Research Commentary [26] December 2018

Dec 3, 2018

The focus of this review is on problem gambling, drug and alcohol addiction in Asian and other ethnic minority communities.

The New Zealand and international studies address: traditional world views in Chinese culture which contribute to problem gambling; barriers to accessing drug and alcohol services for culturally diverse populations; a health needs analysis for problem gambling in Asian populations in New Zealand; and an evidence base for providing culturally competent approaches to drug and alcohol treatment.

Culturally and linguistically diverse (CALD) populations are a high-risk group for problems with alcohol, drugs and gambling but have lower rates of treatment seeking and completion than the mainstream population. A significant barrier to treatment is the lack of culturally relevant and appropriate treatment.

Problem gamblers in New Zealand are more likely to be Maori, Pacific or Asian, they are more likely to smoke, drink and use other drugs (Sapere Research Group, 2018). Gambling is linked with a number of psychotic disorders ranging from alcohol and nicotine dependence, to behavioural disorders. The research findings would seem to substantiate the need to screen for gamblers in other mental health and addictions services, as well as screening problem gamblers for other mental health and addiction issues. Students with ‘more unhealthy’ gambling behaviour had significantly higher depression scores and significantly lower wellbeing scores than students who were gambling at ‘less unhealthy’ levels.

The Asian population is the third largest ethnic group in New Zealand (12%). In Auckland, 24% of all residents self-identify as having Asian heritage (Statistics New Zealand, 2013). A significant number of this growing population drink and binge drink (Ameratunga et al., 2011; Ministry of Health, 2015). In 2014, 18% of Asian adults reported any risky alcohol consumption within the last four weeks after controlling for gender and age (Gordon, 2015). About 14% of Asian students aged 13 – 17 years reported binge drinking at least once within the last four weeks (Ameratunga et al., 2011).

References:

Sapere Research Group (2018). Gambling Harm Reduction Needs Assessment. Wellington: Ministry of Health. Retrieved from:  https://www.health.govt.nz/system/files/documents/publications/gambling-harm-reduction-needs-assessment-aug18.pdf

Statistics New Zealand (SNZ) (2013). Census QuickStats about Culture and Identity. Wellington: SNZ. Retrieved from: http://archive.stats.govt.nz/Census/2013-census/profile-and-summary-reports/quickstats-culture-identity.aspx

Ameratunga, S., Waayer, D., Robinson, E. et al (2011). Youth '07: The health and wellbeing of secondary school students in New Zealand Young People and Alcohol. Auckland: The University of Auckland, Adolescent Research Group. Retrieved from: https://www.fmhs.auckland.ac.nz/assets/fmhs/faculty/ahrg/docs/2007-alcohol-report-2013.pdf

Gordon, C. (2015). Alcohol use among adults in the previous month: ABAS 2014/15. Wellington: Health Promotion Agency Research and Evaluation Unit. Retrieved from: https://www.hpa.org.nz/sites/default/files/alcohol_use_among_adults_in_the_previous_month1415.pdf

Ministry of Health. (2015). Annual Update of Key Results 2014/15: New Zealand Health Survey. Wellington: Ministry of Health. Retrieved from: https://www.health.govt.nz/nz-health-statistics/national-collections-and-surveys/surveys/new-zealand-health-survey

Commentary provided by Dr Annette Mortensen, eCALD® Services Project Manager: Research and Development 

The following articles are reviewed:

Article 1:  Gambling Harm Reduction Needs Assessment

In New Zealand, the contracted approach for problem gambling services is the same for all providers and populations. The services are purchased through the required workforce numbers to deliver a set number of interventions, regardless of whether the population being served has English as the first language, or any cultural or social barriers. Feedback from problem gambling service providers indicates that:

“…the biggest barrier is culture , when doing a brief it can take up to 3 sessions, the contract does not allow for nuances of a cultural approach – we’re trying to get culture to fit European system […] We’re working at 100% but only 40% works into CLIC [Client Information Collection database where service providers record the interventions they provide] system”

Another provider also explained that some of the populations they work with do not understand the concept of “counselling” and so they have to build up trust with them first so they understand that it is confidential and safe.

Some also noted that clinical training lacked cultural competency: that the clinical training came from a very Eurocentric perspective, and did not take into account different cultural requirements or models of health.

Those who attend treatment for problem gambling are at crisis point. In the study all service providers reported that they only see problem gamblers once they hit crisis point. By the time people seek support, they have often already caused the damage to their finances, relationships and sometimes themselves.

Some provider feedback suggested that for some newer migrants to New Zealand, gambling can be seen as part of the ‘kiwi culture’ because it is easily accessible and its legal. This may in part contribute to a lack of understanding of the risks, as well as stigma that surrounds people with gambling problems.

Some also suggested that Asian migrants, and international students, in Auckland in particular, can often become involved in casino gambling as it is a ‘safe place’. Casinos are open 24 hours, employ an ethnically diverse workforce who speak their language and it’s a place to explore new found freedoms from cultures where gambling may be illegal. Some migrants or students can lose all their funds and are reluctant to address the issues that their gambling has caused.

Authors: Sapere Research Group

Citation: Sapere Research Group (2018). Gambling Harm Reduction Needs Assessment. Wellington: Ministry of Health.

Publication

 

Article 2: Chinese beliefs in luck are linked to gambling problems via strengthened cognitive biases: A mediation test

Gambling and its harms are found across many cultures, but, at the same time, have culturally specific expressions. For example, the rates of severe gambling problems amongst the Chinese people are higher than the rates found in European cultures. In this study, 333 Chinese gamblers residing internationally were surveyed. The study explores the sources of cultural variations in gambling harm to help us understand the susceptibility to gambling problems across and within different cultural groups.

Superstitious beliefs in luck are pervasive amongst Chinese people, and the cultural milieu heightens and sustains gambling related harms in this population. Superstitious beliefs reported amongst Chinese peoples includes the beliefs in the effectiveness of feng-shui or geomancy to improve personal luck, the use of horoscopes to predict the future, and the belief that certain numbers such as “6” and “8” have lucky properties because they are homonyms of the Chinese words for “smoothness” and “prosperity” respectively. 

The psychological construct of luck has been defined in the (Western) literature as both an internal property of a person as well as an external property of situations and environments. The western concept of luck as an internal and stable personal characteristic is comparable to the Chinese view of luck expressed in fatalistic terms as one’s predestined ‘life-luck’. These beliefs probably do not increase Chinese people’s susceptibility to cognitive biases about their control within games of chance. However, Chinese conceptions of the external sources of luck may increase such susceptibility. This is because Chinese people view external sources of luck, or ‘lucky circumstances’, as open to manipulation through culturally sanctioned practices. Critically, this latter formulation of luck is consistent with the ubiquitous cultural practices of Chinese geomancy and “luck-talk” during Chinese festive occasions to alter personal fortuity.

The findings of the study advance our understanding of the possible reasons for the higher rates of gambling-related harms reported in Chinese compared to Europeans and other non-Chinese Asians. Specifically, the linguistic and customary traditions of Chinese people maintain a luck-oriented worldview that has been shown in this study to increase risk for clinically significant gambling problems. These superstitious beliefs are embedded in customs such as scripted greetings during lunar New Year celebrations to promote the good health and prosperity of family members. They are also seen in the thriving business of Chinese geomancy practices. For Chinese people, patterns of superstitious belief in this community appear to be linked to the elevated rates of gambling-related harms. 

Authors: Lim, M.S.M. & Rogers, R.D.

Citation: Lim, M.S.M. & Rogers, R.D. (2017). Chinese beliefs in luck are linked to gambling problems via strengthened cognitive biases: A mediation test. Journal of gambling studies 33, (4) 1325-1336.

Publication

Article 3: Culturally sensitive substance use treatment for racial/ethnic minority youth: A meta-analytic review

Community Drug and Alcohol Services in New Zealand are working with adolescents from increasingly diverse cultural backgrounds. CALD adolescents may vary in how they respond to substance use treatment. This review synthesised the current and best available research evidence on the effects of culturally sensitive substance use treatment, and found that these treatments are associated with higher reductions in post-treatment substance use among ethnic minority adolescents. Strong conclusions from the review are hindered by the small number of available studies for synthesis, variability in comparison conditions across studies, and lack of diversity in the adolescent clients served in the studies. Nonetheless, this review suggests that culturally sensitive treatments offer promise as an effective way to address substance use among ethnic minority youth.

This systematic review summarised findings from eight studies examining culturally sensitive substance use treatment for ethnic minority youth. The meta-analysis quantitatively synthesised findings from seven of those studies, and indicated that participation in culturally sensitive treatments was associated with significantly greater reductions in substance use. Substance use treatments in which culture-based considerations were incorporated into the design and delivery yielded over a one-third standard deviation improvement in substance use, relative to comparison conditions. The results of the review suggest that these culturally informed treatments constitute a promising approach to reducing substance use among ethnic minority youth relative to most comparison conditions. However, there is not enough evidence to suggest whether cognitive behavioural therapy with culturally accommodated content and delivery may be more or less effective relative to standard cognitive behavioural therapy delivered by culturally competent providers.

Authors: Steinka-Fry, K.T., Tanner-Smith, E.E., Dakof, G.A. & Henderson, C.

Citation: Steinka-Fry, K.T., Tanner-Smith, E.E., Dakof, G.A. & Henderson, C. (2017). Culturally sensitive substance use treatment for racial/ethnic minority youth: A meta-analytic review. Journal of Substance Abuse Treatment, 75, 22–37

Publicationf

Article 4:  Cultural Competence in the Treatment of Addictions: Theory, Practice and Evidence

Culturally and linguistically diverse (CALD) populations often have high rates of addictive disorders, but lower rates of treatment seeking and completion than the mainstream population. A significant barrier to treatment is the lack of culturally relevant and appropriate treatment. The authors conducted a literature review to identify relevant literature related to cultural competence in mental health services delivery and specifically treatment for addictive disorders. Several theoretical models of cultural competence in therapy have been developed, but the lack of rigorous research limits the empirical evidence available. Research indicates that culturally competent treatment practices including providing therapy and materials in the client's language, knowledge, understanding and appreciation for cultural perspectives and nuances, involving the wider family and community and training therapists can enhance client engagement, retention and treatment outcomes for substance use and gambling. Further, methodologically rigorous research is needed to isolate the impact of cultural competence for the treatment of addictions and guide research to determine treatment efficacy within specific CALD populations. Training therapists and recruiting therapists and researchers from CALD communities is important to ensure an ongoing focus and improved outcomes for CALD populations due to the importance of engaging these populations with addiction treatment. 

Key practitioner messages are: 

  • The treatment needs of culturally diverse individuals with addictions are often not met. 
  • Theoretical models can guide therapists in incorporating cultural competence. 
  • Culturally targeted treatments increase recruitment, retention, and treatment outcomes.  
  • Cultural competence includes matching clinicians and clients on linguistic and cultural backgrounds as well as being mindful of the impact of culture on client’s experience of addiction problems. 
  • Few methodologically rigorous trials have been conducted to guide treatment practices and research needs to be incorporated into existing culturally-relevant treatment services. 

Author: Gainsbury, S.M. (2016). 

Citation: Gainsbury, S.M. (2016).  Cultural Competence in the Treatment of Addictions: Theory, Practice and Evidence. Clinical Psychology & Psychotherapy 24 (4) DOI: 10.1002/cpp.2062} 

Publication

Article 5: Possible Barriers to Enrollment in Substance Abuse Treatment among a Diverse Sample of Asian Americans and Pacific Islanders: Opinions of Treatment Clients  

In this exploratory analysis, the authors examined the treatment experiences of Asian Americans and Pacific Island Peoples (AAPIs) enrolled in substance abuse treatment. This sample provides preliminary information about the possible barriers that may prevent AAPIs with Substance Abuse Disorders (SUDs) from entering substance abuse treatment. The quantitative analysis focused on previously studied barriers among substance using populations. Using qualitative research methods, the authors explored and identified additional factors that were not previously explored among AAPIs with SUDs. The study found that a frequently cited barrier and facilitator concerned relationships with peers. 

In the qualitative analysis, some participants across all AAPI ethnic groups reported that they viewed drug using peers as hindering the treatment process. AAPI respondents reported that it was necessary to avoid environments that elicit and maintain substance abuse and to avoid the negative influence of substance using friends. Social networks that provide models of abstinence are necessary for the treatment of substance use disorders.

In the quantitative analysis, many respondents reported concerns related to a loss of confidentiality and fears of losing one’s employment. It is possible that respondents were afraid that if their employers discovered their SUDs, they would lose their jobs. Another possibility is that a loss of confidentiality is related to a fear of deportation. Filipino and Vietnamese participants were more likely to express concerns about their immigration status as well as expressing more concerns about a loss of confidentiality than other AAPI ethnic groups. 

Both quantitative and qualitative analyses identified how family members may hinder treatment. AAPI family members may minimise SUDs to save face. There is a reluctance to seek outside assistance for a SUD because it may reflect the family’s inability to solve the situation, and may be inconsistent with the cultural mandate to maintain an appearance of harmony within the family. Participants reported that family members may not be supportive of substance abuse treatment, may be unfamiliar with the treatment process, and might view substance abuse treatment as interfering with family obligations to provide financial resources to benefit the family as a whole. In contrast, some families did see the merit of substance abuse treatment and pressured the substance user to enter and complete treatment. These differing opinions among APPI families may indicate that substance abuse treatment is not widely accepted in the AAPI community and that dissemination efforts should be used to inform the AAPI community about evidence-based substance abuse treatments and of the benefits of these approaches.

Participants reported they preferred culturally competent substance abuse treatment programs. Of those who were concerned about treatment programs addressing their cultural needs, an understanding of the clients’ cultural background and ability to provide services in their native language were preferred. The findings suggest that in order to reduce cultural barriers and enhance the treatment systems’ effectiveness to treat AAPI clients, the health and social service workforce should be trained in culturally competent intervention and support, including being familiar with their clients beliefs and values, health-seeking behaviours, and culturally relevant treatment strategies.

Authors: Masson, C.L., Shopshire, M.S. & Sen, S. et al.

Citation: Masson, C.L., Shopshire, M.S. & Sen, S. et al. (2013). Possible Barriers to Enrollment in Substance Abuse Treatment among a Diverse Sample of Asian Americans and Pacific Islanders: Opinions of Treatment Clients.  J Subst Abuse Treat, 44 (3), 309–315. doi:10.1016/j.jsat.2012.08.0

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