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		[This article prints out to about 16 pages] A public health approach for Asian people with problem gambling in foreign countries   Samson Tse,1 John Wong,2 & Hyeeun Kim,3 Problem Gambling Foundation of New Zealand, Aotearoa-New Zealand. E-mail: s.tse@auckland.ac.nz Abstract There has been a rapid increase in Asian immigration to English-speaking countries such as New Zealand, Australia, Canada, and the United States. Anecdotal accounts and research suggest high levels of participation in gambling by people from Asian countries. Asian problem gambling is seen as being a social rather than an individual problem compounded by difficulties with post-migration adjustment. Contemporary public health perspectives are not limited to the biological and behavioural dimensions, but can also address socioeconomic determinants such as income, employment, poverty, and access to social and healthcare services related to gambling and health. This paper discusses how a public health viewpoint can lead to effective strategies against problem gambling. The five principles proposed in this paper are: (1) acknowledging similarities and differences within Asian populations, (2) ensuring that strategies are evidence-based, (3) treating Asian problem gambling in an acculturation framework, (4) addressing the issue of shame associated with problem gambling among Asian people, and (5) targeting at-risk sub-groups. Introduction Over the past two decades, gambling has expanded rapidly in New Zealand, as it has in other countries. For instance, New Zealand gross annual turnover has increased from NZ$1.5 billion in 1989 to over NZ$8 billion in 2001 ( Adams, 2002). In the United States, between 1975 and 1999, adult gambling expenditure increased from 0.3 to 0.74 of personal income, and lower-income Canadian households spent disproportionately more of their money on gambling than higher-income households (Shaffer & Korn, 2002). Macau is regarded as one of the busiest and highest revenue-generating casino operations in the South East Asian region. In 2004 Macau's casinos generated a new record of US$375 million in the single month of January, a 35 percent or more increase compared to the same time for the previous year, which included the Chinese New Year holidays (Ponto Final, 2004). Asians make up the fastest-growing ethnic community in New Zealand today. Between 1991 and 2001, the number of people who self-identify as "Asian" grew by 140 percent to 238,180 people, or 6.7 percent of the New Zealand population (Statistics New Zealand, 2002a). Asians are now the third largest ethnic group in New Zealand, just after European and Māori. Chinese are the largest ethnic group within the Asian population (105,057), followed by Indians (62,190), and Koreans (19,023) (Statistics New Zealand, 2002b). The percentage increase in the Asian population has been mainly due to large gains in migration. Between 1990 and 2000, the United States population changed significantly as well and the Asian/Pacific Islander population increased from 2.8 percent to nearly 3.6 percent (US Census Bureau, 2000). According to the United States 2000 census, nearly 10 percent of the population was foreign born. It is estimated that the Asian population will increase to nearly 8.2 percent of the American population by 2050. Around the world, anecdotal accounts, media reports, and recent research studies have made reference to the increasing level of participation in gambling by people from Asian countries and the high rates of problem gambling among Asian people (e.g., Bell & Lyall, 2002; Chinese Family Service of Greater Montreal, 1997; "The Stake," 2000; Victorian Casino and Gambling Authority, 1999 ). For instances in Australia, using the South Oaks Gambling Screen (SOGS) and a cut-off score of 10, it was found that members of Chinese community might be almost 50 percent more at risk of developing problem gambling compared with their Caucasian counterparts (Raylu & Oei, 2004). In Sydney, Australia, Blaszczynski and colleagues (1998) reported a prevalence estimate of 2.9 percent for problem gambling among Chinese participants compared to 1.2 percent for the Australian population (Dickerson, Baron, Hong, & Cottrell, 1996). (The issue of "Who are the Asians?" will be discussed in the later part of this paper.) This paper aims to propose five key strategies of how to implement an effective public health approach to address problem gambling among Asian people in foreign countries. Terms and concepts For the purpose of discussion, it is important to have a common language when exploring issues of public health approaches to Asian problem gambling. "Race" refers here to classification of people based on their looks and physical characteristics. The United States government uses the following racial categories: American Indian/Alaska Native, Asian American, African American or Black, and Native Hawaiian/ Pacific Islander. In New Zealand, on the other hand, people are asked which ethnic group or groups they belong to and they may specify as many as they wish. "Ethnicity" is understood in terms of self-perceptions and people can belong to more than one ethnic group. Ethnicity is a measure of cultural affiliation, as opposed to race, ancestry, birthplace description, nationality, or citizenship (Statistics New Zealand, 2002c). The four common ethnic groups referred to in New Zealand are: European/Pakeha4, Māori, Pacific peoples, and Asian. Because ethnicity is self-perceived, people can identify with an Asian ethnicity even though they may not be descended from Asian ancestors. Conversely, people may choose to not identify with an Asian ethnicity even though they are descended from Asian ancestors. "Culture" is defined here as a shared system of values, beliefs, and learned patterns of behaviour. In this paper, culture includes racial and ethnic characteristics. Problem gambling among Asian people has to be seen as more than an individual problem and needs to be seen in its social context. A public health orientation to gambling broadens the focus to include culture and thereby enables the emergence of a set of useful strategies in dealing with Asian problem gambling. "Contemporary public health perspectives are not limited to the biological and behavioural dimensions related to gambling and health, but also can address socioeconomic determinants such as income, employment, and poverty" (Shaffer & Korn, 2002, p. 172). These social issues in turn have links to the evolution of local and national public policy. What is needed to address these problems is a range of "healthy public policies"―policies that support the promotion of health and wellbeing (Korn & Shaffer, 1999). A public health orientation can lead to effective strategies for preventing, minimizing, and treating individuals affected by problem gambling (Volberg, 1994). Public health approaches to problem gambling help policy makers distinguish acceptable from unacceptable risks. They promote an epidemiological examination of gambling and gambling-related disorders to better understand the distribution and biopsychosocial determinants of gambling (Shaffer & Korn, 2002). Public health approaches to Asian problem gambling Based on a review of the literature and working experiences in the field of problem gambling, we propose five key principles that form a basis for public health approaches. Acknowledging the similarities and differences within Asian populations In this paper "Asian" is discussed in terms of ethnicity. Asian people in foreign countries include immigrants, refugees and international students. In New Zealand, the term "Asian" usually refers to people coming from South-East Asian countries like China, Korea, Thailand, the Philippines, Japan, Malaysia, Cambodia, Vietnam, and people from the Indian subcontinent. Although the term is used to identify a collection of Asian ethnic groups, the authors are acutely aware of the cultural diversity within that collection, notwithstanding the fact that they do share many commonalities in terms of values and beliefs. In the context of discussing public health approaches for Asian people in foreign countries who are affected by problem gambling, the term "Asian" does have utility in that it refers to individuals who have strong, self-perceived cultural affiliations in terms of similar value systems, beliefs, cultural heritages and experiences of immigrating to a new host country. Some of these migrants are confronted by similar kinds of difficulties related to post-immigration adjustment, such as unemployment (or underemployment in some cases), language barriers, cultural differences, social isolation, and the lack of access to service information regarding settlement and employment (Ngai & Chu, 2001). Sometimes, they also refer to their immigration and post-immigration adjustment process as an "uprooting experience." Ho and associates (2000) identified four major forms of settlement assistance needed for Asian people in Aotearoa-New Zealand. They need assistance in learning to speak English, employment advice, job-finding skills, and supportive connections that assist in their acculturation. More importantly, evidence is emerging suggesting that, as a group, Asian people are disproportionately affected by problem gambling (e.g., Blaszczynski et al., 1998; Chinese Family Life Services of Metro Toronto, 1995; Cultural Partners Australia Consortium, 2000; Petry, Armentano, Kuoch, Norinth & Smith, 2003 ). On the other hand, there are significant variations across different groups of the Asian population in terms of their experience of legalized gambling prior to immigrating to their new host country. These variations included differences in the preferred mode of gambling, where they chose to gamble (home and private places for social gambling as opposed to public legalized gambling venues like casinos), with whom they gambled, and the size of the wagers. In a recent study on problem gambling among South East Asian refugees, it was found that the types of gambling in which individuals participate differed markedly across sub-groups within the South East Asian ethnic population. For example, 67 percent of Cambodians played slot machines compared to 17 percent of Laotians and 6 percent of the Vietnamese (Petry et al., 2003). Asian clients attending Aotearoa-New Zealand counselling services indicated that casino table games were their primary gambling mode whilst a small proportion mentioned non-casino gaming machines and track betting (Paton-Simpson, Gruys & Hannifin, 2003). An effective public health approach to Asian problem gambling needs to strike the balance between using the label of "Asian" to create a population-based public policy to reduce gambling-related harm, while at the same time acknowledging the diversity of culture and gambling practices among Asian people. Ensuring that approaches are evidence-based A search of the literature indicates that there are many definitions of evidence-based practice. The term, evidence-based medicine, was coined by a group of clinical epidemiologists at McMaster University who worked together to produce a user's guide for critical appraisal of the medical literature (Oxman, Sackett, & Guyatt, 1993). One of the most common definitions from Sackett and colleagues defines evidence-based practice as: …the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, p. 71). Since this beginning, definitions have expanded from individual treatment to evidence-based health care and on to evidence-based public policy. We propose the following set of five categories for identifying the types of evidence used in public health approaches to problem gambling: Type I evidence: Effectiveness of public health action. In replicated studies, measures that diminish Asian population exposure to a set of identified risk factors are followed by a reduction of rates in problem gambling in the study population, relative to a comparison group; Type II evidence: Differential incidence in population cohorts. Problem gambling incidence rates differ consistently between population cohorts, in accordance with known differences in levels of risk exposures; Type III evidence: Association of onset of problem gambling with risk exposure. Onset of new cases of problem gambling in a population is consistently found to be associated with exposure to a suspected risk factor; Type IV evidence: Direct association between prevalence rates in problem gambling and level of risk exposure. Exposure to a suspected risk factor is consistently found to be higher among diagnosed problem gambling cases than among controls drawn from the same population; Type V evidence: " Ecological " association between prevalence rates in problem gambling and risk indicators. Area rates of problem gambling are consistently found to vary with levels of risk exposure as shown by relevant administrative indices. (Modified from Cooper, 2003.) To date, research on problem gambling involving Asian people in foreign countries is still in its infancy. What we have seen so far is an early but alarming indication of the degree of seriousness of gambling-related problems. There are virtually no empirical studies on the effectiveness of gambling treatment approaches specific to Asian peoples, so it is little wonder there is no evidence-based public health policies addressing Asian problem gambling. We would argue that there are three major gaps in evidence-based research required to support public health approaches for Asian problem gambling. Firstly, we lack properly designed and statistically powered studies that investigate the extent (the incidence and prevalence rate) of problem gambling among Asian people in foreign countries. Secondly, we have very little knowledge of what is the most effective way to connect with Asian communities and of ways to raise Asian people's awareness of the potential harm caused by problem gambling. For example, should interventions target people who gamble, or concentrate more on their family and relatives? Thirdly, despite the likelihood of higher levels of gambling problems, research has indicated that Asian people may be less likely to seek help for their problems. I t is of critical importance to examine potential factors that provide barriers and incentives for Asian people seeking help (Bigby, 2003; Kung, 2004). In Aotearoa-New Zealand in 2002, Asian clients using face-to-face gambling services made up 3.6 percent of the total client population (Paton-Simpson et al., 2003). Asian clients are still grossly underrepresented in gambling counselling services when compared to the 6.1 percent in the whole Aotearoa-New Zealand population who are Asian adults (those aged 18 and above). Treating Asian problem gambling in an acculturation framework Acculturation is broadly defined as "those phenomena which result when groups of individuals having different cultures come into continuous first-hand contact, with subsequent changes in the original cultural patterns of either or both groups" (Slant & Lauderdale, 2003, p. 72). Acculturation and increased gambling among Asian people in host countries could be viewed in two ways (Raylu & Oei, 2004). Increased gambling is either related to a successful acculturation process (i.e., successfully adapting to a culture that has high acceptance of gambling) or related to difficulties in adapting to the mainstream culture. Gambling often provides individuals with a certain amount of relief or escape from problems. Some describe it as offering them a temporary but effective reprieve from painful personal realities (Wong & Tse, 2003). In our clinical work, we often hear clients describing that when they are gambling they are either not thinking of anything or they are only thinking of the excitement and glamour of winning and being in a casino. Adjustment to living in a new country is not an easy process and may not work out for everyone. Asian immigrants may come across multiple difficulties. After dealing with the acute crises related to problem gambling, it is common to hear Asian clients describing a crisis as an "awakening" experience. They suddenly realize they have a need to integrate with their communities, improve their language skills, re-focus on their personal goals or aspirations, and find a new purpose and meaning to their life in the new country. In accordance with the Ottawa Charter (1986), public health policy for Asian people affected by problem gambling in foreign countries needs to: i) build public policies that support and promote immigrants', refugees', and international students' integration into host communities; ii) create physical and social environments that support health and wellbeing (such as improving employment situations, providing recreational facilities); in other words, to go further than just stopping or reducing participation in gambling activities; iii) strengthen community action in the recognition that, with information, support and funding, the Asian communities can be empowered to work in the interests of their own needs; iv) develop Asian people's skills (such as developing Asian practitioners to work in the problem gambling area), and; v) re-orientate treatment and educational services towards health promotion and effective intervention for problem gambling. Addressing the issue of shame associated with problem gambling Losing more money than what one can afford and thereby jeopardizing the future prospects of one's family in a new country leads a person to experience intense shame, devastating remorse, and the feeling of being a total failure. Shame is closely related to the pervasive influence of stigma and discrimination against people with problem gambling. According to labelling theory, the degree of difficulties faced by individuals with problem gambling can be partly attributed to the stigma attached to having such addictive problems (Link & Cullen, 1990). Stigmatization can be defined as the process of linking the bearer of the labels "problem gambler" or "pathological gambler" to unwanted and usually undesirable attributes that discredit him or her in the eyes of others. As the stigmatizing attitudes of others are frequently internalized by those who encounter them, this can result for problem gamblers in weakened self-efficacy and negative outcome expectancies for recovery (Kaminski & Harty, 1999). Stigma produces discrimination. Discrimination is an act or attitude by a person or organization, which fosters unfair treatment of an individual because he/she is different. Discrimination develops from people's beliefs about problem gambling and the attitudes of others including family, friends, and the general community (Arthur, 2000). An individual's attempts to manage gambling behaviours could end up being viewed by family members and friends as yet "another rip off"―another set of lame excuses to borrow money. Problem gamblers are badly stigmatized and may find themselves labelled as irresponsible, as lacking any willingness to quit gambling, and, consequently, as a burden on the family responsible for the family continuing to "lose face." Such discrimination, combined with the effects of the problem gambling itself, can lead to feelings of disconnectedness and hopelessness, compounding what they have already suffered from the stress of the immigration process. An Asian person with problem gambling in a foreign country may suffer a double dose of stigma and discrimination by carrying both the labels of "problem gambler" and "Asian." This is especially the case in small communities (Tse, 2003). The attitudes and behaviour of fellow workers, friends from the same country of origin or village, people from same religious group and family members can be distressing and not helpful to recovery from problem gambling. Maintenance of the good name ("keeping face") for an Asian family can often be affected by the behaviour of one member. The desire to avoid shaming the family often discourages a problem gambler and his/her friends from seeking help (Tabora & Flaskerud, 1997). This can adversely affect the outcome of an intervention. Many clients only seek help from professionals as a last resort; they still seek to delay the humiliating effects on their family by seeking to hide their problems. Furthermore, the desire to avoid shame also tends to make the person unwilling to self-disclose his or her own needs, feelings, and thoughts; in turn weakening the formation of a trusting relationship. To render an effective public health policy for Asian people in foreign countries, it is pivotal to address the issue of shame associated with problem gambling. This requires the systematic study of gambling in an Asian cultural context, along with its concomitant values and attitudes (Brown, 2002, The Wager, 1997). What are the help-seeking preferences and effective strategies to communicate with Asian communities through the media? Who holds and influences the knowledge of problem gambling in Asian communities? Targeting at risk sub-groups An effective public health policy must have a clear target population and identify a clear set of risk factors. In this instance, we need to identify who are the Asian people at risk of developing problem gambling. Risk for pathological gambling has been correlated with certain aspects of gambling activity, substance use, criminal offending, and socio-demographic features (Welte, Barnes, Wieczorek, Tidwell, & Parker, 2004). In our experience five at-risk groups warrant particular attention; these are people working in the food industry, tourist operators, international Asian students, South East Asian refugees, and members of "astronaut" families (i.e., those in which the mothers stays behind in a foreign country to look after their children while the husband returns to the home country to work). Those disproportionately affected by problem gambling include Asian immigrants who are employed in shift work (e.g., restaurants, factories, takeaway food spots) and newly arrived young Asian adults studying English (P. Au, executive director of Chinese Family Services of Ontario, Canada, personal communications, February 4, 2003 and April 23, 2003; T. Cho, chairman of Auckland Chinese Food and Beverage Business Association, Aotearoa-New Zealand, personal communication, February 5, 2003). A survey carried out by the Chinese Family Service for Greater Montreal in 1997 found that up to 19 percent of Chinese restaurant workers were pathological gamblers (Scalia, 2003), and a survey conducted by Asian Services based in Christchurch, Aotearoa-New Zealand, found a similar trend (Tan & Tam, 2003). Tourist operators form another at-risk occupational group that was recently identified by Aotearoa-New Zealand treatment services (Tse, Wong, Kwok & Li, 2004). Tourist operators will commonly bring overseas Asian visitors to casinos for a memorable experience. Unfortunately, a number of individual operators become addicted to gambling themselves. However, there is no published empirical data to date regarding this observation. A recent study on Asian young people gambling in Aotearoa-New Zealand involved a lifestyle survey of 246 international Asian students recruited from three English language schools in a metropolitan city. It was found that 9.1 percent of students admitted feeling unhappy or worried after a gambling session and 6.5 percent wanted assistance to deal with their gambling problems ( Goodyear-Smith, Arroll, & Tse, 2004 ). Petry and colleagues (2003) also recently found that the lifetime prevalence of pathological gambling among South East Asian refugees to the United States was up to 59 percent. In the same study, 27 percent of problem gamblers and 42 percent of pathological gamblers were interested in learning about ways to reduce or stop their gambling. In Aotearoa-New Zealand there has been an increase in the number of Asian women clients seen by problem gambling counsellors in the year 2003 compared to the previous year. Upon closer examination, a general trend can be seen of more mothers with young children seeking help for their gambling problems. This observation is consistent with mothers feeling isolated and unsupported in their host country, having access to large amounts of disposable money, and facing the stresses associated with raising children in a new cultural environment. This makes solo mothers from astronaut families particularly vulnerable to develop gambling problems. Conclusion With the global proliferation of gambling, policy makers and service providers around the world face challenges in understanding Asian problem gambling. In this paper, we have discussed five important principles in developing effective public health approaches to problem gambling among Asian people. Effective public health policy does not rely solely on research information. It uses available information to underpin decisions for population groups within their particular social context. Treating problem gambling as an individual issue that ignores Asian values, traditions, and community connections tends to obscure the potential for change; while a contextual approach, on the other hand, encourages a greater utilization of Asian community resources and wisdom. Although the focus of this paper has been on a public health approach, there are implications for those who work as case practitioners with Asian clients. Public health approaches that view problem gamblers in their social context need to become a part of how counsellors and therapists work with their clients. From this perspective therapeutic interventions can be conceptualised not so much in terms of resolving problems or reducing or stopping gambling, but as a means of unleashing the potential of people, their families, and their communities to achieve change, thereby promoting the wellbeing of the Asian community as a whole. Lastly, the conversion of public health rhetoric into action necessitates the identification of clear processes and ways in which progress can be measured. This paper is only the beginning of this important process. The challenge lies with the will and determination of policy makers, members of Asian communities, researchers, and problem gambling service providers to translate existing knowledge and policy into effective and culturally responsive action. References Adams, P. (2002). Towards a national strategy for the development of research on tobacco, alcohol, other drugs and gambling. New Zealand: University of Auckland. Arthur, T. E. (2000). 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Gambling in a Chinese cultural context. Retrieved March 19, 2003. Available: http://www/thewager.org Welte, J. W., Barnes, G. M., Wieczorek, W. F., Tidwell, M. O., & Parker, J. C. (2004). Risk factors for pathological gambling. Addictive Behaviors, 29, 323–335. Wong, J., &Tse, S.(2003). The face of Chinese migrants' gambling: A New Zealand perspective. Electronic Journal of Gambling Issues: eGambling. Retrieved November 3, 2003. Available: http://www.camh.net/egambling When the stakes get too high. (2000, November 22). New Zealand Herald, p. A17. U.S. Census Bureau. (2000). Census 2000 and 1990 census of population, general population characteristics. Washington, DC: Author. Competing interests: None declared. For correspondence: Dr Samson Tse. E-mail: s.tse@auckland.ac.nz 1 Samson Tse, Ph.D is senior lecturer in mental health development, School of Population Health, Faculty of Medical and Health Sciences, the University of Aucklandand director (a dvisory) for Asian research Services, Problem Gambling Foundation of New Zealand Centre for Gambling Studies School of Population Health, Faculty of Medical and Health Sciences, the University of Auckland. Email: s.tse@auckland.ac.nz 2 John Wong, MEd (Couns) Hons. is counselor and n ational manager of Asian Services, Problem Gambling Foundation of New Zealand. Email: john.wong@pgfnz.co.nz 3 Hyeeun Kim, MEd (Couns) Hons. is counselor, community worker and co-coordinator of client services, Asian Services, Problem Gambling Foundation of New Zealand. Email: hyeeun.kim@pgfnz.co.nz 4 Commonly used term to refer to European New Zealanders

		issue 12— december 2004