GAMBLING AND PUBLIC HEALTH IN GREENLAND A LARGE INDIGENOUS POPULATION IN TRANSITION

Transcription

1 GAMBLING AND PUBLIC HEALTH IN GREENLAND A LARGE INDIGENOUS POPULATION IN TRANSITION A study of gambling behavior and problem gambling in relation to social transition, addictive behaviors and health among Greenland Inuit. PhD Thesis Christina Viskum Lytken Larsen Centre for Health Research in Greenland January 2014

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3 PhD Thesis Centre for Health Research in Greenland, National Institute of Public Health, Faculty of Health Science, University of Southern Denmark GAMBLING AND PUBLIC HEALTH IN GREENLAND A LARGE INDIGENOUS POPULATION IN TRANSITION A study of gambling behavior and problem gambling in relation to social transition, addictive behaviors and health among Greenland Inuit. Christina Viskum Lytken Larsen January

4 ACKNOWLEDGEMENTS Without question I am indebted to my husband Malik (I have no words!), my daughter Selma and the twins (at the time still unborn) who supported me through a busy summer and fall of 2012 and all the other busy times... This goes for my closest family as well: My brothers, Thomas and Søren, and their very cool women, Eva and Nikoline, for moral support, baby sitting and good fun. My parents, Mogens and Marianne, for intellectual support, lots of love and heroic visits during the last months before deadline, which included fun times for Selma, emptying the dish washer again and again, doing laundry and tidying up (no need to end these visits by the way ). Also, I would like to thank: Cecilia, Inger, Sus, Charlotte, Anni, Marit, Isabelle and Ingelise at the Center for Health Research in Greenland. For fun times, support and great discussions. My colleagues at the Institute for Nursing and Health Science, University of Greenland, and my former colleagues at the Department of Social Work (ISI), University of Greenland, for teaching me about health and people in Greenland even before I came into the research business. The students I had the pleasure to meet at the University of Greenland. I am sure they have taught me more, than I could actually teach them. The people at the National Institute of Public Health for an inspiring working environment and many relevant discussions. I owe a special thanks to my supervisors, Professor Peter Bjerregaard and PhD Tine Curtis, who have guided me through many analyses, discussions and methodological considerations during these years. It has been an inspiring learning process and I look forward to continue our discussions in the future. Finally I would like to dedicate this thesis to my beloved and respected grandfather Poul Viskum, a pioneering medical doctor in his field, who passed away while I was finishing my PhD studies. Among the many inspiring accomplishments of my grandfather, were medical visits to towns in Midwest Greenland during the 1950s with the Danish ship Heimdal. These visits were the foundation of many important discussions along with all the other great discussions we have had during the past 30 years. I will miss you! 4

5 Outline of thesis Paper I: Larsen CVL, Curtis T, Bjerregaard P. Gambling behavior and problem gambling reflecting social transition and traumatic childhood events among Greenland Inuit - a cross-sectional study in a large indigenous population undergoing rapid change; Journal of Gambling Studies, 2013, 29 (4): Paper II: Larsen CVL, Curtis T, Bjerregaard P. Harmful alcohol use and frequent use of marijuana among lifetime problem gamblers and the prevalence of cross-addictive behaviors among Greenland Inuit evidence from the cross-sectional Inuit Health in Transition Greenland Survey ; International Journal of Circumpolar Health, 2013, 72: doi: /ijch.v72i Paper III: Larsen CVL, Curtis T, Bjerregaard P. Health status and health behavior associated with frequent gambling and problem gambling in a large indigenous population A cross-sectional study based on The Inuit Health in Transition Greenland Survey Article in review November 2013 Academic supervisors: Professor Peter Bjerregaard, MD, DMSs. Centre for Health Research in Greenland, National Institute of Public Health, University of Southern Denmark. Professor Tine Curtis, PhD, MA Sociology. Local Government Denmark and National Institute of Public Health, University of Southern Denmark. 5

6 List of abbreviations BBGS CI DSM-III DSM-III-R DSM-IV DSM-IV-R DSM-V ICD-9 ICD-10 IHIT NODS NODS CLiP OR SOGS-R Brief Biosocial Gambling Screen Confidence Interval Third edition of the Diagnostic and Statistical Manual Third revised edition of the Diagnostic and Statistical Manual Fourth edition of the Diagnostic and Statistical Manual Fourth revised edition of the Diagnostic and Statistical Manual Fifth edition of the Diagnostic and Statistical Manual WHO s ninth edition of the International Classification of Diseases WHO s tenth edition of the International Classification of Diseases Inuit Health in Transition Study National Opinion Research Center DSM-IV Screen for Gambling Problems Short version of National Opinion Research Center DSM-IV Screen Odds ratio Revised South Oaks Gambling Screen 6

7 Contents ACKNOWLEDGEMENTS... 4 Outline of thesis... 5 List of abbreviations INTRODUCTION Objective Background Concepts and definitions Gambling activities and gambling behavior Pathological gambling a definition Problem gambling widening the concept of pathological gambling Towards a public health perspective on gambling The role of gambling and problem gambling in a population undergoing social transition MATERIAL AND METHODS Inuit health in transition across the Arctic Sample and participation Data Collection Outcomes and exposures Past year gambling behavior Past year and lifetime problem gambling Sociodemographic variables Social transition Traumatic events during childhood Addictive behaviors Health status Health behavior Data analysis and statistical methods Validity and completeness of data source Ethical considerations RESULTS Overview of results Paper I Paper II

8 4.4 Paper III DISCUSSION Main findings Main findings in perspective to other studies Methodological considerations Selection bias Information bias Confounding and intermediate factors Type-I and type II-errors Lessons to learn about measuring problem gambling Understanding the nature of problem gambling Problem gambling in the light of the ongoing social transition CONCLUSION IMPLICATIONS For research For public health SUMMARY RESUMÉ EQIKKAANEQ REFERENCES APPENDIX APPENDIX APPENDIX PAPERS I-III

9 1. INTRODUCTION During recent years gambling in general and pathological gambling in particular has become a much debated subject in Greenland. The economic and social problems for individuals, families and communities which extensive gambling can lead to are of great concern. At the start of the project, knowledge in the field was limited to a countrywide telephone survey and a qualitative survey conducted by the Department of Health in Greenland (Paarisa) in 2005 among local public health coordinators and more knowledge was needed (1). The health coordinators had pointed out extensive gambling on bingo and card games as the biggest gambling related problem in the Greenlandic communities and especially bingo was suspected to lead to the neglect of children because it is often played both during the day and during the evening, where children need their parents attention (1). The yearly revenue from gambling products sold in Greenland at Danske Spil - who controls the lotteries in Greenland and Denmark had increased with 50% from DKK 47.8 to DKK 71.6 million in the years , indicating an increase in gambling activities. In addition to this, the revenue from gambling on the privately owned slot machines was estimated to be DKK 80.3 million in 2004 alone (1). The revenue from bingo and gambling on cards and dice in private settings are unknown. An increase in gambling activities and the concern for pathological gambling is by no means limited to the Greenlandic context, but a much more global concern following the expansion of gambling opportunities online and liberalization of the gambling legislation seen in many western countries these years. However indigenous populations and ethnic minorities are considered to be especially vulnerable to gambling problems based on a higher prevalence of pathological gambling among these groups compared to the general populations within the same regions (2-5), but little is known of why it is so. Following Shaffer et al. the study of incidence among vulnerable and resilient populations is a road yet to be taken (4), p This is also a road where determinants of gambling problems should be studied more carefully. It is likely that the marginalization many of these populations experience in regions with other majority populations is a part of the explanation. In Greenland, Inuit constitute the majority of the population and the present study therefore provides a unique opportunity to investigate problem gambling in a large indigenous population, that is a majority in own country. An increase in social pathologies such as violence, suicide, alcohol and substance use is a key feature shared by indigenous populations in the circumpolar region undergoing social transition (6;7). In Greenland, the high proportion of the adult population who experienced alcohol problems in their childhood home and a similar high prevalence of persons who were sexually abused as children are examples of such pathologies. An overall motivation for the study was thus to investigate, if pathological gambling should be added to this list of social pathologies among Inuit in Greenland, through a research based understanding of the role of gambling and gambling problems in Greenland today in the light of the ongoing social transition. 9

10 1.1 Objective The objective of the thesis was to investigate the prevalence of gambling behavior and problem gambling in a representative sample of Greenland Inuit and its association with social transition, addictive behaviors and health. The overall objective was investigated based on three research questions answered in Paper I-III: I. How prevalent are different types of gambling and problem gambling among Inuit in Greenland and how is gambling behavior and problem gambling associated with social transition and traumatic events during childhood? [PAPER I] II. How is lifetime problem gambling associated with harmful alcohol use and frequent use of marijuana and does the association vary according to sociodemographic characteristics? [PAPER II] III. How is health status and health behavior associated with different types of frequent gambling and lifetime problem gambling? [PAPER III] 10

11 2. Background 2.1 Concepts and definitions Gambling activities and gambling behavior. Gambling is a common leisure activity in most of the world and can be traced far back in history to archaeologists uncovering of primitive dice found in caves dating back to 3500 BCE (8). Gambling opportunities are available on the internet, television, radio, in casinos, in bars, diners and various gambling venues. You can gamble at home or you can go out and gamble. Gambling activity naturally presupposes gambling opportunities, and most studies have found a significant association between access and availability of gambling on one hand, and the prevalence of gambling on the other. Typically the introduction of new gambling opportunities such as the opening of a casino will lead to an increase in gambling activities, but there is also evidence, that some form of adaptation can take place over time and the prevalence will stabilize (8;9). In the studies for Papers I-III, the term gambling activities refer to different types of available gambling opportunities such as the lotteries and bingo. Gambling behavior refers to the type of gambling activities people engage in and how often they gamble. There is no historic documentation of gambling in Greenland and the possible existence and role of gambling among Inuit back in time is therefore unknown (1). Most gambling activities present in Greenland today have been adopted from the Danish gambling market and thus resemble gambling opportunities in Denmark and more generally Scandinavia. Common gambling activities in Greenland are the lottery, bingo, slot machines/electronic gaming machines (EGMs) and card/dice games. The lottery is a general term for several different types of games such as lotto, scratch tickets, betting on sports and other numbers and knowledge games all controlled by the national lottery in Denmark, Danske Spil. The lottery is available at the local stores in all towns and in some villages. In addition lottery gambling from Danske Spil is available online. Gambling on the lottery is regulated by Danish law, but Greenlandic law applies to the distribution of a proportion of the revenue from the products sold by Danske Spil in Greenland (10). Some of which are spent on sports, youth and cultural activities. Bingo is played all over Greenland both over the radio and in local community halls and sports centers. Most bingo games are organized by local radio stations and local associations for which the revenue serves as the primary source of income. It is also common for parents to organize bingo games to raise money for their children s school trips and excursions. The amount of organized bingo games varies from place to place. In most towns and villages bingo is available on a daily basis. In some places bingo is played several times a day given the availability over different local radio stations in the area in addition to games held in the local halls and sports centers. Only public bingo games require permission from the police. Bingo games arranged by the local associations for members are not registered. A taxation of the winnings is required by law (11). Slot machines are located at the bars and grills, but in towns only. No permissions for slot machines have been granted to villages by the municipal councils. The slot machines are owned by private investors and generate a yearly revenue of up to 1 million DKK (1). The revenues from slot machines serve as a main source of income for the local bars and grills. Taxation is regulated by law (12;13). 11

12 Gambling on cards/dice represent a grey area since gambling on these types of games is prohibited by law. Cards and dice games presumably take place in private settings, but no official records document the extent of gambling in this area due to its illegal status. Despite the lack of documentation, it is well known within Greenland that card games are played extensively on the East coast, where the traditional social gatherings Kaffemik are often turned into gambling tournaments, when coffee and cake has been consumed. People can engage in gambling in very different ways and the role of gambling can vary significantly between communities. Gambling on the lottery can be limited to buying a scratch ticket once in a while or a weekly lotto coupon, when shopping for groceries. Others participate in a weekly bingo game with friends or family as a social event or play cards during the lunch break at work. These are examples of unproblematic gambling behaviors common in modern Greenland and for most people gambling in itself is an unproblematic activity which one can choose to engage in and maybe even win some money. However, for a minority the gambling develops into an extensive activity with negative consequences for the person who gambles, and his or her surroundings. This situation is defined as pathological gambling. Pathological gambling a definition The concept of pathological gambling is rooted in the psychiatric discipline and was first listed as diagnose in 1980 in the third edition of the Diagnostic and Statistical Manual (DSM-III) published by the American Psychiatric Association and in WHO s ninth edition of the International Classification of Diseases (ICD) in In the DSM-III pathological gambling was initially defined as an impulse control disorder. This diagnose has been revised twice, first with the revised DSM-III in 1987 (14) and later in the fourth edition of the Diagnostic and Statistical Manual from 1994 (DSM-IV), which was revised in 2000 (DSM IV-R) (15). The revisions from DSM III to IV were of substantial character and the criteria for pathological gambling have been linked to addictive behaviors such as alcohol and drug dependence based on empirical findings, although it is still listed as an impulse disorder (4;16). Currently the definition of pathological gambling is under discussion again in preparations of the fifth edition of the Diagnostic and Statistical Manual (DSM V). In DSM-IV-R, pathological gambling is listed under Impulse-Control Disorders Not Elsewhere Classified along with disorders such as Kleptomania and Pyromania: The essential feature of Pathological Gambling is persistent and recurrent maladaptive gambling behavior (Criterion A) that disrupts personal, family, or vocational pursuits. The diagnosis is not made if the gambling behavior is better accounted for by a Manic Episode (Criterion B). (15), p.671. The following ten criteria (defined as the DSM-IV-R criteria) for pathological gambling are listed in the DSM IV-R. Fulfillment of five or more of these is diagnosed as pathological gambling in a clinical context. 12

13 Table1. The DSM-IV-R criteria for pathological gambling Preoccupied Tolerance Loss of control Withdrawal Escape Chasing Lying Illegal acts Risked significant relationship Bailout The individual may be preoccupied with gambling (e.g., relieving past gambling experiences, planning the next gambling venture, or thinking of ways to get money with which to gamble). Most individuals with Pathological Gambling say that they are seeking action (an aroused, euphoric state) or excitement even more than money. Increasingly larger bets, or greater risks, may be needed to continue to produce the desired level of excitement. Individuals with Pathological Gambling often continue to gamble despite repeated efforts to control, cut back, or stop the behavior. There may be restlessness or irritability when attempting to cut down or stop gambling. The individual may gamble as a way of escaping from problems or to relieve a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression). A pattern of chasing one s losses may develop, with an urgent need to keep gambling (often with larger bets or the taking of greater risks) to undo a loss or series of losses. The individual may abandon his or her gambling strategy and try to win back losses all at once. Although all gamblers may chase for short periods, it is the long-term chase that is more characteristic of individuals with Pathological Gambling. The individual may lie to family members, therapists, or others to conceal the extent of involvement with gambling. When the individual s borrowing resources are strained, the person may resort to antisocial behavior (e.g., forgery, fraud, theft, or embezzlement) to obtain money. The individual may have jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling. The individual may also engage in bailout behavior, turning to family or others for help with a desperate financial situation that was caused by gambling. Most of the screening tools used in prevalence surveys and epidemiological research of pathological gambling are based on these DSM-IV-R criteria or the earlier revised DSM-III-R criteria, but operate with different levels of threshold compared to the clinical screening in order to catch the less severe gambling problems along with more serious ones. Pathological gambling is considered a chronic disorder in the DSM-IV-R with a natural evolution from a less to a more severe state over time. Problem gambling widening the concept of pathological gambling In our study, we use the term problem gambling, which is typically applied in the epidemiological field of gambling research as a wider concept of pathological gambling, when measured at a population level (8). Problem gambling is used to define problematic gambling behavior that may not qualify as pathological gambling if assessed in a clinical context, which is of relevance in order to get 13

14 an overview of how prevalent more or less severe gambling problems are in a population and thus the need for early prevention and treatment. More specifically problem gambling is used to define a subclinical state of pathological gambling. Internationally the prevalence varies from country to country with a past year prevalence of problem and pathological gambling ranging from less than 2% in the Scandinavian countries (17), and 3.5% in the United States and Canada (4) to 4-5% in several Asian countries (18). The widening of the concept is especially relevant in a public health perspective, where the goal is to target prevention, either towards the general population or towards specific groups, who may be more exposed or vulnerable to the problem. 2.2 Towards a public health perspective on gambling Considering gambling and problem gambling in a public health perspective is a relatively new approach following in the footsteps of the increase in epidemiological surveys estimating national rates for gambling behavior and especially problem and pathological gambling. The public health perspective considers gambling from a societal and population health point of view with a focus on how gambling and problems related to gambling are affecting not just individuals, but families, communities and societies. Furthermore the public health perspective opens up for considerations regarding the influence and significance of structural conditions in a society, which transcends the individuals access to a healthy choice regarding gambling. It is important to recognize that a public health approach to gambling is but one perspective among many. In Table 2 different examples of how gambling is viewed are illustrated. Although these are taken from a Canadian context, they reflect the general perspectives in the public debate in Greenland. Statement H represents the public health perspective promoted by Korn and others (19-21), who argue in favor of a well-informed evidence-based policy for access to gambling, preventive strategies towards gambling related problems and treatment programs targeted vulnerable population groups. Table 2. Different frames for understanding public policy on gambling proposed by Korn, Gibbens and Azmier (19), p. 237 A. Gambling is a matter of individual freedom; apart from addressing a legitimate concern with crime and the protection of minors, governments should not restrict how people spend their after-tax income. B. Gambling is a recreational activity, a form of entertainment. C. Gambling is a major source of public revenue; one rendered all the more appealing to governments because it can be portrayed as a form of voluntary taxation. D. Gambling is an important tool for economic development through increased tourism and employment, one that may be particularly attractive to Aboriginal communities. E. Gambling addiction is an individual rather than social pathology, and therefore should be treated within a medical model much like other mental disorders. F. Gambling is a cultural artifact that is more deeply embedded in some cultures than it is in others. G. Gambling is a way to escape the class constraints of Canadian society, allowing winners to leap with a single bound into the ranks of the wealthy. H. Gambling is seen within the context of public accountability, public responsibility, and public health. Because gambling is in the public domain in Canada, there is an incumbent responsibility for political leaders to be informed about the costs and benefits of gambling, and to be held publicly accountable for their policy choices. 14

15 2.3 The role of gambling and problem gambling in a population undergoing social transition Greenland was colonized by Denmark in 1721 and reforms of the Greenlandic infrastructure, industry and welfare during the 20 th century were based on Danish administrative systems. In the early 1900 climate warming brought the Atlantic cod to the west coast of Greenland and cod fishing became a major source of cash income. This initiated a movement away from the hunting of seals and whales towards a modern fishing industry. People moved to larger and fewer towns. In 1953 Greenland was given the status of a county in the Kingdom of Denmark. This development brought fundamental reforms with it, and G-50 and G-60 were implemented with the purpose of creating a modern infrastructure to handle the new fishing industry, which was planned to be a main source of revenue for the modern Greenlandic society. During these years extensive infrastructural development occurred, which transformed Greenland from a traditional hunting society into a modern economy, where most people depended on earning wages (22). When the cod disappeared in the 1960s the shrimp arrived in the Disko Bay area in North Greenland. This lead to a substantial growth in this region until the shrimp disappeared from the coastal waters in the These changes illustrate how population growth and societal changes are closely linked to local conditions such as the availability of fish or shrimp and how rapid these conditions can change. Many communities are still very vulnerable to these changes because the availability of jobs and income from fishing rely on the availability of certain species (23). In 1979 Greenland was granted Home Rule Government and in 2009 Self-rule. Today there are still close ties between Denmark and Greenland. In less than 100 years Greenland has developed from a traditional subsistence based economy to a modern society. The rapid transition places immense social and cultural demands on both individuals and communities (23-25). Despite its large geographical size, the total population of Greenland is only about 57,000 of whom 90% are ethnic Greenlanders (Inuit). Genetically, Greenlanders are Inuit (Eskimos) with a mixture of European, mainly Scandinavian genes. They are genetically and culturally closely related to the Inuit/Iñupiat in Canada and Alaska and, somewhat more distantly, to the Yupiit of Alaska and Siberia (22). Greenland has a total of 80 communities all located along the coast divided into towns and villages. A town is defined historically as the largest community in each of 17 districts. In 2010, the population of the towns varied between 469 to 5,460 and 15,469 in the capital Nuuk while that of villages varied from less than 10 to around 550. In the towns are located district school(s), health centre or hospital, church, district administration and main shops. These institutions are absent or present to a much smaller extent in villages. Village schools are usually limited to 7 th grade, after which children have to move to the nearest town in order to complete their schooling. High schools are located in two towns in South and North Greenland respectively and in the capital. The University of Greenland is also located in the capital of Nuuk. 15

16 Figure 1. Social transition in Greenland. Changes in the percentage of the total population living in villages in Greenland during the 20 th century. The number of persons living in villages in Greenland has been stable around 10,000 since the beginning of the 20 th century, but the relative distribution between villages and towns has changed dramatically. During the first half of the 20 th century around 80% were living in villages, but this changed around the year 1950 towards the present situation. Today the majority of the population in Greenland lives in towns, more than 25% live in the capital of Nuuk, and only 16% live in villages (22;26). There are also significant differences between the socioeconomic status of inhabitants in towns and villages. In villages the people are in average younger, have a lower income and unemployment rates are higher compared to the towns. In 2007 the average annual income in towns was 179,000 DKK compared to only 98,000 DKK in villages (27). The isolated populations in villages and smaller towns face large challenges with limited opportunities. In contrast, life in the capital reflects contemporary Scandinavian lifestyle with a wide range of educational, occupational and recreational possibilities. Typically a more traditional lifestyle is found in the villages compared to the towns and especially the capital. These differences reflect different stages of social transition in Greenland today, where the traditional Inuit lifestyle of hunting and fishing in villages and smaller towns coexist with the lifestyle of high-educated professionals in larger towns and the capital. There are also great differences between the different regions in Greenland. The majority of the population is concentrated on the south central west coast. Only about 3,500 persons live on the East Coast and only around 1,000 in the far North (Thule). There are also historic differences according to time of colonization. East Greenland was not colonized until the late 19 th century and North Greenland not until the late 20 th century and thus years later than the initial 16

17 colonization of southern and central Greenland by Hans Egede in 1721 (22). The historic and geographic separation is still reflected in modern Greenland with significant differences between North and East Greenland compared to Midwest and South Greenland. The living conditions in the isolated North and East are harsh and access to education and occupation is very limited compared to the rest of Greenland. Figure 2. Map of Greenland 17

18 As touched briefly upon in the introduction of the thesis, an increase in social pathologies is a key feature shared by indigenous populations undergoing rapid changes. The high rates of alcohol consumption in the 70s and 80s (28) as well as the high prevalence of mental health problems (29) and suicides have been linked to the ongoing transition (30;31). Different explanations focus on the stress of rapid social change, acculturation and the inadequacy of traditional conflict resolution behaviors in the new, more urbanized environments (24;30;31). Social transition and its potential influence on health is an important framework for the study of gambling behavior and problem gambling among Greenland Inuit in the present thesis. 18

19 3. MATERIAL AND METHODS 3.1 Inuit health in transition across the Arctic The present thesis is based on data from the Inuit Health in Transition Greenland Survey which is a part of an international cross-arctic collaboration: The Inuit Health in Transition Study (IHIT). IHIT was established with the aim of creating a longitudinal cohort study among the Inuit in Greenland, Canada (Nunavik and Nunavut) and Alaska. The studies in Greenland and Canada (Nunavik in particular) follow similar protocols and a lot of work was put into ensuring comparability between the surveys across regions. The purpose of the collaboration was to start a longitudinal study of the interaction between the environment and genetic factors on the health and disease pattern of the Inuit in Greenland, Canada and Alaska. Thus the data collection in Greenland is part of an international study with data collection in several villages and cities in all three countries. The project is expected to contribute to a better understanding of the health effects of the transition from a traditional lifestyle to a modern, industrialized life, which takes place in most present day developing countries. The present thesis focus on problem gambling is one example this. Others are studies of dietary patterns (32;33), obesity (34), diabetes (35), cardiovascular risk factors (36) and physical activity (37). The first round of data collections were carried out between 2004 and 2010 across the different regions. A follow-up has been scheduled in 2014 for both Nunavik and Greenland. In Greenland the follow-up will also include data from registers. Figure 3. Map of Greenland with study communities for the Inuit Health in Transition Greenland Survey The Inuit Health in Transition Greenland survey was carried out in 9 towns and 13 villages from in Greenland (38). Questions about gambling were included in the self-administered 19

20 questionnaire from 2006 and onwards and was therefore only carried out in 8 of the 9 towns but in all villages. In 2 of the 8 towns, the questions about gambling were included in a second visit carried out to obtain the desired participation rate. The list of towns included: Nuuk, Qaqortoq, Aasiaat, Maniitsoq, Narsaq, Upernavik, Tasiilaq and Qaanaaq. The Inuit Health in Transition Greenland survey also included Qasigiannguit. The list of villages included: Eqalugaarsuit, Narsarmiit, Aappilattoq, Atammik, Napasoq, Kullorsuaq, Innaarsuit, Aappilattoq, Kuummiut, Tiniteqilaaq, Siorapaluk, Qeqertat, Moriussaq (Figure 3). During the five-year period, the study was carried out during summer in some communities and during winter in others. The logistics of the study did not permit data collection throughout the year in each location or the collection of all data in one season. Data was collected by a team of local persons responsible for the recruitment of participants, a supervisor, one of two laboratory technicians, 2-4 interviewers, and two clinical assistants. The interviews were conducted in both Greenlandic and Danish according to the choice of the participant. A total of 81 persons assisted with data collection and the processing of data. Data collection in the Arctic is characterized by very unique circumstances because most destinations can be difficult to access depending on the weather and season of the year. There are no roads between towns or villages in Greenland, thus towns except Upernavik, Tasiilaq and Qaanaaq were visited by public transport (flight). These towns and all the villages were visited on three expeditions by a chartered boat (M/S Kisaq, figure 4). Kisaq can sail in almost all weather conditions and has accommodation for 12 passengers and large volumes of equipment. It is an unambiguously more convenient alternative to public transport, chartered helicopter or local boat charter. Figure 4. M/S Kisaq 20

21 3.2 Sample and participation Participants were selected as a stratified random sample of adults aged 18 years and older, born in Greenland or Denmark. Population lists from the central population register were used to initially specify the sample. Faroese people or persons born in other countries were not included. Greenland was divided into 12 strata based on geography (South west coast; Central west coast; North west coast; East Greenland; North Greenland) and community size (towns with 2000 inhabitants; towns with < 2000 inhabitants; villages). From each of these strata one or more towns and 2-3 villages were selected for the study as being representative of the stratum with regard to living conditions. A random sample was drawn from the central population register to obtain around 300 participants from each town; this number represents the practical limit for a research team during a 4-6 weeks visit. Villages were chosen at random in the strata and in the selected villages all adults were invited to participate. Individuals in the sample were contacted in writing with an invitation to participate. Information about the study and examination procedures was given, and the recipients were asked to inform the investigators by letter or phone whether or not they wanted to participate. The samples were revised locally with information about who were not actually living in the community at the time of the examination. Neighbors and the municipality office (in the villages) were good sources of information. Ethnicity as Greenland Inuit or Dane was determined at enrolment based on the primary language of the participant and self-identification. Only one ethnicity was allowed for each participant. The following concerns Greenlanders only. Participation ranged from 83.3% in the village of Aappilattoq to 55.2% in the village of Napasoq. According to community size, the participation was 61.4% in Nuuk, 65.1% in other large towns, 69.9% in small towns and 68.5% in the villages (p<0.001). Participation rates also varied by age and sex. Women more often participated than men and particularly young men were under-represented. The reasons for non-participation are seen from flow chart 1. There were certain differences between the communities; in particular in the capital, Nuuk, many persons indicated lack of time as the reason for not wanting to participate (17% of the non-participants compared with 2% in the rest of the communities). 21

22 The Inuit Health in Transition Greenland Survey N=6,015 Stratified random sample of adult inhabitants in Greenland (18+) born in Greenland ( Greenland Inuit ) or Denmark ( Danes ). Drawn from the central population register N=1005 Reduction of initial sample: Moved (744) Excluded for logistic reasons (94) Pregnant (60) Deceased (54) Unknown in the community (40) Other reasons (13) N=5010 Revised sample N=350 Exclusion of Danes N=4660 Revised sample Greenland Inuit N=1552 Non-participation: Did not want to participate (796) Illness or disability (107) Hunting, fishing or mining (68) Out of town for other reasons (53) Other reasons (23) No contact (505) N=3108 Participants in clinical examinations and interview Figure 5. Flow chart 1 We know that persons with serious illness or disability are over represented among the nonparticipants as well as those who tend to move often, and we suspect that socially exposed persons, alcohol abusers and persons who frequently go in and out of jobs and the unemployed likewise are over represented among the non-participants. It was the impression of the interviewers that there was a distinct downwards social trend from the beginning to the end of data collection in a town. In some towns it could be demonstrated that during the first week of the study 10% of those who had made an appointment did not show up, while during the last week of the study as many as 26% did not show up (p<0.001). A social bias in the participation was confirmed by information about income obtained from Statistics Greenland. The Inuit participants in the study had an average personal income in of DKK 161,000 while those who were refused to participate had an income of DKK 152,000, those who were excluded from the sample DKK 141,000 and those who couldn t be contacted DKK 134,000 (p<0.001; adjusted for age and sex). For disposable household income per person only those who could not be contacted differed from the rest. Revised sample for the Gambling Study The revised sample for included 3,892 Greenland Inuit. A total of 2,454 persons participated in the general survey (63%) and 2,189 persons filled out the self-administered questionnaire (56%). Only those who filled out the self-administered questionnaire were included in the present study of gambling behavior and problem gambling. In total 2,012 of these 2,189 22

23 participants (92%) answered at least one question about gambling. The analyses were based on the 2189 participants, who had the possibility to answer questions about gambling. The study of gambling behavior and problem gambling among Greenland Inuit Inclusion of gambling questions from 2006 N=4660 Revised sample Greenland Inuit N=768 Reduction of revised sample: Exclusion of revised sample for Qasigiannguit visited in 2005 (413) Exclusion of participants from 1 st visit to Aasiaat in 2005 (135) Exclusion of participants from 1 st visit to Qaqortoq in 2005 (220) N=3892 Revised sample Greenland Inuit N=1438 Non-participation Did not want to participate (758) Illness or disability (91) Hunting, fishing or mining (68) Out of town for other reasons (45) Other reasons (26) No contact (448) N=2454 Participants in clinical examinations and interview N=265 Non-participation in selfadministered questionnaire N=2189 Participants who filled out the self-administered questionnaire N=205 Missing data on gambling behavior N=1984 Gambling behavior Answered at least one question regarding gambling behavior past year (the lottery, bingo, slot machines, cards/dice) N=1542 Problem gambling Answered one or both questions in the lie/bet screen N=647 Missing data on the lie/bet screen Figure 6. Flow chart 2 23

24 3.3 Data Collection The participants were informed about the arrival of the team and about the investigation by a personal letter and they were after the arrival of the team contacted by the person responsible for recruitment. On the day of the investigation the participants were asked to show up at an appointed time, fasting (i.e. at least 8 hours without eating or drinking). They were further informed about the investigation and signed an informed consent. From the time of arrival hours went by. The participants were interviewed (40 min.), filled in a self-administered questionnaire, had various clinical tests performed and were issued with an Actiheart device to monitor physical activity for a 1-4 days' monitoring of heart rate and movements. At the end of the session, participants were informed about the results of the investigation and were invited to ask questions. When the Actiheart device was returned, a compensation of DKK 200 was paid to each participant. 3.4 Outcomes and exposures Past year gambling behavior The questions about past year gambling behavior measured in the self-administered questionnaire regarded four types of gambling; i.e. the lotteries, bingo, cards/dice and slot machines (Figure 7). Respondents answered how often they had gambled within last year, how much time, they spent each time they gambled and how much money they spent on gambling during last month on each of the four types of gambling. The questions regarding past year gambling behavior are identical with questions included in the Inuit Health in Transition Nunavik Survey, with the exception of the question concerning slot machines, which was not included in Nunavik. Only information on past year gambling and gambling frequency has been used in this thesis. Information on time and money spent on each type of gambling has not yet been analyzed, but will be included in future comparative studies with data from Nunavik. 24

25 Figure 7. Questions regarding past year gambling behavior in the self-administered questionnaire Past year and lifetime problem gambling Our perception of problem gambling is based on the assumption that extensive gambling can have a damaging influence on your social life and employment as well as your health and economic status, as it is defined in DSM-IV. Following this perspective, it is important to stress the public health perspective underlying this study, which implies an understanding of problems as structural rather than individual. Problem gambling was measured through four questions in the self-administered questionnaire. Two of these questions were combined in a short screen (the lie/bet questionnaire) used in all three papers, while the remaining two questions were used as separate one-item measures of problem gambling included in Paper III. The short screen and the additional one-item measures are described below. 25

26 Figure 8. Questions regarding problem gambling in the self-administered questionnaire The lie/bet questionnaire The lie/bet questionnaire was originally suggested by Johnson and Hammer (39) and later validated in both treatment (40) and community samples (41). The lie/bet questionnaire represents a twoquestion short version of the 10 DSM-IV criteria (15) for screening pathological gambling. Respondents were asked whether they had lied to friends and family about their gambling activities, and whether they had felt a need to increase bets. Questions are shown in Figure 8 (question 23-24). Both questions were posed regarding past year and previously in life. When these two are combined, it represents a measure for lifetime problem gambling, i.e. problem gambling that has occurred at some point in life whether it is a current and/or previous condition. Persons who answered one of the two questions, but not the other, were kept in the new variable for problem gambling, because one positive answer on either of the two questions qualify you to be considered as a problem gambler. This reduced the number of missing in the final variable. A rather large proportion of individuals indicated they had gambled during past year, when asked about specific types of games, but answered they never gambled in the following questions concerning gambling problems. These were not accepted as non-gamblers, which reduced the total of non-gamblers. International gambling studies have typically reported both past year and lifetime prevalence. The lie/bet screen has been found valid to identify lifetime problem gamblers in a community sample, defined as those who responded positively to five or more of the 10 DSM-IV criteria combined with those who only responded positively to three or four of these criteria (41). The short screen does not qualify to distinguish between pathological and problem gambling. It is important to stress, that the 26

27 purpose of screening for problem gambling in a large health survey is to investigate an overall prevalence of how widely gambling is affecting a population, which is by no means comparable to a thorough clinical assessment of pathological gambling based on the DSM-IV-R criteria. Self-rated problem gambling Self-rated problem gambling was included as an additional one-item measure. Respondents were asked whether they themselves felt they had a gambling problem or had been told so by others (see question 25 in Figure 8. The purpose of including a self-rated measure for problem gambling was to see how well participants own perception corresponded with the lie/bet screen. The question was taken from the revised South Oaks Gambling Screen (SOGS-R) originally developed by Leisure and Blume (42;43). The SOGS-R has been the main instrument used to study the prevalence of problem and pathological gambling, although recently abandoned for newly developed screens for epidemiological research (44;45) such as the 9-item Problem Gambling Severity Index (PGSI) (46), the 17-item National Opinion Research Center DSM-IV Screen for Gambling Problems (NODS) (47) also in a 3-item version called NODS CLiP (48), and the 3-item Brief Biosocial Gambling Screen (BBGS) (49). Too much time and money spent on gambling The second one-item measure of problem gambling regarded whether participants felt they had ever spent too much time or money on gambling during past year or previously (question 22, Figure 8). This item was also included in the Inuit Health in Transition Nunavik Survey, but has not yet been analyzed. We have not been able to combine the data from the two surveys yet either, but this will be done in a future study. Sociodemographic variables Residence at age 10 was obtained from the interview and recoded into village or town. Family job type was determined from questions about job title of participant and spouse and recoded into hunters/fishermen and others. Formal education was determined from questions about highest school education attained and further vocational or academic education and recoded into primary school/high school only, short vocational education (less than three years), and longer vocational/academic education. Age was divided into four groups; 18-24, 25-34, and 60+ years. Place of residence was divided into the capital of Nuuk, villages and towns (also used as a measure of social transition). Social transition Two measures of social transition were included. Place of residence The first measure was place of residence, which was divided into villages, towns and the capital because there are substantial differences in lifestyle and living conditions between these places in general. Level of involvement in the ongoing social transition In order to supplement this measure we combined current place of residence and childhood residence with formal education and family job type in a second measure that has previously been used to document changes in cardiovascular risk factors and physical activity among Greenland Inuit (36;37). Six categories of social transition were defined as (A) hunters and fishermen in villages; (B) other inhabitants of villages; (C) blue collar migrants (inhabitants of towns, with no vocational 27

28 education, having lived in villages at age 10); (D) other blue collar participants (inhabitants of towns, with no vocational education, having lived in towns at age 10); (E) intermediate (inhabitants of towns, with short vocational education); and (F) professionals (inhabitants of towns, with longer vocational or academic education). In order not to misclassify participants who had not yet finished their education and to minimize the proportion of participants outside the work force this measure only included those aged years. Traumatic events during childhood Alcohol related problems in childhood home and sexual abuse during childhood were included as traumatic childhood events. Participants were asked through the self-administered questionnaire if there were alcohol problems in their childhood home and whether anyone had forced any kind of sexual activity upon them as a child (before the age of 13). Addictive behaviors Harmful alcohol use (CAGE-C) Harmful alcohol use was measured by the modified CAGE-test: CAGE-C. It is a simple screening tool suited for identifying alcohol problems in populations with a high prevalence of at-risk drinkers. The original CAGE test was based on a four-item questionnaire and measured harmful alcohol use in a lifetime perspective (50). However the validity of the original questionnaire outside a clinical context has been questioned (51) and the sensitivity of the test has been criticized in several studies (52;53). The six-item questionnaire CAGE-C (Table 3) was suggested by Zierau et al. in 2005 (54) and validated against a diagnostic interview based on ICD-10 (55) and DSM-III R (14) criteria. The questionnaire has been used to assess harmful alcohol intake among Greenland Inuit in an earlier study (56). The modified CAGE-test measures harmful alcohol use in a past year perspective and includes a question regarding the number of days per week of alcohol use and a question concerning alcohol intake on weekdays outside meals. CAGE positives were defined by a positive answer in two or more of question 1-4 and 6 or one positive answer in question 1-4 and 6 in addition to alcohol intake on four or more days per week. Table 3. The CAGE-C questionnaire 1 Have you, within the past year, felt that you should cut down on your drinking? Yes/No 2 Have people, within the past year, annoyed you by criticizing your drinking? Yes/No 3 Have you, within the past year, felt bad or guilty about your drinking? Yes/No 4 Have you, within the past year, from time to time had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener?) Yes/No 5 Have many days per week, do you drink alcohol? 0-1 day 2 days 3 days 4 days 5 days 6 days 7 days 6 Do you drink alcohol on weekdays outside mealtimes? Yes/No Frequent use of marijuana Frequent use of marijuana during past year was measured through two questions in the selfadministered questionnaire. Participants were asked if they had ever smoked marijuana. Those who answered yes, once or a few times or yes, several times were asked how often they had smoked marijuana during past year. Those who had tried to smoke marijuana and additionally answered they 28