (26).The third pathway includes those who have tendencies towards
antisocial impulsivist behaviour. Pathway three gamblers often experience the most severe or complex
problems because of neurological or neurochemical dysfunction. They may experience impulsivity, antisocial
personality disorder, and attention deficit hyperactivity disorder (ADHD) (26). They typically commence
gambling at a younger age, engage in non-gambling criminal behaviour, and have a rapidly increasing
severity of gambling.
Treatment and recovery from problem gambling
Traditionally, individuals seeking help for gambling-related issues obtain face-to-face treatment from general
physicians or specialised counselling services. A Cochrane systematic review examining psychosocial
treatments for gambling suggests that a wide range of face-to-face approaches may be somewhat effective in
reducing harmful gambling behaviour (7). Multiple reviews have indicated that cognitive behavioural therapy
and motivational interviewing appear to be the most effective treatments for problem gambling (27-30).
Cognitive behavioural therapy (CBT) is an umbrella term for any treatment that aims to change unhelpful
cognitions and behaviour. Cognitive behavioural therapy aims to address cognitive bias and change the way
gamblers think about luck and winning (31, 32). This happens through adjustments to thinking about biases
around the illusion of control (the person thinking they can control uncertain outcomes), randomness
3
(misunderstanding how poker machines work), and gamblers’ fallacy (thinking a win is due after a series of
losses). Behavioural approaches used for gambling include exposure therapy and imaginal desensitisation,
both of which aim to change the relationship between gambling stimuli and associated behaviours (33, 34).
CBT also uses techniques involving tracking situations, thoughts, mood, and behaviour through to planning
and enacting pleasurable events (31). Relapse prevention is a branch of CBT that aims to prevent a return to
previous unhelpful gambling behaviours (35). This treatment focuses on the identification of high-risk
situations that make the person vulnerable to unwanted gambling. Relapse prevention helps gamblers
improve their coping response to high-risk situations as well as to change their thinking about the situation,
such as when a relapse occurs (e.g., abstinence violation effect) (32).
Motivational interviewing (MI) was developed for smoking cessation and alcohol reduction but has been
successfully used in treatment for problem gambling (36). MI is a style of counselling aimed at enhancing
intrinsic motivation to change. It achieves this through a set of techniques such as developing discrepancies
between current behaviour and desired behaviour and then through empathy and partnership works towards
resolving this ambivalence. For gambling, MI is usually delivered as a brief treatment consisting one or two
episodes of care (36).
Both CBT and MI have been delivered as in-person as well as self-help programs. Brief interventions are
essentially an approach for working with people that is minimal or short in both time and content.
Considerable variation in time and content is reported, however, as brief interventions range from one to
more than 10 sessions. Brief interventions are often opportunistic in that they are delivered by a range of
healthcare workers (e.g., psychologists, GPs) in a wide range of settings (e.g., hospitals, community health).
Help-seeking and access to treatment
People with gambling problems often report significant distress; however, most will not seek in-person
treatment (37). There are a range of reasons why treatment is not sought. These include individual barriers
(e.g., a preference to self-manage, pride, shame) and systemic barriers (e.g., lack of service availability) (38-
41). There is therefore a need to examine the use of alternative treatment delivery models that capitalise on
advances in technology and involve self-directed interventions that can complement existing services (42).
The need to expand access to evidence-based treatment services was recently identified as an important issue
for Mental Health and Addiction Services in New Zealand (43). An inquiry conducted in 2018 reported
serious gaps in access to services and the need to increase the range of services offered. The report also called
for more tools, support, and guidance for self-help through the provision of e-therapy and e-mental health
programs (43). The adoption of these models reflects the movement towards ‘stepped care’ approaches in the
literature for many mental health disorders (44, 45). Stepped care is defined as an evidence-based, staged
system comprising a hierarchy of interventions, from the least to the most intensive, matched to individual
needs. This approach shifts the focus away from costly or high-intensity psychological therapy services,
where these are not required, towards lower cost or lower intensity evidence-based alternatives. Calls have,
therefore, been made for a major shift in treatment research, whereby innovative treatment delivery models
make use of technology advances as well as the option to support self-directed treatment with or without
clinical support (42).
E-mental health
E-mental health (or e-therapy) involves the provision of mental health services via digital devices. Options
range from email, chat, SMS, internet applications, and community forums as well as apps and websites that
can support self-directed treatment (46). These can be delivered with or without the support of a person (e.g.,
counsellor, peer) (9). E-mental health programs are effective in the treatment of many psychological
disorders, including depression and anxiety (47-49), substance abuse (50-52), chronic insomnia (53), and
4
obsessive-compulsive disorder (54-56). There have been a number of studies demonstrating that e-mental
health is as effective as face-to-face treatment (57).
E-mental health addresses barriers to help-seeking such as wanting to self-manage, shame, and logistical
barriers such as transport. As this service modality can be accessed anytime from any internet-enabled device
including a computer, mobile telephone, and/or tablet, it removes some of these barriers regarding
accessibility and even shame. Compared with face-to-face therapies, e-mental health interventions are
typically briefer and more cost-effective (58, 59) and can provide greater degrees of anonymity to the user.
Studies have examined gamblers’ and their families’ reasons and motivations for using e-mental health (59,
60). These studies indicated that e-mental health was preferred over in-person treatment because of ease of
access, convenience, privacy, opportunity for anonymity, and a preference for typing over talking. Rodda,
Lubman (60) also reported that some people who accessed e-mental health wanted to try out counselling and
saw e-mental health as an easy first step.
From a research perspective, e-mental health has positives and negatives. The positives are being able to
reach a new cohort of people (e.g., young people) and those who otherwise would not access in-person
treatment (61). It also provides a platform for delivering complex self-directed treatments using interactivity
rather than paper-based workbooks. People like the ease of access and ability to join programs with few
barriers (9). However, this ease of access is also related to high dropout rates because people can easily step
away from treatment without interacting with another person (62, 63).
E-mental health treatment approaches for gambling
The development and evaluation of e-mental health programs for gambling problems is an emerging area of
research. Two types of e-mental health methods that have been the most heavily researched are self-
assessment with feedback and i-CBT (internet delivered CBT). The next section discusses these two
treatment types in more detail and examines their effectiveness.
1.7.1. Self-assessment with feedback
Assessments can be delivered face-to-face, over the telephone, or they can be self-delivered (64). Face-to-
face assessments are the most common form of gambling assessment (64). Self-administered assessments are
questions that the person seeking treatment answers without a support person present (i.e., a clinician). After
the completion of the self-assessment, the results are often discussed with a clinician at a later date.
Personalised feedback includes individualised information on participant, and as such, it is an important
component of e-mental health (65). The personalisation of feedback can be used to increase motivation and
show gambling harm risks (65). Personalised feedback is given in the form of advice and information around
common misbeliefs and inaccurate perceptions (66). Feedback can also be given in the form of personalised
normative feedback, which is feedback that includes a comparison with another relevant population (64).
Personalised normative feedback interventions make use of social judgements about a particular behaviour by
an individual’s peer group to elicit behaviour change (67). Personalised normative feedback interventions
confront misperception of peer group’s behaviour to allow the individual to adjust their own behaviour
towards the newly realized norm (67).
Research has shown that educational programs that include information against inaccurate beliefs/perceptions
can successfully assist change (68). A study reviewing alcohol reduction services researched a program
where the participants completed surveys that were immediately used to give personalised feedback (69). An
evaluation of this program found a significant reduction in the average alcohol consumption at six months in
those who were given personalised feedback compared to the people who used an online self-help booklet
5
(69). Research suggests that compared to targeted or generic feedback, personalised feedback is a more
effective intervention (70, 71).
Peter et al. (72) studied two types of feedback: behavioural and psychological feedback. The results indicated
that the personalised feedback from a screener with personalised report offered its bests results when
provided either face-to-face or phone by a clinician (72). Feedback on screener with personalised reports
usually includes feedback on behavioural data. This includes information that the individual provided on their
level of play such as the amount of time/money spent gambling during a specific time (73). Although not
widely used, normative comparisons are also used within feedback on screener with personalised reports.
This feedback ranges from providing percentile comparisons of gambling to the norm, or a comparison of
psychological measures of gambling severity (72). Peter et al. (72) found that interventions that included
feedback on psychological measure(s) of gambling disorder severity scores were less effective than those that
did not. There was no clear reason for this finding; however, it was suggested that behavioural data was a
more tangible source of feedback for participants to understand (72).
There have been several studies that review personalised feedback in gambling. Auer, Griffiths, and
colleagues conducted a series of studies that examined the impact of messaging on gamblers in a gambling
environment (66, 74, 75). Auer and Griffiths (66) reviewed the effects of normative and self-appraisal
feedback in an EGM pop-up message compared to a simple message. The results of this study indicated that
the inclusion of normative and self-appraisal personalised feedback increases the number of gamblers who
stop playing after reading the feedback (66). Another study found that personalized feedback was helpful for
people who gamble (71). Those who received personalised feedback and normative feedback gambled on a
significantly lower number of days than those who received no feedback (71).
A series of reviews have looked at the effectiveness of personalised normative feedback (67, 72, 76, 77).
Saxton, Rodda (67) conducted the first systematic review and meta-analysis evaluating the effectiveness of
personalised normative feedback for self-directed interventions to address four addictive behaviours:
hazardous alcohol use, problem gambling, illicit drug use, and tobacco use (67). The findings showed that
personalised normative feedback with the additional interventions reduced short-term gambling symptom
severity (67). Another systematic review of the literature of personal feedback interventions as an
intervention and prevention method for gambling behaviours (76) found personal feedback interventions to
be reliable for changing maladaptive perceived norms towards gambling (76). A meta-analysis of brief face-
to-face gambling interventions also detected small yet significant improvements in gambling problems with
the use of personalised feedback (77).
1.7.2. Online self-directed interventions
E-mental health can be delivered through a self-directed intervention, also called self-help or self-guided
programs. Self-directed interventions can be purely independent, without any involvement from
professionals, or can involve professional guidance where minimal support is available. Self-directed
interventions have the advantage of being cost-effective, offering immediate access to treatment, and having
increased accessibility, especially for those living in remote locations (58). Furthermore, individuals can
engage in treatment in privacy, at their own time and pace. Over recent years there has been an exponential
growth in the delivery of self-directed interventions via the internet for addictive behaviours (55, 78). Self-
directed interventions go some way to addressing recognised barriers to help-seeking (e.g., accessibility of
services, shame in seeking help).
Self-directed interventions are also effective in changing gambling behaviours and symptoms of problem
gambling (55, 79, 80). A systematic review of internet-based interventions for addiction concluded that
“Internet-based interventions are effective in achieving positive behavioural change through reducing
problematic behaviours”(78). van der Maas, Shi (81) conducted a review of the evidence on e-mental health
6
interventions for gambling globally, finding further support for its effectiveness in reducing problem severity
and time and money spent gambling. Of the seven RCT studies in their review, five produced significant
positive effects. Of the two that did not, one was hypothesized by the authors to have suffered from recruiting
participants who were not yet ready to change their behaviour, and the other used only personalised
normative feedback (suggesting that this alone may not be effective). van der Maas, Shi (81) noted that a key
feature of e-mental health services enabling their success is the improved access to help they provide –
particularly to advice, counselling, and therapy via online text, chat, and email. They also noted that females
are particularly receptive to online interventions.
Even though there is rapid development of these programs for other addictive behaviours, there have only
been just a handful of investigations involving the treatment of problem gambling. The first internet-delivered
self-directed intervention for problem gambling was conducted by Carlbring and Smit (82) who compared an
8-week internet delivered CBT program (i-CBT) which included minimal therapist telephone or email contact
with a wait-list control condition. The i-CBT program included four motivational modules and four CBT
modules that contained essay-style questions and exercises. They reported that the online CBT program was
associated with significant reductions in gambling behaviours compared with the wait-list control, and
improvements were sustained up to the 36-month follow-up evaluation.
Casey et al. (83) conducted a study investigating i-CBT against an active control condition (i.e., monitoring,
feedback, and support) and a wait-list control. The i-CBT program involved six sessions delivered weekly
(around one hour per session) and interactive exercises. The program content included raising awareness
about gambling, identifying and challenging gambling thinking errors, imaginal exposure and relaxation,
problem solving, maintenance of treatment gains, and relapse prevention. The active control involved access
to a portion of the CBT content that was associated with self-monitoring, feedback on progress, and
supportive messages (around 10 minutes weekly). This study reported that the i-CBT program as well as
active control (monitoring, feedback, support) were associated with greater reductions in gambling severity
(measured by the Gambling Symptom Assessment Scale: G-SAS) compared with the wait-list control. The i-
CBT component was also associated with improvements across a range of other indicators including
gambling urge, cognitions, depression, anxiety, and stress. This study also investigated the effect size change
of i-CBT delivered via internet or via face-to-face. Using data collected by the same team in a previous study,
the researchers reported similar effect sizes for both the internet-delivered and face-to-face programs on a
range of gambling outcomes (i.e., amount of money spent on gambling, frequency, urges, and self-efficacy).
However, the face-to-face program appeared superior to the internet-delivered program in improving
gambling-related cognitions.
Dowling and colleagues conducted a pragmatic RCT in Australia that examined i-CBT with and without
guidance (84, 85). Referred to as GamblingLess, the program delivered motivational enhancement, cognitive
and behavioural strategies, and relapse prevention. GamblingLess consisted of four modules made up of
thirteen to fifteen activities. Each of the activities took around 10 minutes to complete. Content of activities
included: motivational enhancement (e.g., negative consequences, values alignment, identification of triggers,
goal setting); behaviour modification (e.g., limiting access to money, budgeting, problem solving, relaxation
skills, pleasurable activities); cognitive restructuring (e.g., gamblers’ fallacy, illusion of control, positive
expectancies, near misses); and relapse prevention (e.g., managing urges, high risk situations, and seemingly
irrelevant decisions). GamblingLess activities were delivered with a combination of video, audio,
questionnaires, interactive animations, and written activities. At the end of each module, participants were
offered questions relating to their gambling spend, treatment goals, and ability to resist gambling urges as a
way of tracking their progress throughout the intervention. The participants also had the option to save each
activity as a PDF and print for later review. While it was recommended that participants complete all
modules and activities in numerical order, GamblingLess allowed participants to complete as many activities
as they liked, and in any order they chose.
7
Dowling, Merkouris (85) reported statistically significant improvements in gambling symptom severity,
gambling urges, gambling frequency, and psychological distress within both treatment groups at 8- and 12-
week evaluations. On gambling symptom severity, 50% of users recovered and 14% improved. Overall, the
study did not find statistically significant differences between guided and unguided conditions for most
outcome measures at 8- and 12-week evaluations. However, participants in the guided group did report higher
rates of low-intensity help-seeking at 8 weeks, and significantly greater reductions in days gambled at a 12-
week post-intervention evaluation than participants in the unguided group (84). At the 12-week evaluation, a
medium effect size also indicated a superior effect of the guided condition for: gambling symptom severity,
gambling urges, gambling expenditure, and quality of life; a considerably higher proportion of guided than
unguided participants (62% vs 35%) “recovered” on the gambling symptom severity at the 12-week
evaluation (84).
A key limitation of the literature is the high rates of attrition. One of the possible ways to increase
engagement with online self-directed interventions is through the involvement of a support person. As
indicated above, current work offering guidance with i-CBT appears to have limited impact on clinical
outcomes (86). Luquiens, Tanguy (62) may provide some insight into methods to improve attrition. This
study compared the efficacy of three i-CBT conditions to a wait-list control condition following problem
gambling screening of consumers using a commercial online poker site: (1) personalised normative feedback
email; (2) a downloadable CBT self-help workbook; and (3) the workbook plus six sessions of emails
including personalised guidance by a therapist. There were no significant differences between these groups
for problem gambling severity or gambling expenditure outcomes. Strangely, the guidance group displayed
no significant improvement in outcomes over time and actually had the highest rates of attrition. The authors
concluded that guidance may have adverse effects in i-CBT for problem gamblers who do not seek help,
possibly because they are too time-consuming, too intrusive, or because they require a commitment to
someone other than themselves. This study, however, employed a downloadable CBT self-help workbook in
PDF format, rather than an internet-based therapeutic intervention, as described by Barak, Klein (87).
Moreover, it was evaluated among non-help-seeking problem gamblers who were naturalistically recruited in
their gambling environment. The influence of guidance in online self-directed interventions for problem
gambling therefore remains unresolved.
1.7.3. Blended treatment options
Blended care is treatment that is carried out face-to-face, as well as with online resources (88, 89). This mode
of delivery is meant to reduce the necessity of frequent face-to-face treatment sessions since those who use
the service are able do parts of their treatment online. The flexibility of blended care treatment allows the
unlimited access to treatment materials and exercises that can facilitate learning and retention. Importantly,
the face-to-face sessions ensure the benefits from a therapeutic relationship play (88).
The blending of internet CBT (i-CBT) and in-person treatment can be done in a variety of ways. Erbe,
Eichert (90) proposed four main types of blending which included (1) non-blended interventions: face-to-face
treatments or stand-alone internet-treatments only; (2) blended interventions: treatment programs that use
elements of both face-to-face and internet-based interventions, including sequential use of both forms of
treatment; (3) integrated blended interventions: blended treatments where the internet-based intervention is
arranged as an adjunct to face-to-face programs or vice versa so that face-to-face and internet-based elements
are provided within the same period and the focus can be either on the face-to-face treatment or on the
internet-based intervention; (4) sequential blended interventions: blended treatments where the internet-based
intervention is arranged before or after the face-to-face treatment such as within stepped care approaches or
aftercare interventions that directly follow the face-to-face intervention.
When blended with face-to-face treatment, the positive results of i-CBT appear to be stronger than e-mental
health interventions on their own. This is shown in a variety of studies which indicate that when blended
8
treatment was introduced, the person seeking help had better outcomes (88, 91, 92). According to these
studies, the blended treatment approach has all the active ingredients needed for change and offers a more
cost-effective option (88, 91, 92).
Beyond gambling research, other evidence suggests that blended interventions may provide advantages over
online or face-to-face interventions alone. Clough and Casey (93) conducted a review to investigate whether
technological adjuncts (mobile phones / personal digital assistants, biofeedback, and virtual reality) enhanced
psychotherapy in multiple clinical settings. Mobile phones were considered a convenient and useful
advantage for the client to be better connected to personal and social networks while receiving additional
support between sessions. Biofeedback (a method increasing client awareness of physiological symptoms)
was useful in reducing anxiety and stress. Virtual reality was useful in particular disorders such as exposure
therapy. Overall, the review found moderate to strong effect sizes across studies, indicating that these
therapies reduced symptoms and increased treatment gains.
To date there has been limited research on blended treatments for gambling. Rodda, Merkouris (94) examined
the pragmatics of providing a blended treatment involving i-CBT with support from treatment providers. The
study conducted in-person, semi-structured interviews with seven service providers. The main aim of the
study was to evaluate the effectiveness of i-CBT for gambling-related harms with and without support (i.e., a
clinician). A thematic content analysis of the interviews identified five themes: (1) participant suitability and
screening (e.g., demographics, motivation, computer literacy access, education, social isolation, complexity
of problems, motivation and commitment); (2) program content and modality acceptability (e.g., amount of
content, timing of content delivery, look and feel, perception of effectiveness, and active components of i-
CBT); (3) participant information and management (e.g., program engagement progression, single page
portal, use of own email); (4) email communication (e.g., use of templates, appointments, rapport building);
and (5) ongoing service integration (e.g., infrastructure, confidence in product, timing of program delivery,
targeted approach, participant engagement) (94). This study found that the clinicians preferred to integrate i-
CBT into their existing treatment programs (94). This research found that gambling therapists may be open to
a blended model if the appropriate model and training were available (94). Co-design research was suggested
to determine the preferred mode of delivery, as well as how feasible this approach may be (94).
Summary of current literature
It is well established that brief interventions are helpful for people to reduce gambling harm. There are now
multiple large-scale studies indicating that brief interventions such as screening tools and other brief
therapeutic exchanges are sufficient to prompt change (81). The most effective of these are screening tools
that offer some kind of normative or other feedback. To date, there are no evidence-based screening tools for
problem gambling in New Zealand. Some support services, such as the ‘Choice not Chance’ website run by
Health Promotion Agency, offer brief screeners, but they are limited in what they assess and the type of
information provided back to gamblers (i.e., not normative). The screening tool on the ‘Choice not Chance’
website also offers no easy steps for increasing intensity of intervention such as easily stepping towards
speaking to someone or seeking help in a face-to-face treatment agency.
To address this issue, services and researchers have attempted to deliver CBT via the internet. There have
been dozens of studies demonstrating that when delivered online (e.g., via websites, apps, text messaging,
chat, email, or video), CBT is effective at reducing addictive behaviours, including gambling problems (55,
78, 81). These studies have demonstrated that it is possible to increase the reach of treatments by attracting
those who otherwise would not attend a face-to-face service. However, the major problem now is a lack of
engagement either with the content or with the program beyond the first log-in. Studies indicate that the
average time spent using an i-CBT program is at best a day but may be up to one week. Multiple recent
gambling studies also indicate that many participants who sign up for i-CBT never actually open the program
or app (95, 96).
9
Attempts have recently been made to improve engagement by linking people with existing treatment services.
Blended programs can work in many different ways from mixing i-CBT with phone, email, chat, or in-person
support (94). The type of support might be guidance only for using the program through to both in-person and
computerised support delivering the same content. Key to understanding a blended approach is identifying
who or what is delivering the active intervention content and who or what is providing support for that
engagement (88, 94). Research on blended treatment has demonstrated that linking i-CBT with a counsellor
in a treatment agency can increase engagement with that program.
Current study aims approach
The overall aim of this project was to develop and evaluate the implementation of the first customised e-
mental health prototype for gambling treatment services in New Zealand. The Ministry of Health funded the
team to explore e-mental health options for the gambling harm reduction sector and to develop one e-mental
health tool. The team was therefore funded to (1) identify the needs of New Zealand service providers and
consumers specific to embedding and accessing e-mental health tools; (2) develop an e-mental health tool
that was customised to meet the needs of the PGF Services, The Salvation Army Oasis, and people impacted
by gambling harms.
To meet the study aims, a mixed-method, sequential-phase design was used. It sought stakeholder input into
key aspects into the configuration of the prototype. This mixed method approach was achieved in multiple
steps that included the (i) convening a Steering Committee (ii) undertaking a needs analysis via an online
survey (iii) refining customisation issues of the prototype with an in-person hui (iv) developing the prototype;
and (v) evaluating the prototype. Evaluation involved quantitative and qualitative analysis of client and
service provider data.
This report summarises the work undertaken to develop the recommendations for how a screener and i-CBT
program are best configured and integrated into the service system in New Zealand. To do this, the project is
guided by participatory action research design (97-99). Participatory action research aims to produce
knowledge that is primarily targeted at real-world settings. It seeks to not just understand the activity (e.g.,
service integration of e-mental health) but simultaneously imagine, shape, and transcend barriers in a way
that service providers find to be positive.
Project research questions
The research questions which were addressed throughout this project include:
1. What are the needs and preferences of service providers and consumers in using e-mental health as part
of routine care?
2. What are the barriers and facilitators for service providers to embed e-mental health into routine care?
3. Is it feasible for service providers to integrate e-mental health into their routine care?
4. Is a co-design workshop successful in developing e-mental health content that is of value to service
providers and their clients?
5. Is e-mental health acceptable to people seeking treatment for reducing gambling harm?
Summary of methods
To answer these research questions, we will employ a range of methodologies, including:
1. Stakeholder and consumer surveys (Phases 1 & 5)
2. Document audit (Phase 1)
3. Literature search to identify best practice in blended treatment (Phase 1-5)
4. Participatory action research (Phases 1–3)
5. Co-design hui workshop (Phase 2)
6. Qualitative analysis of the co-design hui workshop (Phase 2)
10
7. Implementation evaluation and protocol development (Phase 3)
8. Implementation of e-mental health prototype into Problem Gambling Foundation and SA Oasis services
(Phase 4)
9. Post-implementation evaluation using data from clients (n = 772) of gambling services collected with the
first protype (Phase 5)
10. Post-implementation evaluation via qualitative analysis of interviews (n = 30) with gambling services
collaborators and people with lived experience of gambling (Phase 5)
11
2. PHASE I: Exploring e-mental health readiness and need
To commence discussions on e-mental health needs, a Steering Committee was convened. The Committee
included representatives from University of Auckland, PGF Services, Salvation Army Oasis, Deakin
University, and the Ministry of Health. The Committee also included Te Rukutia Tongaawhikau,
Kaiwhakarite Bi-cultural Relationships & Lead Public Health PGF Services as well as people with lived
experience of gambling harm.
One on one and group discussions were held with the Steering Committee and leads at PGF Services,
Salvation Army Oasis and University of Auckland to understand the most urgent e-health needs. These
discussions identified two priority areas which were:
• e-health to increase access to clinical expertise located in gambling treatment services
• e-health to enhance the treatment experience through the creation of a new resource
To meet these priority areas the Steering Committee approved the team to investigate preferences for two
different e-mental health tools. To increase access to clinical expertise the team commenced exploration of a
screening tool that could be offered through services websites with links into each service. To address
enhancement to the treatment, experience the team also commenced exploration of an internet delivered CBT
prototype (i-CBT) that was customised to meet the needs of service providers and people impacted by
gambling harm.
The University of Auckland and Deakin University worked together over a three-month period to draft the
content and functionality of two e-health options for services. Content and functionality were based on a
search of the literature as well as existing knowledge and products.
• Option 1 was a screener that could be implemented on services websites. Screeners have been shown to
be effective in engaging people who are unsure if there is a problem and whether action is required. For
this project Dr Rodda led the development of a draft screener which included questions about gambling
behaviours and harm as well as interest in help-seeking. The draft screener also included a personal report
that summarised scores on the screener in a text or graphical form.
• Option 2 was internet delivered CBT (i-CBT) that could be used in conjunction with in-person treatment.
Content was drawn from the GamblingLess Australian self-help program led by Professor Nicki
Dowling. GamblingLess content was adapted so that it could be administered as part, or alongside, in-
person treatment. A literature search and our own experiences identified options for blending i-CBT with
in-person treatment. This included options for the configuration and grouping of content, delivery,
engagement, and management of i-CBT in services.
Service provider readiness, preferences and needs analysis
A survey was conducted to determine readiness for e-mental health options and current experiences of
working with e-mental health. The survey also examined needs and preferences for the two e-mental health
options (i.e., screener and i-CBT).
The survey was administered in October 2019 via Qualtrics survey software. The eligibility criteria for
participation in the needs analysis required the participants to be either a staff member or a consumer of
Problem Gambling Services or The Salvation Army Oasis. Eligible staff members included anyone with a
client-facing role (e.g., counsellors, social workers, case workers, or team leaders) as well as those with an
12
indirect client-facing role (e.g., work in health promotion, management, or advocacy). Eligibility was
extended to past or current consumers of the two services.
1.12.1. Survey items
Recorded participant characteristics included the following: age, gender, postcode, area of work (e.g.,
psychiatrist, psychotherapist, youth worker, counsellor), qualification, professional role (clinician,
professional support role such as health promotion or consumer), and current working arrangements (e.g.,
casual, full-time). Additional items for clinicians only included number of years working clinically and
number of years working with gamblers.
As part of their work with clients, participants were asked if they currently used any of five internet options
(i.e., email, phone, chat, text messaging, and video conferencing) as well as whether they used internet for
any of ten clinical activities (e.g., find information on referral, treatment, or support between sessions) with
yes/no response options, and the proportion of time with clients involving treatment delivery via the internet
(% response option). The proportion of work currently involving the delivery of e-mental health treatment
was also assessed. See full survey in Appendix A.
Confidence in navigating internet services was measured on a 5-point scale: 1 = not at all confident to 5 =
very confident. Prior participation in professional development (response yes/no) was also assessed: In the
last five years, have you done any of these professional development opportunities to learn about e-mental
health: seminar or lecture, workshop or group training, one-on-one training, formal education, or diploma.
Six items from the Internet Evaluation and Utility Questionnaire (100) were included to measure attitudes
towards the implementation of e-mental health. Items measured perception of stress, helpfulness, value,
concern, comfort, and ease). Responses were given on a five-point Likert agreement scale: 1 = strongly
disagree, 5 = strongly agree. Participants were asked to report the top three concerns or disadvantages from
the use of e-mental health as part of routine care in their service. They also reported the top three benefits or
advantages from the use of e-mental health as part of routine care in their service.
Preferences for screener content were explored. This included duration of assessment, support mode (e.g.,
email, chat, and phone), and support person (e.g., intake worker, peer or volunteer, counsellor). Readiness
and preferences related to i-CBT for gambling included feasibility of blended treatment, levels of integration
between i-CBT and face-to-face treatment and duration and number of i-CBT activities. Participants were
also asked to report on the preferred timing of i-CBT and how it could be integrated into treatment delivery.
1.12.2. Procedure
The needs analysis survey was administered online via Qualtrics survey software using an information sheet
and survey link distributed via e-mail. The survey link was active for a two-week period (24 October to 12
November 2019), with one reminder email sent two weeks later. The survey was tailored so that only relevant
questions were presented. For example, only clinicians received items specific to working clinically.
Participants were advised that the results would be collated to inform the development of an e-mental health
program for reducing gambling harm in New Zealand.
1.12.3. Analysis plan
For quantitative data, descriptive statistics (mean, SD) and frequencies for categorical data were calculated
using SPSS. Where appropriate or relevant, results were compared across three groups: client facing, support
personnel, and consumers / consumer advisors, using one-way ANOVA.
13
The open text questions within the needs analysis survey were related to benefits and disadvantages of e-
mental health. These answers were coded into the conceptual framework of person-centred access to health
care by Levesque, Harris (101). This framework was adapted to understand readiness for e-mental health and
how services perceive the utility of e-mental health tools. From the client perspective, the framework outlines
five processes that influence access to support and treatment. These include the ability to perceive a need for
e-mental health (including internet literacy, health beliefs, and knowledge of e-mental health); ability to seek,
reach, and pay for treatment as well as an ability to engage (facilitating minimal attrition and maximum
adherence). From the treatment provider perspective, client access to e-mental health tools is influenced by
their approachability (service information, screening tools), acceptability (values and culture of the
organisation and support for client autonomy), availability of in-person treatment (physical location, mode of
delivery, qualifications of provider, and flexible opening hours), affordability (time and resource costs), and
appropriateness (delivery of evidence-based treatment tailored to client need). A qualitative content analysis
(102) was used to group our data into the framework of person-centred access to health care. This method
was selected to enable the systematic classification of participant data into themes guided by an established
framework (102).
Extracts were read twice for familiarity with the data and initial codes were developed. Common codes were
grouped into themes that were adjusted to accommodate additional data. As outlined by Hsieh and Shannon
(103), the data was then grouped into broad categories which reflected the selected framework (103). Data
that could not be coded into one of the broad categories were re-examined to describe different manifestations
of e-mental health needs and these were merged into the framework and noted accordingly. Where quotes
were used, these were de-identified to ensure participant anonymity. Quotes were also cleaned to improve
readability (i.e., spelling and punctuation) as well as clarity (i.e., grammar corrected).
1.12.4. Participant characteristics
The survey was sent out to the entirety of the two gambling organisations’ staff. In total, 60 individuals
opened the survey. Of these, seven did not continue to the consent page, and three did not consent to
participate. An additional three participants ceased participation at the unique identifier page requesting an
email address. A total of 47 surveys were completed. Of the completed surveys, there were more females
(74.5%) than males. The majority of responses were from people aged 50-64 years (51.1%). Almost four out
of five respondents reported their highest level of education as undergraduate or postgraduate degree.
Participants were most frequently from the Auckland region (38.3%), followed by Canterbury (27.7%).
Participants included staff members from client-facing and non-client facing roles. The sample included 26
staff working directly with clients (clinician = 13, case worker = 7, team leader = 5, and manager of clinical
services = 1). There were 12 participants who did not directly work with clients (health promotion = 3,
administration and operations = 4, public health role = 2, and communications = 2,) including one Māori
health cultural advisor. In addition to the client-facing and non-client facing participants, there were 9
consumers or consumer representatives. Of those working in client-facing roles, there was a high degree of
clinical expertise, with two-thirds of participants reporting more than five years of experience. Work with
gamblers differed slightly whereby five participants (19.2%) had worked with gamblers for less than one year
and a further three participants (11.5%) had worked with gamblers for less than two years. Eighteen out of 26
(69.3%) participants had worked with gamblers for more than two years (Table 1).
Table 1. Participant demographics and expertise (n = 47)
Demographic categories
n
%
Gender, Female
35
74.5
Age range
18–29 years
3
6.9
14
Demographic categories
n
%
30–49 years
18
38.3
50–64 years
24
51.1
65+ years
2
4.5
Highest level of education
Postgraduate degree
21
44.7
Undergraduate degree
15
31.9
Certificate/Diploma
10
21.3
Secondary education
1
2.1
Participation by region
Auckland
18
38.3
Bay of Plenty
3
6.9
Canterbury
13
27.7
Manawatu–Wanganui
1
2.1
Otago
4
8.5
Waikato
4
8.5
Wellington
4
8.5
Experience (clinician only) *
< one-year of experience
1
3.8
> 1 but < 2 years of experience
1
3.8
> 2 but < 5 years of experience
7
26.9
> 5 years of experience
17
65.4
*clinician-only items were based on a sample of 26 respondents
Needs analysis results
All participants were asked to score their level of confidence and experience with the use of the internet for e-
mental health practices. Almost all participants were somewhat confident or very confident with navigating
internet services (39/47, 83%) with only one indicating they were not confident.
In the last five years, just over 60% of participants (n = 29) had attended one or more forms of professional
development about e-mental health. This included a seminar or lecture (n = 15, 31.9%), workshop or group (n
= 22. 46.8%), one-on-one training (n = 8, 17.0%), formal education (n = 3, 6.4%), or other self-initiated
learning (n = 6. 12.8%). Of the 18 participants who had not attended any professional or personal
development, eleven (42.3%) were client-facing, five were support staff (41.7%), and two were consumers
(22.2%).
Participants reported on their perceptions of working with e-mental health tools. Overall, there was high
agreement that e-mental health tools were helpful, valuable, and relatively easy to use. Just four participants
reported that e-mental health tools were stressful (8.5%). Most participants also reported that they were
comfortable using e-mental health tools and did not have concerns about their use (Table 2).
Table 2. Perception of working with e-mental health systems and tools (n = 41)
Variable
Strongly
disagree
Disagree
Neither agree
or disagree
Agree
Strongly agree
Stressful
6 (2.5)
15 (6.2)
16 (6.7)
3 (1.2)
1 (0.4)
Helpful
1 (0.4)
1 (0.4)
2 (0.8)
22 (9.0)
15 (6.2)
Valuable
1 (0.4)
1 (0.4)
1 (0.4)
19 (7.8)
19 (7.8)
15
Concerning
7 (2.9)
16 (6.6)
16 (6.6)
1 (0.4)
1 (0.4)
Comfortable
-
3 (1.2)
8 (3.3)
25 (10.3)
5 (2.1)
Easy
-
5 (2.1)
14 (5.8)
19 (7.8)
3 (1.2)
1.13.1. Current use of e-mental health tools with clients
Participants who reported a client-facing role were asked about their current level of e-mental health work
with gamblers (n = 26). Clinicians were presented with a list of internet-based services and asked which ones
they currently use as part of their work with clients. All clinicians reported having used phone and text as part
of their work with clients. Almost all clinicians used e-mail (n = 25, 96.2%) while only nine (34.6%) used
skype or video, and only one (4%) used instant chat. No clinicians reported the use of self-help modules,
smart phone apps, or peer-to-peer forums as part of their regular practice.
At the time of the survey, almost half of the clinicians (n = 13, 48%) spent less than 5% of their time involved
in the delivery of e-mental health services with clients. Six (22%) clinicians spent between 6-10% of their
time and three (11%) spent between 21-50% of their time involved in the delivery of e-mental health services.
One clinician reported spending no time at all involved in the delivery of e-mental health services.
Clinicians were asked to report on the types of clinical activities supported by the internet. As indicated in
Table 3, most used the internet for communication before treatment starts, delivery of ongoing treatment,
treatment or support between sessions, and post-treatment support or after-care. There were very few
clinicians who used smartphone apps to support self-monitoring or tracking (13.4%).
Table 3. Clinical activities which clinicians currently use on the internet (n = 26)
Clinical activity
n
%
Communication before treatment starts
25
96.2
Treatment or support between sessions
25
96.2
Administration (e.g., appointment reminders)
25
96.2
Post-treatment support or after-care
24
92.3
Find information on referral
22
84.6
Delivery of ongoing treatment
20
76.9
Find information or enrol for self-exclusion
20
76.9
Conduct assessment (e.g., PGSI)
17
65.4
Calculate money spent gambling (e.g., spending calculator)
12
46.2
Smartphone app for tracking
4
13.4
Other
3
11.5
1.13.2. Perceived benefits and disadvantages of e-mental health
Participants reported 140 perceived benefits and 136 perceived disadvantages of e-mental health systems and
services. Each benefit and disadvantage was coded into the patient-centred access to health care model (101).
The component of approachability referred to the use of e-health to increase reach of gambling services.
16
Within the component of approachability, the advantages included an increased reach of services and meeting
the expectations that gambling support services are offered via the internet. Approachability-related barriers
that need to be addressed include the promotion of the service and specific e-mental health options as well as
information for clients on how to select the best service option for their specific situation and preferences
(Table 4).
The component of acceptability of service delivery referred to increased specificity of service options
whereby more options could be made available so that there was better tailoring to meet client preferences,
readiness, and needs. There was a view that e-health could somewhat address the psychological barriers to
treatment such as anxiety and felt stigma through its increased capacity for anonymity. Barriers that need to
be addressed within the component of acceptability included a perception that e-mental health could erode
sector funding and that a move towards internet-only services would pose a new barrier to service users.
Participants also expressed concern that cultural competency and knowledge must be central to service
development to ensure its acceptability by service users.
Within the component of availability, participants reported flexible access as a benefit of e-mental health
services, including ease of access, immediacy, opening hours, reduced transport, and increased availability to
rural and remote clients. Availability-related barriers that would need to be addressed included the cost and
quality of internet and access to personal computers. There was also a concern that reduced barriers would
mean more people would drop out of services between indicating interest and using the service.
The final component of the model was appropriateness, which referred to services meeting the needs of
service users (e.g., confidentiality) as well as enhancements afforded by the modality (e.g., expanded support
between sessions). There was also a view that e-mental health could enhance methods of communication and
support ongoing engagement. Multiple participants indicated that e-mental health could assist with providing
a wrap-around, holistic approach that extended the weekly contact time. Within the appropriateness
component, barriers that need to be addressed included assessment for risk and concerns about privacy and
confidentiality of client data. The main concern was reduced rapport brought about by reduced physical
presence. It was thought that this might lead to less client engagement and poorer clinical outcomes in some
cases. There was also a concern that providers be provided sufficient training and information in navigating
e-mental health and online treatments.
Table 4. Perceived benefits and disadvantages of e-mental health systems and services (n = 47)
Advantages of e-mental health
Barriers to be addressed
Domain: Approachability of service (advantages: n = 24; barriers: n = 16)
Increased reach: being able to engage more
clients and new cohorts that do not typically
access face-to-face services.
Provision of a new and more attainable first
step to obtaining expert gambling treatment.
Being able to meet users’ expectations on
treatment being offered via the internet.
Future-proof services to expectations and
shifting environments to ensure services remain
relevant and approachable.
Effort needs to be placed into promotion of
services so that people are aware of what is
available.
Ensure information provided online is valid and
reliable. Information should be provided on the
effectiveness of different service options.
Ensure information is provided to guide service
users on suitable options. E-mental health may
not be suitable for those experiencing shame,
isolation or those with low computer literacy.
17
Advantages of e-mental health
Barriers to be addressed
Provide information and resources on reducing
gambling harm and service options.
Domain: Acceptability of service (advantages: n = 31; barriers: n = 23)
Increases the specificity of service options so
that interventions can be tailored for individual
preferences, goals, readiness, and needs.
Addresses psychological barriers to treatment
such as social anxiety and a reluctance to attend
face-to-face counselling.
E-mental health offers a low-stigma way of
engaging with services due to increased
anonymity compared with face-to-face.
Delivered in a way that respects cultural
inclusivity, individual autonomy, and self-
determination.
Concern for loss of clinical roles and staffing
levels and that person-to-person interactions
will be replaced or become redundant.
Places a barrier to help-seeking if clients are
required to engage online.
Cultural competency and knowledge must be
conveyed to ensure services are acceptable.
Domain: Availability of service (advantage: n = 47; barriers: n = 23)
Increased availability from any place including
home or work.
Easy access and usability of services.
Immediate responses to non-clinical questions.
Faster responsiveness to request for assistance.
Increased availability of services to rural and
remote clients.
Increased flexibility in opening hours.
Reduced requirement for transport and travel in
order to access the service.
Potentially more affordable and cost effective.
The quality, cost and availability of internet in
New Zealand is variable.
Not all clients have access to personal
computing or internet access.
Requirements for immediacy require rostering
and service response considerations.
Technical difficulties can impact on interaction
and availability of service.
Reduced barriers to access can mean increased
drop-out and service attrition.
Domain: Appropriateness of service (advantage: n = 41; barriers: n = 73)
Easy assessment and client monitoring.
Confidential and private provision.
Expanded and enhanced support between
sessions and as an adjunct to routine care.
Enhanced way of communicating with clients
and maintaining engagement. Method of
providing ongoing or post-treatment support.
Crisis may not be detected if assessments not
completed.
Concerns about privacy and confidentiality of
client data.
Clients may not be as engaged in the treatment
especially with reduced face-to-face contact and
accountability. This may reduce the
effectiveness of treatment and quality of
service.
18
Advantages of e-mental health
Barriers to be addressed
Treatment options can be packaged and tailored
when working together. E-mental health can
complement other clinical work.
May facilitate linkages with other health and
well-being service providers.
Online data collection can support evidence
gathering as to the effectiveness of the service.
Rapport hindered due to reduced physical
presence.
Providers may not have enough training and
knowledge in navigating e-mental health and
online treatment.
1.13.3. Screener preferences
Participants were provided with information on the proposed screener with personalised report. This meant
multiple gambling measures would be administered and then the results would be presented to the person
with comparisons to the rest of the population. Participants were asked to comment on delivery and support
aspects of the screener.
As indicated in Figure 1, client-facing clinicians and consumers most frequently indicated that six to ten
minutes for screener with personalised report duration was the appropriate length of time. In comparison,
non-client-facing workers most often thought the screener should be less than 5 minutes in duration.
Figure 1. Frequency of preference for time spent on screener with personalised report
Participants were asked to consider the most appropriate method of providing support for the screener with
personalised report. As indicated in Table 5, there was wide support for phone, in-person, and email support
options, whereas the chat/messaging and text messaging options received less support particularly from
consumers
0
10
20
30
40
50
60
< 5 mins 6-10 mins >11 mins
Client facing Non-client facing Consumer
19
Table 5. Method of discussing assessment results (n, %)
Method
Client Facing
Non-client facing
Consumer
Total
Phone
25 (92.3)
11 (100)
6 (66.7)
42 (89.4)
In person
24 (88.9)
11 (100)
6 (66.7)
41 (87.2)
Email
21 (77.8)
9 (81.8)
6 (66.7)
36 (76.6)
Chat/messaging
18 (66.7)
9 (81.8)
4 (44.4)
31 (66.0)
Text Message
19 (70.4)
8 (72.7)
2 (22.2)
29 (61.7)
Don’t know
1 (3.7)
0
3 (33.3)
4 (8.5)
Participants were asked to consider the best way of offering support alongside the screener with personalised
report should a person want to discuss their results. By far, the perceived most appropriate person to provide
feedback on the screener with personalised report was a counsellor followed by an intake worker or someone
with entry-level qualifications. Figures 2-6 indicate the preferred person to deliver email, chat, phone, text, or
in-person support.
Figure 2. Appropriate person to deliver email support
0
20
40
60
80
100
120
Admin Intake Intern Peer Counsellor
Yes No Don't know
20
Figure 3. Appropriate person to deliver chat support
Figure 4. Appropriate person to deliver phone support
0
20
40
60
80
100
120
Admin Intake Intern Peer Counsellor
Yes No Don't know
0
20
40
60
80
100
120
Admin Intake Intern Peer Counsellor
Yes No Don't know
21
Figure 5. Appropriate person to deliver text support
Figure 6. Appropriate person to deliver in-person support
0
10
20
30
40
50
60
70
80
90
100
Admin Intake Intern Peer Counsellor
Yes No Don't know
0
20
40
60
80
100
120
Admin Intake Intern Peer Counsellor
Yes No Don't know
22
1.13.4. I-CBT needs and preferences
Participants were provided information on internet delivered CBT (i-CBT) to prompt consideration of a
blended treatment model. A blended treatment model could involve clients doing ongoing face-to-face
treatment at the same time as i-CBT for gambling. How the blended model could work in practice was
presented for discussion. Participants were asked about their perspectives on the feasibility of a blended
model within their service. Overall, 32/43 (75%) participants indicated that they agreed that a blended
approach would be feasible in their service. A further 25% were not sure and no participant thought that it
was not feasible.
Participants were asked to provide their opinion on how i-CBT for gambling could be blended into face-to-
face treatment. They were asked to rank four options from 1 = 'most preferred' to 4 = 'least preferred' by
dragging-and-dropping them in their preferred order (Table 6). The most preferred option was a partial blend:
86% of participants listed this as their first or second choice. While a full blend was preferred by some
clinicians, this was considered the least preferred option for 41% of the sample. A partial option indicates the
activities could be partially integrated into the treatment plan. This might involve monitoring progress or
encouraging clients to complete content and then discuss the work during treatment times. Just 17% (n = 8)
indicated a preference for complete separation between face-to-face treatment and activities.
Table 6. Ranked preference for blended treatment model (n = 44)
Model option
Pref. 1
Pref. 2
Pref. 3
Pref. 4
Separate from treatment
7 (14.9)
1 (2.1)
13 (27.7)
23 (48.9)
Separate from treatment, but supported by
the counsellor
7 (14.9)
16 (34.0)
19 (40.4)
2 (4.3)
Partially integrated into treatment
17 (36.2)
20 (42.6)
6 (12.8)
1 (2.1)
Fully integrated into treatment
13 (27.7)
7 (14.9)
6 (12.8)
18 (38.3)
Table 7 describes the configuration preferences for i-CBT for gambling. Overall, two-thirds of participants
indicated that the duration of i-CBT should be less than 30 minutes. Participants strongly preferred to have
clients and counsellors co-select activities each week. Approximately 27% of participants indicated that five
to six activities modules be available.
Potential content for clinician support tools is presented in Table 7. Most respondents agreed that the results
of assessment tools and the results of completed content/activities would be helpful for supporting program
completion. There was more variation regarding log-in occurrences and pages viewed, with only
approximately 50% of the total sample indicating these details would be helpful.
Table 7. Preference for i-CBT for gambling accessibility
Duration of each i-CBT for gambling module
n, %
Less than 30 minutes
29 (65.9)
30–60 minutes
13 (29.5)
1–2 hours
0
More than 2 hours
0
Do not know
2 (4.5)
Availability of i-CBT for gambling
23
Duration of each i-CBT for gambling module
n, %
Clients and counsellors select activities every week
29 (65.9)
One set of activities become available each week
7 (15.9)
Other
5 (11.4)
Don’t know
3 (6.8)
Number of i-CBT modules available to clients
Less than two
1 (2.3)
Three to four
9 (20.5)
Five to six
12 (27.3)
Seven to eight
3 (6.8)
Nine or more
8 (18.2)
Do not know
11 (25.0)
Clinical management information (n = 44)
Results of assessment tools
38 (86.4)
Results of completed activities
39 (88.6)
Log-in occurrences
22 (50.0)
Pages views
24 (54.5)
Note: Three client-facing participants did not respond to the questions on clinician management information
(n = 44).
E-mental health offers the possibility for the client to complete their work from anywhere (Table 8). The
majority of participants (74%) indicated that the first or second preference was for the client to complete the
content at home, in between sessions, followed by the client completing the content before the session (60%).
Table 8. Preference for location of lesson content completion, n (%)
Model option
1st pref.
2nd pref.
3rd pref.
4th pref.
Client completes the content in a
separate room at my service BEFORE
talking with me.
9 (19.1%)
19 (40.4%)
11 (23.4%)
5 (10.6%)
Client completes the content in a
separate room at my service AFTER
talking with me.
5 (10.6%)
13 (27.7%)
23 (48.9%)
3 (6.4%)
Client completes the content at home
between sessions.
26 (55.3%)
9 (19.1%)
8 (17.0%)
1 (2.1%)
Other
4 (8.5%)
3 (6.4%)
2 (4.3%)
35 (74.5%)
Note: Three client-facing participants did not respond to this question
Participants were asked about their preferences for follow-up evaluation. As indicated in Table 9, the first
preference for participants was split somewhat equally between the counsellor contacting the client and an
automatic email being sent to both clients and counsellor. When taking into account first and second
24
preferences for follow-up evaluation, the automatic email to both client and counsellor was more strongly
preferred.
Table 9. Ranked preference for blended treatment model (n = 44)
Model option
1st pref.
2nd pref.
3rd pref.
The counsellor contacts the client for follow-up
evaluation.
19 (43.2)
8 (18.2)
17 (38.6)
An automatic email is sent to clients prompting follow-
up evaluation.
4 (9.1)
21 (47.8)
19 (43.2)
An automatic email is sent to clients prompting follow-
up evaluation and the counsellor is prompted to review
the results.
20 (45.5)
15 (34.1)
8 (18.2)
1.13.5. Support needs for e-mental health work
Participants were asked to comment on the support that would be helpful to assist with the delivery of e-
mental health. They were also asked about the main action the organisation could take to support e-mental
health being part of service delivery. By far the most reported need was for specific training in the tools as
well as internet communication. There was also a call for training materials that were self-paced. Around half
of participants suggested that it would be helpful to have in-house mentors and/or someone to contact if there
was a problem (Table 10).
Table 10. Support for e-mental health work (n = 51)
Theme
Description
n, %
Training
Email and chat counselling and communicating online
Opportunity to use the program in advance
Delivered in tandem with a simple-to-follow manual
Self-paced or webinars plus refresher training
20 (39.2)
IT Support
Training and development of in-house mentors, especially those with
existing expertise in e-mental health
IT support to fix glitches and answer questions. Access to help desk
support.
11 (21.6)
Promotion
Promotion within agency to attract new clients
Integrate into routine and standard care
Make it known that e-mental health tools are one of the services offered
Development of information for outlining the service
3 (5.9)
Protocols
Awareness and fit with current complexity
Cheat sheets and guides
Information on risk mitigation
6 (11.8)
Resources
Tablets for clients to use in services
Skype and chat features
Space in the agency for clients to complete activity
6. (11.8)
25
4. PHASE II: Co-design hui
A co-design workshop sought to extend the findings of the needs analysis to understand in more detail
customisation considerations for the two e-mental health tools. The workshop was held on 5 December 2019
and brought together key stakeholders from across New Zealand including clinicians and consumers. A series
of interactive presentations were conducted, followed by small and large group discussions. Topics and sub-
topics discussed throughout the workshop covered aspects of the screener delivery and pathways into services
and i-CBT for gambling components including administrative issues, intake and selection, timing and
evaluation of cultural aspects and IT considerations; information and education requirements; and training
and development needs. The co-design workshop was referred to as hui, which is a Te Reo Māori word that
indicates inclusiveness. This idea of inclusiveness is key to the flow and effectiveness of the workshop.
Participants in the co-design hui
Purposive sampling was used to identify key stakeholders within the Problem Gambling Foundation and
Salvation Army Oasis to attend the workshop. Service leads from each organisation identified interested staff
members and consumers / consumer advisors. Invitations were extended to consumers and consumer
advisors, clinicians, support personnel, supervisors, and executives from the service providers and
government representatives from across New Zealand.
As indicated in Table 11, there were 32 representatives from The Salvation Army Oasis and PGF Services
including Mapu Maia (Pacific health). There were also four attendees from the University of Auckland and
two from Deakin University (Australia), who were presenters and/or note-takers for the day. In attendance
were three managers, twenty-one counsellors, and eight consumers as well as duty counsellors and health
promoters.
Table 11. Co-design workshop participants
ID
Organisation
Role
Location
Role at the hui
001
PGF
Counsellor
Auckland
Participant
002
SA
Consumer
Waikato
Participant
003
PGF
Counsellor
Palmerston North
Participant
004
SA
Consumer
Wellington
Participant
005
PGF
Counsellor
Palmerston North
Participant
006
PGF
Counsellor & Health
Promoter
Christchurch
Participant
007
SA
Counsellor
Christchurch
Participant
008
PGF
Manager
Christchurch
Participant
009
SA
Counsellor
Dunedin
Participant
010
SA
Counsellor
Wellington
Participant
011
PGF
Consumer
Christchurch
Participant
012
PGF
Duty Counsellor
Taupo
Participant
013
PGF
Consumer
Rotorua
Participant
014
SA
Consumer
Auckland
Participant
015
PGF
Counsellor
Dunedin
Participant
016
SA
Counsellor
Auckland
Participant
017
PGF
Counsellor
Christchurch
Participant
26
ID
Organisation
Role
Location
Role at the hui
018
SA
Counsellor
Christchurch
Participant
019
SA
Manager
Auckland
Participant
020
SA
Consumer
Auckland
Participant
021
PGF
Counsellor
Rotorua
Participant
022
SA
Counsellor
Auckland
Participant
023
Mapu Maia
Manager
Wellington
Participant
024
SA
Counsellor
Wellington
Participant
025
PGF
Counsellor
Dunedin
Participant
026
PGF
Consumer
Auckland
Participant
027
PGF
Counsellor
Auckland
Participant
028
SA
Counsellor
Wellington
Participant
029
PGF
Counsellor
Christchurch
Participant
030
PGF
Kaiwhakarite Bicultural
Relationships
Auckland
Participant
031
SA
Counsellor
Auckland
Participant
032
PGF
Counsellor
Christchurch
Participant
033
UoA
Research assistant
Auckland
Note taker
034
UoA
Research assistant
Auckland
Note taker
035
UoA
Research assistant
Auckland
Note taker
036
UoA
Academic
Auckland
Presenter
037
Deakin
Academic
Melbourne, Australia
Presenter/Note-taker
038
Deakin
Academic
Melbourne, Australia
Presenter/Note-taker
Semi-structured group interview schedule
A semi-structured interview schedule was developed to guide the group questions. The full interview
schedule is in Appendix B and shows the questions that were posed in small group discussions during the co-
design hui. The screener discussion prompts related to the proposed content of the screener and preferred
pathways into the service. I-CBT for gambling discussion related to engagement, timing, and selection of
content as well as blending considerations. The discussion prompts were presented via PowerPoint and
participants were also provided with a copy of the prompts to guide the group discussion.
Procedure and materials
Prior to the co-design hui, participants were provided with an agenda and background information. The
information pack contained (1) the results of the needs analysis, (2) an overview of the proposed screener, (3)
sample content and structure of the proposed i-CBT for gambling, and (4) background readings on the model
informing the i-CBT for gambling content. Participants were asked to consider the findings from the needs
analysis to discuss the findings at the workshop.
The workshop was held at Jet Park in Auckland to facilitate easy access for those from regional and rural
areas. The morning session covered the screener content and functionally and pathways into services. The
27
morning sessions covered blended treatment background and proposed content for i-CBT for gambling. The
afternoon session discussed peer support, technology support and training needs, cultural considerations, and
branding. This included a focus on how i-CBT for gambling could be integrated into practice. They worked
in small groups to provide input into the content and design.
At the conclusion of the workshop, an evaluation survey was administered. The evaluation examined
organisation, expertise of speakers, opportunity for collaboration, knowledge gained, importance of the co-
design process, and overall satisfaction with the information provided. Participants were asked to rate their
level of satisfaction on a five-point Likert scale: 1 = strongly disagree, 5 = strongly agree. Two open-ended
questions were also presented: (1) What aspects of the two e-mental health programs do you like most?; and
(2) What aspects of the two e-mental health programs are you still wondering about?
Data collection and analysis
Data collection was conducted via multiple note-takers who were present for the entirety of the co-design hui.
The note-takers included the current investigator, research assistants, and the senior research investigators.
Note-takers were instructed to record the discussion on each of the questions in the semi-structured interview
schedule. The notes taken by the note-takers included all suggestions, comments, discussions, and concerns
talked about by the participants. Where possible, note-takers recorded verbatim quotes that were either
indicative, unusual, or relevant to the research questions. Note-takers were instructed to avoid interaction
with the group to which they were assigned. Where the group had questions, the note-taker referred these
questions to the session facilitators. Careful consideration was taken when combining all the notes into one
document. All notes were combined based on the topics and sub-topics of the hui.
For this report, notes were collated into sections by subject and a reflexive thematic analysis was conducted.
Qualitative data from open-text questions was subject to thematic analysis (104). A reflexive thematic
analysis approach was taken to analyse the open-text questions of the hui post-survey, filled in by the
participants (105). Themes were defined as a pattern of shared meaning underpinned by a central concept or
idea (104).
In line with the six steps for doing a thematic analysis (104), the content was reviewed to acquire an overall
picture of the hui participants’ responses. This included reading and re-reading the data. Next, codes were
created for the important features of the relevant data. Initial themes were generated after reviewing the
collection of codes. The code themes were examined and collated into groups of potential themes to explore
significant broader patterns of meaning. After identifying the potential themes, they were reviewed
individually to determine their viability. The potential themes were checked against the dataset to determine
the quality of the theme and its ability to reflect the concepts asked by the research questions. Next, the
themes were refined by either being split or combined. After finalising the themes, a detailed analysis was
created for each theme. An informative name was assigned to each theme at this stage. In the final stage, a
written narrative was constructed of the theme contextualisation.
Co-design hui – Screener prototype
This section presents the results of the co-design hui. Participants were presented with a draft screener that
included proposed measures and personalised report. Four broad themes emerged from the discussion which
were (1) overall helpfulness, (2) assessment items, and (3) presentation of results in the feedback sheet. Table
12 shows summary of Hui discussion on screener.
28
Table 12. Summary of Hui discussion on screener
Theme
Key points
Overall helpfulness
Participants had mixed views towards the screener. There was a
concern that it would be a barrier to treatment access but could
also be a way to get started with help-seeking. Others thought
completion of a series of measures would not be helpful for
people with gambling problems. Participants also thought that
people with problem gambling would not complete the screener
as they already knew there was a problem.
Assessment items
There was a preference for anonymous completion of screener.
Some participants thought there were too many questions related
to gambling but too few on demographics. There was a
preference to include screens that were part of routine data
collection in services. The PG-YBOCS was introduced as a brief
screen to measure change in gambling symptoms. It was
considered acceptable but extensive changes were needed to
improve item wording and response options so that it was in
plain language. There was a positive response to measures of
motivation, readiness, and distress but mixed views as to the
value of including expenditure in the screen.
Personal feedback report
The report was generally perceived as a good idea that could be
enhanced with more diagrams, images, and information in
pictorial form. However, some participants found the feedback
confronting because of the direct language and focus on
expenditure. There were mixed views on the normative
component where some thought comparisons were useful, and
others thought comparison could prompt feelings of shame.
Overall helpfulness
The first perceptions of participants of the screener with personalised report were mixed. One participant
stated that the screener was a way of engaging gamblers and perhaps get the conversation started. One other
participant stated that it was important to know the target market for the screener as it was unlikely to work
for everyone.
If you are at the stage of seeking help and filling in this report it might be helpful to get the ball
rolling.
People can use this screener as a way to gauge whether they are ready.
Two participants stated that it would be helpful if the results of the screener could be made available to the
counsellor. This would avoid duplicate tool administration.
One of the ways to get clinician buy-in is that we have to do the PGSI anyway. The results should
feed directly based into the database. Scores could come into the clinician dashboard. So, the
paperwork doesn’t need to be completed.
Two participants suggested that there may not be the capacity to complete a comprehensive assessment with
a hybrid model. It was suggested that a comprehensive assessment would likely have to include both
29
traditional face-to-face as well as online assessment. This was because a minimum of two face-to-face
sessions was required to complete the Ministry of health mandatory screens and comprehensive assessments.
I’m worried there isn’t the capacity to do the comprehensive assessments within this process.
We will need to work out what to do with all the screens and how they fit into our process.
There was a perception among five participants that the screener might be helpful for people with lower-level
problems (e.g., moderate-risk gamblers). Regarding people with gambling problems, one participant
perceived that if the person who gambles already knew there was a problem, completing a bunch of
assessment tools was not appropriate. One participant stated that the screener would not be appropriate for
those in distress.
It is a tool that won’t suit everyone – problem gamblers will just want someone to tell their story.
If you are a problem gambler or about to hit rock bottom you are unlikely to get through the
screener, but moderate-risk gambler might.
The screener and feedback report may not be appropriate for all, especially for problem gamblers
who just need help. Might be helpful for moderate-risk gamblers. Might be a good first step to help-
seeking as seeing if they are ready to get help.
The feedback report will not be helpful for people in distress seeking help.
Part of the reason for the negative response was perhaps a perception that all clients would need to complete
the screener. During the discussion, a participant reported thoughts that the screener completion would be
required for any enrolling client which they thought would be a barrier to help-seeking.
When taking the first step to seek treatment this screener is not helpful. Don't think problem gamblers
that are seeking help will want to do this. Just want to speak to a counsellor or get help and not fill in
demographic forms.
Assessment items
The different areas that were discussed in relation to the specific assessment items included anonymity,
demographics, wording on gambling screens, and inclusion of expenditure. Discussions on anonymity and
confidentiality revolved around whether a name should be provided when completing the screener with
personalised report. As for the assessment items, two participants commented that the length of the screener
was too long. However, another participant stated that with the use of progress bars, the number of items
would not be prohibitive.
This is a lot. This would put me off immediately.
Even though looked like a bunch of questions, isn’t that bad. Progress bars. Number of pages.
Six participants suggested the demographics items should align with the Ministry of Health data collection.
This would facilitate data collection in the agency and reduce the need to ask clients to complete different
questionnaires to collect the same type of data. Six participants saw value in demographic data collection to
know who was using the screener. There was a preference for not including demographic questions such as
level of education or employment status unless they were being collected for a specific reason that was
helpful to the client.
Demographic information gives important/useful information on who is accessing intervention.
30
Demographics look okay but make sure that the categories align with what is needed for Ministry of
Health. Add more Asian ethnicities and Pacific ethnicities as this is currently too narrowly grouped.
Participants were positive towards the inclusion of standardised assessment tools to determine gambling
severity. There were no comments specifically on the Problem Gambling Severity Index that may have
reflected the use of this tool as part of standard service delivery. A newly available tool referred to as the 5-
item PG-YBOCS (pathological gambling adaptation of the Yale-Brown Obsessive-Compulsive Scale) was
included as a measure. Six participants were in favour of the tool as a measure of short-term change to
severity of gambling symptoms but queried the language and question structure.
Get rid of all brackets – I found it too wordy. Shorten questions so it is easier to read – simplicity is
best.
Give less examples. We need to give the client opportunity to interpret and not narrow down the
question. I am worried the client could read the example and think the full question only refers to that
thing.
Other screens collected information on readiness to change gambling (3 items), psychological distress (1
item) and motives to gamble (4 items). Two participants noted that the psychological distress item should be
gambling specific.
The most discussed assessment item was financial expenditure. Whether expenditure should be included was
in part determined by the specific agency’s approach to money. A participant from PGF stated that they do
not regularly discuss specific amounts of money with the person who gambles. A view that people who
gamble might not want to know how much they were spending was endorsed by three participants.
We never talk about spend in the group sessions– need to be very careful in how it is presented.
When you go to a GA meeting you do not talk about how much you gamble.
Do consumers want to know how much they spend? It has the potential to help people but also has
the potential to scare them.
A participant disagreed that people who gamble might not want to know how much they were spending,
saying that knowing expenditure was one of the first things that they did in a counselling session. A
participant who works with Pacific people made the point that winning, and money are key motivators and
therefore should be discussed in a counselling session.
Working with Pacific people we are very comfortable with talking about money. For Pacific clients,
money is the main motivator. We are quite direct with talking about money and there is no hesitation
for us.
We talk to a lot of people, to so many people, and we talk to people and write on a board all what
they’ve lost, and they go – ah, how much I’ve lost.
Personalised feedback report
A draft version of personalised feedback was provided to assist participants to consider the content and look
and feel of the report. Five participants liked the feedback report immediately and could see value in it
helping a person increase their motivation to change their gambling behaviour.
I like the idea of a report. The only thing I’d probably look at is Pasifika’s language.
31
I like that they can see how much they are spending.
It would be great for them to know how much they won and how much they lost.
This might push people from pre-contemplation to contemplation.
Ten participants, however, had comments on the purpose and confrontational nature of the feedback. For
some, presenting information on gambling behaviours and how people compare with others was too
confronting. These participants felt that having facts and figures would make the person feel more vulnerable.
Two participants disagreed and explained that this was a commonly used approach that was effective with
other addictive behaviours. One participant stated that the stats were important, but more thought was needed
in how they were presented.
It’s supposed to be confronting – showing them compared to others. They do it with drugs and
alcohol – people are surprised that they drink more than others.
I thought it was confronting – they came to us because they don’t know how to change.
Stats comparing the person to national stats seems shameful. It’s important to have facts though… so
tweak it.
What do we want the client to feel when reading this document? Are we trying to challenge client’s
ideas about gambling?
For someone who wants to go and check their gambling, it’s too much.
There were mixed views on the specific normative feedback component. Five participants thought the
normative feedback would be helpful.
Really good question about gambling more/less or about the same as other New Zealanders.
I don’t mind the statement that 80% of people gamble less than you.
However, others were concerned that normative feedback would add to shame or stigma around gambling.
One participant thought that seeing a large amount of gambling expenditure would cause the person to
experience negative feelings. Others agreed and believed that it could increase a sense of shame. Multiple
participants suggested that there should be a strong link between giving information on current expenditure
and information that normalises gambling harm and help-seeking.
I don’t want them to feel so bad when they see a big number.
Telling someone they are in the top 13% of people with gambling problem is quite stigmatising and
judgemental.
Letting people know about how many other people have the same problem is helpful. It gives
information and lets the person know that they’re not the only one.
Participants also commented on the figures and methods to present normative information. For eight
participants, some of the figures were difficult to understand or work out the main message. Other figures
were also flagged as better if they were percentages rather than raw numbers.
Actual money is on the figure. It would be better if it showed percentage of income.
32
The percentage of gambling spend needs to be proportional compared to others.
Similarly, four participants stated that the information should be visually pleasing with more pictures, large
easy-to-read text and able to be understood immediately. These participants thought that the presentation
needed to include simple statistics and a combination of numbers and images so that the person did not have
to make sense or interpret the meaning of the results.
More visual representation than numbers. A combination of numbers and images would be good
because Pacific are more visual.
Maybe use emojis/faces as a scale because 10 minutes is a long time for a scale.
Eight participants suggested that the language in the feedback sheet should be neutral and focus on presenting
information without judgement. Participants also suggested that there should be a focus on strengths (over
deficits) and also on ways to seek help. Two participants noted that the language should be softer even when
presenting the outcomes of standardised screens, for example, not stating that the person was a ‘moderate-risk
gambler’.
Overall, you’re a moderate-risk gambler – I don’t really like that language.
I wondered about language on report – bit more strengths based.
Four participants stated that there was a lack of questions or feedback on how gambling can harm families.
These participants believed that family is vital for improvement and that considering harm to family could
assist with change to gambling behaviours.
I wonder whether there should be a question about how gambling has affected others?
There are no questions about being married or about children and how they have been affected.
Whānau is the biggest motivator for Māori.
Co-design hui i-CBT prototype preferences
This section reflects the hui discussion on the feasibility of blended i-CBT for gambling. Small group
discussions were prompted to consider issues around the feasibility, timing, client access, and service
integration. Each of these facets of i-CBT are discussed in Table 13 along with other issues that emerged such
as client suitability and counsellor knowledge and expertise.
Table 13. Summary of Hui discussion on i-CBT
Theme
Key points
Feasibility
Broad support for i-CBT as a way of adding value to in-person treatment.
Avoid referring to it as ‘homework’ or setting work to do between
sessions. Rather refer to i-CBT as a resource that clients can use to learn
more and to continue therapeutic work between sessions.
Timing
i-CBT could be offered at the time of making an appointment for
treatment. The timing of activity completion during treatment should be
determined by counsellor and client and may be before, during or after a
counselling session. Getting started with log-in and navigation may be
supported by a counsellor in session.
33
Selection of activity
The selection of content could be made in advance based on client need or
it could be decided during a session and according to current patterns of
thinking. The process of selection can be part of treatment planning and
forming an agreement on focus and the number of treatment sessions.
Client-counsellor
interaction
Participants thought the counsellor’s role in i-CBT delivery was
predominantly oversight and administration. Oversight included checking
in on progress, providing reinforcement for completed activities and
offering general support. There was concern that a role focusing on
oversight could interfere with in-person treatment and therapeutic rapport.
To support i-CBT engagement counsellors would need to develop deep
knowledge of content through training and other counsellor resources.
Cultural
considerations
Cultural considerations were predominantly focused on the look and feel
of i-CBT and the language and examples used within activities. There was
a call for greater focus on values and the use of community.
Feasibility of i-CBT for gambling
There was broad support for i-CBT where it was seen as a welcome extra resource for both the clinician and
clients. Participants reported the perceived benefits of i-CBT as an opportunity to (1) improve client
retention, (2) reach new people, (3) keep in touch with clients, and (4) work together with clients towards the
best outcome.
Online means people don’t have to be there which will help with reach.
It’s about doing it together, walking together.
The program should be offered as part of a ‘suite’ of services. Choice. Self-determination.
It’s good to check in within the session. If it is done together, it is more likely to be completed.
Five participants suggested that materials to support i-CBT should be clear and simple. Small, business card -
sized information that can be carried within a pocket was suggested as a good option to be given to the person
who gambles. Other helpful intake materials mentioned by two participants included a standard information
pack for new clients that contained a link to the online program and step-by-step directions on how to log in.
A QR code to harm reduction websites and resources was also considered helpful. One participant mentioned
that i-CBT should be presented at intake as a part of a ‘suite’ of services and a choice, something that is self-
determined by the person who gambles.
Instructions for the process should be clear and simple.
Supporting information should be business card -sized, with information of the service on one side
and prompts to help client manage/stop on the other.
Small cards should be inconspicuous, wallet-sized.
Should be credit card size, something that could fit in pocket.
Could have a QR code that links to website or resources.
34
Multiple participants indicated that they already integrated CBT handouts and worksheets as part of routine
practice. Three participants suggested that i-CBT could facilitate contact between the person who gambles
and the clinician. One participant stated that i-CBT would be a great option if a person misses an appointment
or is unable to attend. Another stated that having activities to do in between sessions was a good way to fill
the time.
If the person can’t get to a face-to-face appointment for a week – this gives them something to look
at.
The online program would give gamblers something else to do. Time spent on the program is time
not gambling. It’s an extra resource for them to do.
The needs analysis investigated beliefs around client suitability, and this continued to emerge as an issue in
the co-design hui workshop. Two participants noted concerns that specific cohorts would miss out on the
opportunity to engage with the program. There was also discussion around specific cohorts that participants
believe were not suitable for the online work (e.g., elderly, non-English speaking, and non-tech savvy
individuals).
Not every client will be suitable for the program – elderly, English, internet.
Need to be able to investigate and then flag that client as unsuitable in the program.
One participant noted that clients should not be singled out for exclusion or made to feel shameful because
they did not engage with e-mental health tools. There are likely a myriad of reasons for not wanting to do e-
mental health. These could include a preference to talk with a counsellor rather than using online material,
issues with literacy, and other barriers.
People who don’t want to do it, it’s important not to make them feel guilty or shame. They already
have lots of guilt and shame.
Some people don’t have device to do their online homework.
The issue of suitability was not just related to individual characteristics but to cohorts of people based on
their specific situation. Five participants raised concerns that the program would need to be adapted for prison
populations or other people without internet access.
Download the activities so it can be used offline – then upload and submit it for counsellor later …
important because there are still a lot of communities without internet access.
Will we give a paper-based option for clients who don’t have internet?
Is there an option for an ‘offline’ version to be used in prisons?
There was also a discussion on the best way to introduce and talk about i-CBT for gambling with clients.
Two participants thought that i-CBT content could be referred to as homework and that having it online
would make it easier and more accessible. Discussion on the value of homework indicated concern that it
wouldn’t be done as homework, as often that is not the case. One participant suggested that whether it was
done as homework might depend on how much the person is invested in their own recovery.
Completion of homework depends on the client; some people need help with it.
If they’re serious about healing, doing homework won’t be a burden.
35
Three participants expressed concerns around referring to i-CBT for gambling as homework. They suggested
referring to the program as self-directed learning or online modules.
It’s homework but we would call it self-directed learning.
Don’t call it homework – self-directed learning or activities. Content should be referred to as online
modules or the name decided for the program.
Timing of i-CBT for gambling
Participants discussed many facets associated with the timing of i-CBT including delivery as part of the
overall treatment plan and timing during a treatment episode. Some suggested it could be offered when the
person first registered for treatment. Two participants stated taking advantage of readiness was a good idea
for helping the client continue to move forward while waiting for a face-to-face appointment. In this way,
treatment would commence right from the first contact with the service.
It would be good to set people up with a log-in and they can start doing something between making
an appointment and starting treatment.
Capitalising on momentum. Not white knuckle it.
If the person who gambles is interested in the online program, they should be informed upfront of what the
service offers. One participant suggested that because i-CBT was designed to be blended, participants should
be advised of this at the start and the expectation that they also engage with the face-to-face service.
Clinicians will have to come in early. If there is an expectation that people are seen face-to-face but
supported remotely, an extra 15 minutes should be booked to check in.
There is an expectation that the only time you do any work on your gambling is in the session. We
need to get away from the traditional structure of only seeing clients in sessions by setting check-in
appointments.
One participant noted concern that there may not be enough time in the face-to-face session to complete all
the required screening assessments as well as introduce the online program and how the activities work.
Participants were conscious that the introduction of the online program could create more work for the
clinicians with the extra screens and evaluations included in the online program.
At least a minimum of two face-to-face sessions are needed to do the screens – including the Ministry
of Health mandatory screens and comprehensive assessments. I am worried I will not have the time
to complete these requirements as well as introducing this new online program and explain how the
activities work.
Four participants noted that the timing of doing i-CBT during ongoing treatment should be flexible. Two
participants noted that it would be good if clients had a choice of when they did the work, with another
suggesting that this would help the program to be more tailored. One participant noted that people who
gamble should be able to select their preferred timing. All options of before, during, and after treatment, as
well as homework, should be available
Better if they can have a choice to do it before, after, or during.
Flexibility needed – tailoring of options is important.
36
There was, however, a suggestion that the timing should be negotiated as part of the treatment plan. This may
include discussing the optimal timing of CBT and how it is integrated into the treatment.
Has to be an individual thing but also negotiated.
Take it as an opportunity to check what works and what doesn’t.
Two participants noted that while i-CBT might help with planning the content of sessions, plans often change
suddenly due to major situations that arise. There was also a concern among these participants that if the
person who gambles does not choose to have contact (e.g., face-to-face, telephone, or chat) with the
counsellor that all the information within the activities won’t cover what is needed. Two participants raised
specific issues around the possibility that computer-based learning would supersede in-person therapeutic
exchange. As suggested by one participant, this might also involve a discussion on what will happen if and
when other things get in the way of the treatment plan.
Issue raised about while sessions are planned that plan may go out the window because of major
situation that arises in the client’s life – given this have the f2f session and then give them online
content to do after.
I don’t feel comfortable with this whole process – feels too rigid – can see how it works through
gambling but not the facilitation – concerned about how the activity doesn’t relate to what’s going on
for the client that week.
Engagement with i-CBT for gambling content could occur during an appointment. The reported benefits of
doing i-CBT during treatment are that it ensures that the work is done because it capitalises on the
momentum of having come into the treatment. One person noted that whether it is blended into the treatment
time would depend on whether it was a first session or a later one.
Optimal time for some people may be when they are motivated. It can be part of the session but
would depend on what number session it is.
Could say give it a go before and if they can’t do during the session – collect info about what works
best for the client.
Another key reason for doing i-CBT in the session is that some clients might benefit from help in setting up
or navigating the content. It may be that there is benefit in doing the first couple of activities in the session to
assist with building confidence and conveying that the tools are of value to recovery. Another participant
suggested that involving whānau may be a way of ensuring that i-CBT activities are completed. In this case
the person suggested it might be helpful to show whānau how to use the tool so that they too could provide
ongoing support.
Some people need counsellors to help them go through the tool. Nothing more exciting than saying to
a client that you might be able to get something to work for them. Do it with them.
With whānau – someone in the family might take on a role of assisting but they would have to see the
value of doing it. Some might do it before you got there… Think we need to offer it but have the
conversation. Can imagine that the whole whānau might want him to change – presenting crisis
issues with the family that we deal with.
Another option is to schedule time immediately before or after the episode of care. One participant noted that
i-CBT does not have to follow traditional counselling timing of one 50-minute session per week. This
37
participant suggested that extending the appointment by 15 minutes could facilitate the completion of
activities before or after the appointment.
We can set expectations of clients that they come early and book in 15 minutes beforehand to check
in. We need to change the expectation that the only time you do any work on your gambling is in the
session. We need to get away from the traditional structure of only seeing clients in sessions. Most
clients have no idea how face-to-face works and are guided by us.
There were issues raised on how to support a move towards blended treatment done in the service. One
participant stated that the service would need to provide appropriate technology and the means to do the
activities. Another participant suggested though that the lack of technology with some people with gambling
problems could be solved by having such technology available in the service. This option helps the person
who gambles gain some privacy while working on the activities. It was also advised that clinicians could
offer individuals access to free internet services.
Issues with doing it before the session as the services would have to provide the technology
Not everyone will have a device to complete the online program. A solution would be to have a tablet
or laptop in the clinician’s office for use or having laptops available at services.
The final timing option is to complete i-CBT between counselling sessions. This would be similar to
homework where a topic or activity is set and then completed in the person’s own time. Participants
suggested that the benefits of this approach is that it can provide a discussion point for the start of the next
session.
If doing it before the session, then it is good because the client and counsellor can discuss it in that
session.
The online content can be used to reinforce the content of the face-to-face session that was just
conducted.
People don’t have time to come in early to complete or stay after – so need to give options rather
than make it rigid about when the online work should be completed.
A lot of people say “can I do this at home, I can’t think here”, so it could be good to send them home
with a bunch of stuff to do.
Selection of i-CBT content and activities
The discussion on how to select activities was mixed and included a combination of clinician and/or client
selection. Four participants suggested that module content could be aligned with a treatment plan in that it
could be used to structure sessions. One participant suggested that it would be useful to identify in advance
the optimal combination of activities. The optimal combination could be based on assessment and the initial
client interview.
Use it to structure the sessions.
Have all the tools ready and it could give you a structure.
Suggest some activities or skills if you know the client needs it.
38
Multiple participants suggested that content is best selected during the counselling session. This timing
allows for reflection on what has come up in the session so as to address the most pressing concern. One
participant suggested a hybrid delivery plan where the counsellor could start with a structure and then swap
out activities as needed.
Swap out activities according to what comes up in the session with the client – need to focus on their
priorities.
If the session relates to the online content, then after the session would be good too.
Swap out activities according to what comes up in the session with the client – need to focus on their
priorities.
Activities should be client-driven and according to what they have brought to the session that
particular day and what is currently going on for them.
As for bringing i-CBT into the counselling session, participants suggested it would be helpful to link it to
specific conversations. For example, one participant suggested that linking the online content with the session
content could become part of the normal conversation.
You can make it part of normal conversation. If you’re talking about triggers, you can ask – I’m
thinking about gambling triggers module and wondering if you have done it…
At the end of each session, you give them a topic – would you mind doing something that’s important
for you? At home or in this session. Do at the start, then talking about it in the session, then set
recommended activities.
A third option was for the clinician and client to choose together. In this case the section would occur in the
counselling session and be based on what they both think is a good option.
Present the options to the clients and let them decide on what is going to work – also be flexible
within this, in case even what they decide isn’t working – work together in a face-to-face session if
need be.
The fourth option was for clients to independently choose whatever activities they thought were helpful. For
this, counsellor–client autonomy was more important than ensuring specific content or learning was acquired.
One participant commented that it depended on the relationship between the counsellor and client as to who
made the selection.
Direct them to choose the activities because you need to maintain client autonomy.
Engagement determined by the relationship between the client and the worker – driven by the
therapeutic relationship.
There was also a discussion on how many activities should be set each week and how much content should be
available. One participant stated that the number of activities should be aligned with client motivation.
Another suggested these should be tailored according to how quickly the client moves through the activities.
Tailor the process of completing the tool for different clients. For example, if they complete a module
in one sitting, they can do another one in another session.
Gauge motivation of client by giving them one task to do to see how motivated they are.
39
Client–counsellor interaction in i-CBT for gambling
Participants had mixed views on how much engagement they wanted with i-CBT delivery. The discussion
was around the amount of oversight a counsellor should provide and how much client information was
needed. There was also a discussion on options to create presence online as well as the usefulness of
providing positive reinforcement for completed activities.
Two participants thought it would be helpful if the counsellor could check in on i-CBT progress at the start or
end of a session. This check-in might involve the number of activities completed or that the discussed activity
was completed. One participant stated that at the end of the session they would like to tick a box to indicate
the specific activities that could be done.
At the start of every session make sure they check in with client about online content.
I want to check in with the content of the session at the start of each session too.
At the end of the session the counsellor could tick a box to send an email/text to indicate which
content needs to be done.
Two participants indicated an interest in seeing specific information related to activity completion. In these
instances, participants wanted to be able to access a summary of progress, send messages, or communicate
through the platform.
Access to a summary of what has been done This would show me how far along they are on the
journey and their level of motivation.
The counsellor and client must be linked in terms of connecting the face-to-face and online activities.
I want the clinician to see the client’s work and send quick messages. This communication needs to
be via the online platform.
Part of this discussion was on the need for clinician social presence in the platform. Two participants
suggested that being able to do things in the i-CBT platform would help to increase integration between in-
person and the online platform. There was a view that client It was also a way to let clients know that their
counsellor was interested in and supportive of their progress.
Will the online intervention let the gambler know when the counsellor has looked at it? It could help
engagement if the counsellor could give the client positive reinforcement.
Other participants also noted the importance of providing positive reinforcement and support for completion
of activities. These comments were about being able to convey support or take a cheerleading kind of role.
One participant indicated that it would be helpful to be able to provide specific feedback on activities
undertaken.
Positive reinforcement through the program is important.
Some will and some will not. Our work is like a cheerleader…
Would be good if clinicians were able to provide feedback so can support the client’s work and
encourage them to keep going.
40
If you have an idea what they’ve done, then you can give personal feedback. Not a generic answer.
I think it’s significant when you complete the set online activities. We can celebrate it through
positive reinforcement like giving a certificate.
There were some concerns about the counsellor taking the role of oversight. Three participants indicated that
if monitoring became a parent–child interaction this would likely damage the therapeutic relationship. One
participant commented that this could be mitigated if the selection and monitoring were a part of a treatment
plan and agreed to from the start.
I fear that it will impact on the relationship.
Feels like parent–child relationship. The first question when you see a client – have you done the
activity would be demeaning and treating them like a child.
I don’t want to feel guilty if they didn’t do it and they don’t want to come because they did not do it.
If you make this intention/commitment with the client at the start, there is no need to check if
activities were completed. They are adults.
Discussions on training and professional development were related to the development of knowledge and
expertise of the e-mental health tools. One participant noted that to refer to specific activities during
counselling required good knowledge of the program and its content. Similarly, being able to assist a client to
navigate the program required they themselves could use it.
Knowledge of it – counsellors need to really know it. Don’t have the fear that it’s somehow taking
their place. Doesn’t have to be consistently delivered across clinicians – and have a really good
sense of how it can contribute.
One participant discussed how to ensure that clinicians use the tools with clients. This participant suggested
that having client stories on how it helped them might work. It was suggested that the program needed to be
supported by management or through the introduction of tools to support administration of the program.
Clinicians have to be able to see the benefit. Client stories and how it’s helped them would be helpful
to convince clinicians that it works. Has to be supported by management and the funding body –
giving us all i-pads or making them available in the waiting room would help.
There were also comments that due to staff turnover there needed to be professional development resources
that could be easily accessible. These resources would need to provide information on how to use the tools as
well as background information on how and why they were developed.
Cultural considerations
Cultural considerations for the program were discussed at length among the participants of the co-design hui
workshop. Three participants noted that the online program should be easy to read and understand for clients
from every cultural background. Eight participants indicated that the program content should be based on
values specific to the culture of the person who gambles. Two participants suggested referencing specific to
Pasifika culture (e.g., words, visuals, meanings, and greetings into the online program).
Make the online program achievable and easy to read and understood by people from every culture.
Values-based practice, language based on morale, and bicultural relationship.
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The look and feel of the activities will enhance engagement for Pasifika. References to Pasifika
words, visuals, meanings, and greetings.
The language used to address cultural considerations was talked about by eight participants. These
participants noted that it would be best to keep language short and non-technical for ease of understanding for
the person who gambles. Four participants approved of the suggestion to include culturally appropriate
language to increase relevance and efficiency. Three participants emphasised that culture is more than
language, and there should be more consideration than simply adding content in a different language. It was
suggested by two participants that there could be a function on the online program where hovering over text
would offer the same text in a different language.
Keep English language simple. Short sentences and non-technical language.
Culturally appropriate language is important to make it relevant and effective. For example, values –
what are Pacific values?
Culturally appropriate information and language – could hover over words with other languages.
Remember that culture is more than language. A Eurocentric dominant culture may introduce more
racism to Pasifika culture.
Four participants suggested the use of symbols to represent themes in order to be more culturally considerate.
Three participants noted the considerations related to the person who gambles having engagement with
different cultural communities. The considerations included the environment of the person who gambles,
whom they surround themselves with (i.e., peers, family, friends), their personal identity, and the amount of
time that these individuals may have to dedicate to the online program.
Use symbols to represent the themes.
Consider context of living for client: environment, their peers, personal identity, literacy, and time.
Post-workshop evaluation
Results from the post co-design hui evaluation (Table 14) indicated that all participants agreed or strongly
agreed that the presenters were knowledgeable and informative, and that they understood the e-mental health
program better after participating in the hui. No participants answered strongly disagree or disagree to any of
the questions on satisfaction with the workshop. Furthermore, they also agreed or strongly agreed that they
had the opportunity to express their opinion, that working with other service providers and collaborators was
valuable, and that the workshop had been an important part of developing the e-mental health program.
Involvement in the hui ensure that stakeholder were able to provide relevant input to ensure content and
modality of the e-mental health development was tailored to their clinical and organisational needs. Further,
stakeholder’s direct involvement facilitates engagement which will support future uptake when e-mental
health components are implemented.
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Table 14. Co-design hui evaluation (n = 29)
Question
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
My invitation and attendance to this hui was
appropriate or important?
0
0
0
6
23
The hui was well organised
0
0
0
6
23
The presenters were knowledgeable and
informative
0
0
0
1
28
I am satisfied with the information I received
about the new e-mental health program and
how it will work in my service
0
0
1
14
14
The opportunity to work with other service
providers and collaborators was valuable
0
0
0
7
22
I had an opportunity to express my opinion
0
0
0
5
24
I understand the e-mental health program
better after having participated in the hui
0
0
0
10
19
Participating in the hui has been an important
part of developing this e-mental health
program
0
0
0
8
21
All participants provided some feedback on the strengths and outstanding questions following the co-design
hui. Four participants referred to the usefulness of a blended approach. They believed that the proposed
model would help open up opportunities for client engagement and provide more flexibility for meeting client
needs.
A way of consolidating tools and better support client by offering in a different format. An adjunct to
clinical experience.
Blended treatment – additional online tool to support both client and clinician.
Flexible and tailored to client’s needs. Help counsellors by doing screens for them.
The flexibility of how/when to use it and the activities.
I am really excited about being involved in this project and believe the benefit to gamblers will be
significant.
Great workshop. Will be very helpful for gamblers and the future of counselling.
Two participants referred to the usefulness of internet delivery for increasing access. One stated that being
able to engage with help anytime and anywhere was a great outcome.
That it has the ability to be done at any time/anywhere and that there is a chance to continually
educate yourself.
The ability to provide support online.
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Two participants referred to the helpfulness of having a self-assessment that could be undertaken by anyone
and at any time.
Self-assessment to initiate the process.
Opportunity for people to do an assessment online prior to counselling.
Self-assessment for public.
There were multiple comments related to the connection between research and practice. Participants noted
that the tools appeared grounded in research. Participants appreciated the underlying theory and how the tools
should encourage help-seeking, skills, autonomy, and engagement.
Researched well. All the knowledge was backed up with research.
Tangata self-determination.
The universities’ approach to designing this. Awesome to actually be involved and flown up.
The flexibility to support people in the way they want and need. The intentions are clear, and I agree
with them.
There were eight comments specifically on the co-design hui process. The main theme that emerged in these
comments was the collaboration between service providers, consumers, and researchers. For these
participants, there was appreciation of the willingness of the group to share, as well as the willingness of
academic facilitators to share information and listen to feedback.
Openness in sharing ideas (all) and facilitators’ willingness to consider all ideas presented. Time to
work collaboratively and reflect individual thoughts etc. VALUED!!
Collaborative approach. Culturally sensitive.
Collaboration between service providers and researchers. The level of input we are having in the
process and development.
The opportunity to openly speak about my experiences with clients.
Inclusivity of professional roles, including those with experiences.
Collaboration and being part of this.
Great to work with others in the field to work on ideas to help support our people.
Awesome being able to produce feedback at this stage. Great opportunity for collaboration with all
services in the sector – PGF and Oasis.
One participant noted the idea of note-takers was a good one in that it captured the discussions in real time.
Another noted that the invitees were important in that it included both consumers and clinicians.
The hui was interesting and well presented. I didn’t get bored, which was pretty well a first. The idea
of note-takers was a great one, capturing the essence of participants and ideas.
44
Essential to include clinicians and consumers, vital.
The open questions that participants were still wondering about included a focus on culture, look, feel, and
implementation of the e-mental health service.
How will Pacific and Asian clients be engaged in the tool? How would culture be relevant?
I guess how they will look at the end. Cultural aspects will be included.
How the overall program will look like once it’s online.
Look and feel of doing it online.
Five participants wanted more emphasis on family or whānau involvement. These participants stated that the
gambler version was a great start and now it would be helpful to move on to a family-focused version.
Need for family and affected others – further support to be included.
An excellent process to provide the best services for tangata – collaboration with other services. This
would be good/excellent for significant other.
When a family-affected version can be launched.
Finally, there was an expression of future expectations around the outcomes from the co-design hui. These
indicated some change in perceptions about e-mental health before and after the workshop. There was also
strong appreciation for the project team covering the costs of flights for the co-design hui. This meant people
from the South Island were able to be represented without concern for transport costs.
I arrived cautiously hopeful. I am leaving optimistic and excited.
Thank you – a wonderful idea. I hope it rolls out soon – excellent!!
Thanks for this co-production opportunity – it will make the product stronger.
Thank you for taking our knowledge and experience into account and for flying us all in.
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5. PHASE III: Prototype development and pilot testing
Prototype development focused on the screener and i-CBT content and functionality. Pilot testing occurred
over a six-month period between August 2020 and March 2021. Testing and feedback was iterative, with a
continuous loop involving service managers, team leaders, Māori health advisors, consumers, academics, and
counsellors. This comprehensive, albeit lengthy, process of co-design meant the prototypes reflected the
preferences of the two services as well as the best available evidence. This is a key benefit of a co-design
approach which supports user engagement and uptake.
Screener customisation
The findings of Phase I and II informed the development of the screener items inclusive of the measure
selection and their presentation. The project started with brief measures with good psychometric properties
albeit with language modifications, as per below. Table 15 presents service customisation needs for the
assessment items and how these needs have been addressed in the prototype development (i.e., customisation
outcome).
Table 15. Summary of assessment customisation
Customisation need
Customisation outcome
The screener should take
between 5-10 minutes to
complete.
The selection of measures was informed by a combination of
operational need and brevity. For these reasons, measures were
selected based on being short and able to gather meaningful clinical
information. The project started with brief measures with good
psychometric properties albeit with language modifications, as per
below.
Screener questions should be
meaningful to people with
gambling problems.
Screener questions went beyond gambling behaviour and severity and
included questions known to be of interest to help seekers. These
questions included motivations to gamble, readiness to change, self-
confidence to change and perceived self-control.
Gamblers should be able to
access the screener
anonymously.
The screener was set up so that people could complete it
anonymously but are prompted at the end to save their results or
discuss these with a counsellor. People who selected this “Save and
Discuss” options did not remain anonymous because of the need to
register as clients and consent to terms and conditions.
Gambling questions need to be
briefer.
The full list of gambling options as outlined in the New Zealand
National Gambling Study were originally included in the screener.
This extensive and detailed list could not be completed in under 5
minutes and, as such, the list was merged into six different categories
that are frequently employed in research. For example, items such as
lottery, bingo, housie and keno were merged into one group.
More detailed demographics
needed on culture to ensure a
Demographic questions were expanded to capture the full range of
Pacific countries. Demographic items related to employment and
living arrangements were dropped so as to reduce completion time.
46
culturally appropriate
response.
Measures and individual
questions should replicate
routine data collection.
Ministry of Health recommended routine data collection was
obtained and items removed or added so that there was 100% overlap
between MOH needs and the screener items. Some item wording was
therefore changed to be consistent with MOH recommendations.
PG-YBOCS is a good
inclusion but extensive
improvements needed so that it
was in plain language.
Every PG-YBOCS question was modified to present it in plain
language and remove wordiness of examples. Response options were
also changed to improve readability and reduce ambiguity of
responses.
Concern that asking about
gambling expenditure would
be stigmatising.
Questions on expenditure were only asked where the person stated
that they had used the gambling type in the past 12 months. The
instructions for this section were framed in terms of time and money
spent on gambling.
Psychological distress should
be about gambling.
This item was changed from general distress to distress associated
with gambling in the past week.
Readiness rulers were difficult
to complete with the sliding
scale.
A 10-point scale is the usual way of assessing readiness to change but
this did not work well as a drop down list. As such, the response
options were reduced to a five point scale.
Gambling motives scale could
be completed without moving
the slider.
To make sense of the data, we decided all questions need to be
completed. At this time, the website developers were not able to force
a response with a sliding scale. To address the issue, we changed the
response options to a five point scale that were selected using a drop
down list.
A strong preference to focus
on personal strengths.
A search of the positive psychology literature was conducted to
determine tools that could identify personal strengths or values. The
selected tool was adapted so that it was presented in plain language.
Interest in help seeking was
presented as a sliding scale but
did not require completion.
As for the gambling motives scale, the 10-point slider was replaced
with a 5-item drop down list to determine interest in help-seeking.
Screener questions should
prompt a desire to talk to
someone.
At the end of the gambling behaviour questions, we added a question
on whether the person perceives their gambling to be more, less, or
about the same as that of most New Zealanders. This question
provided a key normative comparison related to gambling behaviours
that was designed to prompt action on gambling behaviours.
6.8.1. Prototype assessment items
The welcome page of the screener provides information on the purpose of the screener, how long it will take
to complete, and what to expect at the end. This information was necessary to ensure informed consent by
people completing the screener. On the left side of the screener, there is a progress bar that allows people to
47
easily see their progress through the screener. This visual aid is important for a more streamlined user
experience and greater sense of autonomy.
Demographics: We collected information on demographic characteristics such as age, gender, ethnicity,
income, and location of the person (New Zealand regions).
Gambling consumption: After the welcome page, people were asked about the time and money they spend
on gambling for six groups of gambling products. The products included (i) Lottery ticket, scratchies, bingo,
or housie (ii) Private games (e.g., cards at home) (iii) Horse or greyhound races (iv) Sporting events (v)
Casino table games (e.g., poker, roulette) (vi) EGM (aka pokies).
For each gambling product, people could indicate: (1) yes, done in the past 12 months, (2) no, not done in the
past 12 months, (3) don’t know/refused to answer. If a person responded that they had used a product in the
past 12 months, they were asked additional questions (Table 16) measuring gambling frequency, typical
monthly consumption, and actual past 30 days’ frequency and consumption (on that gambling product).
Table 16. Gambling product consumption in the past 12 months
The screener question
Response options
About how often do you spend money on
[gambling product]
At least weekly
At least monthly
At least every six months
At least once in the past year
When you play [gambling product], how much
do you usually spend in a typical month?
Open text box ($NZD)
In the last 30 days, on how many days did you
play [gambling product]?
Open text box (number of days)
In the last 30 days, approximately how much
money did you spend playing [gambling
product]?
Open text box ($NZD)
At the end of the consumption questions, people were also asked to say how they perceived their gambling,
that is, whether they thought it was more, the same, or less than that of other New Zealanders. The purpose of
this question was to create a cognitive dissonance between other people’s perceived consumption and the
person’s consumption later in the report.
Gambling severity: The level of gambling severity was measured using Problem Gambling Severity Index
(PGSI). The PGSI is a 9-item tool with answers scored on a 4-item Likert scale (0 = never, 1 = sometimes, 2
= most of the time, 3 = almost always). The PGSI allows for scores to be classified into four categories: non-
problem gambling (score 0), low-risk gambling (score 1–2), moderate-risk gambling (score 3-7), and problem
gambling (score ≥ 8) (106).
Gambling symptoms: Gambling symptoms was measured on the sub-scale Gambling Thoughts / Urges of
the adapted Yale-Brown Obsessive-Compulsive Scale (PG-YBOCS) using a 5-point Likert scale (107). The
measure was adapted to reflect the New Zealand context and the needs of the collaborating gambling services
48
(Table 17). Unlike the PGSI, which measures gambling severity over past 12 months, the PG-YBOCS takes
an in-the-moment snapshot which allows people to monitor progress over time if they choose to repeat the
screener.
Table 17. Gambling symptoms measure adapted from PG-YBOCS
PG-YBOCS item
The screener question
Response options
1. Time occupied
by gambling
How much time do you spend
on gambling-related activities
(include any actions before,
during, or after gambling).
• No time on gambling
• Less than 1 hour per day
• Between 1 and 3 hours per day
• Between 3 and 8 hours per day
• More than 8 hours per day
2. Interference
due to gambling
How much does gambling get in
the way of work, study, or your
social life?
• Gambling doesn’t get in the way at all
• Gambling gets in the way a little
• Gambling somewhat gets in the way
• Extreme interference in my social or
work life
• Gambling completely gets in the way
3. Distress
associated with
gambling
How irritated do you become if
you can’t gamble when you
want to?
• Not at all irritated
• Slightly irritated
• Moderately irritated
• Very irritated
• Extremely irritated
4. Resistance of
gambling urge
How often do you put effort into
resisting unwanted gambling?
• Always resist unwanted gambling
• Almost always resist unwanted
gambling
• Occasionally resist unwanted gambling
• Rarely resist unwanted gambling
• Never resist unwanted gambling
5. Degree of
control over
gambling
How much control do you have
over your gambling?
• Complete control over your gambling
• Some control over your gambling
• A little control over your gambling
• Almost no control over your gambling
• No control over your gambling
Psychological distress: Distress was measured with the question How distressed have you been about your
gambling in the last week? The answer options included five items on a Likert scale (not distressed = 1,
slightly distressed = 2, somewhat distressed = 3, moderately distressed = 4, totally distressed = 5). This
question is particularly useful for those who elect to measure their gambling related distress over time.
Levels of importance, readiness, and confidence: Readiness to change gambling was measured by three
items reflecting importance, readiness, and confidence (108). The purpose of taking this measure was not
only to identify a person’s scores on these facets, but to trigger a motivational process and ‘change talk’
aligned with motivational interviewing techniques. The original scale uses a readiness ruler (i.e., a sliding
49
scale which can be changed to indicate any score between 0-10). However, to reduce user burden, the answer
options for the items were adapted to a 5-item Likert scale (Table 18).
Table 18. Levels of importance, readiness, and confidence
Item
The screener question
Response options
Importance
How important is it for you that you
limit/stop your gambling?
• Not important to very
important
Readiness
Where does limiting/stopping gambling fit
on your list of priorities?
• Lowest priority to highest
priority
Confidence
How confident are you that you could resist
an urge to gamble?
• Not confident to totally
confident
Gambling motives: Gambling motives were measured across four groups: social, financial, enhancement,
and coping. These were measured on an 11-point scale (0 = never, 10 = almost always) (109). The exact
questions are presented in Table 19.
Table 19. Gambling motives measurement
Item
The screener question
Financial
How often do you take part in gambling activities to win money, because you
enjoy thinking about what you would do if you won a jackpot, or because
winning would change your lifestyle?
Enhancement
How often do you take part in gambling activities because you like the feeling,
to get a high feeling, or because it makes you feel good?
Coping
How often do you take part in gambling activities to forget your worries,
because you feel more self-confident, or because it helps when you are feeling
nervous or depressed?
Social
How often do you take part in gambling activities because it’s what most of your
friends do when you get together, to be sociable, or because it makes a social
gathering more enjoyable?
Personal strengths: People were asked to select two strengths out of a list of 52 that they identified with the
most. The purpose of asking a person’s strengths was to shift the person towards change talk where they
could identify positive characteristics that could help take control over gambling. The list of 52 strengths was
based on the Action Inventory of Strengths: cognitive, emotional, interpersonal, civic, temperance, and
transcendence (110). All 52 strengths were grouped into these six categories for ease of data interpretation
(see Table 20).
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Table 20. Strength categories containing 52 different strengths
Category
Strengths
Interpersonal
Caring, compassionate, charming, empathetic, considerate, friendly,
generous, kind, outgoing, patient, tactful, tolerant, warm.
Emotional
Adventurous, ambitious, athletic, brave, confident, determined, energetic,
enthusiastic, honest, idealistic, independent, optimistic, persistent.
Cognitive
Clever, creative, curious, flexible, knowledgeable, intelligent, logical, open-
minded, persuasive.
Civic
Fair, dedicated, orderly, organised, practical, respectful, responsible.
Temperance
Authentic, forgiving, disciplined, humble, observant, perseverant.
Transcendence
Appreciative, hopeful, humorous, spiritual.
Help-seeking: Information on past help-seeking was collected by asking: Have you ever sought help for your
gambling? This includes online options as well as face-to-face and phone services. Information on current
help-seeking was asked by How interested are you in talking over your results with a professional? with
answer options given on a 5-point Likert scale (1 = not at all interested to 5 = very interested). These
questions were included to understand previous experiences around help-seeking and current interest in
talking to someone. The answer to the second question about current help-seeking did not trigger referral, but
was intended to strengthen intention to self-refer at the end of the screener.
6.8.2. Prototype report needs
The findings of Phases I-II, as well as the screener customisation, informed the development of the screener
report, inclusive of its look and feel and content. Table 21 presents service customisation needs for the
screener report and how these needs have been addressed in the prototype development. In addition to these
customisations, we included a fidelity check for each of the three pages which asked participants to comment
on their results, as well as to make an informed choice to continue to the next set of results.
Table 21. Screener customisation needs and outcomes
Customisation need
Customisation outcome
Screener report should be
interesting to people with
gambling problems.
Report was presented in sets of results across three pages, with an
opportunity for people to comment on each set of results. Pages focused on
gambling behaviour, motives & strengths, readiness & help-seeking
Screener report should not
increase shame or stigma.
The screener and report used a motivational interviewing style that sought
to increase change talk and reduce ambivalence towards gambling
behaviours. Throughout, the language was supportive and approachable to
present the information without judgement. This approach is consistent with
motivational enhancement therapy that integrates screening and feedback
with motivational interviewing.
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Screener report should be
easy to review.
Gambling frequency and expenditure were presented in graphical form.
Normative comparisons were also graphical. Extensive algorithms were
developed based on data obtained from the National Gambling Study.
Report should highlight
strengths and how this
knowledge is important.
The two strengths identified by participants were presented in the report and
highlighted in a different colour and font to ensure they stood out.
Information was presented on how people can use the personal strengths
they selected to address gambling problems.
People using the screen
were likely on a mobile
phone.
Extensive design changes to the report so that it was easily viewed on a
mobile phone.
Te Reo Māori should be
used in the assessment and
screener report.
All assessment and screener content was reviewed and prepared in Te Reo
by the bi-cultural advisor Te Rukutia Tongaawhikau from PGF Group.
Help seeking should be
normalised
The screener was adjusted to provide information on rates of help-seeking
and different levels of help.
6.8.3. Prototype report content
On completion of the screener, participants were immediately presented with a report. The report summarised
the person’s responses to measures and, where applicable, presented it in comparison to corresponding
measures for average New Zealanders or normative values (Table 22). The report presented a summary of the
most important findings. The summary highlighted harm that gambling might be causing and provided a
focus on action towards behaviour change and help-seeking. The report provided an opportunity for a person
to engage in self-reflection by providing a prompt to write thoughts on their gambling consumption. Other
similar self-reflection activities were prompted.
As the next step, at the bottom of the summary, people had an opportunity to self-refer to the gambling
services. Access options into the services included phone, email, or booking an in-person appointment. The
novelty of these access options was that the person was not expected to make the first contact themselves, but
could just provide contact information for the gambling services to contact them first. This inclusion did not
remove an option for the person to get in touch with the services directly as part of the normal self-referral
process. Participants were also able to save a PDF of the report for their future reference.
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Table 22. Screenshots of the screener report
Feedback on
consumption
(partial view)
Feedback on
frequency
(partial view)
Feedback on
strengths
(partial view)
53
The screener
report
interactive
self-reflection
on gambling
consumption
(partial view)
The screener
report
summary
(partial view)
54
Self-referral
section at the
end of the
report
6.8.4. Screener and service integration
A key anticipated outcome of the screener and report was increased engagement with experts from treatment
services. Multiple elements were included to prompt service engagement including outbound contact from
the service (as opposed to inbound only). The provision of normative feedback theoretically creates cognitive
dissonance which the person could start to resolve by talking to someone. We also added accessible and easy
to use referral pathways, including phone and email. Lastly, we sought to strengthen intention to talk to
someone by adding in a question on desire to talk to someone before asking if the person wanted to talk.
Table 23 shows the pathways customisation needs and outcomes.
Table 23. Pathways customisation needs and outcomes
Customisation need
Customisation outcome
Link people to in-person, phone
and email support.
The end of the report included the option of discussing results
with a counsellor by phone, in-person or email. Chat and
messaging were flagged for future development.
55
Encourage help seeking by those
with less severe problems.
The report prompted action to discuss results rather than help-
seeking. The intention was to encourage a conversation
especially by those who were not sure if counselling would be
for them.
Requests for support should be
responded to by a counsellor.
Protocols were established whereby the counsellor on duty at
each service was alerted of the request for support.
The screener should not be a
barrier to treatment access.
Screener access was provided from each service provider’s
website and completion was not a requirement for new clients.
A protocol was developed for the first response to clients requesting help via the screening tool. As indicated
below (See Figure 7), duty counsellors received an alert that a person had requested assistance through the
screener. Duty counsellors then logged in to the counsellor dashboard and reviewed the request. The duty
counsellor responded in the mode requested by the person, whether that be email, phone, or an in-person
appointment.
Key points of the screening tool
The screener on our website collects gambling-related information and provides participants with an
immediate written and graphical report that reflects current gambling behaviours. The report
delivers personalised normative feedback (comparisons of behaviour against other gamblers in NZ)
as well as identifies strengths and desire for change. The screener offers a stepped approach to
talking with someone with email, phone, or in-person support available through the screener.
Participants can also save their screening results for later viewing. Any person who completes the
screener can request a discussion on their results.
Duty counsellor response
When a person completes a screen and requests support, an email is triggered to the intake email
address. It has a link to information on the nature of the request. Alternatively, it can be accessed by
logging in to the counsellor dashboard.
How to respond to people requesting support:
• Go to the website and log in to dashboard.
• Click on screener results. This opens up a list of people who have taken the screening tool.
• If the field contact method is populated by one of the response options (email, phone, or in-
person), it means the person has requested contact.
• To view the details of the request, click on the last column view to open the screening results.
This will indicate time or day preferences with contacting the person.
• We have deliberately left the purpose of the open text field undefined so that the Duty
Counsellor can decide the best way to use it. In time, we can determine common uses and
update as required.
Figure 7. Protocol for service response to the screener
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i-CBT customisation and prototype
The i-CBT for gambling prototype was developed specifically for services to use as part of a blended
treatment approach. The findings of Phase I and II informed the development of the prototype content,
structure and functionality. The following tables presents service customisation needs for i-CBT and how
these needs have been addressed in the prototype development.
6.9.1. i-CBT content preferences
Content preferences were identified in Phase I and Phase II of this project. Customisation outcomes were
focused on rendering the content presentation appropriate for blended treatment where the number of sessions
and requirements might vary from client to client (Table 24). We reorganised the content into three levels
inclusive of the three motivational pathways, each of which comprised a series of topics with activities from
which clients could select. This approach was in line with feedback from clients and counsellors in their
preference to select the appropriate number of activities for each client’s current needs and preferences. We
also undertook extensive content redevelopment in terms of ensuring plain language and cultural
appropriateness for Aotearoa New Zealand, while maintaining the clinical integrity of the intervention.
Table 24. i-CBT content needs and customisation
Customisation need
Customisation outcome
The assigned activities should be
delivered in around 30 minutes
but some thought it should be
longer.
As part of development, additional levels of content were introduced,
rendering the timing of activities briefer. Each topic contained 3-6
activities of approximately 10 minutes in duration each. This
arrangement meant clients and counsellors could prescribe weekly i-
CBT work from as little as 10 minutes and up to 30 minutes or more.
No agreement on the number of
modules which would group
content into weekly assignments.
Traditionally, i-CBT modules have attempted to mirror counselling
interactions of one hour a week for about 6 weeks. Given the i-CBT
was intended to be blended with face-to-face treatment options (not as
a replacement), this approach did not appear appropriate. Moreover, in-
person treatment could be as brief as one or two sessions or as long as
a year or more. Changing modules to topics meant counsellors and
clients could select as many or as few topics (and activities) as was
needed or relevant, thus allowed for a tailored approach for each client.
Do not call them modules or
lessons.
Modules and lessons was a way of initially organising the content prior
to the co-design process. The term module was replaced with the term
topic, which reflected different categories of content in each of the
three pathways. The term lesson was replaced with the term activity
which reflects the change in tone from i-CBT being instructional and
instead being information that can prompt discussion with a counsellor.
Ensure appropriate cultural
representation in words and
images.
Because the original content was sourced from Australia, we engaged
in an extensive process of translation of terms for Aotearoa New
Zealand.
Content should be in plain
language.
All content was reviewed by members of the Steering Committee for
its presentation in plain language. Extensive changes were made to
content phrasing to make it applicable and relevant in the New Zealand
context. We also simplified terms that were used in CBT programs to
57
ensure that these could be understood by people at a Year 9 reading
level.
Content should include a focus on
values.
Content was adapted to include a focus on values and strengths as well
as prompts to consider personal and community identity. The content
was adapted to incorporate a range of third-wave cognitive behavioural
techniques so that there was a variety of activities with different
theoretical frameworks that would provide a variety of client interests,
as well as enhance or supplement orientations and values employed by
counsellors.
6.9.2. i-CBT functionality preferences
Functionality and service model preferences were identified in Phase I and Phase II of this study.
Customisation outcomes were focused on flexible delivery and blending with in-person treatment (Table 25).
Key to this approach was to facilitate co-creation of treatment plans between clients and their counsellors;
that is, to limit advice or client/counsellor direction for how or when activities are completed and instead
prompt client/counsellor negotiation during treatment planning.
Table 25. i-CBT functionality needs and customisation
Customisation need
Customisation outcome
No agreement on the preferred
service delivery model for
blended i-CBT.
The i-CBT prototype was set up to support partial or full blending by
changing the structure to topics and activities that could be selected
according to need. Counsellors choosing a fully blended approach can
allocate topics during treatment planning. Counsellors choosing a partial
approach can introduce clients to i-CBT and then recommend specific
activities as treatment proceeds.
Viewed as an extra resource
for in-person work not as a
standalone.
i-CBT was established as a resource within a suite of options that could be
incorporated within usual psychological treatment. It is not intended to
account for the wide range of approaches that might be needed to reduce
gambling harm (e.g., group support, pharmacotherapy). Instead, it is
intended to support one aspect of treatment that focuses on changing
thoughts and behaviour within a broad CBT therapeutic approach.
i-CBT needs to be flexible to
account for real world
problems that arise in the
clients life.
We know through various studies of counsellor-client interactions that
CBT is often missed because of acute presenting issues or lack of
counsellor confidence to apply the various techniques. The i-CBT
prototype structure allows for client or counsellor selection of activities
that can occur outside of the office hour. It can be employed as
“homework” activities to support the generalisation of client skills outside
the office.
Work through at own pace so
that it does not deter people
from coming to sessions.
It was important to counsellors that clients were not dissuaded from
attending in-person treatment if they did not complete assigned activities.
For this reason, i-CBT allowed clients to make their own decisions on
what to share with the counsellor through the optional ‘request feedback’
button in the client personal profile page. This feature means that clients
can control their own progress but that it is easy to involve the counsellor
at any time.
58
Some wanted activities done at
home and others wanted them
done at the service where there
internet/technology was
available.
i-CBT information prompts client and counsellors to negotiate the optimal
timing for engagement. This approach supports treatment planning and
establishing expectations of what, when and how i-CBT will be used on
an individual client basis.
Preference to have some
integration between in-person
care and i-CBT.
To meet the need for integration, we established a communication loop
that could easily be initiated by clients. The communication loop supports
clients to write a note to their counsellor on their thoughts, experiences or
questions on specific activities. The system will then prompt the
counsellor to respond.
There was a preference for
counsellors and clients to
control the selection of
content.
The content is organized by motivation and topic so that counsellors and
clients can control what and how much content is selected.
Needs to be a balance between
offering accountability and
motivation versus checking up
on the client.
The nature of the response is up to the counsellor-client agreement and the
degree to which the response is about provide support and encouragement,
advice and education or treatment. The timing of the response is also
determined through negotiation between counsellor and client.
Counsellors prefer to do more
than solely provide guidance
and support to i-CBT.
Our previous studies indicate counsellors are dissatisfied with providing
guidance only to i-CBT programs. As part of the blended model,
counsellors can select activities that supports or supplements their work
with clients and then continue that work by responding to client discussion
points in the i-CBT prototype.
People do not do homework
now and this may not be
different
The option to request discussion or feedback on activities creates the
impression that the counsellor is always there. We expect that this social
presence can help people engage with as little as 10 minutes a week that
extends or supplements in-person treatment.
6.9.3. i-CBT other considerations
Other considerations and preferences were identified in Phase I and Phase II of this study. Customisation
outcomes was focused on how the i-CBT could be delivered as soon as the person contacted the service
(Table 26). To capitalise on momentum of clients, some content could be offered to clients immediately on
contact with the service and before the first appointment. However, the i-CBT functionality means it cannot
be delivered as self-help because facilitating interaction with a counsellor is embedded in the prototype.
Ongoing professional development, especially for new staff, was identified as an important issue by
clinicians. The customisation outcome to address this identified need was the development of self-paced
learning that could be accessed as and when needed.
Table 26. i-CBT other consideration customisation
Customisation need
Customisation outcome
Should be accessible while
waiting for the first
appointment.
A sub-selection of content could be made available to any clients from
their first contact with the service because the topics and activities are
relevant to all gamblers. We added new content to the prototype of setting
a personal vision and goal to prompt clients to consider these aspects of
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recovery prior to the first appointment. We also set up the i-CBT program
so that every client needed to be allocated a counsellor in order to
complete the program activities. It was intended that this allocation would
be a way to commence counselling engagement and help to reduce fear
and worry about the first appointment.
Should contain client stories
and real world experiences.
Two features were included in the website to reflect real world
experiences. The first feature was the inclusion of consumer quotes
intended to provide motivation and enhance engagement with the content.
The second feature was ‘pay it forward’ that provided a space for clients
to record inspiration and advice to other people using i-CBT.
Content should be available on
any device.
i-CBT was developed to be accessible on any internet enabled device. i-
CBT automatically resizes so that clients are able to complete activities on
their mobile phone, tablet or personal computer and all functionality and
aesthetics are consistent across devices.
Self-paced training should be
provided which covers e-
mental health work.
Self-paced training was developed so that it was delivered in brief 10-20
minute sessions and included practical and in-the-moment activities to
support learning. We selected Slack message board as a way of delivering
content and allowing for comments and discussion.
6.9.4. Prototype i-CBT and website
The i-CBT prototype was developed based on each identified need and customisation outcome. The prototype
was referred to as Pathways which represent three core motivations for gambling. The content of the i-CBT
prototype was grounded in content from GAMBLINGLESS which is an e-mental health program developed by
Deakin University (Prof. Nicki Dowling, Dr. Simone Rodda and Dr. Stephanie Merkouris). GAMBLINGLESS
is a suite of i-CBT programs that have been previously tested as standalone websites and smartphone apps in
Australia and New Zealand.
The i-CBT prototype contains three distinct pathways which contained multiple activities (see Figure 8). The
grouping of activities was intended to aid clients and counsellors in their selection of content. Each pathway
contains up to 23 different activities that could be completed multiple times. The website also contains
videos, information, and activities to increase user engagement and that could be readily used by clinicians as
part of their tailored treatment plans with clients.
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Figure 8 Motivational pathways for i-CBT Protocol
Pathway 1: (Un)learn to gamble
Pathway 1: (Un)learn to gamble is the core gambling content that employs traditional cognitive and
behavioural activities focusing on regaining behavioural control over gambling. This pathway employs
counterconditioning, increasing self-efficacy, and relapse prevention. It includes information on self-
exclusion, money management, and resisting social pressure to gamble.
As indicated in Table 27, each of the five topics has a range of activities aimed to create various client
experiences. The Social pressure topic aims to develop skills to withstand peer pressure to gamble, resolve
conflicts, and be a good communicator. Activities in the Funny thinking topic target distorted cognitions and
gambling biases. Self-efficacy activities aim to increase self-belief in the ability to control gambling.
Activities in Finances focus on money-related matters and provide practical advice on how to reorganise
finances to reduce gambling harm. Relapse prevention activities aim to identify high-risk situations and
building skills around goal-consistent responses to prevent unwanted gambling.
61
Table 27. Summary of (un)learn to gamble core topics and activities
Topic
Activity
Client experience
Social
pressure
The "no" word
How to say "no" when it’s in your best interests even if
it can disappoint others
Getting ready to say "no"
Ready-made solutions for when you’re under social
pressure to gamble
Safe and risky contacts
Surround yourself with people supportive of your
decision to gamble less
Conflict management style
What’s your typical response to conflict? The style
makes the difference
Conflict resolution
Conflict resolution can make sticking to gambling
behaviour change easier
Assertive skills
Assertive communication is one helpful way to resolve
or manage conflict
Funny
thinking
Debate captain
Debate common misconceptions about gambling
Gambler’s fallacy
Winning at gambling is completely random, break the
gambler's fallacy
Chasing
Chasing can cause problems, regardless of whether
you win or lose
Illusion of control
Thoughts that gambling is ruled by a reasoned action
are an illusion
Self-
efficacy
Confidence to gamble less
Importance, confidence and readiness are the key to
lasting change
SMART goals
Set your goals based on your values to ensure that
these goals are easier to achieve
Existing skills and strategies
Skills and strategies that you already have can be used
again
Inspiration
Seeing other people succeeding can boost self-belief
Finances
Gambling spending check
A good way to motivate yourself to gamble less is to
honestly work out how much you have spent
Budget
Budgeting can help you to see realistically how much
disposable income is left for gambling
Financial goals
Setting financial goals can help to refocus life as to
what it can be without gambling
Financial control
Temporarily restricting your own control over finances
and limiting your access to money to reduce gambling
Relapse
prevention
High-risk situations
Unwanted gambling can be triggered by high-risk
situations
Seemingly irrelevant
decisions
Everyday mini decisions may be setting you up to fail
by tempting you to gamble
Testing control
Testing control over gambling generally results in
more gambling
Abstinence Violation Effect
Relapse can happen after a small slip up if person feels
like they've failed
Low-risk gambling
If you decide to gamble, you can choose low-risk
gambling to avoid harm
Self-exclusion
Create a barrier to gambling and give yourself a break
62
Pathway 2: Escape motives
Pathway 2: The Escape motives pathway contains content that addresses a pattern of escape into gambling
because of pre-existing emotional vulnerability. The pathway focuses on emotional awareness and reducing
emotional vulnerability. It uses traditional cognitive and behavioural strategies, as well as third-wave
cognitive-behavioural principles (e.g., Acceptance and Commitment Therapy, Dialectical Behaviour
Therapy) to deliver activities around acceptance of what has happened and becoming more aware of how
thoughts can influence gambling decisions and emotions.
As indicated in Table 28, each of the four topics has a range of different activities. The Emotional awareness
topic is focused on understanding thoughts, emotions, and behaviours. Reducing emotional vulnerability
presents techniques that can help to gain better control over emotions. Activities in the Acceptance topic
include steps to accept the self, and being compassionate to and mindful of the self. The Flexible thinking
topic provides a set of skills on how to change thought processes and reach one’s goals.
Table 28. Summary of Escape Motives topics and activities
Topic
Activity
Client experience
Emotional
awareness
Gambling to escape
Weigh up the emotional pros and cons of gambling to escape
The wheel of
emotion
To learn how to cope with emotions is to learn how to identify
them
Thoughts,
emotions, &
behaviour
Knowing how everything interacts can help you understand
your behaviour
The function of
feelings
The purpose of emotions is to communicate info about a
situation
Reducing
emotional
vulnerability
The yellow
elephant
There are better ways to deal with difficult thoughts and
feelings than trying to push it out of your mind
Grounding
Press the pause button on persistent swirling thoughts and get
your mind into the present
The costs of
avoidance
Avoiding thoughts, memories, or other experiences may create
harm in the long run
Enjoyable activities
Staying busy can be used as motivation, or as a distraction and
may help improve self-confidence
Self-care
Take time to regularly do something enjoyable that can fill
your time with happiness
Acceptance
Passengers on a bus
Free your mind and allow room for growth and accept what
cannot be changed
Mindfulness of
emotions
Give space to the sensation to fully understand and accept it
Mindfulness of
thoughts
Distance yourself from the thought to understand and accept it
Self-compassion
Treat yourself with kindness and understanding, open up
towards positive change
Flexible
thinking
The helicopter view
Taking a different perspective helps us to reduce distressing
emotions
Fact or opinion
Emotions influence thoughts and can be misleading if not
based on evidence
Diffusing difficult
thoughts
Understand what a thought is, and allow them to pass without
reaction
63
Pathway 3: Action motives
Pathway 3: Action motives pathway contains content that addresses a pattern of action gambling and
impulsivity. This pathway applies traditional cognitive and behavioural strategies, as well as third-wave
cognitive-behavioural techniques (e.g., Acceptance and Commitment Therapy, Dialectical Behaviour
Therapy) that teach mindfulness and distress tolerance skills. This pathway aims to assist with a reduction in
impulsive decision making by prompting improved problem solving skills. There is also a series of activities
on identity and personal values.
As indicated in Table 29, each of the four topics has a range of different activities. Activities in the Decision-
making topic are about reaching an informed and conscious approach. The client is encouraged to weigh up
the facts and consequences to change their mindset to reach better choices. Mindfulness activities aim to
increase self-awareness and include simple meditation techniques that can be performed almost anywhere.
The Distress tolerance topic develop coping and urge management skills. Identity and values activities shift a
person’s focus towards higher goals, encourage them to take a strength-based approach, and build
commitment.
Table 29. Summary of Action Motives topics and activities
Topic
Activity
Client experience
Decision-
making
Gambling for
excitement
Weigh up the emotional pros and cons about gambling for
excitement
Check the facts
Personal interpretations can muddle the true picture, which is
why it's important to know the facts
Opposite action
Change the way you act by changing the way you feel so that
you can be in control of your emotional reactions
Solve it
Using a clear structure to organise and solve problems can
help you to feel more in control and reduce worry
Mindfulness
Body scan
Tune into your mind and body to understand your own
sensations and release tension
Living in the
moment
Being mindful of the current moment can be practiced almost
anywhere
Focused attention
Focus your attention and bring yourself into the present
moment
Tolerating
distress
Tense and relax
Bring attention to the feeling of relaxation spreading in your
body
Pros and cons
Pros and cons can be used to make a thoughtful decision
about your gambling
Urge surfing
Surf through gambling urges to help you ride the wave
Fast forward
Look closer at the way your images of gambling influence
your behaviour
Self-soothe
Be kind to yourself to soothe negative emotions, stay calm
and get centred
Exciting activities
Replace gambling excitement with the appeal of other fun
activities
Identity and
values
My strengths
Identifying your strengths and qualities can help build a
positive self-image and self-confidence
My values
Consider personal values and what is important to you to
guide you to lasting goals
Committed action
Make a commitment towards effective action and work
towards helpful change
64
i-CBT prototype website development
A website was developed to provide access to the i-CBT prototype. As indicated in Table 30, the website has
three levels. Level 1 contains the three motivational pathways: conditioning, escape, and action motives.
Level 1 is presented on the home page with a brief description of the three pathways. Level 2 contains 13
different topics that are grouped into the higher order motivational pathways. Level 3 contains 52 individual
activities that are delivered with a combination of information and action via text, video, and audio. There are
prompts for written action as indicated by a note/pen icon. Clients are recommended to set up their own
paper-based or Word-based workbook that can be used alongside the i-CBT prototype.
Table 30. Summary of website structure and functionality
Home page of the i-
CBT for gambling
activity
65
Topics in the
(Un)learn to gamble
pathway
Illustrative example:
The activities in the
Finances topic of the
(Un)learn to gamble
pathway
66
Illustrative example:
The Gambling
spending check
activity (partial view)
in the Finances topic
of the (Un)learn to
gamble pathway
67
Topics in the Escape
motives pathway
`
Illustrative example:
The activities in the
Emotional
Vulnerability topic of
the Escape motives
pathway
68
Illustrative example:
The cost of
avoidance activity
(partial view) in the
Reducing Emotional
Vulnerability topic of
the Escape motives
pathway
Topics in the Action
motives pathway
69
Illustrative example:
The activities in the
Identity and Values
topic of the Action
motives pathway
Illustrative example:
The My strengths
and qualities activity
(partial view) in the
Identity and Values
Topic of the Action
motives pathway
70
The website included additional elements designed to increase engagement and return use (see Table 31). For
example, the client profile page included a copy of the client’s goal and vision, as well as any notes made on
activities. Within this page, clients could write a note for their counsellor on their thoughts, questions or
experience of the activities. Clients could easily send this note through the website by checking a box. An
alert was sent to the counsellor with advice that the client had requested a discussion on an activity.
This feature was available for all of the activities. Each activity contained a note pad at the bottom of the page
which prompted clients to write about their thoughts and experiences on the activity. This approach was taken
because often people will scan content in self-help programs without reflection on what it might mean to their
own situation. In the current website, the contents of the notepad were automatically transferred to the client
profile page where notes could be further developed by the client, with or without input from their counsellor.
Table 31. Summary of engagement enhancement and communication loop
71
Professional development for e-mental health
In response to needs identified in Phase I and Phase II specific to counsellors/service providers, a series of 12
self-paced modules were developed and made available in May 2020. These self-paced modules were
intended to support a blended treatment approach inclusive of responding to screener requests and i-CBT
practice integration (Table 32).
Professional development for e-health was brought forward in response to the impact of the COVID-19
pandemic. The self-paced learning was extended to incorporate practice related to technology and included
modules on email, chat, phone, and how to work effectively online with clients. The modules offered a 20-
minute mini-lecture with voiceover. They then prompted a discussion with other counsellors on the topic; the
discussion occurred in the same page under the video. The training modules were uploaded to Slack as a way
of being able to support conversation and audio-visual content. This tool allowed a discussion to occur
between clinicians on how best to use e-mental health and respond in a client-focused manner.
Additional training specific to the screener was provided through video conferencing to practice leads and
counsellors at PGF and Salvation Army Oasis. This training involved reviewing the purpose of the tool, client
72
responsivity, and how to use the counsellor dashboard. This training is available to new recruits/refresher
sessions, if required.
Table 32. Summary of professional development for e-mental health
Topic area
Example of content and activities
73
74
75
76
77
6. PHASE IV: Screener release and patterns of engagement
The content and functionality of the screener prototype is demonstrated below (See Figure 9). The prototype
included an assessment of gambling expenditure, severity, and motives, as well as personal strengths and help
seeking needs. The screener provided immediate access to a personal report which provided information on
assessment items and normative comparisons with other people in New Zealand. It also provided a new
pathways linking gamblers with gambling clinicians through the ‘discuss my results’ option (see Figure 10).
Figure 9. Content and functionality of screener
Figure 10. Pathways from screener results into services
78
Screener implementation
The screener prototype was embedded on the websites of each participating gambling service. This meant
that each screener had their own entry point for users, creating independent data sets consisting only of users
who engaged with the specific service. This function ensured privacy of the people who completed the
screener and simplified data management for each service. The partnership provided collaboration for
implementation and also service-specific tailoring for brand management and in line with organisational
culture The screener was released for community use in June 2021 on the websites of PGF Services and
Salvation Army Oasis.
PGF services have a link to the screener on their website https://www.pgf.nz/. The link is stylised to resemble
the rest of the website for consistent look and feel (see Figure 11). The screener itself is hosted on
https://screener.pgf.nz/.
Figure 11. PGF Services screener link
The SA Oasis have linked the screener on their website https://oasis.salvationarmy.org.nz/. Stylistically, the
link reflects the style of the website (see Figure 12). The screener itself is hosted on https://oasisscreener.
salvationarmy.org.nz/.
79
Figure 12. Salvation Army Oasis screener link
Screener patterns of client engagement
The screener became operational on 11 June 2021. To evaluate engagement, all full responses to the screener
were extracted on 11 November 2021. Data were extracted from the in-built e-tool into an Excel spreadsheet,
cleaned, and imported into Stata 16.0 for further analysis. In total, 897 full screener responses were recorded
during the first five months after the screener became operational. After removing duplicates, there were 772
unique records for further analysis. Duplicates were defined as entries with the same values that were
completed in close succession. Of the 772 individuals who completed the screen, 45 took the screen on the
Salvation Army Oasis website and 727 on the PGF Services website.
In the next sections, data from the screener are presented using simple descriptive statistics in the form of
means, frequencies, and proportions. An overview of participant scores on the PGSI is presented first,
followed by tables on participant characteristics, engagement in gambling activity, and gambling-related
attributes, stratified by level of gambling severity. Specifically, results were reported for the overall sample of
participants who took the screen (i.e., all gamblers, including people classified in the non-problem gambling
category), and then separately for each at-risk gambling category (i.e., low-risk gambling, moderate-risk
gambling, and problem gambling). The second part of the quantitative results focusses on help-seeking and
investigates associations between help-seeking and factors that have been described in the first part.
6.13.1. Gambling severity
All participants were assessed on gambling severity using the PGSI. Of the 772 participants who completed
the screen, about a quarter were classified in the non-problem gambling category (23%), one in five in the
low-risk gambling category (18%), a quarter in the moderate-risk gambling category (24%), and a third in the
problem gambling category (35%).
Scores on individual PGSI items are reported in Table 33. The most commonly endorsed PGSI items (i.e.,
those most endorsed as ‘almost always’ by the participants) were feeling guilty about gambling (11%) and
feeling that one has a problem with gambling (10%). The least commonly endorsed PGSI items (i.e., most
endorsed as ‘never’ by the participants) were borrowing money or selling possessions (75%) and gambling
having caused financial problems (65%).
Table 33. PGSI scores for each item in the screening tool, completed by 722 participants (n,%)
PGSI item
Never
Sometimes
Most of
the time
Almost
always
1. How often have you bet more than you
could really afford to lose?
410 (53.1)
191 (24.7)
106 (13.7)
65 (8.4)
2. How often have you needed to gamble
with larger amounts of money to get the
same feeling of excitement?
383 (49.6)
233 (30.2)
106 (13.7)
50 (6.5)
3. How often have you gone back another
day to try to win back the money you lost?
369 (47.8)
254 (32.9)
94 (12.2)
55 (7.1)
4. How often have you borrowed money or
sold anything to get money to gamble?
581 (75.3)
143 (18.5)
32 (4.2)
16 (2.1)
5. How often have you felt that you might
have a problem with gambling?
305 (39.5)
303 (39.3)
91 (11.8)
73 (9.5)
80
PGSI item
Never
Sometimes
Most of
the time
Almost
always
6. How often has your gambling caused you
any health problems, including stress or
anxiety?
456 (59.1)
186 (24.1)
87 (11.3)
43 (5.6)
7. How often have people criticised your
betting or told you that you had a gambling
problem, regardless of whether or not you
thought it was true?
469 (60.8)
224 (29.0)
53 (6.9)
26 (3.4)
8. How often has your gambling caused any
financial problems for you or your
household?
502 (65.0)
179 (23.2)
50 (6.5)
41 (5.3)
9. How often have you felt guilty about the
way you gamble, or what happens when
you gamble?
306 (39.6)
261 (33.8)
117 (15.2)
88 (11.4)
6.13.2. Sociodemographic characteristics
Table 34 shows demographic characteristics of all participants who completed the screener. The average age
was 49 years and ranged between 17 and 88 years. Most participants were male (66%), New Zealand
European/Pākehā (70%), and located on the North Island Te Ika-a-Māui (68%). The majority of participants
(69%) reported an annual household income over $51,000.
• For those classified in the low-risk gambling category, the average age was 53 years. The majority of
gamblers in this category were male (68%), NZ European/Pākehā (80%), and earned over $51,000 per year
(76%).
• For those classified in the moderate-risk gambling category, the average age was 49 years. The majority
were male and reported earning over $51,000 annually (69%).
• For those classified in the problem gambling category, the average age was 42 years. Proportionally, there
were more females (35%) in this group compared to the other at-risk groups. There were also somewhat
higher proportions of Māori (27.4%) and Pasifika peoples (6.8%) in the problem gambling group. The
majority of gamblers in this category reported earning over $51,000 annually (61%), although there were
less people reporting to earn in the highest income categories compared to the other at-risk groups.
Moreover, there were more people earning under $51,000 compared to other PGSI categories.
Table 34. Sociodemographic characteristics by PGSI categories (%)
Demographic characteristics
Low-risk
gambling
(n = 139)
Moderate-risk
gambling
(n = 187)
Problem
gambling
(n = 266)
All gamblers
(n = 772)
Age (in years), mean (SD)
52.5 (16.9)
48.6 (16.7)
42.2 (15.4)
49.1 (16.7)
Gender
Female
30.9
32.1
37.6
32.5
Male
68.4
65.8
59.0
65.5
Non-binary
0.7
2.1
3.4
1.9
Ethnicity
NZ European/Pākehā
79.9
72.2
54.1
69.6
Māori
8.6
13.4
27.4
15.8
81
Demographic characteristics
Low-risk
gambling
(n = 139)
Moderate-risk
gambling
(n = 187)
Problem
gambling
(n = 266)
All gamblers
(n = 772)
Pasifika
2.9
3.7
6.8
4.2
Asian
2.9
4.3
2.6
2.7
Other
5.8
6.4
9.0
7.8
Income
< $20,000
4.3
4.8
8.7
6.1
$20,000-30,999
3.6
11.2
10.9
9.2
$31,000-50,999
26.6
15.0
19.9
15.5
$51,000-100,999
33.8
28.3
35.7
32.4
$101,000-200,000
28.8
29.4
21.1
26.3
> $200,000
13.0
11.2
3.8
10.5
Location
North Island Te Ika-a-Māui
39.6
37.4
47.4
42.5
South Island Te Waipounamu
20.1
20.9
19.2
20.5
Not reported
40.3
41.7
33.5
37.0
6.13.3. Engagement in gambling activities
Table 35 shows participants’ engagement with six different gambling activities over the last 12 months. The
most common gambling activity participants engaged in was lotto (77%), followed by EGMs (59%),
wagering (38%), sports betting (24%), casino games (22%), and private games (15%). As shown in Table 34,
almost three quarters of participants engaged in at least two types of gambling activity in the past 12 months
(73%).
• For those classified in the low-risk gambling category, lotto was the most commonly reported gambling
activity (81%), whereas each of the other gambling activities were reported by less than half of those in
this category.
• For those classified in the moderate-risk gambling category, lotto was the most commonly reported
gambling activity (78%), followed by EGMs (65%) and wagering (48%).
• For those classified in the problem gambling category, EGM gambling was the most commonly reported
gambling activity (88%), followed by lotto (75%). Engagement with each of the other gambling activities
was reported by around a third or less of gamblers in this category. About half of gamblers in this category
reported engaging in three or more gambling activities.
Table 35. Engagement in gambling activities in the last 12 months per gambling activity (%)
Low risk
gambling
(n = 139)
Moderate risk
gambling
(n = 187)
Problem
gambling
(n = 266)
All gamblers*
(n = 772)
Lotto
81.3
77.5
75.2
77.2
EGMs
48.2
65.2
87.6
59.1
Wagering
40.3
47.6
35.3
38.0
Sports betting
23.7
32.1
23.7
24.0
Casino games
16.5
28.3
31.2
22.2
82
Private games
11.5
17.1
16.5
14.5
*Including gambles in the non-problem gambling category.
Table 36. Number of gambling activities participants engaged in during the last 12 months (%)
No. of gambling activities
Low risk
gambling
(n = 139)
Moderate risk
gambling
(n = 187)
Problem
gambling
(n = 266)
All gamblers*
(n = 772)
None**
0.7
3.2
0.8
4.0
One
28.1
11.2
13.5
23.2
Two
35.3
41.2
36.8
34.3
Three or more
36.0
44.4
48.9
38.5
*Including gamblers in the non-problem gambling category, ** Item non-response to one or more gambling activities
included in category
6.13.4. Gambling frequency
Table 37 shows frequency of engagement in gambling activities (among those who reported engagement in
these activities in the last 12 months). Weekly engagement in lotto, EGMs, and wagering was reported by
about half of the participants (50%, 55%, and 54%, respectively). Weekly engagement in sports betting was
slightly less common (44%), as was weekly engagement in casino games (29%). The lowest frequency of
engagement was reported for private games, with most participants (45%) reporting yearly engagement in
this activity. All participants who indicated that they engaged in a particular gambling activity in the past 12
months were also asked the actual number of days in the past months they spent money on that gambling
activity, as shown in Table 36. Based on this measure, wagering was the most frequent gambling activity,
with participants spending money on it on 8 days a month, on average, followed by EGMs and sports betting
(both 7 days a month, on average).
• About half of gamblers in the low-risk category reported weekly engagement in wagering (54%) and lotto
(53%). Weekly engagement in the other gambling activities was reported by a third or less of gamblers in
this category. In the last month, these participants most often spent money on wagering, on average 7 days
a month, while the average for other gambling activities was 5 days a month or less.
• For those classified in the moderate-risk gambling category, weekly engagement was most often reported
for wagering (61%), followed by EGMs (53%), sports betting (48%), lotto (46%), and casino games (38%).
Weekly engagement in private games was less commonly reported (16%). Eight days a month, on average,
money was spent on wagering and sports, and 6 days a month on EGMs, whereas the average number of
days for other gambling activities was 6 days or less.
• Almost three quarters of people experiencing problem gambling reported weekly engagement in EGMs
(72%), while about half reported weekly engagement in wagering (51%), sports betting (51%), and lotto
(47%). Casino and private games were gambling activities in which people in the problem gambling
category least often engaged in on a weekly basis. Gamblers in this category reported higher numbers of
days per month on average on which they spent money on each of the gambling activities, compared with
the other at-risk groups. On average, they spent money on EGMs and wagering on 9 days, on sports betting
on 8 days, on lotto and casino games on 5 days, and on private games 4 days a month.
83
Table 37. Frequency of engagement in gambling in the last 12 months per gambling activity (%)
Low risk
gambling
(n = 139)
Moderate risk
gambling
(n = 187)
Problem
gambling
(n = 266)
All gamblers*
(n = 772)
Lotto
At least weekly
53.1
46.2
47.0
50.0
At least monthly
20.4
31.0
24.5
24.5
At least every 6 months
22.1
15.9
17.5
16.6
At least once a year
4.4
6.9
11.0
8.9
EGMs
At least weekly
23.9
52.5
71.7
55.3
At least monthly
28.4
32.8
20.6
25.4
At least every 6 months
32.8
10.7
6.4
13.2
At least once a year
14.9
4.1
1.3
6.1
Wagering
At least weekly
53.6
60.7
51.1
53.6
At least monthly
14.3
16.9
19.1
19.5
At least every 6 months
19.6
12.4
19.1
14.3
At least once a year
12.5
10.1
10.6
12.6
Sports betting
At least weekly
36.4
48.3
50.8
44.3
At least monthly
30.3
30.0
27.0
28.1
At least every 6 months
24.2
16.7
15.9
19.5
At least once a year
9.1
5.0
6.3
8.1
Casino games
At least weekly
8.7
37.7
32.5
29.2
At least monthly
17.4
9.4
19.3
16.4
At least every 6 months
26.1
26.4
25.3
25.7
At least once a year
47.8
26.4
22.9
28.7
Private games
At least weekly
12.5
15.6
25.0
20.5
At least monthly
31.3
6.3
25.0
17.9
At least every 6 months
18.8
28.1
15.9
17.0
At least once a year
37.5
50.0
34.1
44.6
The presented results are based on responses from participants who engaged on respective gambling activity.
*Including non-problem gamblers.
Table 38. Number of days gambled in the last 30 days per gambling activity (M, SD)
Low risk
gambling
(n = 139)
Moderate risk
gambling
(n = 187)
Problem
gambling
(n = 266)
All gamblers*
(n = 772)
Lotto
4 (4)
4 (4)
5 (7)
4 (5)
EGM
3 (4)
6 (6)
9 (8)
7 (7)
Wagering
7 (8)
8 (7)
9 (9)
8 (8)
Sports betting
5 (8)
8 (9)
8 (8)
7 (8)
Casino games
1 (3)
4 (5)
5 (7)
4 (6)
Private games
5 (8)
1 (1)
4 (6)
3 (6)
Total**
9 (9)
15 (11)
19 (16)
14 (14)
84
The presented results are based on responses from participants who spent money on respective gambling activity.
*Including gamblers in the non-problem gambling category. ** Based on pooled number of days of all gambling
activities.
6.13.5. Monthly gambling expenditure
Participants were asked how much money they spent on each gambling activity in a typical month, as shown
in Table 39, and how much money they actually spent on each activity in the last month, as shown in Table
40. The highest average expenditure in a typical month was on casino games ($1,133) followed by wagering
($854) and EGMs ($765).
• For gamblers in the low-risk category, the typical expenditure was considerably higher for wagering
($2006), than for any of the other gambling activity.
• For gamblers in the moderate-risk category, the average reported typical spending was also generally
lower than the actual spending, apart from spending on private games. The highest average typical and
actual expenditure were seen for casino games ($1856 and $2110, respectively), followed by sports
betting ($642 and $907 respectively), and EGMs ($423 and $854, respectively).
• For gamblers in the problem gambling category, typical expenditure was highest for EGMs ($1228),
followed by casino games ($1040) and wagering ($871). A similar pattern was seen for actual
expenditure, with reported actual spending being higher for EGMs ($1475) and casino games ($1457),
but not very different from typical spending for wagering ($769).
Table 39. Spending in a typical month per gambling activity (M, SD)
Low risk
gambling
(n = 139)
Moderate risk
gambling
(n = 187)
Problem
gambling
(n = 266)
All gamblers*
(n = 772)
Lotto
$68 (113)
$67 (85)
$146 (423)
$90 (257)
EGMs
$135 (221)
$423 (877)
$1228 (2669)
$765 (2020)
Wagering
$2006 (13340)
$238 (435)
$871 (3212)
$854 (6344)
Sports betting
$58 (100)
$642 (2848)
$575 (1068)
$437 (1759)
Casino games
$320 (509)
$1856 (5811)
$1040 (2708)
$1133 (3772)
Private games
$69 (198)
$206 (886)
$425 (1531)
$246 (1079)
The presented results are based on responses from participants who spent money on respective gambling activity.
*Including gamblers in the non-problem gambling category. ** Based on pooled amount of all gambling activities.
Table 40. Spending in the last 30 days per gambling activity (M, SD)
Low risk
gambling
(n = 139)
Moderate risk
gambling
(n = 187)
Problem
gambling
(n = 266)
All gamblers*
(n = 772)
Lotto
$102 (377)
$74 (95)
$145 (309)
$97 (251)
EGMs
$234 (982)
$854 (3778)
$1475 (2463)
$1020 (2703)
Wagering
$2033 (13338)
$468 (1558)
$769 (1555)
$885 (6146)
Sports betting
$71 (116)
$907 (4075)
$894 (3215)
$633 (3000)
Casino games
$577 (1552)
$2110 (6445)
$1457 (3896)
$1447 (4550)
Private games
$19 (30)
$39 (143)
$415 (1551)
$188 (990)
The presented results are based on responses from participants who spent money on respective gambling activity.
*Including gamblers in the non-problem gambling category. ** Based on pooled amount of all gambling activities.
85
6.13.6. Impact of gambling
As part of the screen, all participants were assessed on gambling symptoms using the gambling
thoughts/urges sub-scale from the PG-YBOCS. This scale consists of five items with response options on a 5-
point Likert scale reflecting least severe to most severe. The five items are: (1) time occupied by gambling
(How much time do you spend on gambling-related activities? Include any actions before, during or after
gambling); (2) interference due to gambling (How much does gambling get in the way of work, study, or your
social life?); (3) distress associated with gambling (How irritated do you become if you can’t gamble when
you want to?); (4) resistance of gambling urge (How often do you put effort into resisting unwanted
gambling?); and (5) degree of control over gambling (How much control do you have over your gambling?).
Table 41 shows the proportion of participants answering the items in the two most severe response categories.
The most commonly mentioned area of severe impact was resistance of gambling urge, with about one in five
participants (18%) reporting that they rarely or never put effort into resisting unwanted gambling. About one
in ten participants (12%) reported that they had no or almost no control over their gambling. About one in ten
(11%) spent three or more hours a day gambling. It was less common that participants got very or extremely
irritated when they were unable to gamble (6%) or thought gambling got extremely or completely in the way
of work, study, or social life (5%).
• For people classified in the low-risk gambling category, responses in the more severe categories were
infrequently reported, apart from resistance of gambling urge: about one in eight participants (14%)
reported that they rarely or never put effort into resisting unwanted gambling.
• For people classified in the moderate-risk gambling category, responses were largely similar to low-risk
gamblers. More severe responses were mostly seen where participants reported rarely or never putting
effort into resisting unwanted gambling (13%).
• For people classified in the problem gambling category, more severe responses were more common for
each of the questions. They most commonly (33%) reported having no or almost no control over their
gambling. This was followed by rarely or never putting effort into resisting unwanted gambling (29%),
spending three or more hours a day on gambling (29%), becoming very or extremely irritated when unable
to gamble (15%), and thinking that gambling extremely or completely gets in the way of work, study, or
social life (13%).
Table 41. Impact of gambling (%)
Low risk
gambling
(n = 139)
Moderate
risk
gambling
(n = 187)
Problem
gambling
(n = 266)
All
gamblers*
(n = 772)
Time occupied by gambling
Three or more hours a day
1.4
3.2
28.6
11.0
Interference due to gambling
Extreme/completely gets in the way
0.0
1.1
13.2
4.8
Distress associated with gambling
Very or extremely irritated
0.7
2.1
15.4
6.0
Resistance of gambling urge
Rarely or never
13.7
12.8
28.9
18.4
Degree of control over gambling
Almost no control / no control
0.0
1.1
32.7
11.5
*Including gamblers in the non-problem gambling category.
86
6.13.7. Perceived comparison with others
Table 42 shows how participants perceived their gambling behaviour in comparison to others. Participants
were asked the question: When you think about how often you gamble, would you say it’s more than, about
the same as, or less than most New Zealanders? Overall, a slight minority of gamblers (45%) thought they
gambled more than most others.
• About two in ten participants in the low-risk gambling category (22%) thought they gambled more than
most others.
• Almost six in ten participants in the moderate-risk gambling category (58%) thought they gambled more
than most others.
• It was considerably more common for participants in the problem gambling category to think they gambled
more often than most others, with around seven in ten (70%) reporting that was the case.
Table 42. Perceived gambling frequency compared to other New Zealanders (%)
Low risk
gambling
(n = 139)
Moderate risk
gambling
(n = 187)
Problem
gambling
(n = 266)
All gamblers*
(n = 772)
Perceived frequency
More than most others
21.6
58.3
69.9
45.1
*Including gamblers in the non-problem gambling category.
6.13.8. Level of importance, readiness, and confidence
The screen also included questions related to importance, readiness, and confidence to change gambling.
Specifically, the questions were: How important is it for you that you limit/stop your gambling?; Where does
limiting/stopping gambling fit on your list of priorities? and How confident are you that you could resist an
urge to gamble? Answer options to these questions were measured on a 5-point Likert scale. Table 43 shows
the proportion of participants providing a response in the two highest categories. Overall, less than half
(39.4%) of the participants stated that changing their gambling was moderately important to very important.
About a third of the participants (35.7%) considered limiting or stopping gambling to be a moderate to high
priority. The majority of the participants (59.7%) were moderately to totally confident that they could resist
an urge to gamble.
• For people classified as in the low-risk gambling category, only a small proportion (16%) considered that
changing their gambling was moderately or very important and that it was moderately high or high on their
priority list (14%), while the majority (85%) were moderately or totally confident that they could resist a
gambling urge.
• In the moderate-risk gambling category, around a third (31%) considered changing their gambling
moderately or very important, a quarter (25%) had it moderately high or high on their priority list, and over
half of moderate-risk gamblers (54%) were moderately to totally confident that they could resist a gambling
urge.
• People in the problem gambling category commonly reported higher levels of importance and readiness to
change gambling, with almost three quarters of participants (74%) thinking it was moderately or very
important to change. Almost seven in ten participants (68%) considered it a moderate or a high priority to
change. A high level of confidence to change gambling was less common in gamblers in this category than
in the other at-risk groups, with only about one in four (27%) thinking they could resist a gambling urge.
87
Table 43. Importance, readiness, and confidence to change gambling (%)
Low risk
gambling
(n = 139)
Moderate risk
gambling
(n = 187)
Problem
gambling
(n = 266)
All gamblers*
(n = 772)
Importance
Moderately / very important
15.8
30.5
74.4
39.4
Readiness
Moderate / high priority
14.4
24.6
68.0
35.6
Confidence
Moderately /totally confident
84.9
53.5
27.4
59.7
*Including gamblers in the non-problem gambling category.
6.13.9. Motives for gambling
Participants were asked about four common motives to gamble, namely, (1) financial (How often do you take
part in gambling activities to win money, because you enjoy thinking about what you would do if you won a
jackpot, or because winning would change your lifestyle?); (2) enhancement (How often do you take part in
gambling activities because you like the feeling, to get a high feeling, or because it makes you feel good?);
(3) coping (How often do you take part in gambling activities to forget your worries, because you feel more
self-confident, or because it helps when you are feeling nervous or depressed?); and (4) social (How often do
you take part in gambling activities because it’s what most of your friends do when you get together, to be
sociable, or because it makes a social gathering more enjoyable?). Answers were measured using a 0 to 10
sliding scale, in which 0 reflected ‘never’ and 10 reflected ‘almost always’.
Overall, the category enhancement was most strongly endorsed as a gambling motive (mean score 5.5),
followed by coping (mean score 4.6) and social (mean score 3.3), with financial being the least strongly
endorsed motive (mean score 2.9). It should be noted that due to early versions of the tool some answers were
optional (i.e., people completing the screen did not have to provide a response to these questions to progress
through the screen questions), and where this was the case a non-response was automatically coded as 0. As
such, average scores are likely lower than if the questions required a response (i.e., forced-response).
While examining mean scores provides some insights, considering the frequency of responses can provide an
alternative interpretation; provided in Table 44. For this interpretation, scores of eight to ten were considered
to reflect that a particular motive was ‘often or almost always’ the reason for gambling.
• For people classified in the low-risk gambling category, enhancement was the frequently endorsed motive
for gambling, with about one of six (17%) reporting that it was often or almost always the reason to gamble.
• For people classified in the moderate-risk gambling category, coping was the most frequently endorsed
motive for gambling, with approximately one in five (21%) reporting that it was often or almost always the
reason to gamble.
• For people classified in the problem gambling category, enhancement and coping motives were the most
frequently endorsed reason for gambling, with almost half reporting these as often or almost always the
reason to gamble. Interestingly, financial motives were reported as ‘often or almost always’ being the
reason to gamble by a considerably smaller proportion of the participants (14%).
88
Table 44. Motives for gambling (%)
Low risk
gambling
(n =139)
Moderate risk
gambling
(n = 187)
Problem
gambling
(n = 266)
All gamblers*
(n = 772)
Financial
Often to almost always
7.2
6.4
13.9
8.3
Enhancement
Often to almost always
17.3
20.3
48.9
27.8
Coping
Often to almost always
5.8
20.9
45.1
21.8
Social
Often to almost always
0.0
11.8
35.3
15.0
Often to almost always indicates a score of 8+ on a 10-point scale. Due to a technical error which is now rectified, non-
response was automatically coded as 0; % are lower than if non-responses were excluded. *Including gamblers in the
non-problem gambling category.
6.13.10. Strengths that help control gambling
Participants’ strengths were grouped into categories according to the values in the Action Inventory of
Strengths (Ruch et al., 2010). These categories were: (1) cognitive strengths related to wisdom and
knowledge (e.g., creativity, curiosity, open mindedness, love of learning, perspective); (2) emotional
strengths related to courage (e.g., bravery, persistence, honesty, zest); (3) interpersonal strengths related to
humanity (e.g., love, kindness, social intelligence); (4) civic strengths related to justice (e.g., teamwork,
fairness, leadership); (5) temperance related to protection against excess (e.g., forgiveness, modesty,
prudence, self-regulation); (6) transcendence related to connection with a higher meaning (e.g., appreciation,
gratitude, hope, humour, religiousness).
The most frequently endorsed personal strengths were being caring (9.5%), compassionate (4.6%), and clever
(4.1%). Table 45 shows the proportion of participants who identified having one or more strengths within a
category. Overall, interpersonal strengths were endorsed by the largest proportion of participants (50%),
followed by emotional (43%) and cognitive strengths (27%).
• Gamblers in the low-risk category most commonly reported having emotional (45%) and interpersonal
strengths (44%), while strengths within the transcendence category were least commonly reported (12%).
• Gamblers in the moderate-risk category most commonly reported having interpersonal strengths (48%),
followed by emotional strengths (44%). Strengths within the temperance category were least common
(8%).
• Similarly, people with problem gambling most commonly reported having interpersonal strengths (56%),
followed by emotional strengths (43%). Strengths within the temperance category were least common
(13%).
89
Table 45. Strengths identified by participants (%)
Low risk
gambling
(n = 139)
Moderate risk
gambling
(n = 187)
Problem
gambling
(n = 266)
All gamblers*
(n = 772)
Interpersonal
43.9
47.6
56.4
50.1
Emotional
44.6
44.4
42.5
42.5
Cognitive
31.7
27.3
25.6
27.3
Civic
16.5
23.0
13.2
17.5
Temperance
20.1
8.0
12.8
15.7
Transcendence
12.2
18.7
17.3
15.4
The percentage reflects the proportion of participants who reported having one or more strengths within a category.
*Including gamblers in the non-problem gambling category.
6.13.11. Interest in discussing screener results with a professional
Table 46 shows the extent to which participants were interested in talking to a professional about the results
from their completed screen. Using a 5-point Likert scale, participants could indicate whether they were not
at all (1), slightly (2), somewhat (3), moderately (4), or very (5) interested in talking over the results. Overall,
approximately one in eight participants (13%) were interested in discussing the results with a professional.
• Very few gamblers in the low-risk category (1%) were moderately or very interested in discussing the
results with a professional.
• Few gamblers in the moderate-risk category (4%) were moderately or very interested in discussing the
results with a professional.
• In people with problem gambling, high levels of interest in discussing results were reported more
commonly than in the other at-risk groups, with about a third (32%) of gamblers in this group being
moderately or very interested in discussing their results.
Table 46. Interest in discussing screener results with a professional (%)
Low risk
gambling
(n = 139)
Moderate risk
gambling
(n = 187)
Problem
gambling
(n = 266)
All gamblers*
(n = 772)
Perceived frequency
Moderately or very interested
0.7
4.3
32.3
12.7
*Including gamblers in the non-problem gambling category.
Participants were also asked to leave their contact details if they wanted to discuss their results and their
gambling further with a health professional. In total, 71 participants (9%) requested to be contacted after
completing the screener. Of these, 6% were classified in the low risk category, 7% in the moderate risk
category, and 85% in the problem gambling category.
90
7. PHASE V: Screener and i-CBT evaluation
In Phase V, we evaluated the implementation of the screener prototype and the i-CBT prototype.
Evaluation of screener prototype
An evaluation of the screener prototype involved 9 participants including managers, team leaders (TL),
clinicians, health promotors (inclusive of Māori health) and people with lived experience who had been
involved in the screener development. Interviews were conducted in November 2021 by video conferencing
and recorded and transcribed for further analysis (see Appendix C for interview schedule). Data was analysed
in NVivo software using thematic analysis (104, 105), similar to Phase II qualitative data analysis procedures.
As indicated in Table 47, themes related to the screener evaluation were (i) potential impact (ii) dissemination
(iii) screener content (iv) engagement (v) pathways and (vi) administration.
Table 47. Summary of qualitative evaluation of screener
Themes
Positive Experiences
Areas for improvement
Potential
impact
Lower intensity option increased reach
Thought provoking and non-judging which
may prompt further action
Adds value to client assessment
Is useful as a stand-alone brief intervention
Immediate report is available 24/7
Easy to integrate into treatment so as to
reduce duplication or in session assessment
Useful for monitoring gambling trends
Anonymity limited any further contact even
though contact details were collected for
anyone who saved the screener results
Need to assess screener as BI and the impact
of the intervention longer term
Could be used to assess and monitor progress
Absence of affected other version was
considered an important future option but
would require careful consideration of
questions and feedback report.
Dissemination
Promotion of the screener increased its use
and contact with services. It was offered
through some other gambling agencies and
used in health promotion activities.
Expansion to other health areas including
GPs and primary care, and alcohol and drug
services
Ensure dissemination retains links to expert
advice and counselling
Screener
content
Comprehensive summary of gambling
Normative comparison prompt help-seeking
Build on strengths assessment
Useful questions on previous help
Later access important
Good representation of Te Reo Māori
Gambling questions lengthy
More information on online gambling
desirable
Inclusion of stories and quotes desirable
Offer a similar tool for other concerns
Consider listing help-seeking options
Replace professional with gambling expert
Enhanced
engagement
Easy to access and easy to use
Graphs with comparisons impactful
Increase visual appeal through graphs and
figures instead of words
Include more interactive elements
Include more lived experience
Provide in languages other than English
Pathways into
the service
Four options work well and allow people to
choose their most comfortable pathway
Low pressure way of making contact
Add text and chat option and messaging via
social media
Offer support via lived experiences
Add click to call button
Administration
Broad support for continuing screener
Part of routine service delivery
Client management system was adequate
Need for ongoing funding to support
maintenance, updates and hosting
91
Useful information for service delivery
Training adequate but more needed
Integration of client management system
with other e-health tools
Induction package needed for new staff
6.14.1. Potential screener impact
There was a strong view that the screener was very useful for the clients, counsellors, and the service model
of care. Benefits of the screener included that it provided an easy way to assess gambling and did this with a
good set of assessment items. Most of the comments on usefulness were in relation to the personal report
provided immediately on completion of the assessment. Participants thought the immediate report provided
information that people could take away to think about particularly in relation to comparison of gambling
with others. The usefulness of the screener was not just about having an immediate impact on thoughts about
gambling but on providing a new pathway into services.
It's fantastic. We're really happy that there's this tool that people can fill in themselves and reflect on
their responses and decide whether they want to take next step. (Clinician, Oasis)
The screener gives the person something to take away and also connects them to further help. (Health
promoter, PGF)
They're able to access that information about their gambling via that summary report based on their
responses, which is really fantastic. And of course, the self-help. Self-help in those initial stages and
accumulating that information and trying to come to a decision about whether this is an issue that you
need to get professional support around. (Manager/TL, Oasis)
We've always had lots of people go to our website, and we used to have a test, which was the PGSI, the
Problem Gambling Severity Index, but it wouldn't give them anything. It didn't give them anything
back, didn't prompt them, didn't take them further. (Manager/TL, PGF)
This tool should be available on an ongoing basis, and available to any service provider that has a
website and happy to use it. The screener is certainly increasing numbers and getting people onto our
services, which is exactly what we wanted to do. We wanted to increase engagement and easier access
for our clients at a time that's suitable to them. (Manager/TL, Oasis)
It’s a great screener and I found it very easy to do. (Lived experience)
People with lived experience also found the screener a useful tool because it asked the right questions and
provided immediate feedback.
I think it’s easily accessible to people with gambling problems. And I think it gives a clear report. It
gives an opportunity to make that decision to seek help on their own without feeling like they were
forced into it. (Lived experience)
I found it really easy. It was really easy to use. And it asked all the right questions. (Lived experience)
I think it's good. It's good because I don't think there's been anything out there in the past for people to
do that. There has been one TV ad a long time ago. But this one's definitely more comprehensive than
that one. I think it's good and definitely hitting in the right direction. I feel like I wish I had this stuff in
front of me when I needed it. (Lived experience)
If I was giving the screener a rating out of ten, I'd have to say nine and a half. I liked the questions,
how they have been formulated. (Lived experience)
92
Accessibility of the screener was another important feature. The screener provided an opportunity to assess
gambling behaviours at a convenient time of the day and from any location. This was particularly important
for people living in a rural New Zealand.
People can get a good idea outside of normal working hours what their situation is, whether it's
normal gambling as such, or whether they are gambling more than the average New Zealander. To
give them that information, outside of work hours, so that they can do the screener in their own time in
the comfort of their own home, I think is really beneficial. Because a lot of the ones that do fill it out in
the evenings, or early morning. (Clinician, Oasis)
I live rural New Zealand - in the middle of nowhere. So it was really good that I didn't have to go into
town to find something. I could just go online and do it. (Lived experience)
I think that that's part of the beauty of it really is the screener accessibility. (Manager/TL, PGF)
It was noted that there were some people with low gambling harm scores who later accessed services after
completing the screener. This indicated that the screener was reaching not only people with problem
gambling but those at low to moderate severity of gambling harm.
Some people are referring themselves to us when they have fairly low scores. In terms of usefulness, I
think that's great that we're having those early conversations with people. (Manager/TL, Oasis)
The key informants thought the screener was useful not only to the people looking into their gambling for the
first time, but past and current clients. For people with past problems, the screener provides an opportunity to
periodically assess themselves without the need to immediately connect with services. If a problem is
identified, then it is easy for past clients to request a call and re-engage with the service. Key informants also
reported that doing repeat assessments can assist in keeping track of progress and that these could be
incorporated into episodes of care.
We had a lot of conversations in my team around our follow-up clients, the ones who finished their
formal counselling, that anyone who wants to finish their follow-up or anyone in general, that self-help
tool is on the website that they can go on and do it at any time. (Manager/TL, Oasis)
An assessment can sometimes be seen as a one-off process, and it's not. I think it’s a good idea to do
the screener again. When you’re first getting into that space of recognising that you actually have a
problem, you’re most likely to lie. But when it really sort of sinks in, as you go back and do it again,
then you’re going to become truthful and say – right, I need the help, I need to answer the questions
truthfully. (Lived experience)
You could use it for down the track, if you could print off the report, in PDF with the graphs, and at
session six show it to your client. This is what you were spending per month, per year. And these are
the answers to your questions in June, and then reflect upon where they're at now. That could be a
useful thing for them. (Clinician, Oasis)
The screener was also perceived as useful for those who chose not to connect with services after completion.
There was a view that the screener feedback could trigger re-thinking of person’s gambling. It triggered self-
reflection that could lead to behaviour change even if the person did not seek help from the services.
The screener provides people with the opportunity to anonymously have a look at where they're at. We
know how hard it is to step through the virtual door. I actually like that it says ‘this is where you are
compared to other New Zealanders’. It gives them something to set themselves against because people
93
don't know, if all of their mates are TAB gamblers, then they don't know that there's a whole
population out there that aren't. (Manager/TL, PGF)
It's just great that people are feeling like they've got some information. And, you know, it’s a really
great tool that they can use, reflect upon the behaviour, and hopefully, change. (Manager/TL, Oasis)
Information collected by the screener was useful for clinicians in preparation for the first session. Having the
screener results beforehand helped to build rapport and draw a more complete picture of gambling. People
with lived experience also noted that the screener made it easier to share information about gambling so by
the time of the first session there were fewer barriers to communication with the counsellor.
That information is really helpful for the caseworkers when they first initiate that contact with the
client. (Clinician, Oasis)
When you go into treatment at the start, you're first getting used to the counsellor. And sometimes
sharing is not easy for people face to face. When you share information on the screener, then they've
already got it. So, they kind of know what is there and it comes out straight away. (Lived experience)
It was also suggested that the gambling industry and the Ministry of Health may benefit from more detailed
data around gambling products consumption, but this would be an unreasonable burden on people doing the
screener. The screener data itself was very useful for collecting data required for internal and external
reporting.
The industry wants to know what's going on, what does this mean for us? And then they started saying,
‘well, how much is that scratchies? How much of that is online? How much is that?’ You know,
because the actual question is lotto bingo, and it's all grouped. And I, honestly, I don't think we can
change it and get the level of data that they're after. (Manager/TL, PGF)
It is information that we are required to collect. So there is data in the screener that we have for our
contract requirements. And so that's where it's useful for us as a service, it provides some of the data
that we are required to collect. (Manager/TL, Oasis)
I really liked being able to download the data. Really appreciate being able to see the whole lot
whether they referred or not. I can report on that to the Ministry of Health as well. (Manager/TL, PGF)
The immediate brief intervention format was another feature that made the screener useful for the gambling
services and public health in general. For gambling services, the screener was useful to include into
presentations to other services or public because the live link to the screener allowed people to access it
immediately, to distribute the screener further, or to use at a later time. Health promoters were able to engage
with people during events and get them to complete the screener on the spot. From a public health
perspective, the screener provided an online brief intervention that was invaluable during the COVID-19
pandemic when most activities, including gambling, shifted online, and therefore treatment options also
needed to shift online. For other non-gambling services, the screener is a great addition into their toolbox.
Many non-gambling and non-clinical health professionals are not familiar with what help is available for
people who gamble and where to refer them. The screener allows these health professionals to support and
direct people.
Health promotors don't necessarily need to be able to screen people who gamble because that's what
clinicians do. But to get started the screener can be used as a resource for anyone. So anywhere that
sees tāngata whaiora, people seeking wellbeing, is a good place that they could use this tool. (Health
Promoter, PGF)
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Anonymity was an important part of the screener as it allowed people to assess their gambling without
disclosing it to anyone. Being anonymous may have made people more honest rather than if doing an
assessment in front of another person.
I think the anonymity is one of the things that draws people to it. We know gambling is a very hidden
and underdiscussed thing, and you don't want to be attached to it at all. So anonymity options seem
pretty reasonable. (Health promoter, PGF)
I think people are more honest in their assessment of themselves when doing it on their own, rather
than in front of the caseworker. (Clinician, Oasis)
If people want to stay anonymous like I did, I think it is a good idea to keep contact details section at
the end, so they can make that decision after they've read the results of the screener. And I thought that
was really good having the results there and then. (Lived experience)
From the services perspective, however, anonymity created a missed opportunity. If the screener was not
anonymous, gambling services could contact these people proactively, so the people could receive help
sooner.
Even if somebody decided at that point, they don't want to go forward, is it possible to gather
everything up and check in with the person.
It could be a really simple way for them to either re-refer back because I think one of the things we
noticed is that when people reach out, they sort of dip their toe in the water and freak out a bit. Often
that's what gamblers will say – I've tried to do it on my own and I've worked out that I can't, and that's
why I've come back to you. A bit more proactive follow up with them may help. (Manager/TL, PGF)
It's worse if you've got no way of contact. They're leaving absolutely no details and you feel like you
could really help them. That's worse. (Manager/TL, PGF)
All key informants raised the need for a screening tool for whānau and affected others. There was a view that
a screener for affected others would be useful in normalising the experience and providing information on
available help options.
We're focusing on the gambler, but it would be cool to be able to do something that integrates affected
others, for them to be able to seek support and help through a screener. They often are trying to figure
out is this normal? Is this okay? What do I do if it's not? I think we need to focus on affected others
being able to identify the harm that they're experiencing. (Health promoter, PGF)
We should actually build something for whānau affected by other people's gambling, that might give
them a little report with some suggestions at the end. (Manager/TL, PGF)
If they’re doing it themselves, it’s one thing. But if they’re doing it with friends, family, loved ones, it's
very different. And I think you'd get a different result if that was the case. (Lived experience)
In relation to affected others, key informants also thought it would be helpful to carefully consider the
questions in the screener and provide a report (similar to the gambling). There was a suggestion that it would
be helpful to explore affected other needs to identify the preferred focus of the interaction.
It would be great if family members had a self-help screening tool developed too. Because I really
don't like the screening questions we ask family members at the moment. They're not very sensitive at
all. (Manager/TL, Oasis)
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The other thing is addressing what they’re usually looking for when they talk to us at events.
Obviously, they know someone's got a gambling and it's bothering them – what do I do about it?
Helping them put things into perspective and look at what they can control, who they can seek out, how
they can help that person. (Health promoter, PGF)
Key informants also suggested that affected others should have access to resources that helped them to
understand gambling problems and their role in responding to harm. One participant with lived experience
suggested it was important to provide information on how affected others could support a person with a
gambling problem to change their gambling.
It’s a good idea to have something like resources where whānau can help themselves or to help that
person and what they can do to keep themselves safe. Then the whānau can also understand what the
impacts are, what will happen if they allow the gambling to continue and how to approach the person
with the problem. (Lived experience)
6.14.2. Dissemination
The dissemination of the screener was considered crucial for the screener uptake. In the current COVID-19
environment, where many activities were online, having an e-tool was an advantage, but it needed to be
actively promoted. At the time of evaluation, promotion was undertaken mainly via Facebook advertising and
through regular free Facebook posts. Social media was considered an effective and non-threatening way to
promote the screen.
I know we've got many people because we put a lot of effort into promoting it. Every month we do a
promotion on Facebook, and we have a lot of followers on Facebook so it helps too. It needs
promotion, otherwise it sits here, not really doing much. (Manager/TL, PGF)
When we advertise, the screener gets used more and as soon as we stop advertising it goes down.
Advertising is really important. We need to find other ways to promote it. (Manager/TL, Oasis)
Key informants thought the key component of promotion was involvement of people with lived experience.
This method included presenting stories on the use of the screener and pathways into the service.
You need to use people that actually have this addiction so that they can tell a small part of the story in
some way, shape or form. People can relate to someone who has been there and you can draw in more
people. (Lived experience)
It was stated that other agencies and services had been promoting the screener but there was potential for
more cross-sector collaboration. PGF Services and Salvation Army Oasis had shared the screener with some
other health and community organisations.
We do presentations to other people, services, and communities. The screener is a big part of what we
talk about and get people to go to. As many of our presentations are online we screen share, or make it
a bit more interactive, and get them to go there and have a look for themselves. We often do it at the
end of talks so then they can take their time and go through the tool. It makes it easier for them to also
recommend it or use it alongside any of the whānau or tangata whaiora that they have. (Health
promotor, PGF)
Promote it through the GPs. A lot of people go to the GPs before they've even realized they've got a
gambling problem because people get into the depressive state and they’ll end up talking to the GP
about it. So the GP may say – ‘Maybe you should look at this’. (Lived experience)
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Presenting the screener to communities and consumers directly was another method utilised by gambling
services. Presentations included were formal talks and stalls at community and health events. The screener
was easy to promote using the link as people could check it and complete it at the spot or access it at a later
time.
We presented to the Indian community just before lockdown started in August. We mentioned the
website, and that there were self-help tools on the website. (Manager/TL, Oasis)
Presentations take a long time to kind of get the word out. But it's really important to do, I think.
(Manager/TL, Oasis)
Key informants reported a strong preference to disseminate the screener beyond gambling harm reduction
services. This was because the screener was seen as a way of reaching new people and providing a link into
services. There was a view that dissemination beyond gambling services would be a way to monitor gambling
activity in the local population so that services could adjust and target new or increasing forms of gambling.
There was also discussion on different methods of dissemination such as to mental health, AOD and the
gambling industry.
Our original intention was that the screener would create a new group of clients that would come in
that may never have sought services before. That’s why it needs to be across other services, so that
they can also link clients with experts in gambling harm reduction. (Manager/TL, PGF)
It would be good if it was it was available across the whole of the gambling sector and other sectors as
well like mental health addictions, so that it was something that could be utilized. You'd get a better
idea of really what's going on, if it wasn't just dedicated to gambling services. (Clinician, PGF)
We're not particularly funded to do promotion of new service initiatives. It would be helpful to have
funding to promote it and let people know that it is there and an easy way to talk to us. (Manager/TL,
Oasis)
A further opportunity for promotion was to include information on the screener into the individual plans of all
public health workers, whereby every worker is asked to promote the screener. This would require individual
effort and may take time for everyone to get on board.
As part of our Public Health mahi, we want to talk to other alcohol and drug and mental health
services and promote it as well. (Manager/TL, PGF)
It's about building it into the public health workers plans that when they do their presentations, they
include the link to it. That's work that takes a bit of time for people to come on board with, but I think it
needs to be in those individual public health plans of staff. (Manager/TL, Oasis)
6.14.3. Screener content
Overall, the screener and screener report received very positive feedback from all key informants. They found
the screener and the report to contain useful and helpful information for people with gambling concerns. The
main discussion on this theme centred around the number of questions asked including too little/too much
detail and the look and feel of the screener and report.
The view was that the screener had the right mix of questions and now needed little adjustment. Key
informants noted that the number of items on gambling engagement were laborious because each group of
gambling products was investigated separately. However, there was agreement that this was unavoidable
because identifying each gambling type individually was important. It was agreed that other questions
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around motivation and strengths balanced out extensive questions on gambling consumption and created a
positive overall experience.
There are questions on different gambling modes. It was just a bit laborious, but I'm not sure if you can
change the order of things at all. It gets more interesting when it asks about motivation and impact and
those sorts of things. People will like to reflect upon that. (Manager/TL, Oasis)
The increase of online gambling in response to COVID-19 restrictions, however, made it important to know
whether reported gambling was online or via a traditional mode. There was a view that it would be helpful to
know how people gambled and the extent that it was online.
One of the things that we've really had trouble with is was not knowing whether this is online gambling
or not. It would be good to have a question in there that just says – of the gambling that you've
indicated today, how much of it is online, and maybe a slider 50%, 100%. (Manager/TL, PGF)
Regarding the use of help-seeking data by the gambling services, both used information collected in the
screener as a starting talking point in the session and kept the screener results in each client file. In this
instance, history of help-seeking assisted with an understanding of the client context.
Very useful questions. It's really good to know whether they've tried to control their gaming and what
kind of support was accessed. It is also helpful to know whether they're interested in continuing that or
restarting. (Clinician, Oasis)
There was feedback that the help seeking items could be more clearly defined. For example, the use of the
term professional help seeking was considered ambiguous as it could include online, face-to-face or phone.
There was also a view that professional was associated with mental health issues and would be costly. It was
suggested to replace the word “professional” with “free support services”.
Some people want know that it's a professional and that it's going to be confidential, but then other
people might be put off by the word professional. They might feel that they have to pay or that they're
going to be sitting there with somebody who's going to analyse them. (Manager/TL, PGF)
My only query would be around the word professional. What would that be replaced with, I don't
know. But whether that be a counsellor, or caseworker, or… (Clinician, Oasis)
People with lived experience suggested that the screener could be more impactful if it asked questions around
what effect the person’s gambling has on the other family members. This was viewed as a powerful self-
reflective exercise that could strengthen the screener report by summarising not only the effect on the person,
but on their loved ones. The report could also include quotes or videos of affected others telling their side of
the story.
Affected others need to be able to tell their side of the story. People going to do the survey, they need to
see those videos of affected others. So when they fill in the screener, they can think about how to fix it.
So they don't think about it just affects them, but that it affects other people as well. (Lived experience)
The screener could also include questions for family members to provide feedback to the person who
gambles so the impact on the family is clear.
Even something on the side on the screen – if you want it to be successful, do this with friends or
family. Like this is the effect that it's having not only on your life, but our lives as well. We can't pay the
rent, or we can't pay the mortgage, or we can’t pay for food. We have a problem. (Lived experience)
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The strengths measure received was perceived as important so that the screener was not focused solely on
harm. The strengths screener required the person to select two strengths and later these were included in the
report on strengths that could support gambling change. One key informant suggested the tool could be
adapted so that more strengths could be identified as it provided a balance to focusing on harm.
It's a fantastic question to ask and so important to ask people their strengths, and then prompt self-
reflection. It’s a very positive opportunity for people to really tick as many strengths that they think
they might have. That could be a nice way to feel a bit more secure in yourself after answering some
pretty uncomfortable questions around how much you've been gambling, how many days, and how
much money. (Manager/TL, Oasis)
Just a few technical issues were identified in terms of using the screener. One person noted that some of the
dropdown options needed improvement and another noted that it was difficult to revisit the report at a later
date.
Yeah, so it was good, but I found when you're going to answer the questions and there's the arrow on
the side. If you tap the arrow stuff doesn't drop down. You actually have to tap in the middle, so it
seems kind of odd that the arrow is there, but when you actually tap on that arrow it doesn't bring up
the list of you know your choices of answers. (Lived experience)
We say ‘you might want to go back into your report and see it two days later’. But I don't think that's a
really easy process. (Manager/TL, PGF)
There were mixed views on the layout of the report. Some thought that having the report across multiple
pages was helpful and others thought that it should be one page or at least front and back. Others noted that
interpreting the results required a reasonable proficiency in English language.
When I tested it, the results were over multiple pages online. And it'd be really good if the report was
sort of just like a PDF. You know, front and back of a PDF rather than like this one. (Manager/TL,
PGF)
I think the report is not very well laid out and that so there's probably a lot of improvements that can
be done on the layout of the report and the ease of use. (Manager/TL, Oasis)
It does rely on English reading, obviously. We know this is a research project, we know that there
might be another stage that it could be in other languages, but it does require that you can read
sentences and read quite a lot of information. And I was just wondering that people with English as a
second language with the different alphabet. What that would be like for them? (Manager/TL, Oasis)
Key informants also envisioned that the screener could be expanded to include other health areas such as
alcohol and drug use. If the screener demonstrated utility and effectiveness for gambling, it was considered
reasonable to create a similar e-tool for other addictive or life-style problems (e.g., sugar, caffeine).
Can the screener be done around alcohol? Could it expand into other areas? For alcohol and drugs,
you can test yourself. I know that there is a lot of information online where people could then also test
themselves. (Manager/TL, PGF)
I think doing a survey is great and getting help is great. But after a while you stop seeing your
counsellor. You know, you don't see them forever. It is all the other stuff that gets important and having
some kind of tool would be quite important. Potentially, it could be continually new stuff put on a
digital space as things develop, and as the things are found to be more helpful with the behaviour or
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whatever. Keep adding to it, you know, so the people still can go on it and keep working on their
gambling. (Lived experience)
In regards of the screener language, an important component of the screener was the use of Te Reo Māori. Te
Reo Māori was identified as important during co-design. The implemented screener was viewed positively
for meaningful integration of Te Reo.
I want to add one other thing on having Te Reo in there. I found it was good to introduce a lot of Te
Reo. The screener has a variety of it throughout not just sort of your common kia ora, ngā mihi.
(Health promoter, PGF)
What's fantastic, though, is that the screener has the headings of the questions in Te Reo Māori. The
heading of the question, and then it's in Te Reo Māori underneath. That was good. (Clinician, Oasis)
6.14.4. Enhanced engagement
An important part of the screener and the screener report was look and feel. Overall, the general impression
of the look and feel was positive. There were however extensive comments on how the screener and the
report could be improved. The key informants had numerous suggestions on how to make the screener and
the report more appealing and engaging. For example, it was noted that the graphs that were already included
in the screener were good. Including more diagrams, infographics, images, or even videos could create more
engaging content. A person with lived experience suggested that making the screener more interactive may fit
better with people who gamble.
I think the graphs are so helpful especially the comparison with other people and their annual
spending per year. It was a great visual image but we need more. That’s what actually really hits you.
(Manager/TL, Oasis)
I found the screener items and report pretty plain. It needed to be a lot more visual to keep people
interested. (Clinician, Oasis)
There should be more of an interactive component to it, rather than just asking the questions. Just mix
it up, make it a bit more interactive because gamblers are very visually orientated. (Lived experience)
People with lived experience suggested that the impression of the screener and the screener report could be
more impactful if it included personal stories of people who had problems with gambling and who managed
to take control over it. These stories could be presented as testimonials, quotes, or videos. Stories could have
an impact even on those at lower level of gambling consumption by providing examples of people who
slowly increased their gambling without realising it. It could prompt people to seek help sooner by seeing
real-life examples of gambling and help-seeking. Successful stories of people with lived experience can also
create the positive spirit in the screener, increase motivation, and give people hope.
When people are going through the screener, it would be good to have some content written by a
person with lived experience. That way you know it's not just coming from a survey type of thing.
Actually, there are people like this out there, and this is what in this situation happening to them. So
that way you might have some more impact as well. (Lived experience)
I think we need to add stories of people that have been through the journey and come out the other
side. People who have accessed the site, and used it, and this has been the beginning of their journey
through in to recovery. (Lived experience)
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There were multiple suggestions on how to enhance engagement with the screener. This included having
more interactive and visual content with fewer words as well as more links, images and immediate self-help
options. Participants also thought that translation into other languages would be meaningful so that it could be
disseminated to other gambling harm reduction services (e.g., Asian Family Services).
I just think we're in the 21st century, yet the screener is done like of bricks and mortar. The
interactivity is the key. It needs to be more interactive, better options, images, videos, links. Better
timeliness, immediate response. (Lived experience)
It is really good to have it in other languages. You know, Māori, some of the Pacific ones, maybe some
of the Asian ones in a later date. (Manager/TL, Oasis)
Key informants perceived other opportunities to introduce a seamless user experience around instant
connection with the service. Suggested options included being able to call, chat, message at a click or even to
be linked to a forum straight away. These options could apply to counsellors and peer support people.
If you're using a phone, it would be good to go ‘click to call’ and not have to copy it and go over
somewhere else. It would be nice to have full integration. (Health promoter, PGF)
There was a view that the screener could have add-ons such as self-help or a discussion board that could
provide an immediate 24/7 response. One way to add value and start a conversation would be to offer
materials via a website that the counsellors could also support.
If a person does the screener but doesn't want help, they can click on those links and start working on
some of those things. You know, because some people are private. There's a lot of embarrassment
around gambling. But if people have those links, so people can go to do that. You're doing a bit of this,
you're doing a bit of homework type of things. And if they're inactive for a while, they get a prompt
saying hey you haven't being doing it for a while or just checking how are you. (Lived experience)
Online forums could be a safe space. I think it is important for a lot of people that when they are
talking about gambling that they are in a safe space where it is safe to share. (Lived experience)
In terms of delivery there were different views on the most preferred mode. Some thought that the tool
needed to be integrated into a smart phone app especially where other service options were added. There was
also support for chatbot options that could enhance engagement with the app or website.
I think it should be an app. I think it should have these graphics other people were talking about, and
then it will become an interactive app. It’s going to entice people to go and have a look at it – oh,
what’s this about? (Lived experience)
A chatbot would be great! I use a quit smoking site that uses Facebook Messenger to message me every
day at particular times. It's got an avatar you got to pick, and messages that say – hey, how your
cravings, how are you doing? Here's some tips, here's a space to vent, and dump it when you're done.
You know, and the other thing is, it doesn't tell you to quit actually, it's just helping you to manage your
cravings, cut it down, wherever you are at in terms of your journey. I found that very helpful. That
could be an extension to doing the screener. (Health promoter, PGF)
6.14.5. Pathways into services
Key informants said the options to access a pathway into the service was helpful. There was a view that the
positioning at the end of the report made sense and did not create discomfort as to whether help should be
sought.
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I was actually alright with the help-seeking questions and I didn't feel like I would hate to hear about
seeking help if I didn't want to. (Lived experience)
It's great the way it links someone when they read their summary report, what the results have been in
a comparison to the average, and then their answer to the question “have you ever sought help?” and
“do you want help now?” I just think that's a great amount of information to sit with. And going -
okay, I may need help. (Clinician, Oasis)
The screener was established with escalation options in terms of talking over results with an expert. Options
included contact by email, phone call, and in-person. There was a general view that these options covered the
most commonly used means of communication, provided a good choice to potential clients, and worked well
for clinicians who contacted people who requested support.
I think the current contact options are fine. I think that covers all the bases in terms of reply options.
That seems logical to me. (Clinician, PGF)
That's enough information to make contact and it's a way of contacting that they're comfortable with.
Not everybody is comfortable with a phone call, so emails are good. If it's in person, it's even better. It
works well for our caseworkers to be able to follow up with them and to offer the support that they
need. (Clinician, Oasis)
The gambling services were particularly concerned about the pathways options that could be limiting due to
personal circumstances. For example, contact over a telephone might not work for some people if they do not
have credit, or they cannot answer a phone when at work. For these people, an email option might be
preferred. On the other hand, the phone option in the existing pathways could be widened as phones are not
limited to making a call. Even though people could request a text message, the options of texting and
messaging using other apps (e.g., Facebook or WhatsApp) could be emphasised in the screener. Similarly, in-
person appointments could be offered via video call (e.g., on Zoom) if the person cannot get to the services
physically.
It's generally the phone numbers that are difficult. People don't have credit on their phones, or they
aren't able to be contacted because they're working or whatever, and they don't have their phones with
them. (Clinician, Oasis)
Maybe we should add when people select phone that they can choose call or text. I wonder if that
would make a difference to uptake. (Manager/TL, Oasis)
WhatsApp and Facebook Messenger. Yeah, that's a goodie for consults. (Manager/TL, Oasis)
It was also noted that services recently started to offer chat on their respective websites. The nature of chat is
that it is inbound unless an appointment had been scheduled which limited the option of discussing results.
Services also noted that chat was only available during specific hours so it was challenging to find a way to
offer it as part of the screener but then also let people know that it had limited hours of operation.
We've now got the online chat feature on our website… I don't think the chat function stays visible, they
have to go back to PGF services. (Health promotor, PGF)
I definitely think chat, linking things to chat if available. So it has to be something like “chat”, and
then in brackets "if within hours available" or something like that. Just so they know, there may not be
somebody there on the chat or it won't work if there's nobody there, you know, on the chat function. If
they link to our chat and chat is available, then they'll be able to talk straight to us or there'll be a
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message saying “we're offline at the moment, leave your contact details”. I think link to the chat is
appropriate and something like that should be added. (Manager/TL, Oasis)
The only problem with chat is that we can't contact them, they have to contact us first. So we can't
contact them on chat unless they're online, and wanting to be talked to on chat. So that makes it
difficult. (Clinician, Oasis)
People with lived experience suggested adding a pathway that involved peer support. This would be where
the person could request contact by a person with lived experience rather than a clinician. The modes of
connecting with peer support could include the same options of a phone, email, chat, one-on-one in person,
but could also include more anonymous options like a forum or in-person options like group sessions or
community groups.
At the end of the report, you've got the options of talking to a counsellor via phone or whatever, but
there's also an option there to talk to somebody who has lived experience. So you can talk to somebody
that's been through the same thing, or going through it. (Lived experience)
Immediacy of a response from the service was regarded crucial for a successful pathway. Although the
person has an opportunity to contact the services directly any time, it was suggested that contact should
happen as soon as possible after the request is made. Considering human resources constrains, automatic
emails or messages were an option as well as having tools like forums that can be available 24/7.
You want to be able to contact them while they're in their thought process. They have just done the
screener. They decided – I need help. So get them when they are in the right frame of mind, not two
days later, or whatever the time frame is actually. (Lived experience)
My concern is the turnaround time typically from when it's submitted as to when it's responded.
Because if that happens on a Friday night, for example, there's no way that they would be seen before
Monday or even sometime next week. (Lived experience)
6.14.6. Administration
Key informants across service providers identified a range of administration issues including ongoing
funding, client management system and reporting and professional development. There was broad support for
the continued delivery of the screener beyond the research project. Key informants reported that the tool
appeared to meet its objective of attracting new clients into the service and reaching a cohort that previously
did not connect. The main reasons it worked appeared to be related to it being a low intensity option that was
easy to access and created an easy opportunity to reach out for more support.
I think it the screener definitely needs to continue. I think its capturing people that wouldn't normally
contact our service. And it's giving them an opportunity to contact the service outside of normal work
hours, which is helpful, because it's capturing them when they're in the most need. (Clinician, Oasis)
My recommendations would be to continue this project and to do the e-gambling modules, because I
think we need that as another tool. The chat and the screener is really the first step that we have made.
(Manager/TL, Oasis)
Interviews identified concerns about how the tool would be funded beyond the life of the research project.
Funding was required to update the tool, generate reports and respond to changing sector needs. There was an
understanding that the screener cannot continue operating without ongoing support from the Ministry of
Health and that it would be impossible to improve or promote the screener without additional funding. Key
informants thought that the screener could be funded as part of their normal contractual obligations.
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Depending on the cost, it should be part of our contract. The ministry should be supporting it on an
ongoing basis and it should be part of our set of client tools. (Manager/TL, Oasis)
I think it should be part of the funding that the ministry provides because it is another tool for
engaging those gamblers that are reluctant to seek help. (Clinician, Oasis)
There was concern as to where the tool would be hosted in the future. The tool had been developed to be
specific to the needs of the service and there was reluctance to share the tool because it was a result of
extensive collaboration. Key informants expressed concern that the tool that was developed by services
would be relocated and subsumed by HPA or the Gambling Helpline.
I wondered about an overarching group like HPA having our screen and promoting it as part of a
range of e-health tools. We’ve done a lot of work with our own brand to bring people to our screener
and it is working to bring in new clients. If it goes to HPA then the screener just becomes another
government tool and loses the personalisation of being a step into our service. (Manager/TL, PGF)
At the same time, there was a concern among the gambling services that the screener and similar e-tools can
be under-utilised by locking them with health organisations that do not specialise in gambling treatment like
Te Hiringa Hauora or Health Promotion Agency. In previous discussions, services suggested that other
agencies could promote the screener and host it on their websites, however, they thought that the screener
needs to have a direct pathway into the gambling treatment services such as PGF Services and Salvation
Army Oasis.
We know there is very low referral rates from the Gambling Helpline. I would hate to see the screener
go somewhere like the Gambling Helpline or the Health Promotion Agency, because it was built for us
and I think it's a really good pathway into specialist gambling services. We need these sorts of tools to
get people linked into the specialist gambling services. (Manager/TL, Oasis)
There was however a view that providing links to the screener on other sites such as Choice not Chance
(HPA) would be a way of linking gamblers to services.
The HPA website gets the bulk of the funding. People are directed to that website to find out about
gambling counselling services. It would be good if the links are on there. (Manager/TL, Oasis)
Choice not Chance website are not a treatment service. They could promote the screener with links to
both Oasis and PGF. People could choose maybe which one they want to do. (Manager/TL, PGF)
A basic client management system was established so that services could track and respond to new client
requests. Overall, the client management system worked but multiple areas were identified for improvement.
When first developed the system only permitted services to ‘view’ new clients but this was considered
difficult to manage and as such new functions were added where services could add notes to each client
request.
The system is pretty good because it gives keeps all of the information that's entered. It functions all
right and works but it's functional and basic. (Clinician, Oasis)
If we could add, if it went a different colour if you've clicked on it and have forwarded that information
on for referral or the tick button that you could tick, that you've actually read it and that's been dealt
with. That sort of thing. (Manager/TL, Oasis)
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Information currently provided includes all data entered by participants, but the actual report provided is not
available to services. One manager/TL noted that participants were prompted to discuss their report but not
seeing the comparison data restricted this discussion.
We don't see the whole report that the person sees. So it's difficult for us to talk to the person about
how they compare to the rest of Aotearoa. It would be good to be able to see that. (Manager/TL, PGF)
The current client management system was a low-cost option intended to provide basic information. Services
suggested that much more could be done to streamline information into the service to save both the client and
service time transferring the results into various data collection repositories. Having a version of the results as
a PDF or word document would also improve the process of referral.
When I'm downloading that information, I copy and paste onto a Word document and send that as a
referral to our centres. So if there could be a way that we just download it, that would be easier. Or a
PDF? (Manager/TL, Oasis)
Participants were asked to comment on access to data and reporting options. Options included being able to
generate a simple report, having access to an annual summary as well as access to specific client
characteristics such as age and ethnicity.
Data is so important and we don't get enough of it. A report would be really helpful. It's great for our
services and teams and people that are using it to see that it's being used. And it's just good
information. And that also to promote our services, and clients will probably be interested in numbers
in it too. (Manager/TL, Oasis)
I can look at the data and do a little bit with the spreadsheet, but it would be good to have some more
analysis of it. Maybe annually or something. Because there's heaps in there, there is absolutely heaps.
We would be interested in ethnicity, age and location especially the regional areas. There's so much
that could be done. (Manager/TL, PGF)
We use that data in our own reporting on our own services. Being able to have that information about
how many people are using the screener, and how many people are actually being referred through, at
a very basic level. That's information that we need for our reporting. (Manager/TL, Oasis)
Ethnicity data, PGSI screening numbers or just categories of low medium high would be helpful to give
a bit of an understanding who's using the screener. Are there people that are coming through that have
never sought services before? There are a lot of those sorts of things that would be interesting. What
type of people are using it? And also help us figure out how to promote it better. (Manager/TL, Oasis)
There was also a view that the data entered into the screener was a useful snapshot of gambling harm in New
Zealand. Because the screener was accessed by people with varying levels of gambling severity it could
identify new and emerging problems as they developed.
The screener could shine a light on how much actual harm is in the communities. At the moment, all
we do to find out how much harm there is we look at our stats, which is most people don't ever seek
help. And then the other stats we look at is through the HPA survey, where people won't admit how
much harm they're doing. Because they're being interviewed. (Health promoter, PGF)
Key informants pointed to the importance of using collected data to evaluate the tool. Some suggested that it
was a way of determining if the tool was having an impact. This included a better understanding of where
people dropped out of the screener as well as the overall experience of having completed the screener.
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You want to know how many people have completed the screening tool. How many anonymous and
how many are reluctant to get help at this point in time. This can go on as evidence for the tool
working. (Manager/TL, Oasis)
I think the point we're making is about getting feedback from tangata whaiora. We need to know what
it's like for people to do the screener. Is this something that you go – Oh, God, that was hard work, but
I did it because I really, I knew, I really need to change or is it something that they felt like was really
helpful in terms of getting awareness and understanding about what they're doing? (Manager/TL,
PGF)
It'd be good to know, at some stage where people drop out at any time. And, if we're able to capture
that, people that started and don't finish it. (Manager/TL, PGF)
One manager highlighted the importance of counting the work on the screener as a brief intervention. Others
suggested that it was important to evaluate the impact of the screener over the longer term. This included the
impact for those who used the screener as a brief intervention as well as those who used the screener and
continued on to access the service.
I think I think it's a really important piece of work. And I think there's a lot to it, and we do need to
expand it. And we still need to capture the data from it and make sure that we can do, you know, do it
properly. It does need a bit of work to count it as a brief intervention, and I think we need to make it
count. (Manager/TL, PGF)
As a bigger rollout for the future, look at the results year or two years’ time. How many lives have
been changed? What’s the effectiveness of peer support? What could you do with that? How do they do
it? (Lived experience)
The gambling services received two types of training during development of the e-tool. One training was
directly on how to use the screener and another was on building counsellors’ skills around e-health delivery
in general. Regarding the screener training, the services suggested that in the future, the training should
include a one-page of information on the screener and a practical element where each new counsellor would
complete the screener to understand it first-hand. For duty counsellors and those responsible for data
management and referrals, there is a need for more detailed training on how to work with the dataset.
It would be helpful to have a one pager or something around what the screener is and the areas that
it's screening that could be part of an induction pack for new staff. (Manager/TL, Oasis)
There was a view that training and information resources would be needed if the screener was to be offered
through other health organisations.
If we are able to extend the reach of the screener, we would need to make sure these services are
trained on how to use and interpret the results. (Health promoter, PGF)
It would be money well-invested by the Ministry of Health to train people with lived experience to
promote and deliver the screener. (Lived experience)
There was a suggestion that the training modules in e-health could be extended to include induction on the
screener. The training modules continued to be used especially for new staff as a way of orientating people to
e-health methods.
I still use the training that was provided on Slack. I send all our new staff, new counsellors to the site
and get them to do it. We had to upskill our team to get used to e-Health methods. How to do email,
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how to do live chat because it all happened at once and the screener did come afterwards. It's a
different way of working when you're used to just doing face to face counselling. And I do think it's an
important part, if this screening tool rolls out to other services that they also get that sort of level of
support and training. (Manager/TL, PGF)
Evaluation of the i-CBT prototype
An evaluation of the i-CBT prototype that was built with gambling services was conducted via Qualtrics in
December, 2021. The evaluation included six open text questions which evaluated conceptual acceptance,
user experience and ideas for further refinement and enhancement. Twenty-one service providers and
consumers conducted the evaluation including 14 health professionals (counsellors, case workers, health
promoters, and managers from gambling services), 5 people with lived experience of gambling, and 2 people
affected by someone else’s gambling (i.e., affected other). Open-text survey data were analysed using
thematic analysis (104, 105) similar to Phase II qualitative data analysis procedures. As indicated in Table 48,
themes emerged associated with i-CBT impact, content, delivery, blending, service model and administration.
Table 48. Summary of evaluation of i-CBT prototype
Theme
Description of findings
i-CBT impact
The i-CBT prototype has the potential to impact on gambling harm. It was deemed
suitable for most clients because it is easy to use and provides access to extensive
information and insight.
i-CBT content
Content was considered comprehensive, broad and relevant to people who want to
change their gambling. Enhancement of content focused on new forms of
gambling/gaming and a stronger focus on maintaining cultural safety and practices.
Additional content included daily gratitude and self-monitoring.
i-CBT delivery
Content delivery via the prototype was considered broadly clear and easy to access.
There was a call for more interactive activities, fewer words and more video or audio
content that could be delivered by counsellors. Navigation according to pathway was
supported but this should be tailored by assessment with the capacity to recommend
activities from across different pathways. Useful enhancements to delivery could
include smart phone delivery, daily messages, and a support forum. There were
strong calls for a version of the prototype for affected others and whānau.
i-CBT blending
A communication loop was considered beneficial as was the client notepad, prompt
for reflection and option to discuss further with a counsellor. Clear instructions on
how to use and the rationale for the novel approach should be provided. Blending
was seen to reinforce in-person treatment and to provide the client access to more
information on difficult or complex concepts (e.g., abstinence violation effect).
There was a preference to develop a checklist and other resources that could guide
the selection and completion of content.
i-CBT administration
Administration focused on establishing expectations on the frequency and
responsivity to client requests. Training opportunities were identified specifically
related to the variety of activities. Continued co-design of activities and website
features was desirable.
i-CBT service model
The i-CBT prototype was developed to meet in-person service needs which focused
on a blended approach to delivery. Other types of self-help should be developed for
delivery as standalone treatment.
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6.15.1. i-CBT impact
The i-CBT prototype was developed according to specifications identified in the needs analysis and Hui,
conducted during Phases I and II. The prototype was perceived as helpful in terms of reducing gambling
harm. Key informants also reported that the tool would add value to the service and were enthusiastic about
opportunities to promote the tool.
Such an inspirational tool that I know tāngata whaiora are really going to get some benefit from. So
up with the current age. Very impressed, fantastic work! (Counsellor, PGF)
This is an excellent tool. I believe it will add value to clients, gambling counsellors and for reducing
gambling harm reduction. I feel excited about this tool and look forward to promoting it. (Health
promoter, PGF)
I found this a great website, with tools that would be helpful to gain a greater understanding of my
behaviours and how to work with them to be free from gambling harm. (Counsellor, PGF)
For gambling counsellors, it is useful to have another tool up our sleeve for the client to take away
and use between sessions. (Counsellor, Oasis)
This provides more options to add to our intervention tools to reduce gambling harm with easy
access for clients. (Manager/TL, Oasis)
Key informants stated the i-CBT prototype made the content of counselling highly accessible. This was
because it was easy to use, easy to understand, interesting and helpful. There was some concern that it would
not be suitable for all clients, but overall the perception was that it would work for many clients and
counsellors because it contained useful insight and information.
This is very accessible and therefore could go a long way to gambling harm reduction. (Counsellor,
Oasis)
The content is excellent. Easy to comprehend and interesting. (Health promoter, PGF)
I think it does in having a wide range of tools to support clients with, as well as being able to have
access all in one place. (Counsellor, PGF)
I think it is great. I imagine there will be some clients who it will not appeal to, however I think those
that it does would find it relatively straight forward to use, and helpful. (Health promoter, PGF)
There are some useful insights, information and tools available on this website. Any tool really can
be helpful. During a pandemic doubly useful. (Counsellor, Oasis)
It allows client access outside of sessions and ability to reflect on their own gambling when it suits
them with support from a gambling counsellor in session as required. (Manager/TL, Oasis)
6.15.2. i-CBT content
i-CBT content was organized according to gambling motives and included behavioural, escape (coping) and
action (enhancement). Across the sample there was a view that the content of the prototype was
comprehensive and covered a broad range of information and topics. There was also a view that while the
content focused on gambling, it took a holistic and strengths-based approach.
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It is excellent that the content is broad enough to cover common gambling behaviours and treatment
pathways are tailored specifically to support those behaviours and actions – very comprehensive
approach. (Manager/TL, Oasis)
I like that there is a wide variety of topics and activities. I think this can help clients not only to focus
on their gambling but in other aspects of their life which could provide a strength-based perspective.
(Health promoter, Oasis)
I like the three pathways as we know as gamblers these are the three common ones that stand out in
our space. I know that we need more advice on the mental side as we know that gambling is a
disease. (Lived experience)
I think so as it is a multi-faceted approach to wellbeing. I think one on one counselling is still the
gold standard with dealing with harm, but things like this can help with that process and move things
along, as well as have tools people can share with others to increase general wellbeing. (Counsellor,
PGF)
Informants commented on specific content that they liked or thought could be improved. Overall, there was
good support for the written and audio/visual content. Minor suggestions were made on swapping out the
video on the abstinence violation effect, adding a budget template and including a greater focus on online
gambling. There were also multiple informants that noted most of the activities were focused on individuals
and could be extended to include a greater family and community focus.
I didn't like the explanation on the video with Dr. Katz - Abstinence Violation Effect - all the other
videos were awesome. (Counsellor, PGF)
This would also be an effective tool for Family and Affected Other clients but would need to be
tailored specifically to their needs or add in more information on impacts on family and whanau and
community. (Manager/TL, Oasis)
I noticed that most of the themes/activities come from an individualistic perspective -there are not
many activities about engaging with the community and the culture, social interactions or finding
purpose. The only ones are mainly focused on the money expenditure and not on their positive
aspects/consequences. (Counsellor, PGF)
The content for the iCBT program included first and second wave CBT (i.e., behavioural and cognitive)
strategies, as well as strategies from third-wave CBT interventions, such as Acceptance and Commitment
Therapy and Dialectical Behaviour Therapy. These third-wave activities were included predominantly in
pathways 2 and 3. Suggestions for enhancing the content included new topics, such as the convergence of
gaming and gambling and its potential harm. Other suggestions for improvement included additional options
for urge management, such as the website providing in-the-moment distraction to be used when there is an
urge to gamble. There was also a suggestion that prompts for daily gratitude would be helpful. One informant
suggested inclusion of a karakia or waiata could be helpful, particularly as a way of connecting to daily
activities and to maintain cultural safety.
Have a karakia or waiata or some way of maintaining cultural safety and practices while doing the
activities. I’m not sure where or how, but I am happy to ponder the inclusion of this aspect as I am
not sure if the tool is to be used with the counsellor or on their own. Maybe a prompt to remember
wairuatanga or if they need to do something mindful after completed a heavy kaupapa like mapping
your spend. (Health Promoter, PGF)
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6.15.3. i-CBT delivery
There was a positive response to the prototype look and feel as well as website features. The overall feel was
reported as user friendly and non-judgemental. The delivery of content was accessible because it was
provided in small chunks of information.
It looks really good. It's not judgemental, gives facts about gambling harm without blame or saying,
'you have a problem.' (Health promoter, Oasis)
The website tool is very user-friendly and easy to understand and engage with. (Manager/TL, Oasis)
This tool is very easy to use, the graphics are clear and the wording is clear. (Counsellor, Oasis)
The information is provided in bite-size chunks and the language is mostly accessible. (Manager/TL,
PGF)
Some informants thought that the amount of written content could be lessened. Health promoters and those
with lived experience perceived some of the written content as wordy and a lot of reading and writing. The
prototype contained extensive audio/visual content to reinforce the written text. This audio/visual content was
perceived as helpful and there were many requests for more audio/visual content. Multiple informants
suggested opportunities for counsellors to be integrated into the prototype through the delivery of
audio/visual options. For example, having counsellors involved in explaining activities was considered useful
for engagement.
Maybe too much text versus videos - everyone has a short attention span nowadays and I'm sure
clients would be experiencing this even more as their dopamine levels reset post gambling.
(Manager/TL, PGF)
There is a lot of information and words and I think this could be improved by simplifying and
summarizing. Perhaps adding some videos with a counsellor speaking could be a good idea to reduce
some text and make it easier? Or perhaps presenting one text box at a time instead of all at once? To
help the client focus. (Health promoter, Oasis)
Generally, the prototype navigation was easy to use but could be improved. Website content was organized
by pathway with the intention that clients and counsellors would work together in session to determine the
best pathway and set of activities. Consistently however, there was a view that clients were likely to need or
want options from more than one pathway. One option was to have an overview of all of the content in one
place to aid activity selection. Others suggested it would be helpful to include a self-assessment that would
provide guidance on the activities most suited to the person.
Navigation from topics/kaupapa to activity hei mahi is simple, smooth, easy to understand visually
and I liked the short caption/summary provided and simple colour blocks. (Health promoter, PGF)
It would be helpful to have a navigation overview so all content to be viewed and counsellors and
clients could select topics that would be helpful or relevant to discussion in-session. (Manager/TL,
Oasis).
It may be helpful to have one headline page that lists everything in one place. You do have to click
around into each module to see what is available, which might be confusing for some people who
may not have the patience to click around into each module to see what exercises are behind the title.
(Counsellor, Oasis)
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I think it needs to be stressed that the ‘how to use this site’ is the starting point or otherwise things
just won’t make sense and may make people feel overwhelmed. (Counsellor, PGF)
When asked about ways to improve delivery of the content, informants suggested a range of different options.
These options included delivery via smartphone app or messaging. For example, multiple participants
suggested a smartphone app could make the content more accessible. There was a view that smartphone
delivery would also allow for the content to be supported by other website features such as self-monitoring of
gambling and gambling triggers.
Mobile apps would be interesting, mainly to make it easier for clients to record expenditure,
gambling sessions, triggers that they identify. (Health promoter, Oasis)
I think an app would be ideal as then a person can use it easily anywhere anytime - while they are
sitting outside a pub thinking about going to gamble and it could be just the thing to stop them.
(Lived experience)
There was also a view that i-CBT engagement would be supported through sharing with others in a similar
situation. Multiple participants suggested that a forum or message board would be helpful but that it would
need to be carefully monitored.
I think if there was a way people with a gambling issue could communicate with others that have the
same issue or are in recovery, it may help more people to realise they are normal and they can lead a
better life and stop gambling. (Lived experience)
A forum would be great, but it would need to be regularly moderated. A lot of mental health users
and addiction online groups can become hotspots for misinformation, re-victimisation and
conspiracy theories, so effective and efficient moderation is key. (Health promoter, PGF)
Other suggestions for increasing engagement with content was to have daily motivational, notifications or
other messages. These could be delivered via a smartphone app or social media messaging. Others considered
it important to have the content available in booklet form or offline for those who were not able to access the
internet.
There is a small chance that some clients could have difficulty accessing online content. If there was
an option of a printable workbook, that might be helpful - clients could record questions they want to
ask the counsellor or what they want to talk about next session in between attending telephone or
face to face sessions. I appreciate that is moving in the opposite direction intended by making an e-
module! (Counsellor, Oasis)
There was also a strong call for content that was specifically for affected others and whānau of people with
gambling problems. This call was in terms of helping the person impacted by another person’s gambling as
well as ways that the family could help someone with a gambling problem.
Content for people like me, not gambling but my life a mess because of gambling. I feel like I have a
little bit better understanding from reading the questions, suggestions for my husband. Maybe we can
do them together with our counsellor. (Lived experience – affected other)
This tool could be a good tool for family and whanau but needs to be developed specifically for this
client group (Manager/TL, Oasis)
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It would be good to have the option for whaanau to do this with me or some of it at least and are
there activities for my whaanau to deal with the harm they are experiencing? (Lived experience –
affected other)
6.15.4. i-CBT blending
The i-CBT prototype was designed to be blended with in-person counselling work. Key informants liked the
different aspects of the prototype that supported blending. These elements included the client activity
notepad, activity reflection prompt and the option to discuss the activity with a counsellor.
Really love the set-up, ease of use and whole concept. (Counsellor, Oasis)
This communication loop seems very effective - I can't think of a way to improve it. (Counsellor,
Oasis)
Excellent use of the notes in each activity, then going to the plan section and interacting with your
counsellor. (Health promoter, PGF)
The notepad on each activity page prompts clients to write about their experiences of the activity. Informants
stated that they thought this would be a good way to prompt clients to reflect and remember each activity.
Others stated that being able to make notes for later discussion during counselling was helpful. Importantly,
one person with lived experience stated that feedback from their counsellor would be a reason to log back
into the website.
I also really like the centralised note pad and save centre - it can make it much easier to go back,
reflect and remember what you have worked on. I imagine it will help with the clinicians to see where
their clients are at. (Health promoter, PGF)
The ability for client reflection within the modules is fantastic and can be used to enhance interaction
in counselling by reviewing in sessions or providing feedback online. (Manager/TL, Oasis)
I know I sometimes want to send my counsellor a message on something I would like to discuss, so
having a system to do that, that also allows the counsellor to access when they can/during our
session, would be very helpful. (Lived experience)
I like being able to log back in and find a response from my counsellor. (Lived experience)
Minor changes to the presentation were also suggested including changing the font of the notepad and
increasing the size of the counsellor feedback request box. Some informants not working directly with clients
thought the communication channel was a bit complex. For example, the wording of these prompts was
provided in a motivational interviewing style (i.e., starting with what and how rather than why and presenting
one prompt at a time) and was intended to prompt deeper reflection on the content. Similarly, the intervention
purposely separated the notepad from the deeper reflection work so that clients would be promoted to revisit
the activity and reflect again on the take home messages.
I consider communication channel is a good idea but perhaps it is a bit complex. There is a lot of
information and words and I think this could be improved by simplifying and summarizing. (Health
promotion, Oasis)
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I think the 3 questions: "Activity notes", "What to discuss with my counsellor" and "How this activity
can be helpful for me" could be reduced to one or two at least. (Health promoter, PGF)
From the activities' tab you only answer the activity notes and then you have to go to My Profile tab
to complete the other two questions which makes you spend more time and makes it harder for the
client. This should be either reduced as I said before, or enable the client to answer the questions
during the activity. (Counsellor, PGF)
Informants stated that the i-CBT prototype provided an excellent resource to support engagement with
treatment between in-person sessions. There was a suggestion that it might only appeal to clients who are
highly motivated, and this does speak to the importance of ensuring that the selection of content is driven by
both client and counsellor.
This helps as it makes it all in one place and are things I can do in between sessions. (Lived
experience)
I think some clients will use this that are very motivated and want something to do, activities, between
counselling sessions. (Counsellor, Oasis)
It gives plenty of different avenues so there would almost always be one that suits a particular client.
(Counsellor, Oasis)
This tool summarises a lot of very useful exercises and gives good ideas for where to go with clients if
stuck. (Counsellor, Oasis)
Importantly, the i-CBT prototype content and in-person treatment were viewed as complementary.
Informants stated that i-CBT content could reinforce in-person discussions and provided a different way for
clients to reflect on how thoughts impacted on gambling behaviour. Two informants also reported that the
prototype could be a way of keeping track of treatment content to ensure critical concepts are covered during
treatment.
If a client does not remember/ fully understand something that was discussed, they can use this tool
to read as many times as they need. (Counsellor, PGF)
Therapy in sessions could be reinforced through client work and reflection through the modules or
vice versa. (Manager/TL, Oasis).
Positively reinforces what may be discussed in a counselling session. (Counsellor, PGF)
It could also be a good way to keep track of and practice tools that have been discussed in in person
with a therapist. (Counsellor, PGF)
6.15.5. i-CBT Administration
There were multiple comments on administration related to communication between clients and counsellors.
When offering a blended approach, informants noted it would be important to manage client expectations on
the frequency and response time to requests for discussion. Because the tool was developed for use in
counselling sessions, it was expected that response times would be negotiated as part of treatment. Informants
noted the importance of being clear as to what would happen when the counsellor was away on leave or out
of office.
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How would you balance time between them expecting a counsellor to see they have seen their mahi
and the next session (negotiate it per case maybe?) (Health promoter, PGF)
When it is sent to a counsellor, do they get an out of office response if their counsellor is away? I
couldn't see that function. (Counsellor, PGF)
The concern related to response times was, in part, informed by the service model. Some informants assumed
that i-CBT would be offered as standalone and therefore would need the option of an out of office message.
Others considered it important to have contact information where i-CBT was used as relapse prevention. In
this case, i-CBT would be offered after treatment and provide an easy way to stay in contact with a counsellor
over the longer term.
It would be ideal if my profile was linked to my counsellor and a prompt shows up at their end when
I’ve been using the program. They may see changes in behaviour and discuss this with me. We can
become complacent over time with our gambling which can lead to lapses that could be prevented.
(Lived experience)
There were multiple comments related to counsellor notification of client activity. Based on stakeholder
feedback during the survey/hui, counsellors did not want to monitor engagement, but preferred a tool that
clients could engage with and discuss with counsellors, as was needed. As such, the website was set up so
that counsellors would be notified when clients requested a discussion on a particular activity. This approach
ensured client autonomy as well as reduced burden on counsellors to review or monitor client engagement.
Key informants highlighted a need for clear information on client and counsellor roles when using i-CBT
with in-person treatment.
Do you have to send them a message for them to notice that you have completed this or do they
automatically get a notification when you finish and activity? That might be a lot of notifications for
counsellors. It might just have to be part of practice to review the activities/profiles of tangata whai
ora before you see the client. (Health promoter, PGF)
It is not clear what the counsellor sees and how a client sends counsellors a message. It looks like in
the pathway module the client can write a note to themselves - this saves to draft activities but not
sure if the counsellor can see this and there is nothing to indicate to the client that the counsellor will
or won't see it. (Manager/TL, PGF)
Key informants highlighted a need for training and ongoing professional development. Training was required
on how to use the i-CBT as part of a blended model – especially for new counsellors who were not part of the
co-design process and therefore did not have background knowledge of the project. There were also
comments that the CBT content was an ideal learning tool for new gambling counsellors.
Perhaps for counsellors, links to workforce development, for further knowledge on specific topics.
(Manager/TL, PGF)
There is a need for ongoing training on understanding the Blended Therapy model and use of website
modules – particularly for new staff on-boarding. (Manager/TL, Oasis)
I did not figure out how this actually worked. It looks like clients and counsellors need to invest some
time into understanding how this website works. (Counsellor, Oasis)
Multiple informants noted the importance of maintaining the website if it became part of routine service
delivery. Maintenance requirements were not limited to website functionality, but also to include the
continued co-design of activities.
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Leave it open for feedback, regular reviewing and incorporating new activities or pathways would
ensure it remains useful and responsive. (Health promoter, PGF)
6.15.6. i-CBT Service model
The i-CBT prototype was developed in response to client and counsellor need for in-person services. There
was broad support for the use of a blended approach because i-CBT could extend and enhance in-person
treatment. There was recognition that a blended approach was important because people with gambling
problems appeared to benefit from a person-to-person interaction.
In my opinion, the solution in this website is concentrating on the individual and individual
completing activities with a counsellor (which is a start). The individual cannot get out of the
addictive cycle on their own. The chronic gambler needs a lot of support. This seems like an
individualistic solution (with some input form a counsellor). I believe a gambler needs a lot more
support than this for a sustainable recovery. (Lived experience)
Any tool is really helpful for clients and counsellors to use and this one is no different. The inclusion
of a counsellor in this process is a start, gambling is isolating and usually done in isolation. (Lived
experience)
There was a view that i-CBT could be offered to new clients as a way of getting started. Some suggested that
the program could be provided to clients as an early step in a stepped care approach and for those not yet
comfortable talking to a counsellor.
I think this tool is great and when new people come into a service could be given this as work to do to
help themselves. (Health promoter, PGF)
I feel this would add value to clients who like to explore things in their own time or clients who don't
feel comfortable discussing their issues with a therapist for some reason. (Lived experience)
Others highlighted limitations with having i-CBT as a standalone treatment. The intervention was developed
specifically as a blended approach and therefore contained a high proportion of activities that are unlikely to
be suitable if utilised as a standalone option. In line with stakeholder support for the blended treatment model,
the activities overall were designed to be delivered with a counsellor, whereby activities would be discussed
between clients and counsellors in-person.
Even though it is great to have a wide range of activities, it can be overwhelming and discouraging
for clients. Maybe reducing wording and some gradual exposure to activities could be helpful.
(Counsellor, Oasis)
To gain the best outcome for clients this should be used in conjunction with the counsellor to help
guide the client in topics and gaining a deeper understanding for the client – it enhances our work
together. (Manager/TL, Oasis)
It's easy to forget the intention to have the counsellor and client together work through the modules
together, rather than use them for homework, due to the ability to leave notes to the counsellor. Be
good to clarify the purpose and whether it is self-help or blended support as this would influence the
design of an app and how we move onto the next stage. (Manager/TL, PGF)
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8. Recommendations and conclusions
This project team successfully completed a program of work that included examining workforce readiness,
needs and preferences for e-mental health as well as the development, implementation and evaluation of two
e-mental health prototypes. The work commenced pre-COVID-19 and indicated that gambling treatment
services were ready and able to provide treatment via technology. Service providers were already using a
range of e-mental health tools to support people with gambling problems. However, these tools were
primarily for communication such as email or text for appointment scheduling. This project established a
Steering Committee, conducted an audit of existing e-mental health practice and protocols, and established
the service gaps that e-mental health had the potential to address. Two service gaps were prioritised, which
were (i) supporting engagement between gamblers and expert treatment providers, and (ii) enhancing support
through e-mental health to existing clients of gambling treatment services. The project scope was to identify a
gap and need to minimise risks associated with gambling and was funded to develop one tool that could
address this need. Two tools were identified for potential development, with content and implementation
acceptability and feasibility explored with stakeholders in a large-scale needs analysis survey, followed by a
co-design hui conducted in Auckland. Enthusiasm for both tools was high and at this time, we decided to
proceed with the development of two relatively low-cost prototypes that could be refined and improved over
time if found to be useful and further funding is available.
Over 30 months, the project team worked collaboratively to develop the two e-mental health prototypes that
were customised for the needs identified by both gambling services and people with lived experience; that is,
a co-design approach. We co-designed and implemented a screener prototype that allows people to assess
their gambling. The screener then provides a brief personalised intervention in a report form that encourages
help-seeking and supports entry into gambling support services. Survey results showed that the screener is
popular, useful, and has a potential to be developed further, helping to reduce gambling harm in New
Zealand. We also created an i-CBT for gambling prototype which presented a range of topics and activities
that clients and counsellors could select and complete in line with treatment goals. A preliminary evaluation
found this tool to be highly desirable and useful, and having substantial potential to improve service delivery
and treatment effectiveness. Throughout the evaluation, several recommendations have been identified by
stakeholders to further enhance these initial prototypes and fully integrate them into the services.
Screener findings and recommendations
Assessment findings and recommendations
The screener prototype is available online and relevant for anyone concerned about their gambling. It
included a series of questions that measured gambling behaviours, gambling severity and motives, and
identified personal strengths, readiness to change, and interest in help-seeking. Extensive work was
undertaken to ensure minimal questions, while providing sufficient information and insights for maximum
impact. One major piece of work was to adapt assessment items and response options for online unassisted
delivery by simplifying terms and ensuring all wording was in plain language. This meant many of the
validated measures were not delivered in their original form, which may impact on the psychometric
properties of these measures. Future research should consider the impact of adapting validated tools so that
they are in plain language and can be understood by people who have a gambling problem without the
support of a professional. Customisation of assessment items also involved a focus on strengths, and we
developed a method of assessing personal strengths and then linking these back to ways these strengths could
be useful for changing gambling behaviours. This novel client-centric approach provides a new way of
leveraging individual strengths and tailoring treatment plans in line with each client. Future research might
consider expanding on this work even further such as identifying strengths according to recovery needs such
as strengths to reconnect or make amends to family or repairing harm to finances or mental health. Table 49
shows screener assessment findings and recommendations.
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Table 49. Screener assessment findings and recommendations
Screener assessment
findings
Screener assessment recommendations
Gambling expenditure and
frequency questions still
too time consuming.
We had sought to replicate the methods from the National Gambling
Study which asks about typical expenditure and expenditure in the
past month. To reduce the number of questions (and potential
completion burden), removing typical expenditure and frequency or
past month expenditure and frequency could be considered.
Assessment of strengths
should be expanded and
enhanced.
The reasons for choosing a minimum number of strengths is to
prompt the person to consider and reflect on their choice. One option
is to make this question more specific so that the person selects
strengths for different types of recovery tasks (e.g., financial
recovery, family recovery, mental health recovery).
Ensure questions are in
plain language and are
engaging.
Examine the psychometric properties of the screener questions when
translated into plain language.
Make the screener
questions more interactive
One way to improve both readability and engagement is to use icons
and images in the question stem and response options. For example,
questions related to specific types of gambling could simply be
replaced with icons representing different forms and the person
could then select any images/icons that are relevant. Response
options can also be replaced with icons so as to remove numbering.
Assessment of online
gambling activities should
be improved.
One enhancement could include the requirement to nominate method
of gambling against each of the gambling types.
Consistent with a public
health approach – broader
harm should be assessed
The assessment measured gambling symptom severity over 12
months with the PGSI and current symptom severity with the PG-
YBOCS. Future iterations should consider incorporating the Short
Gambling Harm Screen or other valid measure of gambling harm.
Add item on the
helpfulness of the tool.
An additional item should explore the helpfulness of the tool and
provide opportunity for tool feedback.
Screener report findings and recommendations
A prototype of a personalised report template was developed which provided gamblers with immediate
feedback on assessment. The purpose of the personalised report was to prompt increased awareness of
gambling behaviours which is proposed to prompt a person to act. Research on the impact of personalised
feedback indicates that the inclusion of a normative component can increase cognitive dissonance thereby
prompting a person to change the behaviour (67). The prototype used data from the New Zealand National
Gambling Study to provide a comparison of expenditure and frequency against other people in New Zealand.
This approach was deemed acceptable but could be enhanced through more interactive elements, graphical
presentation of results and the ability to generate a well-designed PDF that could be saved for future use.
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Future research should consider enhancement to the prototype so that it is more interactive and engaging to
people who gamble. Table 50 shows screener report findings and recommendations.
Table 50. Screener prototype report findings and recommendations
Screener prototype finding
Recommendation
Some believed the three-
page report was too long
and not sufficiently
engaging.
The project team had planned a one-page report, but this was not
technically possible within the available budget. The next iteration
could include interactive elements on the webpage which translate to
a clean and engaging one-page report that could be printed and saved
for future reference.
Presentation of strengths
should be expanded and
enhanced.
As a low budget option, the report presents the two selected
strengths in different colours and fonts. Future iterations could
provide information on how these strengths might be helpful or
prompt those completing the screen to create their own record of
where their strengths could help. One option is to add content from
lived experience and how personal strengths can be helpful. A
greater focus on lived experience should also be incorporated across
all of the materials.
More interactive elements
are needed to make it more
engaging.
The report could be made more interactive such as comparing
expenditure against people of a similar age, gender, culture or
location.
The report should be able
to be saved or printed in an
easy-to-read format.
The report could be saved to the i-CBT client profile if the person
elects to engage in the service. If there is an option for a lower
intensity self-help option, then the report could be saved to an online
self-help website.
Te Reo Māori should be
used in the assessment and
screener report.
Ideally the report is designed to be culturally appropriate, engaging
and relevant to the client population. The next iteration should have
a greater focus on the look and feel of the report in line with cultural
needs.
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Screener prototype – Service Integration
The screener prototype was established as a way of linking clients to treatment experts through the creation of
new technology facilitated pathways. Approximately 13%
1
of people who completed the screener requested a
discussion with an expert gambling counsellor. Protocols were established to respond to requests for email,
phone and in-person discussion within 24-48 hours of screener engagement. Protocols appeared to be
effective, and the prototype client management system was functional. It is recommended that the pathways
be extended to offer even lower intensity interactions such as text messaging. There was also a view that self-
help tailored to readiness could be offered to those who completed the screener but did not want to
immediately discuss the results. Ideally, self-help for those who come to a treatment provider site is
customised such as a focus on treatment readiness and reduction of gambling harm.
There was a perception by some service providers and people with lived experience that people with
gambling problems would not complete a screener to assess gambling harm. Discussion in the hui indicated a
belief that people already knew they had a problem and would not want to complete a screen for this to be
confirmed. We found almost one-third of people who completed the screener had a gambling problem, with
similar rates of completion by people at low and moderate risk. These findings speak to the importance of the
co-design process where we were able to share the journey of need identification, customisation and
implementation and could jointly identify gaps and opportunities in connecting with people experiencing
gambling problems. Future improvements in the screener should take the same approach whereby those
involved in its delivery and usage are involved in content and functionality improvements. Table 51 shows
screener prototype findings and recommendations in terms of service integration.
Table 51. Screener prototype findings and recommendations – service integration
Screener prototype finding
Recommendation
Client management system is
functional but could be
improved.
The client management system was a basic summary of
completed screens that provides counsellors information on
contact preferences. This system requires co-design and ideally
integration with the client management system for the i-CBT
prototype.
Provide training for new staff
in how to effectively respond
to request for discussion on the
screener results.
Motivational enhancement therapy is the optimal approach for a
first response to clients requesting a discussion on the screener
results. This therapy combines motivational interviewing and the
screening tool results to prompt readiness to change and
resolution of ambivalence. Existing online training developed for
the current project could be extended to include motivational
enhancement therapy.
1
Note that it is likely this proportion of participants is substantially higher than 13% because we did not screen for
ineligible participants such as those who were (i) overseas (ii) family and friends (iii) researchers or other interested
people testing the tool (iv) bots or other non-valid users.
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Self-help is needed for those
who complete the screener and
have gambling problems but
are not yet ready to talk to
someone.
Self-help should be developed that targets motivation and self-
efficacy. This self-help can also include feedback and advice by a
counsellor as part of the tool, thereby creating an initial
relationship between the service and potential client.
Anonymity was initially
preferred, but this was
identified as a major missed
opportunity to initiate contact.
Most screeners ask for email validation which is then used to do
follow-up contact with the person. An automated email to all
gamblers who complete the screener could enable further contact
with the service.
Screener prototype – Other considerations
The screener provided new promotion opportunities for services. Promotion of the prototype through social
media appeared to be effective in driving clients to the service via the screener. This highlighted opportunities
to make the screener available in mental health and alcohol and other drug services as a way of screening for
gambling problems as well as offering another pathway into expert in-person gambling treatment.
The relatively large number of participants who were classified in the non-problem and low-risk gambling
indicates that the screener is reaching people prior to them developing more severe forms of gambling. The
screener appeared to have an impact in terms of increasing engagement with services, but more could be
known about those who (i) have an interest in help-seeking but do not request contact, (ii) have no interest in
help seeking but are experiencing gambling problems, and (iii) have low and moderate risk gambling
problems and no interest in talking to a professional. Furthermore, more needs to be known of the impact of
completing the screener as it is well established that screening with personalised feedback can have a direct
impact on gambling behaviours and gambling severity (67). There is an opportunity to meet multiple
treatment, relapse prevention and evaluation needs by implementing ongoing monitoring with the screener
over the longer term. For example, completion of the screener every 3 to 6 months would provide easy access
back into service if a lapse has occurred as well as to evaluate recovery from gambling problems over the
longer term.
People with lived experience who were involved in the evaluation included affected others and whānau of
people with gambling problems. They identified a need for a similar screener for affected others that could
identify the impact of gambling on others as well as identify strengths and readiness to act for themselves or
the person with the gambling problem. Other research has indicated that family want both a family-focused
treatment approach and a gambler-focused approach (111) and these different approaches may be needed at
different times during recovery from gambling harm. The current study highlighted the importance of taking
a co-design approach for the development of a whānau tool including the identification of appropriate
measures and personalised report. Table 52 shows screener prototype findings and recommendations in terms
of other considerations.
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Table 52. Screener prototype findings and recommendations – other considerations
Screener prototype finding
Recommendation
87% of clients used the
screener without immediately
initiating contact. More
information on what these
clients subsequently do is
needed (note see footnote 1).
Longer term follow up could easily be initiated with a proportion
of consenting service users. This information would be useful to
understand the needs and preferences of gamblers who don’t
initiate in-person contact and their pathway into and out of
gambling.
There was concern that
affected others and whānau
were not offered a screener
that was appropriate to their
needs.
A similar screener is required for affected others. This screener
could include items measuring exposure to people with gambling
problems, the severity of these gambling problems, the degree to
which exposed respondents perceive they have been affected by
this exposure, the specific types of harm experienced, the severity
of these harms, coping strategies, and help-seeking awareness,
preferences, and behaviour. There are, however, currently no
known evidence-based screening tools for affected others. There
is a need to develop and validate screening tools for affected
others.
Need for ongoing funding to
support maintenance, updates,
and hosting.
The screener is currently hosted at the web developer’s server and
incurs a small fee each month. To maintain the screener beyond
the current project, it would be essential to allocate funding for
maintenance, updates, and hosting fees.
Promotion of the screener was
an effective way of connecting
people to the service.
Agencies promoted the screener through social media and by
other means such as health promotion events. Future options
would be to fund agencies to promote the screener more widely
as a way of creating greater awareness.
Many mental health and AOD
services do not screen for
gambling and the screener
could be a way of facilitating
that option.
Develop best practice guidelines on how to offer screener access
to mental health and AOD treatment services. Higher level
facilitation might be helpful.
Health Promotion Agency
should offer the screener as a
way of directing people to
expert services.
Where the screener is promoted on other websites, potential
clients should be provided an option on which referral pathway
they prefer including the service that will respond to their request.
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Other languages would be
useful so that the screener
could be made more widely
available.
The screener be translated into other languages using a co-design
approach to ensure concepts remain culturally relevant and
clinically appropriate.
i-CBT findings and recommendations
The current project is the first to develop a prototype integrating GAMBLINGLESS content and a blended
service delivery approach. As identified in the preparatory work for the prototype, service providers and
people with lived experience wanted a tool that could support in-person treatment and was sufficiently
flexible so as to be initiated by counsellors and/or clients. To meet these needs, the prototype presented
content according to gambling motives which were aligned with the well-established Pathways Model of
problem gambling (26). Three motivational pathways were developed based on (i) behavioural conditioning,
(ii) escape (coping) motives, and (iii) action (enhancement) motives. Each pathway contained a range of
different topics and activities. There were some suggestions developed to improve i-CBT content,
functionality, engagement as well as other considerations such as expanded access and targeting specific
groups. These opportunities and recommended future work are detailed in the next section of this report.
i-CBT prototype – content recommendations
The content of the relatively low-cost prototype was generally well received following extensive co-design
work to render it relevant and culturally appropriate for Aotearoa New Zealand. Across all phases of this
research, there were calls for more interactivity options with the content, including the capacity to take
quizzes and activities within the website. Future iterations should consider the inclusion of interactive options
and the ability to save the results in the client’s profile. The prototype included videos available on YouTube
(with appropriate permissions) to keep costs down. There was, however, a view that content could be
presented more frequently as videos that were locally produced and involved people who had engaged with
in-person care or who were recovering. Moreover, the involvement of counsellors in the delivery of i-CBT
content related videos would increase their social presence in the program, and firm up expectations that i-
CBT was part of a suite of options for clients. In terms of the depth and breadth of the overall content, there
was a view by some that there was too much content and that it contained too many words. Analysis
indicated that these views were not held by counsellors and instead was the perception of health promoters
and others not involved in treatment delivery. These findings highlight the important of establishing
expectations that i-CBT is not a single session fix all but contains activities and content designed to support
longer term care with a counsellor.
A consistent finding was that counsellors wanted to be able to share control of activity selection with clients
but also needed guidance on the most appropriate selection. This apparent contradiction in selection
preferences is because selection can occur at multiple important time points during treatment. For treatment
planning, it is important to have some guidance as to the most useful pathway, topics and activities that fit
with the client’s current need. For ongoing treatment delivery, the selection of content needs to include that
identified in treatment planning but be sufficiently flexible to include other topics that come up in the course
of treatment. It is common for clients to experience a range of unexpected challenges during treatment and i-
CBT topics can be used to support treatment priorities as and when they change. Currently, there are few
relapse prevention options offered to clients after an episode of care. I-CBT has the potential to be a resource
that is dipped in and out of as needed and where clients can redo activities and stay in touch with their
counsellor over the longer term. This low-impact method of continued engagement then provides an easy step
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up back into the service should the person experience a lapse or relapse back to previous levels of gambling
behaviours. Table 53 shows i-CBT prototype findings and recommendations in terms of content.
Table 53. i-CBT prototype findings and recommendations - content
i-CBT prototype findings
Recommendation
The prototype should
contain less written text
and more video and audio
content.
Open-source video content on the wide range of activities included in
the prototype is currently limited internationally. Future studies should
consider producing a range of videos that expand and explain the
range of CBT activities so that there is less written text.
There needs to be more
locally sourced videos.
Videos for i-CBT were obtained via YouTube at no cost to the project.
Future iterations should consider content creation that is derived from
clients and counsellors from different cultural perspectives in New
Zealand. To fit with other content sourced internationally, video
content should be high-quality and professionally produced.
There should be an
increased focus on family
and community
engagement in activities.
Pathway 3 (Action motives) contains some content focused on identity
and community, and this could be further enhanced. Future co-design
should work with providers to expand this content while still working
within the CBT framework.
Activities should be more
interactive so that clients
can take quizzes, polls
and do written work in the
activity.
The prototype currently prompts clients to answer quizzes and
interactive elements in a diary separate to the prototype. Future
iterations could consider the inclusion of an online diary that is part of
the client profile. It should also consider increasing interactive
elements with the capacity for clients to save their answers directly in
the i-CBT program.
Provide a screening tool
to guide selection of
pathways and topics.
A screening tool can be developed that identifies motives for gambling
and other treatment needs. Further work is required to develop an
algorithm that employs this information to develop recommendations
tailored to each individual client. Ideally, these recommendations
could be presented as most important to least important topics and this
information could be integrated into the treatment plan.
Quotes work well but
more client stories are
needed.
The ‘pay it forward’ option where clients provide advice and
information to others on what worked for them is currently located on
the personal profile page. The results of ‘pay it forward’ could be
presented on the home page or elsewhere as well as stories and
testimonials of people who have engaged with treatment in services.
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I-CBT functionality and blending
A key concern with i-CBT is lack of meaningful engagement with the content. The i-CBT for gambling
prototype was established as a joint tool between counsellor and client whereby the communication loop
prompts clients to make notes on the content and then share these with their counsellor. The idea is to
encourage people to engage with the content such that they have a conversation about what is learned and
how it can be used to affect change to gambling behaviours. Communication on content is through the
website or via any other frequently used mode, such as email or in-person. Table 54 shows i-CBT prototype
findings and recommendations in terms of functionality and blending.
Table 54. i-CBT prototype findings and recommendations – functionality and blending
i-CBT prototype findings
Recommendation
Full or partial blended
approach is facilitated
because there is no
evidence that one is better
than the other.
Conduct research to determine whether full or partial blending is
associated with better treatment retention and improvement in client
gambling symptoms.
Counsellors need to have
stronger social presence
in the i-CBT program.
Make audio and visual recordings of counsellors talking about their
experiences of different activities. This could include counsellors
talking about their interpretation of techniques and explaining them
via video content in plain language. Counsellors could also have a
profile page that when allocated to specified clients becomes available
for viewing. This profile might include their experience with gambling
and service provision, views about recovery and tips for getting the
most out of treatment.
Most clients will need
assistance in setting up
their profile, navigating
and selecting content.
Counsellors should have access to training in how to help a client set
up their log-in and use the site. There needs to be a troubleshooting
guide in the absence of a help desk and the presence of a super user in
the agency (i.e., someone with advanced knowledge of the program)
as well as a series of ‘how to’ videos.
A bespoke model was
preferred in terms of the
amount of counsellor
engagement with i-CBT.
The bespoke model meant that the client drives engagement with i-
CBT outside of the counselling session. Future studies should examine
the optimal approach to i-CBT engagement in terms of whether
direction is predominantly client or counsellor focused and the impact
on reducing gambling harm.
People do not do
homework and may not
do i-CBT either.
The option to request discussion or feedback on activities provides a
connection with their counsellor outside of each session and the
impression that the counsellor is always there. We expect that this
perceived social presence can help people engage with as little as 10
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minutes a week that extends in-person treatment. Future research
should investigate the amount of time people spend on i-CBT per
week and its impact on gambling.
i-CBT delivery considerations
Counsellors and people with lived experience identified an opportunity to extend i-CBT so that it was
available to those who do not yet want to access in-person support. The findings from the screener indicate a
clear need to offer self-help to those at low and moderate risk for gambling problems as they are very
unlikely to elect to talk to someone about their gambling. The current i-CBT prototype was customised to
meet the needs of people who access in-person support and demonstrates a move away from a one size fits all
approach. It is recommended that i-CBT for people at low or moderate risk for gambling problems have
access to co-designed tools that focus on improving readiness to change and the development of skills around
gambling control. This approach is consistent with other studies that report in-depth CBT is not of interest to
people with low and moderate risk for gambling harm (95, 96). Offering an inappropriate treatment that is not
wanted may do harm in that people then do not access something that could assist them to reduce gambling
harm. Future research should investigate the impact of tools targeted towards low and moderate risk gamblers
and the utility of linking these tools with expert gambling providers.
Screening results indicated that about 2/3 of gamblers completing the screen did not want to discuss their
results with a counsellor. These findings indicate there may be some advantage of offering self-help to people
with problems but this option should be tailored to address treatment readiness. Ideally, i-CBT for treatment
readiness works on increasing confidence and perception of normality of help-seeking as well as the benefits
for the individual and their family. A less intensive approach can be taken that connects the person with a
counsellor through the same communication loops as developed for the blended treatment which should assist
the person to easily step up to in-person treatment as needed. i-CBT for treatment readiness should be co-
designed with service providers and people with lived experience to ensure it is relevant and useful to people
with gambling problems. Table 55 shows i-CBT prototype findings and recommendations in terms of
delivery considerations.
Table 55. i-CBT prototype findings and recommendations – delivery considerations
i-CBT prototype
findings
Recommendation
Website requires
paper-based support
materials.
Support materials should be developed including (i) how to use the
website and benefits of its use and (ii) materials to assist counsellors to
make activity recommendations such as a prescription type pad that
allows activities to be selected.
Consider a variety of
service models.
There could be a variety of blended service delivery models: before first
appointment (MI-based), during treatment (to complement current
treatment, to provide therapeutic activities not employed during current
treatment, as homework), and post-treatment (relapse prevention and
facilitation back into services).
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i-CBT could be
offered to new clients
before the first
appointment.
There are multiple benefits to offering i-CBT immediately on contact
with the service including the leveraging of motivation and readiness and
to reduce fist appointment jitters / no-shows. Future iterations could
provide links to i-CBT when an appointment is made with the service. At
this time, the allocated counsellor would be assigned to the client in terms
of an appointment time and within the i-CBT program. Access to i-CBT
before the first appointment would require more work in developing
client guidance on the best ways of using i-CBT.
i-CBT could be
offered as a standalone
treatment for those not
ready to engage with
in-person care.
The i-CBT prototype was customised to respond to the needs of in-person
treatment and is not suitable as a standalone treatment. If a standalone
treatment was wanted, it is recommended that this be co-designed so that
it was tailored to the target group. Initial examination of screener data
suggests that those not ready for in-person care are likely to be in the low
and moderate risk categories and report moderate levels of importance or
readiness to change. For this group, standalone i-CBT content should be
focused on resolving ambivalence and increasing readiness for change. It
is recommended that the same communication loop be included in the
module to connect gamblers with an expert gambling counsellor within
the i-CBT getting ready program.
Avoid increased
stigma or shame for
those who are not able
to access technology.
i-CBT can be introduced to clients as part of a suite of treatment options
and enhancements. It should be made clear that i-CBT is optional,
available for any client interested in enhancing their treatment experience
but it is not detrimental for those unable to access it.
Identify options for
those who are not able
to access internet.
Those with no or limited internet access (e.g., homeless, prison
populations who have contact with a counsellor) could benefit from the
CBT content. An offline version could be made available in the form of
hard copy content. For those with limited internet access, an app could be
made available that functions without continuous internet access.
Resource development
that guides site
engagement.
Develop a set of guidelines to facilitate client and counsellor expectations
of use as blended model. This would include an introductory video
explaining how the website works.
A client barrier to
engaging with i-CBT
was access to a device
or internet.
Informants suggested that i-CBT activities could be undertaken at the
service premises before or after in-person counselling to address barriers
of technology access. Future delivery could include the provision of
tablets or internet access to clients who might benefit from i-CBT but are
unable to gain access outside of the service location.
i-CBT could be
offered by services
During the project period, there was an opportunity to initially explore
readiness for i-CBT more broadly. Work undertaken by Shirleen Prasad
126
who provide cultural-
specific care but would
need to be translated.
as part of her Master of Health Practice indicated i-CBT was of interest to
clients and counsellors of Asian Family Services, but concluded that
adaptations were needed, including offering it in different languages.
Future iterations of this project could consider co-design of i-CBT with
stakeholders from specific cultures to ensure cultural relevance and
accurate translation into other languages.
I-CBT Other considerations
Other considerations focused on professional development, i-CBT for family and whānau and promotion of
the suite of options to clients and other mental health and addiction services. Table 56 shows i-CBT prototype
findings and recommendations in terms of other considerations.
Table 56. i-CBT prototype findings and recommendations – other considerations
I-CBT prototype findings
Recommendation
Ongoing professional
development is needed,
and this should be
expanded as more
practice wisdom
develops.
Self-paced professional development was provided as part of this
project delivery which covered a wide range of e-mental health topics.
Engagement with professional development activities was excellent as
indicated by extensive discussion in the Slack channel throughout the
project. The partnership approach allows for the multi-disciplinary
team to continue to develop and document practice wisdom. These
experience-based insights should be integrated into future professional
development content to maintain and improve workforce capacity.
i-CBT should have a
complementary website
that is counsellor facing
and provides information
and professional
development related to
each CBT technique.
Some counsellors may be unfamiliar or have limited experience with
using CBT for gambling and may struggle with explaining or avoid
delivering CBT techniques. Self-paced training could be provided, that
focuses on each activity and explains its theoretical basis and practical
application to fully support counsellors.
i-CBT should be made
available for affected
others and family
impacted by gambling
harm.
To our knowledge, there are no blended approaches for whānau or
other people impacted by gambling harm. Future studies should
consider the content and functionality of i-CBT for affected others and
this should be tailored to a gambler-focused approach (content that
supports the person to support the gambler) or family-affected
approach (content that is specifically for harm to family).
127
i-CBT impact on
gambling behaviours and
harm should be evaluated.
To evaluate the effectiveness of treatment as usual to treatment as
usual with a blended model on client outcomes.
i-CBT within the suite of
treatment options needs to
be promoted to people
with gambling problems
and other mental health
and addiction service
providers.
The blended approach developed for this project is a novel way of
enhancing the client treatment experience and extends treatment
beyond the standard hour. Once the prototype is finalised and part of
routine service delivery, there is an opportunity to promote this
innovative approach to treatment of gambling harm to other mental
health and addiction providers.
Project conclusion
Interviews with gambling services and people with lived experience showed that the screener prototype was
very useful for clients, counsellors, and gambling services. The screener achieved its original goal of reaching
out to populations that usually do not seek help from gambling services or cannot access help during hours it
is available. To become truly successful, however, the screener requires further improvements, such as
making it more interactive and adding more visual content, and promotion to reach more people. A special
feature of the screener is that it has Te Reo Māori meaningfully integrated across the screener. This reflected
the New Zealand Aotearoa context and public health commitment to Te Tiriti o Waitangi. It was also
important to use Te Reo Māori to connect with potential users and increase cultural relevance of this brief
intervention.
The next steps are to refine the prototype and release the screener for wider administration. Ideally, the
prototype is improved in terms of look and feel and interactivity where text is reduced and interactive
elements are increased. Pathways into service can be broadened so that interaction with an expert is initiated
at a lower level of intensity such as text messaging or support for self-help. The long-term effectiveness on
gambling harm needs to be monitored to understand how to engage those with problem gambling but are not
ready to talk over their concern. A version of the screener for affected others and whānau is needed which
screens for harm to family and offers an assessment of viable coping options and ways to support the person
with the gambling problem.
Stakeholder feedback during multiple phases of this project indicated a blended approach is feasible. The
initial findings from the survey indicated 75% of services providers thought a blended model was feasible.
Over the course of the project, we found that acceptance of a blended model increased with very few
concerns raised in the last evaluation phase. A key reason for these positive findings was the development of
the customised screener and i-CBT prototypes that were specifically designed to support and encourage in-
person care.
The success of the current project demonstrates the value of using a co-design approach, for both clients and
service providers. Through the contracted partnership, we were able to undertake an impressive amount of
work in the 30 months of this project. The findings demonstrate value to the sector in terms of being ready
and willing to enhance service delivery through e-mental health and this only became stronger following the
emergence of COVID-19. The responsivity to the surveys, hui and interviews was overwhelmingly
enthusiastic and positive. Stakeholders made significant contributions and were engaged across the five
128
phases of the project covering the development, implementation and evaluation of two e-mental health
prototypes. Co-design of tools with people who ultimately will use those tools is vital for the ongoing and
long-term success of incorporating such change into established services. In doing so, New Zealand can
continue to provide world-class treatment, tailored to the needs of those engaged in reducing the risks of
gambling.
129
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10. Appendix A: Survey items for needs analysis
SECTION 1: DEMOGRAPHICS
PARTICIPANT ID:
First two letters of your middle name ____ ____
First two letters of home street name ____ ____
Two numbers of your birth month ____ ____
1. With which gender do you most
identify?
2. What is your age?
3. What is your postcode?
4. How many years of experience do you have working clinically?
5. How many years of experience do you have working with gamblers?
6. What is your highest level of education?
Secondary
education
Certificate/
diploma
Undergraduate
degree
Postgraduate
degree
Other (please specify)
7. What is your discipline qualification?
Social work
Psychologist
Psychiatrist
Youth worker
Other (please specify)
Counsellor
Psychotherapist
Family therapist
AOD worker
8. What is your main role in the sector?
Clinician
Case worker
Manager
Team leader
Other (please specify)
Public health
Health
promotion
Project manager
Administration
IT
Communications
Operations
Consumer
9. What are your current working arrangements?
Full time
Part time
Casual
Other (please specify)
SECTION 2: CURRENT E-MENTAL HEALTH USE AND EXPERIENCES
10. Do you currently use
these e-mental health
treatments in your
practice?
Email counselling
Instant chat
Telephone counselling
Skype or video
Self-help activities
Peer to peer forums
Smartphone app
Something else: (please describe)
11. How many hours on
average per week do you
access each of these
online services for your
employment?
Social media
News and information (e.g., browsing)
Health information/referral information
Email
Instant messaging (e.g., Facebook messenger, WhatsApp)
Video conferencing (e.g., Skype, Zoom)
SMS or mobile communication
12. Which of these activities
do you currently use the
Find information on referral
Find information or enrolment in self-exclusion
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internet to deliver?
Calculation of expenditure (e.g., spending calculator)
Assessment (e.g., WISC, PGSI)
Communication before treatment starts
Treatment or support between sessions
Post-treatment support or after-care
Administration (e.g., non-attenance, reminders)
Delivery of treatment (e.g., concurrent CBT)
Find information on comorbidity (e.g., alcohol use)
Treatment of comorbidity (e.g., alcohol use)
Smartphone app for tracking gambling
Something else: (please describe)
13. What proportion of your
work currently involves
delivery of e-mental
health treatment?
None
Less than 20% of my time with clients
21-50% of my time with clients
51-75% of my time with clients
76-100% of my time with clients
14. For your clinical work, how confident are you in navigating internet services for your work?
Not at all
confident
Not confident
Neutral
Somewhat
confident
Very confident
15. In the last 5 years, have you undertaken any of
the following to deliver e-mental health
treatment?
Yes
No
Seminar or lecture
if yes, indicate number of hours
Workshop
if yes, indicate number of hours
One on one training
if yes, indicate number of hours
Formal education such as completing a diploma
Type
Something else (please specify)
16. Indicate your level of agreement with the following statements: Overall, I think working with e-
mental health systems in clinical work would be….
Stressful
Strongly disagree
Disagree
Neither agree or
disagree
Agree
Strongly
agree
Helpful
Strongly disagree
Disagree
Neither agree or
disagree
Agree
Strongly
agree
Valuable
Strongly disagree
Disagree
Neither agree or
disagree
Agree
Strongly
agree
Concerning
Strongly disagree
Disagree
Neither agree or
disagree
Agree
Strongly
agree
Comfortable
Strongly disagree
Disagree
Neither agree or
disagree
Agree
Strongly
agree
Easy
Strongly disagree
Disagree
Neither agree or
disagree
Agree
Strongly
agree
17. Please list your top three concerns or disadvantages about the use of e-mental health as part of
routine care.
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18. Is embedding some e-mental health options into your current clinical practice feasible?
Yes / No. Please provide some details to explain your answer.
SECTION 3: NEW E-MENTAL HEALTH PROGRAM DEVELOPMENT
A Screener with personalised report will administer problem gambling screens with personalised feedback.
This means multiple gambling screens will be administered and then the results will be re-presented to the
person with comparisons to the rest of the population. This theory driven approach is based on cognitive
dissonance and designed to highlight differences in current behaviour and that of others of the same age and
gender.
19. How much time should it take to complete the
screener with personalised report?
Less than 15 minutes
15-30 minutes
31-45 minutes
46-60 minutes
1-2 hours
More than 2 hours
20. As part of a stepped care approach, gamblers could
have the option of talking over their assessment
results. If (insert each type on the right as listed) were
offered as a way of talking over the assessment
results, how could we provide this service?
Email
Instant messaging
Phone
In-person
Something else (please specify)
21. Who is the best person to provide advice or support
on the screener with personalised report? (Rank the
following items from 1=most preferred option to
6=least preferred option).
An administration person
An intake worker
An intern or someone with entry
level qualifications
A peer or volunteer
A counsellor
Someone else (please specify)
These questions are around the Blended i-CBT treatment. We would like to offer this to services as part
of a blended model. The idea of a blended model is that clients can do their ongoing face-to-face (or email,
phone) treatment at the same time as i-CBT.
22. How should the i-CBT be blended
with face-to-face treatment? Rank
the options from 1 = 'most preferred'
to 4 = 'least preferred' by dragging-
i-CBT could be offered separate to treatment.
i-CBT could be offered separate to treatment, but
the counsellor could offer motivation and guidance
for completion.
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and-dropping them in your preferred
order.
i-CBT could be PARTIALLY integrated into the
treatment plan (e.g., progress is monitored and the
client is encouraged to ask questions about the
content).
i-CBT could be FULLY integrated into the
treatment plan (e.g., in-person and i-CBT mirror
and support each other).
23. How much time should it take to
complete i-CBT content?
< 30 minutes
30-60 minutes
1-2 hours
More than 2 hours
Don’t know
24. If i-CBT were offered as part of
treatment, how should it be made
available each week?
One set of lessons become open for completion
each week (e.g., Lesson 1 open week)
Clients and counsellors choose the lessons to focus
on each week (i.e., all lessons are available at the
outset)
Other (please specify)
25. How many i-CBT activities should
be available to clients?
Less than two
Three to four
Five to six
Seven to eight
Nine or more
Don't know
26. How should the CBT program be
completed by clients? Rank the
options from 1 = 'most preferred' to
4 = 'least preferred' by dragging-
and-dropping them in your preferred
order.
Client completes the content in a separate room at
my service BEFORE talking with me.
Client completes the content in a separate room at
my service AFTER talking with me.
Client completes the content at home between
sessions.
Other
27. What client information would be
helpful to you in providing support
for completion of program content?
Results of assessment tools
Results of completed content/activities
Log-in occurrences
Pages viewed
Something else (please specify)
SECTION 4: IMPLEMENTATION READINESS AND SUPPORT NEEDS
28. What is the main action your organisation could take to support e-mental health being part of
your service delivery?
29. Is there anything else that you consider important for the success of, or use of, e-mental health as part
of routine care in your clinical practice / team / organisation?
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Thank you very much for completing the survey.
We appreciate the time and effort you have taken to provide these details. Your responses will be collated
with others and incorporated into the development and implementation plans of the e-mental health program
for your service.
Approved by the University of Auckland Human Participants Ethics Committee on 4/10/19 for
three years. Reference Number 023701.
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11. Appendix B: Semi-structured group prompts at co-design hui
Screener with personalised report
o We have shown you the proposed content for the screener in terms of assessment items and feedback
sheet. Are all these items needed? What would you remove? What should be included but is not there?
• Prompts: Easy to understand, look and feel, appropriate for client group.
o In terms of supporting the screener with personalised report what is the best option for someone seeking
help for the first time? That is, could email, phone or face-to-face be a good adjunct?
• Prompts: benefits of e-mental health, what should be removed, what is missing?
i-CBT for gambling
o Now we would like to turn to i-CBT for gambling and ask you about engagement and timing of activities,
selection of activities and service integration considerations.
• Prompts for timing: i-CBT for gambling could be done before in-person counselling, during or
after, frequency of activities.
• Prompts for selection: i-CBT for gambling may match the content of counselling sessions,
clients or counsellors could select the content, what drives the decision.
• Prompts for service integration: Delivery of i-CBT for gambling could be part of treatment as
usual or offered as homework and therefore separate to the interaction, how can homework be
better support.
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12. Appendix C: Screener semi-structured interview schedule
1. Usefulness of the screener. To get started I thought it would be helpful to talk about your overall
impression of the usefulness of the screener. To date we have had 809 people complete the screener since
April 2021. What do you think of the screener usefulness? We are open to any definition of usefulness
from prompting client change to having a tool that can be used at any time during the treatment process.
• Prompt: How useful do you think the screener is for people visiting your website?
• Prompt: What could be done to improve the usefulness of the screener?
2. Promotion of the screener on website. People find the screener through your website. Sometimes there
is also targeted advertising. Do you know of any ways that the screener was promoted?
• Prompt: What could be done to improve knowledge of the screener?
• Prompt: What about other services like AOD or mental health?
3. Screener report. You have been working with the screener for few months now. The screener has
questions on gambling expenditure and frequency, gambling motives, symptoms, and readiness to
change. Answers to these questions are all used in client’s feedback report. The report is offered
immediately after the screener is completed and provides feedback on scores, comparisons with other
people and also an option to take the next step. Do you think there is something that needs to change?
Something to be removed or added?
• Prompt: What do you think about the mix of questions in the screener? Are there enough questions
about gambling or too many? What other questions would you like included?
• Prompt: What is your overall impression of the client report? What do you think about how it is
presented? What about the content?
4. Pathway into services. At the end of the screener participants can select one of four options. These
include contact from your agency by email, phone or in person. The client can also save and print the
screener report.
• Prompt: Are there other pathways that can be added? Or are there too many options?
• Prompt: Do you think the screener influenced clients decision to access services? Did it make it
easier or more difficult?
5. Help-seeking
We also included two questions on help seeking in the screener. What do you think about these questions?
Are they helpful?
• Prompt: Could there be more questions on help-seeking?
• Prompt: How could help-seeking information be used in the future? Can we improve what we do
with that information?
6. Responding to the help seekers
We are interested in the process of responding to help seekers from your end. What was your experience of
the client dashboard (Screener results table)? What worked well? How can the dashboard be improved?
• Prompt: Once someone booked an appointment were the screener results ever looked at again? Is
there a way that the process could be improved so that it was easier to integrate into care?
7. Quality improvement
The final area we are interested in is how you would like the screener to operate beyond this research project.
As mentioned earlier, if the screener is useful, we will need to apply for funding to ensure its continued
operation. Do you see value in continued use of the screener?
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13. Appendix D: i-CBT for gambling prototype evaluation
Demographics
Name
Open text box
Email address
Validated field
Role (e.g., counsellor, person with lived experience)
Open text box
Review questions
In an overall sense, what do you like about this tool? Does it add value to 1) clients, 2)
gambling counsellors, 3) gambling harm reduction?
Open text box
The site is set up to prompt communication between client and counsellor (see “My
Plans”). What do you think of this communication loop, and how can it be improved?
Open text box
At the moment, the i-CBT for gambling consists of three pathways (56 activities in
total). What do you think about this content? What other content (for clients or
counsellors) do you think can improve this tool?
Open text box
The tool is currently independent of the gambling services data management system.
What ideas do you have about the technical integration of this tool into the data system
of a service you work with?
Open text box
Currently, i-CBT for gambling is accessible on a website. What other modes of
delivery (e.g., app) would you like that could increase the accessibility and usability of
the tool? Are there other add-ons that would be helpful such as a forum or diary or other
options?
Open text box
