Producing knowledge together: a participatory approach to synthesising research across a large-scale collaboration in Aboriginal and Torres Strait Islander health.

BACKGROUND: Despite that stakeholder participation in evidence synthesis could result in more useful outcomes, there are few examples of processes that actively involve them in synthesis work. Techniques are needed that engage diverse stakeholders as equal partners in knowledge co-production. The aims of this paper are to describe an innovative participatory process of synthesising a large body of academic research products and compare the findings of the participatory process against two traditional approaches to synthesis: a rapid review and a structured review. METHODS: First, a rapid synthesis of all research outputs (n = 86) was conducted by researchers with in-depth knowledge of the collaboration's research. Second, a team of researchers and service providers conducted a structured synthesis of seventy-eight peer-reviewed articles and reports generated by the collaboration. Fifty-five publications were brought forward for further synthesis in part three, a facilitated participatory synthesis. Finally, we explored the value added by the participatory method by comparing findings generated across the three synthesis approaches. RESULTS: Twelve researchers and 11 service providers/policy partners-8 self-identified as Aboriginal and/or Torres Strait Islander-participated in two facilitated workshops (totalling 4 h). Workshop activities engaged participants in reviewing publication summaries, identifying key findings, and evoked review, discussion and refinement. The process explicitly linked experiential knowledge to citations of academic research, clearly connecting the two knowledge types. In comparing the findings generated across all three methods we found mostly consistencies; the few discrepancies did not contradict but gave deeper insights into statements created by the other methods. The participatory synthesis generated the most, detailed, and unique findings, and contextual insights about the relevance of the key messages for practice. CONCLUSION: The participatory synthesis engaged stakeholders with diverse backgrounds and skillsets in synthesising a large body of evidence in a relatively short time. The participatory approach produced findings comparable to traditional synthesis methods while extending knowledge and identifying lessons most relevant for the participants who, ultimately, are the end users of the research. This process will interest other large-scale research collaborations seeking to engage stakeholders in evidence synthesis.

Scope and quality of economic evaluations of Aboriginal and Torres Strait Islander health programs: a systematic review.

OBJECTIVES: Identify the number, type, scope and quality of economic evaluations of Aboriginal and Torres Strait Islander health programs. METHODS: A systematic review of peer-reviewed and grey literature was conducted for articles published from 2010 to 2020 that reported a full economic evaluation of Aboriginal and Torres Strait Islander health programs. Data extraction included: type of economic evaluation, comparators, data sources and concerns, and outcome measures. Methodological quality was assessed using the Drummond checklist. RESULTS: Thirteen publications met inclusion criteria: two cost-consequence analyses, two cost-effectiveness analyses, five cost-utility analyses, and four cost-benefit/return on investment analyses. Most studies (n=10) adopted a health system perspective and used a range of key data sources for economic analyses. Ten studies identified data access limitations that restricted analyses and two studies identified data quality concerns. Twelve studies were of good methodological quality and one was of average quality. CONCLUSIONS: Despite significant investment in strategies to close the gap in health outcomes for Aboriginal and Torres Strait Islander people, there is limited evidence about what constitutes a cost-effective investment in Aboriginal and Torres Strait Islander healthcare. IMPLICATIONS FOR PUBLIC HEALTH: More economic evaluation is required to justify the significant investment in health programs for Aboriginal and Torres Strait Islander people.

VOICE-Validating Outcomes by Including Consumer Experience: A Study Protocol to Develop a Patient Reported Experience Measure for Aboriginal and Torres Strait Islander Peoples Accessing Primary Health Care.

Aboriginal and Torres Strait Islander peoples' (hereafter respectfully referred to as Indigenous Australians) experiences of health care are shaped by historical, social and cultural factors, with cultural security critical to effective care provision and engagement between services and community. Positive patient experiences are associated with better health outcomes. Consequently, it is an accreditation requirement that primary health care (PHC) services must formally gather and respond to patient feedback. However, currently available patient feedback tools were not developed with Indigenous Australians, and do not reflect their values and world views. Existing tools do not capture important experiences of care of Indigenous Australians in PHC settings, nor return information that assists services to improve care. Consistent with the principles of Indigenous Data Sovereignty, we will co-design and validate an Indigenous-specific Patient Reported Experience Measure (PREM) that produces data by and for community, suitable for use in quality improvement in comprehensive PHC services. This paper presents the protocol of the study, outlining the rationale, methodologies and associated activities that are being applied in developing the PREM. Briefly, guided by an Aboriginal and Torres Strait Islander Advisory Group, our team of Indigenous and non-Indigenous researchers, service providers and policy makers will use a combination of Indigenous methodologies, participatory, and traditional western techniques for scale development. We will engage PHC service staff and communities in eight selected sites across remote, regional, and metropolitan communities in Australia for iterative cycles of data collection and feedback throughout the research process. Yarning Circles with community members will identify core concepts to develop an "Experience of Care Framework", which will be used to develop items for the PREM. Staff members will be interviewed regarding desirable characteristics and feasibility considerations for the PREM. The PREM will undergo cognitive and psychometric testing.

Integrating Healthcare Services for Indigenous Australian Students at Boarding Schools: A Mixed-Methods Sequential Explanatory Study.

INTRODUCTION: Many Aboriginal and Torres Strait Islander Australian adolescents from remote communities attend boarding schools, requiring integrated healthcare between home and schools. This study explored students' health status, healthcare service use and satisfaction. METHODOLOGY: A two-phased mixed-methods explanatory design was implemented. 32 Indigenous primary and 188 secondary boarding school students were asked their health status, psychological distress, use of healthcare services in community and boarding school, and service satisfaction. Results were fed back to students, parents and community members, and education and healthcare staff to elicit further explanation and interpretation. RESULTS: In the previous year, 75% of primary and 81% of secondary boarding school students had visited a doctor. More than 90% were satisfied with healthcare services used. Despite 27.1% reporting high psychological distress, students did not perceive distress as reducing their overall health, nor was distress associated with mental healthcare service use. DISCUSSION: Despite high levels of service use and satisfaction, this study highlighted the need for improved healthcare integration for Indigenous adolescents between school-based and remote community services. Further research is needed to identify students' expectations and models for healthcare integration. CONCLUSION: With resourcing, schools could play a greater role in facilitating access to healthcare.

Working well: a systematic scoping review of the Indigenous primary healthcare workforce development literature.

BACKGROUND: Strong and effective workforce models are essential for improving comprehensive Indigenous primary healthcare service (PHC) provision to Indigenous peoples in Canada, Australia, New Zealand and the USA (CANZUS nations). This review systematically scoped the literature for studies that described or evaluated models and systems that support the sustainability, capacity or growth of the Indigenous PHC workforce to provide effective PHC provision. METHODS: Eleven databases, 10 websites and clearinghouses, and the reference lists of 5 review articles were searched for relevant studies from CANZUS nations published in English from 2000 to 2017. A process of thematic analysis was utilised to identify key conditions, strategies and outcomes of Indigenous PHC workforce development reported in the literature. RESULTS: Overall, 28 studies were found. Studies reported enabling conditions for workforce development as government funding and appropriate regulation, support and advocacy by professional organisations; community engagement; PHC leadership, supervision and support; and practitioner Indigeneity, motivation, power equality and wellbeing. Strategies focused on enhancing recruitment and retention; strengthening roles, capacity and teamwork; and improving supervision, mentoring and support. Only 12/28 studies were evaluations, and these studies were generally of weak quality. These studies reported impacts of improved workforce sustainability, workforce capacity, resourcing/growth and healthcare performance improvements. CONCLUSIONS: PHCs can strengthen their workforce models by bringing together healthcare providers to consider how these strategies and enabling conditions can be improved to meet the healthcare and health needs of the local community. Improvement is also needed in the quality of evidence relating to particular strategies to guide practice.

Instruments for Measuring the Resilience of Indigenous Adolescents: An Exploratory Review.

Introduction: Resilience is enabled by internal, individual assets as well as the resources available in a person's environment to support healthy development. For Indigenous people, these resources and assets can include those which enhance cultural resilience. Measurement instruments which capture these core resilience constructs are needed, yet there is a lack of evidence about which instruments are most appropriate and valid for use with Indigenous adolescents. The current study reviews instruments which have been used to measure the resilience of Indigenous adolescents in Canada, Australia, New Zealand, and the United States (the CANZUS nations). The aim is to provide guidance for the future use of instruments to measure resilience among Indigenous adolescents and provide recommendations for research to strengthen evidence in this area. Method: Instruments were identified through a systematic search of resilience intervention and indicator studies targeting Indigenous youth from CANZUS nations. The studies were analyzed for information on the constructs of resilience measured in the instruments, their use with the targeted groups, and their psychometric properties. A second search was conducted to fill in any gaps in information. Instruments were included if they measured at least one construct of resilience reflecting individual assets, environmental resources, and/or cultural resilience. Results: A total of 20 instruments were identified that measured constructs of resilience and had been administered to Indigenous adolescents in the CANZUS nations. Instruments which measured both individual assets and environmental resources (n = 7), or only environmental resources (n = 6) were most common. Several instruments (n = 5) also measured constructs of cultural resilience, and two instruments included items addressing all three constructs of individual assets, environmental resources, and cultural resilience. The majority of the reviewed studies tested the reliability (75%) and content or face validity (80%) of instruments with the target population. Conclusion: There are several validated instruments available to appropriately measure constructs of resilience with Indigenous adolescents from CANZUS nations. Further work is needed on developing a consistent framework of resilience constructs to guide research efforts. Future instrument development and testing ought to focus on measures which include elements of all three core constructs critical to Indigenous adolescent resilience.

Til Debt Do Us Part: Comparing Gambling Harms Between Gamblers and Their Spouses.

This study compared the experience of gambling related harms between gamblers and spouses, whilst taking into account gender and problem gambling severity. Participants (N = 5036, 2603 females) from Australia and New Zealand completed a retrospective survey that probed the prevalence of specific harms from gambling within six harm domains (financial, work/study, health, emotional/psychological, relationship, and social deviance). Overall there was a similar count of total harms reported across all domains experienced by spouses (vs gamblers), however the types and patterns of harms reported were markedly different. Spouses reported the highest number of harms within the emotional/psychological and relationship domains, whereas gamblers experienced a higher number of harms in all other domains. Spouses were five to six times more likely to report increased conflict in their relationship due to gambling, greater relationship tension, and ending a relationship. In comparison, gamblers reported more severe health-related harms, such as suicide attempts and increased alcohol consumption. The findings highlight the unique ways in which gamblers and their spouses each respond to the presence of gambling problems.

Validation and Factor Analysis of the Child and Youth Resilience Measure for Indigenous Australian Boarding School Students.

Introduction: Resilience is a strengths-based construct that is useful for understanding differences in health and wellbeing among youth. There are a range of validated survey instruments available to measure resilience for Aboriginal and Torres Strait Islander (hereafter respectfully Indigenous) youth. However, standard international instruments should only be used if they have been subjected to a rigorous cross-cultural adaptation process and psychometric evaluation in the target population to ensure their validity. The aim of the study was to validate an adapted Child and Youth Resilience Measure (CYRM-28) within a sample of Indigenous Australian boarding school students. Method: The CYRM-28, augmented with an additional 11 site specific items was administered to a purposive sample of Australian Indigenous boarding school students (n = 233) as part of the broader T4S survey instrument that captures demographic information and measures resilience, psychological distress and risk, and service usage. Confirmatory factor analysis was undertaken to verify the relationship between the observed variables with the theoretical constructs of the CYRM-28 and previous findings on the factor structure. Cronbach alpha was also calculated to assess the internal consistency of the CYRM-28 within this sample. Results: Survey data were not a good fit for any previously identified models of the CYRM-28, although the inclusion of a site-specific variable improved the overall fit statistics. Two separate scales were confirmed that capture the sources and expressions of resilience for Indigenous Australian boarding school students. This structure is different to previous findings in relation to the CYRM-28, but consistent with conceptualizations of resilience as a dynamic process. Conclusions: The findings are useful in guiding the future use of the CYRM-28 instrument, explorations of Indigenous youth resilience, and for services working with Indigenous youth in out of home care situations. They highlight contextual differences in the measurement of resilience and the importance of validating standard instruments that have been subjected to rigorous cross-cultural adaptation processes. The two scales offer practical guidance to human services working with Indigenous youth on strategies to build and monitor resilience in Indigenous Australian youth and contribute to the emergent understanding of their resilience.

A tale of two countries: comparing disability weights for gambling problems in New Zealand and Australia.

PURPOSE: This study aimed to assess the impact of gambling problems on quality of life. Specifically, we generated disability weight estimates for gambling problems in New Zealand, and compared these results with (i) Australian figures (J Gambl Issues, 10.4309/jgi.v0i36.3978, 2017) and (ii) other health states (Lancet, 10.1016/S0140-6736(12)61680-8, 2013); such as anxiety and alcohol use disorders. METHOD: The 324 participants (48 experts and 276 general population members) evaluated a series of gambling harm vignettes. The participants rated the decrement to one's quality of life using Visual Analogue Scale and Time Trade-Off protocols (Br Med Bull, 10.1093/bmb/ldq033, 2010). These evaluations enabled the calculation of disability weights for three categories of gamblers (low-risk, moderate-risk, and problem gamblers). RESULTS: Disability weight estimates for low-risk, moderate-risk, and problem gamblers in NZ were consistently higher than the Australian weights: low (0.18 vs. 0.13), moderate (0.37 vs. 0.29), and problem (0.54 vs. 0.44). The quality of life impact for problem gambling in NZ (0.54) was comparable to that experienced in severe alcohol use disorder (0.55) (Lancet, 10.1016/S0140-6736(12)61680-8, 2013). CONCLUSIONS: This study represents one of the first attempts to assess gambling-related harm through a public health perspective. The results of this study are informative for policy-making, resource allocation, and service planning. These estimates now allow for the population-level impact of gambling in NZ to be calculated and tracked over time, which is essential for informing harm-minimisation initiatives.

Gambling and Sport: Implicit Association and Explicit Intention Among Underage Youth.

This study examined whether an implicit association existed between gambling and sport among underage youth in Australia, and whether this implicit association could shape their explicit intention to gamble. A sample of 14-17 year old Australian participants completed two phases of tasks, including an implicit association test based online experiment, and a post-experiment online survey. The results supported the existence of an implicit association between gambling and sport among the participants. This implicit association became stronger when they saw sport-relevant (vs. sport-irrelevant) gambling logos, or gambling-relevant (vs. gambling-irrelevant) sport names. In addition, this implicit association was positively related to the amount of sport viewing, but only among those participants who had more favorable gambling attitudes. Lastly, gambling attitudes and advertising knowledge, rather than the implicit association, turned out to be significant predictors of the explicit intention to gamble.

Social influences normalize gambling-related harm among higher risk gamblers.

BACKGROUND AND AIMS: Social influences are key drivers of gambling, and can begin in youth through parental modeling and facilitation. Over time, social influence from friends and colleagues also becomes important. Social network analysis provides a method to measure the combined nature of these social influences. This study aimed to compare social influences across gambling risk groups, by examining key characteristics of the social networks, among Australian adults. METHODS: A total of 784 respondents (egos) reported their demographics, gambling behavior and gambling risk, as well as those of the 20 most influential people in their lives (alters). Egos also reported the strength of the connection between themselves and each of their alters, and between each pair of alters. Data were analyzed using egocentric social network analysis approaches. RESULTS: Egos in higher risk groups reported more alters who gamble, including a higher proportion experiencing gambling-related harm. Relationship strength indicated that egos in higher risk groups tended to feel closer to their alters, regardless of whether the alter gambles or not. Network density (interconnectedness between alters) was greater for egos in higher risk groups. DISCUSSION AND CONCLUSIONS: The findings indicate that both gambling behavior and gambling-related harm are normalized through social connections. Greater interconnectedness in the networks of higher risk gamblers indicates difficulties in reducing or removing these influences. The findings indicate limitations of individualised interventions, and instead highlight the important role of changing norms within society, which can be transmitted throughout these networks.

How gambling harms experienced by Pacific people in New Zealand amplify when they are culture-related.

Pacific people in New Zealand are a minority ethnic population identified in national prevalence studies as having the highest risk of developing gambling problems. As earlier studies identified some links between culture and gambling for this population, our study aimed to deepen understanding of these links and their role in explaining the disproportionate gambling harms experienced by Pacific people. To achieve this aim we employed intersectionality as a theoretical framework to explore the culture-gambling intersection for this population group. We analysed data from a subset of focus groups conducted for a broad study of gambling harms in New Zealand. The subset was selected based on the presence of individuals knowledgeable about Pacific people's gambling behaviours, including staff from Pacific problem gambling treatment services who provided examples from a cultural perspective. We identified themes at a latent level via an interpretive process to identify underlying cultural contexts of gambling harms. Findings indicated that whilst harms experienced by Pacific people were similar to those identified amongst the general population, the cultural contexts in which some harms manifested were complex. This paper contributes to the existing knowledge base about gambling harms for Pacific people in relation to six culture-gambling intersecting themes that emerged from the data: collectivism, gift-giving, gambling-based fundraising, patriarchy, beliefs about blessings, and sports celebrities. Findings are discussed in relation to the current knowledge of gambling and conceptualisations of gambling harm within Pacific communities. Implications for culturally appropriate harm minimisation strategies and prevention interventions for this population are suggested.

Social and Emotional Wellbeing Screening for Aboriginal and Torres Strait Islanders within Primary Health Care: A Series of Missed Opportunities?

BACKGROUND: Social and emotional wellbeing (SEWB) is a critical determinant of health outcomes for Indigenous Australians. This study examined the extent to which primary healthcare services (PHSs) undertake SEWB screening and management of Aboriginal and Torres Strait Islander clients, and the variation in SEWB screening and management across Indigenous PHS. METHODS: Cross-sectional analysis between 2012 and 2014 of 3,407 Indigenous client records from a non-representative sample of 100 PHSs in 4 Australian states/territory was undertaken to examine variation in the documentation of: (1) SEWB screening using identified measurement instruments, (2) concern regarding SEWB, (3) actions in response to concern, and (4) follow up actions. Binary logistic regression was used to determine the factors associated with screening. RESULTS: The largest variation in SEWB screening occurred at the state/territory level. The mean rate of screening across the sample was 26.6%, ranging from 13.7 to 37.1%. Variation was also related to PHS characteristics. A mean prevalence of identified SEWB concern was 13% across the sample, ranging from 9 to 45.1%. For the clients where SEWB concern was noted, 25.4% had no referral or PHS action recorded. Subsequent internal PHS follow up after 1 month occurred in 54.7% of cases; and six-monthly follow up of referrals to external services occurred in 50.9% of cases. CONCLUSION: Our findings suggest that the lack of a clear model or set of guidelines on best practice for screening for SEWB in Indigenous health may contribute to the wide variation in SEWB service provision. The results tell a story of missed opportunities: 73.4% of clients were not screened and no further action was taken for 25.4% for whom an SEWB concern was identified. There was no follow up for just under half of those for whom action was taken. There is a need for the development of national best practice guidelines for SEWB screening and management, accompanied by dedicated SEWB funding, and training for health service providers as well as ongoing monitoring of adherence with the guidelines. Further research on barriers to screening and follow up actions is also warranted.

Breaking Bad: Comparing Gambling Harms Among Gamblers and Affected Others.

This article examines gambling harms from both gamblers and affected others' perspectives. Participants (3076 gamblers and 2129 affected others) completed a retrospective survey that elicited information on harms they experienced from gambling across their lifetime. Their responses were analyzed through testing measurement invariance, estimating item-response theoretic parameters, calculating percentages, confidence intervals, and correlations, as well as regressions. The results indicated large commonalities in the experience of harms reported by gamblers and affected others. Further, gamblers appeared to 'export' about half of the harms they experienced to those around them. The findings also provided detailed profiles of evolving harms as problem gambling severity varies.

Sense of Coherence and Gambling: Exploring the Relationship Between Sense of Coherence, Gambling Behaviour and Gambling-Related Harm.

Understanding why some people experience problems with gambling whilst others are able to restrict gambling to recreational levels is still largely unexplained. One potential explanation is through salutogenesis, which is a health promotion approach of understanding factors which move people towards health rather than disease. An important aspect of salutogenesis is sense of coherence. Individuals with stronger sense of coherence perceive their environment as comprehensible, manageable and meaningful. The present study examined the relationship of individuals' sense of coherence on their gambling behaviour and experience of gambling related harm. This exploratory study utilised an archival dataset (n = 1236) from an online, cross sectional survey of people who had experienced negative consequences from gambling. In general, a stronger sense of coherence was related to lower problem gambling severity. When gambling behaviour was controlled for, sense of coherence was significantly related to the experience of individual gambling harms. A strong sense of coherence can be seen as a protective factor against problematic gambling behaviour, and subsequent gambling related harms. These findings support the value of both primary and tertiary prevention strategies that strengthen sense of coherence as a harm minimisation strategy. The present study demonstrates the potential value of, and provides clear direction for, considering sense of coherence in order to understand gambling-related issues.

Hierarchy of Gambling Choices: A Framework for Examining EGM Gambling Environment Preferences.

This paper presents the Hierarchy of Gambling Choices (HGC), which is a consumer-oriented framework for understanding the key environmental and contextual features that influence peoples' selections of online and venue-based electronic gaming machines (EGMs). The HGC framework proposes that EGM gamblers make choices in selection of EGM gambling experiences utilising Tversky's (Psychol Rev 79(4):281-299, 1972). Elimination-by-Aspects model, and organise their choice in a hierarchical manner by virtue of EGMs being an "experience good" (Nelson in J Polit Econ 78(2):311-329, 1970). EGM features are divided into three levels: the platform-including, online, mobile or land-based; the provider or specific venue in which the gambling occurs; and the game or machine characteristics, such as graphical themes and bonus features. This framework will contribute to the gambling field by providing a manner in which to systematically explore the environment surrounding EGM gambling and how it affects behaviour.

Understanding gambling related harm: a proposed definition, conceptual framework, and taxonomy of harms.

BACKGROUND: Harm from gambling is known to impact individuals, families, and communities; and these harms are not restricted to people with a gambling disorder. Currently, there is no robust and inclusive internationally agreed upon definition of gambling harm. In addition, the current landscape of gambling policy and research uses inadequate proxy measures of harm, such as problem gambling symptomology, that contribute to a limited understanding of gambling harms. These issues impede efforts to address gambling from a public health perspective. METHODS: Data regarding harms from gambling was gathered using four separate methodologies, a literature review, focus groups and interviews with professionals involved in the support and treatment of gambling problems, interviews with people who gamble and their affected others, and an analysis of public forum posts for people experiencing problems with gambling and their affected others. The experience of harm related to gambling was examined to generate a conceptual framework. The catalogue of harms experienced were organised as a taxonomy. RESULTS: The current paper proposes a definition and conceptual framework of gambling related harm that captures the full breadth of harms that gambling can contribute to; as well as a taxonomy of harms to facilitate the development of more appropriate measures of harm. CONCLUSIONS: Our aim is to create a dialogue that will lead to a more coherent interpretation of gambling harm across treatment providers, policy makers and researchers.

Attitudes Towards Gambling and Gambling Reform in Australia.

The Attitudes Towards Gambling Scale (ATGS) is a 14-item survey instrument examining general attitudes towards gambling (Orford et al. in Int Gambl Stud 9(1):39-54, 2009). The current study examined the validity of this scale in an Australian community sample of 1794 adults (52.8 % female). As well as considering measures of internal consistency and factor loadings, we examined the functional utility of the scale as a mediator of gambling activity, problem gambling status, and consequent opinions on national gambling-reform legislation. We found internal consistency and factor loadings of the ATGS within the Australian sample to be comparable with those observed in the original UK study. Additionally, ATGS scores were found to be a relatively robust predictor of attitudes towards gambling reform and harm minimisation. Further, the ATGS mediated the relationships between experiences with gambling and attitudes towards harm reduction. The findings suggest that the ATGS is a useful tool for examining general attitudes towards gambling within an Australian context.

Veiled EGM Jackpots: The Effects of Hidden and Mystery Jackpots on Gambling Intensity.

Understanding the impact of EGM Jackpots on gambling intensity may allow targeted strategies to be implemented that facilitate harm minimisation by acting to reduce losses of gamblers who play frequently, while maintaining the enjoyment and excitement of potential jackpots. The current study investigated the influences of Hidden and Mystery Jackpots on EGM gambling intensity. In a Hidden Jackpot, the prize value is not shown to the player, although the existence of a jackpot prize is advertised. In a Mystery Jackpot, the jackpot triggering state of the machine is unknown to players. One hundred and seven volunteers (males = 49, females = 58) played a laptop-simulated EGM with a starting $20 real-money stake and a chance to win a Jackpot ($500). Participants played for either a Hidden or Known Jackpot Value, with either a Mystery or Known winning symbol combination in a crossed design. Lastly, a control condition with no jackpot was included. Gambling intensity (speed of bets, persistence) was greater when the Jackpot value was unknown, especially when a winning-symbol combination suggested that a win was possible. While there is no evidence in the present investigation to suggest that Hidden or Mystery jackpots contribute to greater player enjoyment, there is some evidence to suggest a marginal positive contribution of hidden jackpots to risky playing behaviour.