'Everyone knows grandma'. Pathways to gambling venues in regional Australia.

In regional Australia, families (including children), attend community venues that contain gambling products, such as electronic gambling machines (EGMs), for a range of non-gambling reasons. However, there is a gap in research that seeks to understand how these venues may become embedded into family social practices. Drawing on Bourdieu's concepts of habitus and cultural capital, this paper aimed to explore factors that influence family decisions to attend venues and perceptions of risk associated with children's exposure to gambling products. Face-to-face qualitative interviews were conducted with 31 parents who attended community gambling venues with their children, in New South Wales, Australia. Families attended venues for three key reasons, first because of the influence of others in their social networks, second for regular social activities and third because of structural factors such as a lack of alternative, affordable, family friendly environments in their local area. Despite recognizing the harm associated with EGMs, parents distanced themselves from EGM harm with all parents perceiving venues to be an appropriate space for families. Research in this study indicates that family social practices within venues affect perceptions of risk associated with community gambling venues. The impact of these practices on longer-term health requires more investigation by public health and health promotion researchers and practitioners. Health promotion initiatives should consider identifying alternative sources of support and/or developing alternative social spaces for families in regional communities that do not contain gambling products.

Women and gambling-related harm: a narrative literature review and implications for research, policy, and practice.

BACKGROUND: While the prevalence of women's participation in gambling is steadily increasing, there is a well-recognised male bias in gambling research and policy. Few papers have sought to synthesise the literature relating to women and gambling-related harm and provide practical suggestions to guide future research, policy, and practice which take into account the specific nuances associated with women's gambling. METHODS: A narrative literature review was conducted to review the evidence base on women's gambling behaviours and experiences of harm. Drawing from strategies used effectively in other areas of public health, key elements for a gendered approach to harm prevention were identified and adapted into practical public health research, policy and practice strategies. RESULTS: Results indicated a lack of research that explores women's gambling. Few studies have examined the impact of gambling on the lives of women, with limited understanding of the factors that influence women's engagement with gambling products, and the impact of industry tactics. A gendered approach was identified as a strategy used successfully in other areas of public health to shift the focus onto women and to ensure they are considered in research. In tobacco control, increasing trends in women's smoking behaviour were combatted with targeted research, policy and practical initiatives. These key elements were adapted to create a conceptual framework for reducing and preventing gambling harm in women. The framework provides regulatory direction and a research agenda to minimise gambling-related harm for women both in Australia and internationally. Evidence-based policies should be implemented to focus on the influence of gender and associated factors to address gambling-related harm. Practical interventions must take into account how women conceptualise and respond to gambling risk in order to develop specific harm prevention programs which respond to their needs. CONCLUSION: A gendered approach to gambling harm prevention shifts the focus onto the unique factors associated with women's gambling and specific ways to prevent harm. As seen in other areas of public health, such a framework enables harm measures, policies, and interventions to be developed that are salient to girls and women's lives, experiences and circumstances.

Recall and awareness of gambling advertising and sponsorship in sport in the UK: a study of young people and adults.

BACKGROUND: The impact of gambling advertisements shown during sporting events on young people is an important public health issue. While extensive research has taken place in Australia, there is still only a limited understanding of this issue in the United Kingdom (UK). METHOD: A mixed methods study was conducted with 71 family groups comprised of 99 young people (8-16 years) and 71 adults recruited at six sites across South London, England (May-July 2018). Interviewer-assisted surveys investigated recall and awareness of sports betting brands using interviews and a magnet placement board activity developed in Australia. Quantitative data were analysed using descriptive statistics, with qualitative data interpreted using thematic analysis techniques. RESULTS: Just under half of young people (n = 46, 46%) and more than two thirds of adults (n = 49, 71%) were able, unprompted, to name at least one gambling brand. Boys had a significantly higher recall of brands than girls, as did young people who watched a lot of football on television. Almost two thirds of young people (n = 63, 63%) correctly placed one or more shirt sponsor magnets next to the corresponding football team, and 30% (n = 30) correctly placed three or more sponsors magnets next to the corresponding football team. Just under two thirds of adults (n = 44, 62%) correctly placed one or more shirt sponsors magnets next to the corresponding football team. Young people recalled seeing gambling advertising on television (n = 78), technology/screens (n = 49), and in association with sports teams (n = 43). Adults recalled seeing advertising on television (n = 56), on technology/screens (n = 37), in sports stadiums (n = 34), and in betting venues (n = 34). Over three quarters of young people (n = 74 out of 95 responses, 78%) and 86% of adults (n = 59 out of 69 responses) thought that betting had become a normal part of sport. CONCLUSION: In order to reduce the exposure of young people to gambling advertising, policymakers in the UK should consider comprehensive approaches, similar to those applied in tobacco control, which cover all forms of advertising, including promotion and sponsorship.

Systems Thinking as a Framework for Analyzing Commercial Determinants of Health.

Policy Points: Worldwide, more than 70% of all deaths are attributable to noncommunicable diseases (NCDs), nearly half of which are premature and apply to individuals of working age. Although such deaths are largely preventable, effective solutions continue to elude the public health community. One reason is the considerable influence of the "commercial determinants of health": NCDs are the product of a system that includes powerful corporate actors, who are often involved in public health policymaking. This article shows how a complex systems perspective may be used to analyze the commercial determinants of NCDs, and it explains how this can help with (1) conceptualizing the problem of NCDs and (2) developing effective policy interventions. CONTEXT: The high burden of noncommunicable diseases (NCDs) is politically salient and eminently preventable. However, effective solutions largely continue to elude the public health community. Two pressing issues heighten this challenge: the first is the public health community's narrow approach to addressing NCDs, and the second is the involvement of corporate actors in policymaking. While NCDs are often conceptualized in terms of individual-level risk factors, we argue that they should be reframed as products of a complex system. This article explores the value of a systems approach to understanding NCDs as an emergent property of a complex system, with a focus on commercial actors. METHODS: Drawing on Donella Meadows's systems thinking framework, this article examines how a systems perspective may be used to analyze the commercial determinants of NCDs and, specifically, how unhealthy commodity industries influence public health policy. FINDINGS: Unhealthy commodity industries actively design and shape the NCD policy system, intervene at different levels of the system to gain agency over policy and politics, and legitimize their presence in public health policy decisions. CONCLUSIONS: It should be possible to apply the principles of systems thinking to other complex public health issues, not just NCDs. Such an approach should be tested and refined for other complex public health challenges.

Young people's awareness of the timing and placement of gambling advertising on traditional and social media platforms: a study of 11-16-year-olds in Australia.

BACKGROUND: Research has demonstrated that the promotion of gambling, particularly within sport, may have a significant impact on positively shaping young people's attitudes towards gambling. While some governments have implemented restrictions to limit young people's exposure to gambling advertising, few studies have investigated where young people recall seeing gambling advertising, and whether they perceive that advertising restrictions have gone far enough in reducing exposure to these promotions. METHOD: Mixed methods, interviewer-assisted surveys were conducted with n = 111 young people aged 11-16 years, who were self-reported fans of basketball in Victoria, Australia. Interviews were conducted at basketball stadiums between May and July 2018. The study assessed media viewing patterns; recall and awareness of the timing, placement, and content of gambling advertising; the impact of gambling advertising restrictions; and attitudes towards sporting organisations' roles in the promotion of gambling. RESULTS: The majority of young people recalled seeing gambling advertising on television (n = 101, 91.0%), with most recalling advertising within sporting matches or games (n = 79, 71.2%). Most young people recalled seeing gambling advertising in the early evening before 8:30 pm (n = 75, 67.6%). Just over half of young people described seeing gambling advertisements on social media (n = 61, 55.0%), and over a third (n = 40, 36.0%) recalled gambling advertising on YouTube, predominantly before watching sporting or gaming videos. The majority stated that they continued to watch sport after 8:30 pm (n = 93, 83.7%), which is when restrictions on advertising in live sport in Australia end. The majority (n = 88, 79.3%) stated that there were too many gambling advertisements in sport. Three quarters believed that sporting codes should do more to prevent young people from being exposed to advertising for gambling in sport (n = 84, 75.7%). CONCLUSIONS: There is now a clear body evidence that current regulatory systems for gambling advertising are ineffective, with further restrictions urgently needed across a range of media channels to prevent exposure to promotions that may encourage young people's interest and involvement in gambling.

'A place for men to come and do their thing': constructing masculinities in betting shops in London.

During fieldwork conducted with workers and customers in betting shops in London research participants consistently conceptualized betting shops as masculine spaces in contrast to the femininity of other places including home and the bingo hall. According to this argument, betting on horses and dogs was 'men's business' and betting shops were 'men's worlds'. Two explanations were offered to account for this situation. The first suggested that betting was traditionally a pastime enjoyed by men rather than women. The second was that betting is intrinsically more appealing to men because it is based on calculation and measurement, and women prefer more intuitive, simpler challenges. I use interviews with older people to describe how the legalisation of betting in cash in 1961 changed the geography of betting. I then draw upon interviews with regular customers in order to show how knowledge about betting is shared within rather than between genders. Finally, I use my experience of training and working as a cashier to describe how the particular hegemonic masculinity found in betting shops in London is maintained through myriad everyday practices which reward certain kinds of gendered performances while at the same time suppressing alternatives. The article shows how particular spaces may become gendered as an unanticipated consequence of legislation and how contingent gendered associations are both naturalized and, at the same time, subjected to intense attention.

Ageing with HIV: Medicine Optimisation Challenges and Support Needs for Older People Living with HIV: A Systematic Review.

BACKGROUND: Older people living with HIV (PLWH) are at increased risks of co-morbidities and polypharmacy. However, little is known about factors affecting their needs and concerns about medicines. This systematic review aims to describe these and to identify interventions to improve medicine optimisation outcomes in older PLWH. METHODS AND DATA SOURCES: Multiple databases and grey literature were searched from inception to February 2022 including MEDLINE, CINAHL, PsycInfo, PsychArticles, the Cochrane Database of Systematic Reviews and the Cochrane Controlled Register of Trials, Abstracts in Social Gerontology, and Academic Search Complete. ELIGIBILITY CRITERIA: Studies reporting interventions/issues affecting older PLWH (sample populations with mean/median age ≥ 50 years; any aspect of medicine optimisation, or concerns). Quality assessments were completed by means of critical appraisal checklists for each study design. Title and abstract screening was led by one reviewer and a sample reviewed independently by two reviewers. Full-paper reviews were completed by one author and a 20% sample was reviewed independently by two reviewers. SYNTHESIS: Data were extracted by three independent reviewers using standardised data extraction forms and synthesised according to outcomes or interventions reported. Data were summarised to include key themes, outcomes or concerns, and summary of intervention. RESULTS: Seventy-nine (n = 79) studies met the eligibility criteria, most of which originated from the USA (n = 36). A few studies originated from Australia (n = 5), Canada (n = 5), Spain (n = 9), and the UK (n = 5). Ten studies originated from Sub-Saharan Africa (Kenya n = 1, South Africa n = 6, Tanzania n = 1, Uganda n = 1, Zimbabwe n = 1). The rest of the studies were from China (n = 1), France (n = 1), Germany (n = 1), Italy (n = 1), the Netherlands (n = 1), Pakistan (n = 1), Switzerland (n = 1), Saudi Arabia (n = 1) and Ukraine (n = 1). Publication dates ranged from 2002 to 2022. Sample sizes ranged from 10 to 15,602 across studies. The factors affecting older PLWH's experience of and issues with medicines were co-morbidities, health-related quality of life, polypharmacy, drug interactions, adverse drug reactions, adherence, medicine burden, treatment burden, stigma, social support, and patient-healthcare provider relationships. Nine interventions were identified to target older persons, five aimed at improving medication adherence, two to reduce drug interactions, and two for medicine self-management initiatives. CONCLUSION: Further in-depth research is needed to understand older PLWH's experiences of medicines and their priority issues. Adherence-focused interventions are predominant, but there is a scarcity of interventions aimed at improving medicine experiences for this population. Multi-faceted interventions are needed to achieve medicine optimisation outcomes for PLWH. TRIAL REGISTRATION: This study is registered with PROSPERO registration number: CRD42020188448.

Study protocol: evaluation of the 0-5 public health investment in England - a mixed-methods study integrating analyses of national linked administrative data with in-depth case studies.

INTRODUCTION: Health visiting is a long-established, nationally implemented programme that works with other services at a local level to improve the health and well-being of children and families. To maximise the impact and efficiency of the health visiting programme, policy-makers and commissioners need robust evidence on the costs and benefits of different levels and types of health visiting, for different families, in different local contexts. METHODS AND ANALYSIS: This mixed-methods study will analyse individual-level health visiting data for 2018/2019 and 2019/2020 linked with longitudinal data from children's social care, hospitals and schools to estimate the association of number and type of health visiting contacts with a range of children and maternal outcomes. We will also use aggregate local authority data to estimate the association between local models of health visiting and area-level outcomes. Outcomes will include hospitalisations, breast feeding, vaccination, childhood obesity and maternal mental health. Where possible, outcomes will be valued in monetary terms, and we will compare total costs to total benefits of different health visiting service delivery models. Qualitative case studies and extensive stakeholder input will help explain the quantitative analyses and interpret the results in the context of local policy, practice and circumstance. ETHICS AND DISSEMINATION: The University College London Research Ethics Committee approved this study (ref 20561/002). Results will be submitted for publication in a peer-reviewed journal and findings will be shared and debated with national policy-makers, commissioners and managers of health visiting services, health visitors and parents.

Young people's reflections on the factors contributing to the normalisation of gambling in Australia.

OBJECTIVES: To explore young people's perceptions of the factors that may normalise gambling, and their opinions about the messages they see about gambling in their environments. METHODS: An analysis of qualitative data from a mixed methods study of n=111 young people aged 11-16 years in Victoria, Australia. Questions investigated: i) the normalisation of gambling in sport; ii) the impact of advertising on young people; and iii) potential strategies to alert young people about the risks associated with gambling. An inductive approach was used to analyse the data. RESULTS: Participants perceived that gambling was a regular and everyday activity and that gambling was becoming normalised in sport. However, some directly challenged this alignment. They were particularly critical that gambling advertising may influence young people's current and future gambling-related attitudes and intentions. Most participants supported public health interventions, including more advertising restrictions. CONCLUSION: Young people's awareness of gambling and gambling marketing may be increasing their perceptions of the alignment between gambling and sport. Implications for public health: Strategies should be developed to increase young people's awareness of the risks associated with gambling. Young people's voices and views should be considered by policy makers in responding to this new public health issue.

A public health approach to gambling regulation: countering powerful influences.

Often portrayed as a harmless leisure activity in the UK, gambling is being increasingly recognised as a public health concern. However, a gambling policy system that explicitly tackles public health concerns and confronts the dependencies and conflicts of interest that undermine the public good is absent in the UK. Although there is a window of opportunity to change the gambling policy system, with the UK Government's launch of a review of the Gambling Act 2005, the adoption of a comprehensive and meaningful public health approach is not guaranteed. Too often, government policy has employed discourses that align more closely with those of the gambling industry than with those of the individuals, families, and communities affected by the harms of gambling. In view of the well described commercial determinants of health and corporate behaviour, an immense effort will be needed to shift the gambling discourse to protect public health. In this Viewpoint, we seek to advance this agenda by identifying elements that need challenging and stimulating debate.

The case for developing a cohesive systems approach to research across unhealthy commodity industries.

OBJECTIVES: Most non-communicable diseases are preventable and largely driven by the consumption of harmful products, such as tobacco, alcohol, gambling and ultra-processed food and drink products, collectively termed unhealthy commodities. This paper explores the links between unhealthy commodity industries (UCIs), analyses the extent of alignment across their corporate political strategies, and proposes a cohesive systems approach to research across UCIs. METHODS: We held an expert consultation on analysing the involvement of UCIs in public health policy, conducted an analysis of business links across UCIs, and employed taxonomies of corporate political activity to collate, compare and illustrate strategies employed by the alcohol, ultra-processed food and drink products, tobacco and gambling industries. RESULTS: There are clear commonalities across UCIs' strategies in shaping evidence, employing narratives and framing techniques, constituency building and policy substitution. There is also consistent evidence of business links between UCIs, as well as complex relationships with government agencies, often allowing UCIs to engage in policy-making forums. This knowledge indicates that the role of all UCIs in public health policy would benefit from a common approach to analysis. This enables the development of a theoretical framework for understanding how UCIs influence the policy process. It highlights the need for a deeper and broader understanding of conflicts of interests and how to avoid them; and a broader conception of what constitutes strong evidence generated by a wider range of research types. CONCLUSION: UCIs employ shared strategies to shape public health policy, protecting business interests, and thereby contributing to the perpetuation of non-communicable diseases. A cohesive systems approach to research across UCIs is required to deepen shared understanding of this complex and interconnected area and also to inform a more effective and coherent response.

Global expectations and local practices: HIV support groups in the Gambia.

This paper looks at the ways that people living with HIV in the Gambia, as members of HIV support groups, engaged with the programmes available to them in this context. People living with HIV engage with the global in a variety of ways. Following Ong and Collier this paper analyses the way in which people in this context experience and negotiate with the "global assemblage" around international HIV work. This can be observed in everyday practice in the formation of networks and partnerships linking people and their activities into international structures. Using qualitative methods and a grounded theoretical approach, the research followed events around HIV treatment in the Gambia 2006-2007. Looking at the support societies and their members' struggles to gain some material support, findings show how support group members negotiated and expressed agency within the available structures. They make use of accepted frames of international action which bypass the state, presenting an internationally linked "biological citizenship" which brings associated opportunities to access resources. Through the intervention of the president and his "cure" programme, this case also illustrates that people's commitment to the value structures implicit in these funding streams may not be as strong as might be assumed. In these circumstances two alternate treatment programmes, linked to very different values, were on offer, both backed up by the powerful machinery of either the state or international funding. The negotiation by people living with HIV of these avenues through which to acquire benefits and so support and health, calls into question assumptions of a "buy in" to global ideas and values without further scrutiny of the ways in which such assemblages function in different contexts.

'It's a tradition to go down to the pokies on your 18th birthday' - the normalisation of gambling for young women in Australia.

OBJECTIVE: To understand the range of factors that may influence the normalisation of gambling for young women in Victoria, Australia. METHODS: In-depth qualitative telephone interviews with 45 women aged 18-34 years. RESULTS: Young women were exposed to gambling environments and some were gambling from an early age. Family members were the key facilitators of these activities. Once reaching the legal age of gambling, peers and boyfriends were instrumental in young women's gambling practices. Women attributed the normalisation of gambling to excessive marketing, feminised gambling environments, and the widespread availability of gambling in the community. CONCLUSIONS: This study found several factors that influenced and encouraged young women to gamble, such as the feminisation of gambling products and environments, and determined that gambling is becoming a socio-culturally accepted activity for young women. Implications for public health: Researchers and policymakers should be increasingly focused on how different forms of gambling may be normalised for young women. Attention should be given to how young women may become a target market for the gambling industry, and how to implement strategies aimed at preventing any future potential harm posed by these industries and their marketing tactics and products.

Young people's recall and perceptions of gambling advertising and intentions to gamble on sport.

BACKGROUND: There has been an increased international policy focus on the factors that may contribute to, and prevent, the normalization of gambling for young people. However, there is still limited research, which investigates the role of advertising in shaping young people's gambling attitudes and consumption intentions. METHODS: Mixed methods study of 111 young people aged 11-16 years recruited from community basketball stadiums in Victoria, Australia, between May and July 2018. Interviewer-assisted surveys investigated recall and awareness of sports betting brands, perceptions of promotional strategies, intention to gamble, and reasons for betting on particular sports. Quantitative data were analyzed using descriptive statistics and χ2 tests. Thematic analyses were used to interpret qualitative responses. RESULTS: Young people had high recall and awareness of advertising, with most able to name at least one betting brand (n = 90, 81.1%), and many demonstrating a high awareness of the distinct characteristics (such as colors and appeal strategies) of different brands. A fifth of young people (n = 25, 22.5%) expressed intentions to gamble at 18 years, with boys significantly more likely than girls to state they would gamble (χ2 = 10.90, p = .001). Young people perceived that advertising strategies associated with inducement promotions would be the most influential in encouraging individuals to gamble. While many young people took promotions at face value, there was evidence that some were able to critically engage with and challenge the messages within marketing. DISCUSSION AND CONCLUSIONS: Current regulatory structures appear to be ineffective in limiting young people's recall and awareness of gambling advertising. Lessons from tobacco control support the application of precautionary approaches as a more effective way to limit young people's development of positive gambling attitudes and behaviors.

'Nothing can be done until everything is done': the use of complexity arguments by food, beverage, alcohol and gambling industries.

BACKGROUND: Corporations use a range of strategies to dispute their role in causing public health harms and to limit the scope of effective public health interventions. This is well documented in relation to the activities of the tobacco industry, but research on other industries is less well developed. We therefore analysed public statements and documents from four unhealthy commodity industries to investigate whether and how they used arguments about complexity in this way. METHODS: We analysed alcohol, food, soda and gambling industry documents and websites and minutes of reports of relevant health select committees, using standard document analysis methods. RESULTS: Two main framings were identified: (i) these industries argue that aetiology is complex, so individual products cannot be blamed; and (ii) they argue that population health measures are 'too simple' to address complex public health problems. However, in this second framing, there are inherent contradictions in how industry used 'complexity', as their alternative solutions are generally not, in themselves, complex. CONCLUSION: The concept of complexity, as commonly used in public health, is also widely employed by unhealthy commodity industries to influence how the public and policymakers understand health issues. It is frequently used in response to policy announcements and in response to new scientific evidence (particularly evidence on obesity and alcohol harms). The arguments and language may reflect the existence of a cross-industry 'playbook', whose use results in the undermining of effective public health policies - in particular the undermining of effective regulation of profitable industry activities that are harmful to the public's health.