Intrinsic and Extrinsic Barriers to Health Care:Implications for Problem Gambling

Dave Clarke

Received: 3 January 2007 /Accepted: 9 May 2007 /Published online: 19 May 2007# Springer Science + Business Media, LLC 2007

Abstract To establish guidelines for research into help for problem gambling, this paperreviews literature on barriers to access and utilisation of health care for alcohol abuse,substance abuse and mental health problems. Research findings from international and NewZealand studies are examined, highlighting gender differences and cultural aspects. Intrinsicfactors are presented within the transtheoretical model of change (TTM). Extrinsic barriersconsist of predisposing, enabling and need factors, according to the socio-behavioral model(SBM). The dynamic interaction between intrinsic and extrinsic factors is explained by thenetwork-episode model (NEM) which emphasises the importance of social networks andevents. Personal, socio-cultural and institutional reasons for delays in seeking help arepresented. The greatest barriers to seeking health care are intrinsic. Specific researchquestions regarding the implications for barriers to help for problem gamblers and theirfamilies are proposed. In conclusion, the SBM and the NEM seem to explain barriers tohealth care access and utilisation for addictive disorders and mental health problems betterthan the TTM. Barriers to health care access and utilisation for substance abuse and mentalhealth problems may have some relevance to similar barriers for problem gamblers andtheir families.

Keywords Problem gambling . New Zealand . Transtheoretical model of change .

Socio-behavioral model

Introduction

Removing barriers to health care access and utilisation for addiction interventions may havelong-term economic and social benefits. For example, a review of economic studies in theUSA (McCollister and French 2003) showed that the greatest unique economic benefit of

Int J Ment Health Addiction (2007) 5:279–291DOI 10.1007/s11469-007-9089-1

D. Clarke (*)School of Psychology, Massey University, Albany Campus, 229 State Highway 17, North Shore LibraryBuilding, Albany Village, Private Bag 102 904, North Shore, Auckland 0793, New Zealande-mail: d.clarke@massey.ac.nz

treatments for alcohol abuse and illicit drug use was avoided criminal activity. Reducedneed for health care services was an additional economic benefit. Furthermore, from a studyof the total population of African-American and white women using North Carolina publicmental health services in 1997 (Jerrell et al. 2002), the costs of fitting patterns of care withconsumers’ needs may not be significantly greater than generic services which do not tailorprogrammes to their needs.

In New Zealand, culturally appropriate interventions for Maori with problems associatedwith alcohol and substance use are being encouraged, developed and supported bytreatment services (Huriwai 2002; Robertson et al. 2001). Extended family (whanau) andrelationships are important key concepts in treatment (Huriwai et al. 2001). In one study(Huriwai et al. 1998), a large number of socially disadvantaged Maori in dedicated Maorialcohol and drug treatment services stayed in treatment longer and were more satisfied withtreatment than a comparable group of Maori in non-dedicated services. The problem seemsto be in overcoming barriers for minority cultural group members who need treatment.

This paper reviews literature on barriers to access and utilisation of formal and informalhealth care services. The review covers major literature databases such as PsychINFO andMEDLINE, web-based searches to identify unpublished research, and contacts withresearch centres, particularly in the substance abuse area. “Models of Change for HealthCare” describes models of health care change and access, and ways of conceptualisingintrinsic and extrinsic factors in the models. Intrinsic factors refer to personal emotions,cognitions and behavior, including shame, fears of stigma and treatment, motivation andtreatment readiness (Cancer Prevention Research Centre 2000a; Jessup et al. 2003).Extrinsic barriers are objectively defined and are usually socially located. In addition todiagnostic criteria and practical limitations such as accessibility, they include the attitudesand beliefs of social/cultural groups and of treatment providers (Jessup et al. 2003).“Intrinsic Barriers to Health Care” integrates the findings from the literature, using themodels as conceptual frameworks, and proposes questions for research into barriers forproblem gamblers and their families.

Models of Change for Health Care

Transtheoretical Model (TTM)

The most popular model among researchers and practitioners in the health field whichseems to be related to intrinsic factors is the transtheoretical model of change (Prochaskaet al. 1992). It focuses on the intentional, decision-making behaviors of individuals andconsists of five stages (Cancer Prevention Research Centre 2000a, b):

– Precontemplation is the stage at which there is no intention to change behavior in theforeseeable future. People may be in this stage because they are uninformed or under-informed about the consequences of their behavior. Or they may have tried to change anumber of times and become demoralized about their ability to change. Both groupstend to avoid reading, talking or thinking about their high risk behaviors. They areoften characterized in other theories as resistant or unmotivated or as not ready forhealth promotion programmes...(which) are often not designed for such individuals andare not matched to their needs.

– Contemplation is the stage in which people are intending to change in the next sixmonths. They are more aware of the pros of changing but also acutely aware of thecons. This balance between the costs and benefits of changing can produce profound

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ambivalence that can keep people stuck in this stage for long periods of time. We oftencharacterize this phenomenon as chronic contemplation or behavioral procrastination.These people are also not ready for traditional action oriented programmes.

– Preparation is the stage in which people are intending to take action in the immediatefuture, usually measured as the next month. They have typically taken some significantaction in the past year. These individuals have a plan of action, such as joining a healtheducation class, consulting a counsellor, talking to their physician, buying a self-helpbook or relying on a self-change approach. These are people that should be recruitedfor action-oriented smoking cessation, weight loss, or exercise programmes.

– Action is the stage in which individuals modify their behavior, experiences, orenvironment in order to overcome their problems. Action involves the most overtbehavioral changes and requires considerable commitment of time and energy.

– Maintenance is the stage in which people work to prevent relapse and consolidate thegains attained during action. For addictive behaviors this stage extends from 6 monthsto an indeterminate period past the initial action.

The model has been most frequently researched and applied to smoking cessation(Cancer Prevention Research Centre 2000a). Recently it has been criticised for lack ofempirical support (Callaghan and Herzog 2006; Sutton 2001; West 2006). For example,high correlations among the scales measuring the stages of change show that they are notyielding discrete stages; longitudinal and experimental studies of smokers fail to confirmpredictions based on the model; and evidence for the application of the model to substanceabuse is “meagre and inconsistent” (Sutton 2001, p. 175). It does not provide sufficientattention to positive reasons for behavior change and external factors including socialnetworks that influence help seeking and change (Barber 2004). Prochaska (2006) hasacknowledged the limitations, but has argued that the model’s concepts go beyond standardefficacy trials with samples of single-problem, motivated individuals with addictions, toentire populations with multiple problems in a wide range of formal and informal settings.

Social Behavioral Model (SBM)

Andersen’s social behavioral model (Aday and Andersen 1974; Andersen 1995) is the mostwidely known model for understanding the use of health care services (Jerrell et al. 2002).It consists of three types of extrinsic factors. Predisposing factors include demographicvariables such as gender, age, ethnicity and referral sources. Enabling or access factorsinvolve the actual and perceived means for individuals to use services. They includeavailability, accessibility, affordability and acceptability of services (Booth et al. 2000).Acceptability includes social stigma associated with seeking and utilising care, andcommunication difficulties between service providers and clients. From a recent review ofNew Zealand literature on services for Maori (Thomas 2006), a fifth element related toacceptability could be added: appropriateness for specific ethnic and cultural groups. Needfactors are determined by objective measures of the severity of a disorder. They includediagnoses, comorbidity with other disorders, previous treatment history and negativeconsequences such as work-related and financial difficulties (Booth et al. 2000).

Network-Episode Model (NEM)

The TTM and the social behavioral model seem to omit the dynamic interaction betweenintrinsic and extrinsic contextual factors associated with the access and utilisation of health

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care services. The network-episode model attempts to remedy this omission by highlightingthe importance of social networks and events, with a focus on coercion in the decision-making process (Pescosolido 1992; Pescosolido et al. 1998). Decisions to seek help and careare influenced by pressures from family members, friends, employers or the legal system. Forexample, in one study (Furstenberg and Davis 1984) elderly people were asked about theinfluence of others on their decision to seek help for medical problems. They gave responsesconsistent with individual decision making theories and the social-behavioral model, ratherthan pressures from others. But when they were asked to tell open ended stories about gettinginto care, suggestions, cajoling, nagging and coercion by many others came to the fore.

Intrinsic Barriers to Health Care

Perhaps the greatest intrinsic barrier to seeking help during the precontemplation andcontemplation stages of TTM is people’s tendency to procrastinate for various reasons,even in acute medical or psychiatric situations of distress (DiMatteo 1997; Wu and Bancroft2006). They might misinterpret and minimize the importance of their symptoms, fearembarrassment if there is nothing really wrong, or be reluctant to alter their plans andlifestyle. In a review of literature on intrinsic barriers to treatment, Cunningham et al. (1993)noted from population and clinical surveys that many people with alcohol and drug abuseproblems have attitudinal barriers. Generally, they do not think that they have a problem orthat it is not serious enough to warrant seeking treatment; they believe that they can handlethe problem on their own; or they like the intoxication feeling and do not want to relinquishit. Compared with drug abusers, the authors found that Canadian alcohol abusers in clinicaland community samples were more likely to want to handle the problem on their own. Forall health problems, the traditional masculine belief of self-reliance has resulted in delays inseeking help, especially among lower socioeconomic status men (Galdas et al. 2005;Jackson et al. 2003). From interviews with a large, representative sample of the USpopulation with an alcohol use disorder in the 1992 National Household Survey on DrugAbuse, attitudinal barriers were approximately twice as frequent as enabling factors such asaccessibility and affordability (Grant 1997).

From the longitudinal Dunedin Multidisciplinary Health and Development Study(DMHDS) which began in 1972, the main barriers to professional health care services for18 year-olds included embarrassment, particularly for females, and fears that a parent wouldbe consulted (Dixon et al. 1995). At age 26, 59% of the 144 interviewees who reported self-harm behaviors within the past year had not sought help, and 39% revealed attitudinalbarriers to seeking help (Nada-Raja et al. 2003). Self-harm behaviors included suicideattempts, self-battery and intoxication to deal with emotional pain. Smaller percentages(<13%) indicated fear of what others might think, reluctance to answer personal questionsor practical barriers such as lack of appropriate services, time or money.

Fears of stigma, shame and treatment are commonly found among people with alcoholand drug problems or depression, and are greater barriers to treatment than the extrinsicenabling factors of availability, affordability and accessibility (Barney et al. 2006; Cowanet al. 2003; Cunningham et al. 1993; Grant 1997; Lane and Addis 2005; Simpson and Tucker2002). In Australia, a large, random community sample was surveyed about seekingprofessional help for depression (Barney et al. 2006). Many respondents expressed that theywould be embarrassed to seek such help and would expect others such as family and friendsto have negative reactions to them if they did. The authors suggested that public healthinterventions should be aimed to lower the expectations of adverse reactions from others,which might be more imagined than real, especially for young people.

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For drug dependent mothers (McMahon et al. 2002) and women who are pregnant(Jessup et al. 2003), and for men with substance abuse or depression who define the malegender role in terms of success, power and competition (Lane and Addis 2005; Mansfield etal. 2005), these fears present formidable intrinsic barriers to seeking help. The actual andperceived stigmas associated with substance-abusing mothers and weak or dependent malesmay discourage susceptible individuals at the precontemplation and contemplation stagesfrom approaching services where their personal weaknesses would be exposed. In contrast,it has been found that while substance-abusing mothers who lived in a sexual relationshipwith substance-abusing men entered treatment infrequently, once both partners movedbeyond the contemplation stage, their commitment to treatment was strengthened, perhapsbecause of mutual support and caring for the children (McMahon et al. 2002).

Shame in seeking professional help for alcohol and substance abuse may be prominentamong young people (Dixon et al. 1995) and among minority groups such as Maori andPacific Island groups in New Zealand (Alcohol Advisory Council of New Zealand 1997;Barnes et al. 2003). From in-depth interviews with a small sample of young, immigrantChinese males in drug treatment programmes in Vancouver (Kwok 2000), there was astrong sense of shame among participants before they entered treatment, such that theyavoided both mainstream helping agencies and their own families. However, much to theinterviewees’ surprise, once the abuse was discovered, their Chinese parents did all theycould to help their children. Consistent with the network-episode model, when they hadexhausted all their resources, the parents were keen to get their offspring to mainstreamagencies. Similarly, from a very large population sample of non-smokers calling the multi-lingual California Smokers’ Helpline for smokers whom they knew and who were ready toquit (contemplation stage), Asian speakers were much more likely to seek help for theirsmokers than English-speaking whites, blacks, native Americans or Hispanics (Zhu et al.2006). Across all ethnic groups, non-smoking callers were primarily women and living inthe same households as the smokers.

The TTM specifies self-efficacy as a subjectively defined construct which affects anindividual’s responses through the change process (Cancer Prevention Research Centre2000a). Self-efficacy involves confidence that one can deal with high risk situations such asemotional upsets and social pressures without relapse into addictive behaviors. The TTMpurports that self-efficacy should increase through treatment, as the benefits begin tooutweigh the disadvantages of changing. However, self-efficacy might predict behavioralchange through the preparation and action stages, but not help-seeking behavior at theprecontemplation and contemplation stages (Jackson et al. 2003; Lane and Addis 2005).For example, compared to male and female substance abusers in US federal prisons whochose to enter a voluntary substance abuse treatment programme, inmates with a history ofsubstance abuse who did not enrol in the programme were more likely to have higher levelsof self-efficacy, after controlling statistically for gender, age, ethnicity, education, comorbiddiagnoses and drug-use history (Jackson et al. 2003). The authors suggested that because oftheir excessive self-reliance, the non-volunteers might have underestimated their need forprofessional treatment, and avoided stigma and shame that they might not be as self-reliantas they thought they were or appeared to be. Further, strong motivation to quit a substanceproblem might not be sufficient to carry men through all stages of the TTM process. Forexample, substance abusing men who reported that their lives were out of control andwanted to quit were significantly more likely to drop out of a government sponsoredsubstance abuse treatment programme than lesser motivated men (Green et al. 2002).

Although conventional views assume that denial occurs at the precontemplation stage,research evidence supports early recognition of a drinking problem. For example, consistent

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with previous research, a large community sample of problem drinkers showed thefollowing temporal sequence of events leading to help-seeking behavior (Simpson andTucker 2002). Problem recognition occurred very early with pathological drinking patterns,usually many years before initial help-seeking. Relationship, employment, financial andlegal problems developed somewhat later, followed by severity of physical and emotionalsymptoms. Once in the contemplation and preparation stages, women were quicker thanmen to seek help.

Extrinsic Barriers to Health Care

The enabling factors of availability, accessibility, affordability and acceptability of servicesdepend upon differences among the predisposing factors of gender, age, ethnicity, andsocioeconomic status. They also depend upon the type of problem, its severity andcomorbidity with other disorders. Women are more likely than men to seek treatment forphysical and mental health problems, but men are more likely than women to seek help forsubstance abuse (Booth et al. 2000; Galdas et al. 2005; Green et al. 2002). For alcoholdependence, no significant differences between percentages of men and women seeking oreven perceiving the need to seek treatment from alcohol treatment services were found inthe 1999 US National Household Survey on Drug Abuse (Wu and Ringwalt 2004). Bothpercentages were remarkably low (<10%), indicating that the majority of alcohol dependentindividuals do not seek treatment until family, employment, legal and health problemsbecome substantial (Booth et al. 2000; Wu and Ringwalt 2004).

From a 1 year prospective study of 579 at risk drinkers in six southern states (Booth etal. 2000), these social consequences predicted the use of alcohol treatment services,whereas the enabling factors did not. After controlling for all extrinsic factors in the logisticregression model, only female gender, social consequences, social support, severity of thedrinking problem, concurrent medical problems and prior treatment experience significantlyand uniquely predicted use of treatment facilities. Consistent with the network-episodemodel, the authors proposed that when social consequences become severe enough, socialsupport is likely to be salient in helping abusers seek treatment. Social support involveshelping abusers identify problems, providing information and encouragement to seek help,and reducing stress. Although severity of drinking problem was a stronger factor than socialconsequences in this study, social pressures and social problems were more influential thanseverity of symptoms of alcohol abuse in getting Dutch male abusers into treatment(Hajema et al. 1999).

Alcohol dependent women in the 1992 and 1999 US national surveys were significantlymore likely than alcohol dependent men to indicate that they did not know where to go forhelp, that they had difficulties getting child care, that they feared loss of custody of theirchildren, and that they would fail to fulfil childcare responsibilities if they entered treatment(Grant 1997; Wu and Ringwalt 2004). These barriers and economic barriers such as cost ofcare and lack of insurance also apply to women with substance abuse problems (Cowanet al. 2003; Goldberg 1995; Green et al. 2002; Jessup et al. 2003; Marsh et al. 2000),especially among minority groups such as African-American women (Allen 1995; Jerrellet al. 2002; McMahon et al. 2002). Even when treatment facilities are available, womenwith children face greater problems than men for transportation, economic support andchild care (Marsh et al. 2000). In New Zealand there are very few childcare facilitiesavailable for alcohol and drug dependent women (Cowan et al. 2003).

From the 1-year prospective study of at-risk drinkers in six southern states (Booth et al.2000), from the Australian National Survey of Mental Health and Wellbeing (Issakidis and

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Andrews 2006), and from New Zealand focus groups of clinicians, clients and their familiesinvolved in substance abuse or mental health services (Todd et al. 2002), rural at-riskdrinkers and persons with mental health problems are more likely than urban ones to havedifficulties with accessibility, affordability and acceptability of some treatment services,especially among indigenous groups such as aboriginal Australians and native NorthAmericans (Duran et al. 2005; Gruen et al. 2006; Manson 2000; Roberts et al. 2005).Primary health care services such as general practitioners and public health emergencyservices are usually the first contacts for people with substance abuse and mental healthproblems (Booth et al. 2000; Issakidis and Andrews 2006; Lester et al. 2005).

Findings regarding the relationships of other demographic variables to seeking treatmentfor alcohol and substance abuse or psychiatric disorders are generally inconsistent (DeSouzaand Garrett 2005; DiMatteo 1997; Green et al. 2002; Hajema et al. 1999; Jackson et al. 2003;Kessler et al. 1998). As would be expected, from the 1992 US National Household Survey onDrug Abuse, senior citizens were significantly more likely than younger age groups toendorse having problems getting to treatment for substance abuse, and significantly lesslikely to endorse time and fear of losing their jobs as barriers (Grant 1997). In the 1999survey, although younger women (18–25 years) were significantly more likely than olderwomen to be alcohol dependent, they were less likely to use treatment services, or to perceivea need for treatment, especially among women from high income households or with morethan one child (Wu and Ringwalt 2004). Paid employment and younger age have beenmitigating factors against seeking treatment among male alcohol abusers, but not highsocioeconomic status and imbibing social networks as predicted by the network-episodemodel (Hajema et al. 1999). It was expected that employed and high socioeconomic statusmen would avoid getting help for fear of stigma, social disapproval or loss of employment.

In a northwestern US survey of a large, representative sample of male and femalesubstance abusers who were eligible for outpatient treatment, young age, incompletesecondary school education, and difficulties with employment and income were negativelyassociated with beginning and completing treatment (Green et al. 2002). From the USNational Comorbidity population survey (Kessler et al. 1998), people with substance-related disorders across all age cohorts had low rates of initial treatment contact. Theauthors suggested that intrinsic attitudinal barriers, public intolerance and lack of insurancefor treating addictions contributed to the low rates. In contrast, contacts for majordepression, general anxiety disorder and phobias progressively decreased with the age ofbirth of the cohorts, indicating that public attitudes and policies toward mental healthproblems other than addictions were encouraging younger people to seek treatment.

Acceptability and Appropriateness

Knowledge about symptoms of substance abuse, the availability of treatment services andtheir effectiveness is important for abusers, caregivers, their families and social contacts(Cunningham et al. 1993; de Bonnaire et al. 2000; de Zwart et al. 2002; Wu and Ringwalt2004). In New Zealand, from a population survey of 433 parents of New Zealand youthaged 14 to 18 years (de Bonnaire et al. 2000), the authors found that less than 5% of themwere aware of support networks available to them for adolescent alcohol problems, such asAlcohol Helpline and the Alcohol Advisory Council of New Zealand’s web page. The mostfrequent sources mentioned were school, church, extended family, Alcoholics Anonymousand the police. When the Alcohol Advisory Council of New Zealand (ALAC) surveyed themajor Pacific Island groups to ascertain drinking patterns, both men and women in all thegroups except the Niues seemed totally unaware of the health effects of binge drinking.

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For Asian immigrants in New Zealand, the main barriers to primary healthcare caninclude language difficulties, and lack of knowledge of services and entitlements, especiallyamong those born in Mainland China (DeSouza and Garrett 2005). There might be otherreasons for not using conventional agencies. For example, Asian females have been lesslikely than females of other ethnic groups to have used primary healthcare services or atelephone help line for help, but more likely to use alternative tradition remedies beforeapproaching allopathic practitioners.

Even when knowledge of the availability of health care services is present, the attitudesof social groups and clinicians, and communication barriers between clients and health carepractitioners can mitigate against effective utilisation of services (Goodwin and Happell2006; Kennedy et al. 2004; Kerkorian et al. 2006). The stigma associated with substanceabuse is much greater for women than for men, especially if they are pregnant or haveyoung children (Cowan et al. 2003; Goldberg 1995; Grant 1997; Green et al. 2002; Jessupet al. 2003). Women who drink to excess are likely to be seen as immoral, whereas menwho drink to excess are seen as manly, even amongst women who drink heavily (Lyons2006). Possibly because of cultural stigmas and denial among the communities, femalealcohol dependency among Maori and Pacific Island groups is a hidden problem (AlcoholAdvisory Council of New Zealand 1997; Barnes et al. 2003).

A recent survey of a random sample of 217 alcohol and drug treatment clinicians in NewZealand (97% response rate) by the National Addiction Centre, found that almost one-quarter of the sample did not support the view that women have different needs than men(Cowan et al. 2003). Among those who believed that women should receive differenttreatment than men, only 13% of the male clinicians and 36% of the female clinicianshelped their female clients with parenting issues. In contrast, more than 60% of the non-Maori individual clinicians took some form of culturally appropriate interventions such asreferring Maori clients to specialist Maori practitioners or making contacts with theextended family (Robertson et al. 2001). Cultural appropriateness refers to “the delivery ofprogram and services so that they are consistent with the cultural identity, communicationstyles, meaning systems and social networks of clients, program participants, and otherstakeholders” (Thomas 2006, p. 66). Impersonal, professional clinical styles can beunsettling for clients who identify with their respective ethnic groups, and be interpreted asaloofness and lack of support.

Many of the barriers to access and utilisation of healthcare services for mental healthproblems in Western countries stem from the current system of managed care. Referrals tounder-resourced specialist services from primary care physicians can take weeks or months,a limited number of treatment sessions are funded by governments and insurance plans, andclients are re-routed to less well trained helpers (Zatzick 1999). Further, both primary andsecondary care professionals can overestimate a client’s understanding of technical terms,what they have been told and what the need to do (DiMatteo 1997).

Need Factors

For people with coexisting substance abuse and mental health disorders, a number ofbarriers have been identified by focus groups of clinicians, clients and their familiesinvolved in New Zealand substance abuse or mental health services (Todd et al. 2002).Maori expressed lack of trust of the intentions of government agencies and mainstreamprofessionals. Consistent with research in other countries, systems barriers includedfragmentation of services, poor communication between agencies, inconsistency of care,and time and resource constraints. Few clinicians had the knowledge and skills in

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Table 1 Specific Research Questions for Problem Gambling

Research Questions

Intrinsic barriers1 Are there discrete stages of change in the decision-making process of problem gamblers, and do

longitudinal and experimental studies of problem gamblers support these changes, as predicted by thetranstheoretical model?

2 In the contemplation and preparation decision stages, are women quicker than men to seek help?3 Are problem gamblers more likely to enter treatment if they are pressured to get help than if they rely

on individual decision making or on lower extrinsic barriers to access?4 Are problem gamblers more likely to handle problems on their own than alcohol and substance abusers?5 Is the male gender role of self-efficacy, success, power and competition negatively related to seeking

help for problem gambling?6 Are problem gamblers who report that their lives are out of control and they want to stop gambling

less likely to complete treatment programmes than problem gamblers who are not as stronglymotivated?

7 To what extent do attitudinal barriers and fears of stigma, shame and treatment present barriers to helpfor problem gambling among the following groups: (a) mothers, (b) men who define their gender rolein terms of success, power and competition, (c) young people, and (d) ethnic minorities?

8 Before seeking help, do problem gamblers follow the same temporal sequence of events as substanceabusers: (1) early recognition of the problem, (2) relationship, employment, financial and legalproblems, (3) severe physical and emotional symptoms?

9 Are problem gamblers more likely to consider professional knowledge and training more salient thantrust in treatment providers?

10 Are attitudinal barriers and fears of stigma, shame and treatment for problem gambling greater barriersto treatment than the extrinsic enabling factors of availability, accessibility, affordability, acceptabilityand appropriateness?

Extrinsic barriers11 Is the stigma associated with female substance abuse greater than the stigma associated with female

problem gambling?12 Is the stigma of problem gambling greater for women than for men, and what gender differences are

there for different ethnic groups?13 Are men more likely than women to seek treatment for problem gambling?14 Are youth, low education, employment difficulties and low socioeconomic status negatively associated

with beginning and completing treatment for problem gambling?15 Are high socioeconomic status, employed, male problem gamblers less likely to seek treatment than

low socioeconomic status, unemployed, male problem gamblers?16 Do women and ethnic minority groups have more economic and childcare barriers than men in seeking

treatment for problem gambling?17 Are young women more likely to gamble than older women, but less likely to perceive a need for

treatment?18 Are rural problem gamblers more likely than urban ones to have difficulties with availability,

accessibility, affordability, acceptability and appropriateness of some treatment services, especially forindigenous groups such as Maori?

19 Are primary health care services such as general practitioners and public health emergency servicesusually the first contacts for problem gamblers?

20 Are there culturally appropriate interventions for Maori, Pacific Island and Asian problem gamblers inNew Zealand?

21 Are Asian families in New Zealand more likely to seek help from mainstream agencies for problemgamblers in their families than New Zealand European, Maori or Pacific Island families?

22 Do immigrants have more language difficulties and less knowledge of problem gambling services andentitlements than residents in a country?

23 What proportions of different clinicians believe that female problem gamblers have different needs thanmale problem gamblers, such as assistance with parenting difficulties?

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assessment, treatment planning and interventions for comorbid disorders. Judgmentalattitudes existed, particularly among mental health practitioners. Substance abuse problemswere seen as a matter of choice and therefore were considered personal and moral deficits.Confrontation and insistence on abstinence without considering alternatives, rejection ofmedical interventions, and rivalry between professional groups and regions were found,even among some Maori helping agencies.

Substance dependence and mental health disorders present further challenges to helpingagencies, especially if comorbidity between the two syndromes exist and particularly formajor depression (Booth et al. 2000; Dixon et al. 1995; Green et al. 2002; Jackson et al.2003; Jessup et al. 2003; Muir-Cochrane 2006; Wagner et al. 2006; Wu and Ringwalt2004). For example, from the Dunedin Multidisciplinary Health and Development Study,untreated schizophrenic or substance-dependent 21 year-olds had higher rates of assaultsand violent crimes than comparable control members of the cohort (Arseneault et al. 2002).Comorbid cases were more likely than single-disordered cases to have a history of chronicmental and physical health problems, fewer social networks and greater frequency of use oftreatments (Newman et al. 1998). Although women are less likely than men to seektreatment for substance abuse, when they do seek help, their substance-related and mentalhealth problems are likely to be more severe, and they are less likely to begin treatmentafter initial assessment that they are eligible for treatment programmes (Green et al. 2002).In addition to intrinsic and extrinsic barriers, treatments for alcohol and substance abusetend to be oriented more toward men (Goldberg 1995; Marsh et al. 2000).

Summary and Conclusions

Table 1 summarises the findings discussed above in terms of potential research questionsfor problem gambling. There is some evidence that the questions may be appropriate. Forexample, like alcohol and substance abusers, problem gamblers are also likely to want tohandle problems on their own (4) (Hodgins and El-Guebaly 2000). Attitudinal barriers andfears of stigma, shame and treatment for problem gambling are greater barriers to treatment

Table 1 (continued)

Research Questions

24 What proportions of different clinicians working with problem gamblers and their families take someform of culturally appropriate interventions?

25 Are women more likely than men to seek help for problem gambling from other sources such as theInternet rather than mutual self-help groups such as Gamblers Anonymous?

26 Are social pressures and social consequences more influential than severity of behavioral symptoms ingetting problem gamblers into treatment?

27 Do problem gamblers with comorbid substance dependence or mental health disorders encountersystems barriers, including fragmentation of services, poor communication between agencies,inconsistency of care, and clinicians’ judgmental attitudes, lack of knowledge and skills in assessment,treatment planning and interventions for comorbid disorders?

28 For comorbid problem gambling with substance abuse, are women less likely than men to entertreatment and have more severe symptoms of the disorders?

29 For problem gambling and substance abuse, are comorbid cases more likely than single-disorderedcases to have a history of chronic mental and physical health problems, fewer social networks andgreater frequency of use of treatments?

30 Are changing public attitudes and policies towards problem gambling encouraging problem gamblers toseek help?

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than the extrinsic enabling factors of availability, accessibility, affordability and accept-ability (10) (Evans and Delfabbro 2005). Problem gamblers with comorbid substancedependence or mental health disorders can encounter systems barriers (27) (Hodgins andEl-Guebaly 2000). In contrast, social pressures and social consequences may be lessinfluential than severity of behavioral symptoms in getting problem gamblers into treatment(26) (Evans and Delfabbro 2005). Barriers to help seeking by problem gamblers and theirfamilies, and ways of changing barriers to access and use of services are discussed furtherin a second paper presented at the conference (Clarke et al. 2006).

In conclusion, the SBM and the NEM seem to explain barriers to health care access andutilisation for addictive disorders and mental health problems better than the TTM. Barriersto health care access and utilisation for substance abuse and mental health problems mayhave some relevance to similar barriers for problem gamblers and their families.

Acknowledgements The research on which this paper is based was funded by a grant from the NewZealand Ministry of Health (MOH: 467589/303177/00).

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