Tse, S., Hong, S.I., Wang, C.W., & Cunningham-Williams, R.M., (2012). Gambling behavior and problems among older adults: a systematic review of empirical studies. Journals of Gerontology Series B:
Psychological Sciences and Social Sciences, 67 (5), 639–652, doi:10.1093/geronb/gbs068.
Gambling Behavior and Problems Among Older Adults:
A Systematic Review of Empirical Studies
Samson Tse,1 Song-Iee Hong,2 Chong-Wen Wang,3 and Renee M. Cunningham-Williams4
Department of Social Work and Social Administration, The University of Hong Kong, China.
2
Department of Social Work, National University of Singapore.
3
Centre for Behavioral Health, The University of Hong Kong, China.
4
George Warren Brown School of Social Work, Washington University, St Louis, Missouri.
1
Objectives. With the rapid aging of the population and the increased availability of gambling facilities over the past
three decades, older adults may gamble more and may be increasingly at risk for problem gambling (PG) or pathological
gambling disorder (PGD). To facilitate a better understanding of gambling behavior among older adults that will inform
preventive strategies, this article systematically examined empirical studies on issues related to older adults’ gambling.
Method. This article reviewed 75 empirical studies including data on the distribution and determinants of PG and
PGD and the outcomes of gambling.
Results. This review used the broad term of “disordered gambling” as a means to explain a continuum of problems
caused by PG and PGD. The analyses covered seven topics concerning older adults’ gambling behaviors: Participation
rates for gambling, prevalence rates of disordered gambling, motivation for initially beginning to gamble, risk and protective factors for disordered gambling, and negative and positive health outcomes from gambling.
Discussion. Based on research gaps identified in the review, this article proposes six recommendations for future
studies focusing on well-being of older adults who gamble, research method issues, and taking into account older adults’
inspirations and adjustment to the aging process in the 21st century.
Key Words: Activity levels—Behavioral addiction—Lifestyle—Mental health.
G
ambling is a popular form of recreation with a long
history in most parts of the world. Legal gambling opportunities have increased markedly in many countries due to
favorable public attitudes toward gambling as entertainment,
governments’ desire to create jobs and generate revenue, and
cities’ desire to foster tourism and economic development
(Bjelde, Chromy, & Pankow, 2008). For example, during
the past three decades, legalized gambling has become one
of the fastest growing industries in North America (Martin,
Lichtenberg, & Templin, 2010). Currently, some types of
legalized gambling are available in almost all states in the
United States, except for Utah and Hawaii (Kerber, Black, &
Buckwalter, 2008; Martin et al., 2010). The number of casino
venues in other parts of the world, for example, in Macau and
Singapore, has also increased markedly over the past two decades (Tse, Yu, Rossen, & Wang, 2010).
The number of older adults participating in gambling has
increased dramatically in recent years and may continue
to increase. For example, 50% of adults aged 65 or older
in the United States participated in casino gaming in 1998
compared with 23% of adults in 1975 (National Gambling
Impact Study Commission, 1999), and the proportion of
older Americans who reported gambling in their lifetime
increased to 80% in 1998 from 35% in 1975 (National
Opinion Research Center, 1999). The gambling industry
in the United States, Canada, and Australia has responded
swiftly to the rapidly growing market of older adults in these
countries (Chhabra, 2009). Compared with their younger
counterparts, older adults perhaps have more free time and
disposable income to gamble (McNeilly & Burke, 2002).
Furthermore, older adults face later life transitions such
as retirement, lack of opportunities to socialize, death of a
spouse and friends, and chronic illness, which may lead them
to turn to gambling and other behaviors (e.g., drinking) as a
distraction from the age-appropriate changes they experience
at this time in their lives (McNeilly & Burke, 2000). Further
older adults may be drawn to casino venues by the special
hot meals offered during the day, chartered transportation/
excursions to gambling venues, and in other cases, individuals
from ethnic minority background are attracted by the cultural
icons (e.g., large scale carvings are placed in strategic entry
points) or specific cultural events (e.g., dance, art exhibitions)
taking place within the casino facilities (Dyall, Tse, & Kingi,
2009). Coupled with increased availability of various forms
of gambling, older adults may gamble more and may be
increasingly at risk for gambling addiction.
Although a wide range of recent epidemiological and
empirical studies have focused on issues related to gambling among older adults, there is a lack of up-to-date systematic review of the latest research in the field. Several
© The Author 2012. Published by Oxford University Press on behalf of The Gerontological Society of America.
All rights reserved. For permissions, please e-mail: [email protected].
Received July 25, 2011; Accepted June 20, 2012
Decision Editor: Merril Silverstein, PhD
639
640
TSE ET AL.
articles have reviewed the literature in the field of older
adult gambling (Lucke & Wallace, 2006; McKay, 2005;
McVey, 2003; Stewart & Oslin, 2001; Tirachaimongkol,
Jackson, & Tomnay, 2010). One review focused on addictions in general in the older adult population (Stewart &
Oslin, 2001), and three others focused on gambling addictions in older adults in particular (Lucke & Wallace, 2006;
McKay, 2005; Tirachaimongkol et al., 2010). Notably, only
one study (McVey, 2003) was in fact a systematic review;
however, it was primarily based on gambling studies of the
general population because the number of studies particularly focusing on older adults was limited at that time.
Participation in gambling should be considered as a continuous variable. “More specifically, people’s gambling
behavior can range from none to a great deal. At many points
along this continuum, people can experience problems associated with their gambling, though these difficulties tend to
emerge more among frequent gamblers who wager at higher
levels. The point of demarcation between moderate and
severe problems and addiction is somewhat arbitrary” (Korn
& Shaffer, 1999, p. 308). Nevertheless, according to the most
recent Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR) (American Psychiatric Association, 2000),
pathological gambling disorder (PGD) is defined as a condition in which an individual exhibits five or more DSM-IV-TR
diagnostic criteria such as showing persistent and recurrent
maladaptive gambling behavior, resulting in impairments in
the areas of work, studies, and social and family relationships (American Psychiatric Association, 2000). Problem
gambling (PG) is characterized by having difficulties in
limiting money or time spent on gambling, which results in
adverse consequences for individual players, their families,
and those around them. Furthermore, PG also refers to typically between three and four PGD criteria but does not meet
the diagnostic threshold for a PGD (Volberg, Nysse-Carris,
& Gerstein, 2006). In some situations, individuals who
exhibit only one or two diagnostic criteria are defined as “at
risk” gamblers given their exposure to gambling and their
vulnerability for excessive gambling (Volberg et al., 2006).
Generally, the broader “disordered gambling” term refers to
the combination of PG and PGD. The present review uses the
broad term of “disordered gambling” as a means to explain
a continuum of psychosocial problems caused by excessive
gambling including the PG and PGD.
To facilitate a better understanding of older adults’ gambling behavior that could inform health promotion efforts,
this study aims to systematically examine empirical studies
on issues related to gambling among older adults. Based
on our critical review of older adult gambling literature,
the authors summarize empirical evidence on the distributions, determinants, and health consequences of gambling
and review theoretical approaches. The study is concluded
by identifying gaps in the current studies to inform future
research that may facilitate the development of better strategies to protect older adults from PG and PGD.
Method
Scope and Inclusion Criteria of Gambling Studies in
This Review
Gambling behavior can be examined from multiple pers­
pectives including demographics, economics, marketing,
morality, addictions, mental health, public health, and
policy (McVey, 2003). Due to this study’s focus on health
and well-being for older adults, the authors restricted the
search to the PubMed/Medline and PsycInfo databases from
January 1996 to December 2010, with terms (gambling
OR gamblers) AND (older OR elder* OR senior* OR
geriatric OR later life OR late life) in the title, abstract,
or keywords. The inclusion criteria included original
studies on issues related to gambling among older adults
published in English. The present authors interpreted the
topic of “older adults and gambling” broadly because the
purpose of this review is to cover the spectrum of gambling
activities among older adults. Thus, the authors included
gambling studies with samples aged 50 years and older
and included any form of gambling such as casino games,
bingo, lotteries, betting on sports, or in mahjong houses.
Literature searches located 134 references in the PubMed/
Medline database and 199 references in the PsycInfo
database. In total, 271 references (66 references overlapped
between the two databases) were retrieved; of these, 209
references were excluded because the studies were not
related to gambling, were not focused on older adults, were
not related to health outcomes, were not original studies,
or were not published in English. Sixty-two references met
the inclusion criteria, including 57 peer-reviewed articles
and 5 unpublished dissertations (Jadlos, 2003; Langewisch,
2005; Phillips, 2009; Wiebe, 2002; Winslow, 2002). Of all
62 studies, 23 focused on social or recreational gambling,
29 focused on PG or PGD, 3 examined gambling activities
among older adults from a policy perspective (Bjelde et al.,
2008; Higgins, 2001, 2005), and 7 employed gambling as a
theoretical mechanism to examine decision-making ability
among older adults (Boggio et al., 2010; Denburg, Recknor,
Bechara, & Tranel, 2006; Denburg, Tranel, & Bechara,
2005; Denburg et al., 2009; Fein, McGillivray, & Finn,
2007; Isella et al., 2008; Wood, Busemeyer, Koling, Cox, &
Davis, 2005). Most of the included studies were quantitative
studies; only five were qualitative research (Bjelde et al.,
2008; Higgins, 2001; McNeilly & Burke, 2002; Parekh &
Morano, 2009; Quandt, Grueninger, & Wimmer, 2009) and
one was a case study (Higgins, 2005).
Additional Searches
In addition, reference lists of all located articles were
reviewed, and nine additional articles (Abbott & Volberg,
2000; Abbott, Volberg, & Ronnberg, 2004; Desai, Desai, &
Potenza, 2007; Gullickson & Hartman, 1997; Gullickson,
Hartmann, & Wiersma, 1999; Volberg & McNeilly, 2003;
Welte, Barnes, Wieczorek, Tidwell, & Parker, 2001, 2002;
GAMBLING BEHAVIOR AND PROBLEMS AMONG OLDER ADULTS
641
Figure 1. Summary of literature search of gambling studies.
Wong, McAuslan, & Bray, 2000) that report the estimated
rates of social gambling or disordered gambling among older
adults were identified and included. Google Scholar was
also used as a search tool for relevant literature or reports
in recent years because literature around or before the year
2000 had been reviewed elsewhere (McVey, 2003). As a
result, four additional surveys (Boreham, Laffan, Johnston,
Southwell, & Tighe, 2006; Moore, 2001; Rönnberg et al.,
1999; Volberg et al., 2006) and one problem gambling
prevention manual (Lemay, Bakich, & Fontaine, 2006)
that focused on older adults were identified and included.
Figure 1 summarizes the above literature search process.
Results
Most of the included studies were conducted in the United
States and Canada with a few conducted in New Zealand
(e.g., Abbott & Volberg, 2000), Australia (e.g., Nower &
Blaszczynski, 2008), and Sweden (Rönnberg et al., 1999)
(see Table 1). Most studies were conducted with Western
samples, and some epidemiological surveys were conducted with a representative sample that included multiple
ethnic groups. Only four studies particularly focused on
older adults from diverse racial/ethnic groups, including
African Americans (Bazargan, Bazargan, & Akanda, 2001;
Christensen & Patsdaughter, 2004), and ethnic Chinese in
Canada (Lai, 2006; Zheng, Walker, & Blaszczynski, 2010).
Based on the findings from these studies, the present
authors synthesized and reframed the knowledge into seven
categories in relation to gambling among older adults as
further discussed below: (a) participation rates for gambling, (b) prevalence rates of disordered gambling, (c) motivation for initially beginning to gamble, (d) risk factors for
disordered gambling, (e) protective factors for disordered
gambling, (f) negative health outcomes from gambling, and
(g) positive health outcomes from gambling.
Participation Rates of Gambling
Public attitudes about gambling have changed greatly over
the past decades. During the first half of the 20th century,
gambling was considered a sin or a vice (McNeilly &
Burke, 2000). More currently, older adults generally possess positive attitudes toward participating in gambling
activities (Martin et al., 2010) and consider gambling to be
a normative and harmless form of entertainment (Hagen,
642
TSE ET AL.
Nixon, & Solowoniuk, 2005; McNeilly & Burke, 2000)
and a relatively new social outlet (Hagen et al., 2005; Hope
& Havir, 2002; McNeilly & Burke, 2000, 2001, 2002;
Preston, Shapiro, & Keene, 2007; Zaranek & Chapleski,
2005). However, nearly all of these studies were conducted
in the context of Western culture and in developed regions
of the world. It is still unclear whether attitudes toward
gambling among older adults have changed in other cultures or countries.
Nineteen separate studies have reported the participation
rates of gambling among older adults (Table 1). Three studies were conducted with a sample recruited from gambling
sites, senior centers, or primary-care clinics (Bazargan et al.,
2001; Ladd, Molina, Kerins, & Petry, 2003; Levens, Dyer,
Zubritsky, Knott, & Oslin, 2005). The remaining studies were
conducted with samples recruited from communities. None
of the studies assess changes in participation over time except
two investigations that used longitudinal data sets to perform
the analyses (Martin et al., 2010; Vander Bilt, Dodge, Pandav,
Shaffer, & Ganguli, 2004). Based on a prospective epidemiological study, Vander Bilt and associates (2004) found that
being between 70 and 79 years old, being male, having more
social support, using alcohol, and having previously gambled
predicted future participation in gambling activity. On the
other hand, Martin and colleagues (2010) showed that 25.5%
of the research participants reported gambling monthly or
more at initial survey with a decline to 16.9% reported at
2-year follow-up study. The older adults gambling participation rates for the prior year ranged from 26.6% (Lai, 2006) to
85.6% (Rönnberg et al., 1999), and the lifetime participation
rate ranged from 28.7% (Pietrzak, Morasco, Blanco, Grant,
& Petry, 2007) to 100% (Ladd et al., 2003). This disparity in
both current and lifetime participation rates may be attributed
to differences in sampling, regions surveyed, and variation in
the definitions of “older adult,” the type of gambling investigated, and the definition of gambling.
Several studies have compared participation rates
between older adults and other age groups (Abbott et al.,
2004; Desai et al., 2007; Desai, Maciejewski, Dausey,
Caldarone, & Potenza, 2004; Stitt, Giacopassi, & Nichols,
2003; Welte et al., 2001). The results from these studies support older adult gambling participation rates that were lower
than those of other age groups. In particular, recent studies
revealed that “young-old” adults (e.g. about 60 years old)
were more likely to visit a casino (Zaranek & Chapleski,
2005) or to participate in gambling (Vander Bilt et al., 2004)
than “older-old” adults (i.e., about 65 years or older).
Multiple studies compared older adults’ participation
in various gambling types. For example, McVey’s (2003)
study of older adults in Iowa found that playing the slot
machines was the most popular gambling activity. McNeilly
and Burke’s (2001) study in Nebraska found that bingo was
the most popular social activity at senior clubs and casino
gambling was the most popular day-trip social activity for
active older adults. Other studies indicated that the lottery
was the most popular form of gambling followed by casino
gambling (Martin et al., 2010; Welte et al., 2002), whereas
Mahjong was a popular form of gambling in Chinese
communities all over the world (Zheng et al., 2010).
Studies also indicate that gambling patterns of older adults
differ from those of younger adults (Desai et al., 2004).
Older recreational gamblers were less likely to gamble
to win money or to escape from boredom than younger
gamblers (Desai et al., 2004). McNeilly and Burke (2000)
reported that older adults usually withdrew from multiple
types of gambling and concentrated on more limited types
of gambling activity, in contrast to younger adults who
tended to gamble on several different games. Other studies
reported that older gamblers were the least likely to engage
in other recreational activities besides gambling, unlike
younger adults who participated in multiple activities
(Moufakkir, 2006; Zaranek & Chapleski, 2005). Evidence
from the Iowa gambling task force suggested a difference in
the decision-making strategies of younger and older adults
(Fein et al., 2007; Wood et al., 2005). One study found that
older adults, in comparison to younger adults, were more
likely to make decisions that could result in long-term
negative financial consequences (Fein et al., 2007). Among
older adults, studies also suggested a gender difference in
gambling patterns (McVey, 2003), with women preferring
bingo and men preferring card games (Cousins & Witcher,
2004; McVey, 2003).
Prevalence Rates of Problem Gambling and PGD
Table 1 shows the prevalence rates of PG and PGD among
older adults that were extracted from the empirical studies.
The reported prevalence rates of lifetime PG ranged from
0.2% (Rönnberg et al., 1999) to 12.9% (Ladd et al., 2003).
Similarly, the estimated rates of current PG (past 12 month)
among older adults ranged from 0.3% (Abbott & Volberg,
2000; Desai et al., 2007) to 10.4% (Zaranek & Chapleski,
2005). The wide range in prevalence rates may be explained
by the sheer fact that some surveys were conducted
among general populations (including participants who
self-reported having never gambled) versus only those individuals who have gambled before (excluding nongamblers).
The prevalence rates of lifetime PGD ranged from 0.3%
(Abbott & Volberg, 2000) to 2.4% (Preston et al., 2007).
For current PGD, these prevalence rates ranged from 0.3%
(Moore, 2001) to 2.7% (McNeilly & Burke, 2000) for older
adults sampled from communities, to 3.8% (Erickson,
Molina, Ladd, Pietrzak, & Petry, 2005) for older adults
in senior centers, and a high of 11% (McNeilly & Burke,
2000) for older adults sampled from gambling venues. In
addition, one study reported that the estimated rate of at risk
gambling among older adults was as high as 17% (Bazargan
et al., 2001).
The great variability in the prevalence rates of PGD
may be attributed to differences in sampling, locations or
USA
USA
(Las Vegas)
Canada
(Montreal)
Canada
(Multicities)
Pietrzak et al., 2007
Preston et al., 2007
Ladd et al., 2003
Desai et al., 2004
Christensen & Patsdaughter, 2004
Vander Bilt et al., 2004
Zaranek & Chapleski, 2005
Wiebe & Cox, 2005
Levens et al., 2005
Erickson et al., 2005
Volberg et al., 2006
Lai, 2006
Philippe & Vallerand, 2007
USA
(Connecticut)
USA
(Detroit)
USA
(Pittsburgh)
USA
(Boston)
USA
USA
(Philadelphia
and
Pennsylvania)
Canada
(Manitoba)
USA
(California)
USA
(Connecticut)
USA
(Detroit)
USA
Zaranek & Chapleski, 2005
Desai et al., 2007
USA
Country
(region) a
Hong et al., 2009
Study
492
387
(2,417)b
67
1,016
1,410
1,000
843
1,432
(7,121)b
343
2,272
810
449
8,205
(25,485 aged
40+ or 43,093
aged 18+)b
10,563
489
(2,974)b
1,410
N
Sampling
Types of
gambling
Casino visit
Multiform
n.r.
65+ Convenient sample with 132 recruited Bingo
from bingo sites and 360 from
senior centers
87%
—
—
—
—
—
—
—
—
74%
28.74%
—
—
—
Lifetime
—
—
1.6%
(Measure: SOGS-R)
10.9% at risk gamblers
(Measure: Questions derived
from SOGS
—
(Measure: NODS)
6.4%
(Measure: SOGS)
—
(Measure: DSM-IV)
2.0%
(Measure: NODS)
1.6%
(Measure: SOGS-R)
—
8.4%*
(Measure: DSM-IV)
10.4%c
(Measure: 2 single questions)
0.3%c
(0.5% for all aged 40+)
(Measure: DSM-IV)
Past-year
—
—
—
—
2.0%
(2.2%)*
—
—
—
2.9%
0.85%c
—
—
10.8%c
Lifetime
% of problem gambling
—
—
1.2%
—
3.8%
—
—
1.2%
—
—
—
—
0.5%
(1.5%)*
—
—
—
2.4%
—
—
1.8%
—
—
—
Lifetime
—
—
—
Past-year
% of pathological
gambling
GAMBLING BEHAVIOR AND PROBLEMS AMONG OLDER ADULTS
(Table 1 Continues)
3.0%
—
1.5%
—
(Measure: MAGS)
50.3%
—
0.5%
—
—
—
(65.5% for
(2.43% for those aged
those aged
below 65)
below 65)
(Measure: DSM-IV)
—
100% in the Combined problem and pathological gambling lifetime rates: 12.9%
bingo samin the bingo sample, 9.7% in the senior center sample(Measure:
ple, 86.6%
SOGS)
in the senior
center
sample.
—
47.7%
57.8%
74.7%
69.6%
—
—
Multiform
n.r.
26.6%
47.5%
79%
—
28.7%
(30.8% for all
aged 40+)
—
—
Past-year
Multiform
n.r.
Multiform
n.r.
65+ A representative community cohort of Multiform
senior residents
50+ Convenient senior community
n.r.
residents (Black Americans)
65+ Subgroup of a nationally
Multiform
representative random sample
survey by telephone
60+ A representative random sample of
senior civilians interviewed by
telephone
60+ A random sample of senior residents
60+ A nationally representative sample of
noninstitutionalized older adults
55+ A random sample of senior
residents
55+ Stratified sample in randomly selected
communities
55+ A random sample of older Chinese
in Canada, selected with telephone
numbers
65+ Subgroup of a random-digit-dial
telephone survey of residents
60+ Convenient sample recruited from 12
senior centers, 8 bingo sites, and 3
other sites
65+ A random sample of older adults with
a scheduled primary-care clinic
appointment
65+ Subgroup of a nationally representative n.r.
sample of noninstitutionalized U.S.
residents
50+ Subgroup of a nationally representative Casino,
sample of general population
lottery
60+ A random sample of senior residents Casino
Age
% of participation in
gambling
Table 1. Participation and Prevalence Rates of Gambling Among Older Adults
643
USA
(Florida)
USA
USA
(Los Angeles)
USA
(Nebraska)
USA
(Oregon)
USA
New Zealand
USA
(Nebraska)
USA
(Detroit)
USA
(Michigan)
Volberg & McNeilly, 2003
Bazargan et al., 2001
McNeilly & Burke, 2001
Moore, 2001
Welte et al., 2001
Abbott & Volberg, 2000
McNeilly & Burke, 2000
Wong et al., 2000
USA
(Michigan)
Gullickson & Hartman, 1997
N
857†
(12%)
(7,139)b
514
(3,942)b
178
(1,200)b
136
(400)b
511
(2,638)b
1,465†
(22.7%)
(6,452)b
315
1,512
6,957
509
(2,630)b
80
1,260
677
(2,768)b
Sampling
Multiform
Bingo,
Casino
n.r.
Multiform
n.r.
Multiform
—
—
n.r.
(95%)
85.6%
(88.8%)
—
—
—
65+ Subgroup of a random sample selected Multiform
from four areas in the city
65+ Subgroup of a sample of residents
Multiform
recruited from four regions in the
state
65+ Subgroup of a nationally representative Multiform
sample of residents
—
—
—
65+ Subgroup of a representative sample
of residents in the state
—
—
—
—
Lifetime
0.7%
(Measure: SOGS)
1.2%(3.5%)*
(Measure: DIS)
17% were identified as at risk
to pathological gamblers
(Measure: SOGS)
—
—
Past-year
0.4%
(1.4%)*
(Measure: SOGS-R)
1.6%
(Measure: SOGS)
3.1%
0.2%
(2.7%)*
5.5% in gambling patron
11% in
group, 1.3% in community
gamgroup
bling
(Measure: SOGS-R)
patron
group,
2.7% in
community
group
1.7%
—
(Measure: SOGS)
—
0.7%
(Measure: SOGS)
0.4%
—
3.4%c
—
0.8%
—
(0.6%)*
—
1.7%
—
—
1.8%
0.4%
(1.2%)*
0.7%
—
—
0.3%
—
—
0.3%
—
—
—
—
0.8%
—
Lifetime
—
—
—
—
—
0.4%
—
Past-year
% of pathological
gambling
1.0%
—
Lifetime
% of problem gambling
23% played 16% visited
bingo
casino more
more than
than once
4 times a
month.
58%
75%
0.9%
(Measure: SOGS)
—
—
1.2%
(Measure: DIS)
38.6% in past
80.2%
0.3%
6 months
(Measure: SOGS-R)
69%
(82%)
36%
39.6%
(47.2%
for those
under age
63)
—
Past-year
% of participation in
gambling
Multiform
65+ Random cluster sampling from gambling venues (n = 910) and senior
centers or communities (n = 224)
61+ Subgroup of a randomized national
n.r.
telephone survey
65+ Subgroup of a nationally representative Multiform
sample of residents
62+ A random sample of senior residents
55+ Random sample interviewed with
telephone
61+ Subgroup of a nationally representative
random sample survey by telephone
60+ A cohort of African Americans
selected from two senior citizen
centers
65+ Senior citizens from all organizations
in the area
63+ A subgroup of a sample selected from Casino
multiple communities in different
cities
Age
Types of
gambling
Notes. n.r. = not reported; MAGS = the Massachusetts Gambling Screen; DIS = Diagnostic Interview Schedule; NODS = NORC DSM-IV Screen for Gambling Problems.
a
Country/region refers to where the sample was collected.
b
Sample size of the whole sample with a wide range of ages.
c
Combined prevalence rate of problem gambling and pathological gambling.
*Prevalence rate in the whole sample.
†
This number was calculated using the percentage of older adults in the whole sample.
Sweden
Rönnberg et al., 1999
Gullickson et al., 1999
Welte et al., 2002
USA
(Multicities)
Stitt et al. 2003
Study
Country
(region) a
Table 1. Participation and Prevalence Rates of Gambling Among Older Adults (Continued)
644
TSE ET AL.
GAMBLING BEHAVIOR AND PROBLEMS AMONG OLDER ADULTS
venues where participants were recruited, definitions of
older adults, and measures of disordered gambling (Volberg,
2004). For example, in a nationally representative sample
of U.S. adults (Welte et al., 2001), current PGD had an
overall prevalence of 1.3% as measured by the Diagnostic
Interview Schedule (Robins, Helzer, Croughan, & Ratcliff,
1981) and 1.9% as measured by the South Oaks Gambling
Screen (SOGS) (Lesieur & Blume, 1987) (see Cox, Enns,
& Michaud, 2004; Petry, Stinson, & Grant, 2005 for further discussion on using DSM-based screening and SOGS).
As shown in Table 1, various instruments were employed
to measure PG and/or PGD across studies. Of these instruments, the SOGS was the most widely used to estimate
the prevalence of probable PG or PGD, but the Canadian
Problem Gambling Index or the nine-item of Problem
Gambling Severity Index has been used with increasing
frequency by more recent studies (Ferris & Wynne, 2001;
Lorains, Cowlishaw, & Thomas, 2011).
Several studies have compared the PG and PGD
prevalence rates between older adults and younger adults
(Abbott et al., 2004; Desai et al., 2004, 2007; Volberg
et al., 2006; Welte et al., 2002). Results suggest that the
prevalence rates of both current and lifetime disordered
gambling among older adults were lower than those
among younger adults. With respect to gender differences,
the results are generally consistent, suggesting that the
estimation for disordered gambling among male older
adults was higher than among female older adults (Hong,
Sacco, & Cunningham-Williams, 2009; Moore, 2001).
Motivation for Initially Beginning to Gamble
In a study on older adults’ casino motivation and gambling
intention, Phillips (2009) identified five distinctive gambling motivation dimensions: Thrill of winning, socialization, escape, enjoyment, and curiosity. Clarke and Clarkson
(2009) examined the literature and focused on three types of
gambling motivation: intrinsic motivation, extrinsic motivation, and amotivation. “Intrinsic motivations” include
understanding or exploration of knowledge, stimulation,
excitement, or achievement of skills. “Extrinsic motivations” include material rewards, release of tension or guilt,
social connection, or recognition. “Amotivation” is characterized by behavior that avoids boredom but has no real
purpose. These motivations are underlying mechanisms that
initiate, intensify, and maintain older adults’ participation
or involvement in gambling activities (Clarke, 2008; Clarke
& Clarkson, 2009). Based on this framework, the present
authors identify several factors that motivate older adults to
begin to gamble. However, these factors should be viewed
with caution as the studies include samples from various
socioeconomic strata, living environments, and cultural
contexts; in addition, participating in different gambling
activities and using different motivation measurements.
Older adults gamble for many reasons, such as the food
served at gambling venues, the excitement, chances to give
645
to charity, chances to have an inexpensive holiday, the need
for a safe way to be ‘‘bad’’ (Hagen et al., 2005), and to
find a quick-fix solution for financial problems (Vander
Bilt et al., 2004). McVey (2003) noted additional reasons
such as winning money, passing time, being with others or
friends, enjoying freedom to do what one wants, and getting
a break from taking care of other people. Some age-related
circumstances might motivate older adults to participate in
gambling such as widowhood, low annual income, isolation from society, physical disabilities and health problems
that limit older adults’ daily activities (Cousins & Witcher,
2007; Southwell, Boreham, & Laffan, 2008), living in rental
accommodation, receiving federal income supplements, and
inner-city location (Hirshorn, Young, & Bernhard, 2007).
A desire to exercise the mind may be another potential
motivator for gambling among older adults. As they reach
an older age, individuals may be more likely to experience
changes in cognitive performance (Boggio et al., 2010;
Denburg et al., 2005, 2009). Thus, older adults may try to
seek various opportunities, either consciously or unconsciously, that may improve their cognitive functioning.
Cognitive stimulation and inexpensive excitement provided in a safe environment have been identified in several
studies as reasons for the popularity of gambling among
older adults (Hong et al., 2009; McNeilly & Burke, 2002;
Southwell et al., 2008). Laditka and associates (2009) conducted a qualitative study to examine perceptions about
ageing across six racial/ethnic groups (Caucasian, African
American, American Indian, Chinese, Vietnamese, and
Hispanic). It was found that all groups, except African
Americans and Vietnamese, mentioned that engaging in
some sort of cognitive activity, such as gambling, helped
keep their brains active and was a sign of aging well.
McNeilly and Burke (2000) reported that older adults at
gambling venues were more likely to gamble to facilitate
getting away for the day (extrinsic motivation), access to
inexpensive meals (extrinsic motivation), passing the time
or relieving boredom (amotivation), and relaxation (intrinsic motivation). However, Martin and colleagues (2010)
explored reasons for casino gambling by urban older adults
residing in the community and found that individuals more
frequently reported entertainment, enjoyment (intrinsic
motivation) as the reasons for casino gambling rather than
for financial gain (extrinsic motivation).
Risk Factors for Disordered Gambling
Although gambling is now commonly regarded as a social
and recreational activity, excessive gambling or increasing accessibility of gambling opportunities may result in
PG and PGD and adverse mental health consequences.
A comprehensive review of empirical studies that identify
risk factors related to PG and PGD suggest behavioral, psychological, PG age of onset, comorbidity, and other factors
(McCready, Mann, Zhao, & Eves, 2008). Some studies considered behavioral factors related to gambling experience,
646
TSE ET AL.
frequency, and onset (e.g., Desai et al., 2007; Hong et al.,
2009; Vander Bilt et al., 2004). Two studies indicated
that more frequent gambling, participation in more types
of gambling, and spending more on gambling in a single
session were significantly associated with PG (Clarke &
Clarkson, 2009; McCready et al., 2008). A study reported
that older respondents recruited at bingo sites were more
likely to have experienced 9 of 13 gambling activities in
their lifetimes and were more likely to bet weekly or more
frequently, compared with those recruited from senior centers (Ladd et al., 2003). Other studies suggested that older
adults sampled from gambling venues were more likely to
have higher levels of disordered gambling than older adults
sampled from communities (McNeilly & Burke, 2000; von
Hippel, Ng, Abbott, Caldwell, Gill, & Powell, 2009). For
example, one study indicated that visiting a casino was the
largest contributor to gambling problems; older adults who
visited the casino monthly or more were 2.6 times more
likely than older adults who rarely or occasionally visited the casino to show evidence of a gambling problem
(Zaranek & Lichtenberg, 2008). It is worth noting that no
firm conclusion has been established about the cause-effect
relationship between frequenting gambling venues and
developing gambling problems given there are very few
longitudinal studies on the topic.
A few other studies examined psychological factors associated with PG and PGD. Philippe and Vallerand (2007,
p. 277) argued that passion—defined as “a strong inclination
toward an activity that one likes, finds important and in which
one invests time and energy”—may discriminate problematic from nonproblematic gamblers. Distinguishing between
types of passion in older adults (Philippe & Vallerand, 2007;
Vallerand & Houlfort, 2003), they conclude that harmonious passion was lower and obsessive passion was higher for
those with PGD than for those at risk and without gambling
problems (Philippe & Vallerand, 2007). Clarke (2008) compared older gamblers with younger gamblers on involvement, motivation, and PG and found that increased severity
of PG was more likely to be associated with releasing tension
than with winning money or seeking sensation. One study
suggested that the decreased self-control brought about by
the diminished executive functioning characteristic of aging
was a possible contributor to PG among older adults (von
Hippel et al., 2009).
Studies among older adults with disordered gambling
indicated that a later age of onset of gambling was an
important risk factor for disordered gambling (Grant, Kim,
& Brown, 2001; McNeilly & Burke, 2002). A recent study
of PGD confirmed that late onset of a gambling problem
was associated with a higher level of psychopathology
(e.g., paranoid ideation, depression) (Jimenez-Murcia et al.,
2010). However, another study found that those who began
to gamble at an earlier age gambled more frequently and
had more severe medical and psychiatric problems, compared with gamblers who had a later onset of gambling
(Burge, Pietrzak, Molina, & Petry, 2004). Furthermore,
Petry (2002) compared gambling and psychosocial problems between young, middle-aged, and older treatment
seekers with PGD and found that the middle-aged and older
gamblers were more likely to be women than the younger
gamblers. The author pointed out that older women did not
begin gambling regularly until an average age of 55 years,
whereas older male gamblers generally reported a lifelong
history of gambling (Petry, 2002). This mixed finding raises
important questions that warrant additional research, in
particular using longitudinal designs: Do older adults who
have a later initiation into gambling have a different trajectory of gambling problems (i.e., develop psychosocial
problems more quickly or slowly) or show a different clinical symptom presentation than those older adults with an
earlier gambling onset and thus more gambling experience?
If the differences exist, what are the individual or sociological/cultural contextual factors, and the processes contributing to these different gambling trajectories and clinical
presentations?
With regard to comorbidity, it was found that alcohol and
substance dependence significantly increased the odds of
reporting a gambling problem (McCready et al., 2008). In
addition, another study reported that the predictors of at risk
gambling behavior included being a binge drinker, presence
of symptoms of posttraumatic stress disorder, and being of
a racial/ethnic minority (Levens et al., 2005).
Other predictors of PG and PGD among older adults
included lower income, having no vocational or tertiary
qualifications, unemployment or retirement, single or widowed status, poor self-rated health, low level of optimism,
poor quality of social support network, and limited access to
the public transportation system (Lai, 2006; McVey, 2003;
Vander Bilt et al., 2004, Zaranek & Chapleski, 2005; Zaranek
& Lichtenberg, 2008). A recent study suggested that the risk
for PG among those who considered gambling as a significant
part of their recreation activities was four times higher than
that of other older adults (Pietrzak et al., 2007). Additionally,
it appears that other predictors are man, being of younger
age (60–69 years old), being motivated to gamble to experience excitement and to win money (Clarke & Clarkson,
2009; Southwell et al., 2008). Another survey among 775
older adults suggested that gambling to escape problems and
loneliness and to pass the time were the predominant reasons
for gambling among older adults with PG or PGD (Boreham
et al., 2006; McVey, 2003; Wiebe & Cox, 2005).
Protective Factors for Disordered Gambling
In addition to motivational factors for gambling and risk
factors for disordered gambling, a few studies have also
documented protective factors for gambling among older
adults. A study of 1,410 randomly selected older adults
revealed that those who reported a higher social support
network, participated in a variety of other social activities, were married, had a higher educational attainment,
GAMBLING BEHAVIOR AND PROBLEMS AMONG OLDER ADULTS
and earned a higherlevel income were less likely to visit
casinos compared with their counterparts (Zaranek &
Chapleski, 2005). A multisite study on the patterns of gambling and associated predictors among older ethnic Chinese
in Canada indicated that having a postsecondary or higher
level of education and having a higher level of life satisfaction reduced the probability of gambling (Lai, 2006).
McCready and colleagues (2008) also reported that being
married and having a higher education level were associated with reduced risk of gambling problems. Hong and
colleagues (2009) examined determinants of lifetime and
current problem gambling, based on a randomly selected
national sample of older adults in the United States, and
found that participation in religious services was a protective factor in both lifetime and current PG.
In an exploratory qualitative study of nonproblem gambling among 12 older adults (Hagen et al., 2005), participants described a number of cognitive and behavioral
strategies they used to prevent their gambling from becoming problematic. Cognitive strategies included realizing the
danger, recognizing the odds against them, and not considering themselves “lucky.” Behavioral strategies included
only taking a preset amount of money and stopping when
that money was gone, quitting while ahead and not reinvesting wins, making money and time go farther while
gambling, and not gambling alone. In a state-administered
casino self-exclusion program, which was the predominant
harm-reduction strategy used by the gaming industry to help
problem gamblers limit losses. Nower and Blaszczynski
(2008) examined characteristics of older adults with PG
who banned themselves from casinos using the casinos’
voluntary self-exclusion program. Their results indicated
that starting gambling in midlife, experiencing gambling
problems around age 60, a preference for nonstrategic
forms of gambling, and fear of suicide were predictive factors of self-exclusion from gambling among older adults.
Although these studies significantly add to our knowledge base, studies on protective factors for gambling
behavior among older adults are limited and under investigated. Moreover, few studies have examined the factors
contributing to recovery and rehabilitation from gambling
addictions among older adults. Further studies to examine
protective factors for gambling or motivational factors for
self-exclusion from gambling are particularly needed.
Negative Health Outcomes From Gambling
Although financial, legal, and occupational problems resulting from gambling among older adults are rarely reported in
the literature, negative psychological and health outcomes
from gambling among older adults are well documented in
many studies (e.g., Bazargan et al., 2001; Erickson et al.,
2005; McNeilly & Burke, 2000; Pietrzak, Molina, Ladd,
Kerins, & Petry, 2005). A study of a nationally representative sample of 10,563 older adults suggested that compared
with older adults without a history of regular gambling,
647
recreational gamblers and disordered gamblers had significantly elevated rates of alcohol, nicotine, and illegal
drug use and higher rates of mood, anxiety, and personality disorders (Pietrzak et al., 2007). Studies also found that
older adults with disordered gambling had elevated rates of
comorbid psychiatric disorders including mood, anxiety,
and personality disorders (Kerber et al., 2008).
Previous studies have found that older adults with PG and
PGD suffered from significantly greater physical and mental
health problems than nonproblem gamblers (Erickson et al.,
2005). One study indicated that older adults with disordered
gambling reported increased severity of family (e.g., poor
role functioning), social, medical (e.g., lower vitality level,
arthritis), psychiatric (e.g., depression, anxiety, paranoid
ideation), and alcohol problems compared with non/infrequent gamblers (Pietrzak et al., 2005). Another study also
indicated that older adults suffering from PGD reported a
greater number of stressful life events, higher levels of anxiety, a greater number of obsessive-compulsive symptoms,
and a lower level of control over their future health status
(Bazargan et al., 2001).
Compared with those with PG, adverse health impacts
are more significant and severe among those with PGD.
A clinical study among a group of older gamblers with PG
and PGD indicated that the latter group reported increased
severity of gambling, family, social, and emotional problems and scored higher on the measures of depression and
loneliness compared with the former (Pietrzak & Petry,
2006). McNeilly and Burke (2000) reported that those with
PGD had the highest incidence of depression, the lowest
reported life satisfaction, and the most frequent spending
on gambling. Morasco and colleagues (2006) found that a
diagnosis of PGD was associated with higher rates of medical utilization.
Some research has compared health consequences
between older gamblers and younger gamblers. Kausch
(2004) reported that older gamblers were just as likely
as younger gamblers to have a lifetime history of serious
suicidal ideation and that they were equally likely as the
younger cohort to have a psychiatric diagnosis, mainly
depression (Kausch, 2004). However, results of another
study indicated that older adult problem gamblers were less
likely to report gambling-related mental health problems
compared with younger adult problem gamblers (Potenza,
Steinberg, Wu, Rounsaville, & O’Malley, 2006).
Older adults were hesitant to deal with their gambling
addiction issues (Bjelde et al., 2008) and less likely than
younger adults to seek mental health services or professional treatment when faced with such challenges (Atchley
& Barusch, 2004). Bjelde and colleagues (2008) argued
that, among older adults, their reluctance to discuss mental
health issues and lack of recognition of gambling as an illness affected treatment-seeking behavior. On the other hand,
Zoellner (2002) reported that women called the PG hotline
service readily (made up 75% of the calls to Gamblers
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TSE ET AL.
Anonymous hotline in Arizona); one possible explanation
was that older women might be inclined to use the hotline
service about another person’s problem gambling.
Positive Health Outcomes From Gambling
Although most studies on gambling have focused on its
adverse mental health and social consequences, Shaffer and
Korn (2002) have posited the normative elements of gambling as a form of adult play for fun and excitement. In fact,
according to The National Academy of Science (Committee
on the Social and Economic Impact of Pathological
Gambling, National Research Council, 1999), about 98%
of Americans gamble recreationally and without any clinically significant problems. The casino industry’s American
Gaming Association states that older adult gambling has far
more positive than negative outcomes for individuals and
communities by providing fun, excitement, and opportunities for socializing (McVey, 2003). Beyond recreation,
some types of gambling actually appear to enhance coping strategies by building skills and competencies such as
memory enhancement, problem solving through game tactics, mathematical proficiency, concentration, and hand–eye
coordination (Rowe & Kahn, 1997; Shaffer & Korn, 2002).
Observational studies of older adults’ gambling behaviors
have found that gambling increased older adults’ self-esteem
(Campbell, 1976; Volberg, Reitzes, & Boles, 1997). Along
similar lines, a study by Loroz (2004) indicated that gambling was a popular recreation choice for older adults
because of hedonic responses of “fantasies, feelings, and
fun” and that the psychological benefits of gambling may
ultimately reinforce and enhance older adults’ self-concept.
In a study based on a nationally representative sample of
2,417 adults, Desai and colleagues (2004) reported that
older recreational gamblers were more likely to report better health than were older nongamblers and that recreational
gambling in older adults was not associated with negative
measures of health and well-being in contrast to findings in
younger adults (aged 18–64 years). A two-stage study (using
both a mail-in survey and an in-depth interview) in a small
sample of 146 older adults aged 60 or over found no evidence
that casino gambling activities threatened their well-being
(Hope & Havir, 2002). A study among a community cohort
of 1,016 older adults also indicated that gambling participation in certain forms and contexts (e.g., the state lottery,
going to the race track, and playing bingo for charity) could
all have positive social and psychological outcomes (Vander
Bilt et al., 2004). A study with a nationally representative
sample of 43,093 noninstitutionalized U.S. residents also
reported that recreational gambling was associated not only
with some negative measures but also with some positive
measures (Desai et al., 2007). Therefore, health benefits
from recreational gambling among older adults are evident,
and a major focus of scientific studies in the field is on how
to minimize harm or adverse health impacts.
Another commonly documented positive outcome from
gambling is that gambling may offer older adults a source of
social benefit or social support which in turn can positively
affect their well-being (Everard, Lach, Fisher, & Baum,
2000; Hope & Havir, 2002; Preston et al., 2007; Vander
Bilt et al., 2004). Gambling gives older adults a chance to
cope with loneliness or negative emotions such as anxiety or
depression (Vander Bilt et al., 2004) and may make them feel
young and alive again (Bjelde et al., 2008). Nevertheless,
studies on the relationship between social support and gambling among older adults revealed mixed findings. In a study
among a community cohort of 1,016 older adults, results of
both cross-sectional and longitudinal data analysis indicated
that gambling participation was associated with greater
social support (Vander Bilt et al., 2004). A multisite study
among older ethnic Chinese in Canada also indicated that
having a higher level of social support was a predictive factor for gambling participation (Lai, 2006). This finding on
Chinese gambling and social support may be particularly
relevant given the majority of Chinese popular gambling
activities are group games, for example, mahjong and pai
gow. However, a U.S. study among 1,410 randomly selected
older adults in Detroit, MI, revealed that older adults who
reported having a larger social support network were less
likely to visit casinos, whereas older adults who frequently
visited casinos had less social support than older adults who
had infrequent or no visits to casinos (Zaranek & Chapleski,
2005). These findings suggest that gambling may offer a
form of natural social support for older adults and that social
isolation or loneliness may make older adults vulnerable to
higher levels of participation in gambling; on the other hand,
social isolation or a limited social network may reduce the
opportunity for gambling in particular those group gambling
activities (Lai, 2006; McNeilly & Burke, 2001; Zaranek &
Chapleski, 2005; Zaranek, & Lichtenberg, 2008).
Conclusion
This systematic review of the prevalence of disordered
gambling, motivators of gambling participation, risk and
protective factors of disordered gambling, and diverse
health outcomes from gambling has identified the fairly
fragmented state of the field. The present authors review
six limitations subsequently and offer recommendations for
developing this area of research. Table 2 summarizes these
main points. First, most studies were conducted in the context of Western culture and in developed regions. Although
some studies were conducted with a sample that included
multiple racial/ethnic groups, studies that focused on gambling among diverse racial/ethnic groups were very limited.
Because culture, values, and beliefs influence gambling
participation, gambling patterns, and attitudes or actions
toward seeking professional help (Raylu & Oei, 2004),
further studies in different cultural contexts and among
different racial/ethnic groups are needed. Second, there is
GAMBLING BEHAVIOR AND PROBLEMS AMONG OLDER ADULTS
649
Table 2. Summary of Limitations of Existing Literature and Recommendations for Future Studies on Older Adults and Gambling
Limitations of existing literature
1. Cultural context
2. Instrumentation
3. Empirical research
4. Methodology
5. Holistic approach
6. Older adults and contemporary
gambling landscape
Recommendations for future gambling research
The study populations have been limited to Western culture
and developed countries.
There is little evidence on which gambling assessment
instruments are accurate.
Further research should be examined in different cultural
contexts and among different racial/ethnic groups.
More rigorous examination of gambling assessment
instruments is needed to establish their psychometric
properties.
There have been theoretical assumptions to explain why older Empirical research design should be employed to test for
causality of gambling mechanism among older adults and
adults gamble and why some gamble excessively, but rarely
thus confirm a theoretical approach.
are they subject to empirical testing.
Most of the studies on older adults’ gambling have been
More theory-driven qualitative studies are necessary to
primarily quantitative and utilize survey methodology.
elucidate the complex dynamics on gambling in later life.
The gambling literature has focused on adverse consequences Future gambling research should be more balanced to
and risk factors for gambling.
examine both negative and positive outcomes from
gambling for older adults. Beyond risk factors, more
meaningful protective factors should be studied within the
context of productive aging.
Most of the past studies focused on conventional and
Future studies should be expanded to include alternative
commercial gambling.
forms of gambling (e.g., online betting, Apps on 3-G/smart
phones) to reflect changes in lifestyles among older adults.
such a diversity of measurement tools and little evidence
on which tools are accurate. More rigorous testing of gambling instruments will increase accuracy in estimating the
prevalence rates of gambling and will support an analytical
inquiry to identify determinants related to gambling. Third,
although various theoretical assumptions have been applied
to explain the causes and consequences of gambling, empirical evidence is limited. More empirical evidence based on
rigorous experimental studies testing the causality of gambling mechanism is needed to inform a theoretical approach.
Such an approach can serve as the basis for more advanced
studies on prevention and intervention for PG and PGD, and
health promotion and education programs for older adults.
Fourth, most of the studies have been predominantly quantitative and population-level survey studies. There is a pressing need to conduct more theory-driven qualitative studies
to examine the very complex dynamics among older adults,
specific games individuals play, gambling settings, and the
trajectory of changes over time. Fifth, most of the studies
on older adults’ gambling mainly examine adverse health
consequences of gambling and associated risk factors. This
skewed view may be limited in its ability to suggest meaningful protective factors within the context of productive
aging (Gergen & Gergen, 2002; Khaw, 1997). Knowledge
of preventive strategies for disordered gambling could
inform the design of intervention programs and research
on health promotion. Longitudinal studies comparing older
adults who gamble but do not experience harm and those
who gamble and suffer from PG or PGD will yield pertinent
information on protective factors against gambling-related
harms. Lastly, although a great majority of studies focused
on conventional and commercial gambling, internet-based
gambling or online gambling was rarely examined. With
the increased availability of online gambling and its ease
of accessibility, older adults may be more likely to take part
in online gambling at home. Future studies should be more
inclusive of alternative forms of gambling to reflect changes
in lifestyles among older adults. It is worth noting that the
earlier discussion may also reflect the state of the larger
gambling studies literature across various age groups.
The larger public is generally interested in eliminating
problems and harms caused by disordered gambling and maximizing health benefits from a form of recreational gambling
for older adults (Basham & Luik, 2011; Williams, Belanger,
& Arthur, 2011). Future empirical studies should attend to
specific methodological issues such as target sample particularly focusing on well-being issues of older adults who gamble, sampling design, measurements, and taking into account
older adults’ adjustment to the aging process in the 21st century context (Hooyman & Kiyak, 2011). It is imperative that
studies on older adults and gambling will move beyond risk
analyses to a focus on early help-seeking behaviors, fundamental character strengths, and personal inspirations, which
will prevent older adults from developing disordered gambling or enhance their recovery from gambling-related harms.
Acknowledgments
S. Tse and S.-I. Hong planned the systematic review, supervised the
analysis, and wrote the paper. C.-W. Wang helped perform the review and
write the paper. R. M. Cunningham-Williams contributed to the analysis
and revised the article. All authors reviewed and approved the final version
of the manuscript.
Correspondence
Correspondence should be addressed to Samson Tse, PhD, Department
of Social Work and Social Administration, The University of Hong Kong,
Pokfulam Road, Hong Kong, China. E-mail: [email protected].
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