Gambling-Harm in a Community Foodbank Setting: Exploring the Feasibility and Utility of a Brief Non-Clinical Screening Approach

Gambling-Harm in a Community Foodbank Setting: Exploring the Feasibility and Utility of a Brief Non-Clinical Screening Approach | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Gambling-Harm in a Community Foodbank Setting: Exploring the Feasibility and Utility of a Brief Non-Clinical Screening Approach Carolyn Downs, John Towse, Abhishek Goli, Georgia Kritikaki, Stephanie Ng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9106160/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Gambling is a significant public health issue, with recent prevalence data confirming that people who have gambled in the previous 12 months experience severe consequences including bankruptcy, relationship breakdown and suicide ideation. There is a critical need to assess and respond to the distribution of problems across population subsets and communities, especially in non-clinical, volunteer-administered, time-limited contexts. This study aimed to assess the prevalence of gambling harm in a foodbank setting and to evaluate the feasibility of brief, volunteer-administered screening tools. Methods All foodbank users accessing a service in NW England over 2023 were screened using two gambling harm tools. Positive screen responses were recorded based on responses from a mixed sex sample to a modified Lie/Bet screen (n = 1247) and PGSI-Mini (n = 1922). Results Over 3% of respondents reported experiences of severe gambling-related harm, with males substantially over-represented among positive screens. However, despite signposting to rapidly available support and treatment delivered via a variety of formats (face-to-face, telephone or online) no individual identified as experiencing severe gambling harm accepted a referral. Conclusions We argue that rolling out rapid, community-based screening using tools accessible to non-clinical and volunteer staff can support earlier identification of gambling harms and inform a public health approach that better reflects where and how gambling-related distress is experienced. Although support and treatment was often refused, knowledge of the source of distress equips help providing organisations to better target support for gambling harms within their own settings while screening in community settings could offer new delivery points for treatment services. Gambling harms food insecurity foodbanks advice services gambling screening short PGSI lie/bet screen voluntary services Background As noted by the Lancet Public Health Commission on Gambling [ 1 ], harms to individuals, families and communities generated by widespread availability and accessibility of gambling are both substantial and widespread. The notion of gambling disorder has accordingly been expanded to include a substantial range of gambling harms, which affect many people, beyond those individuals who actually gamble. The most recent national data, presented in the Gambling Survey for Great Britain (2025) [ 2 ] incorporates methodological changes recognising more effectively the complexity of gambling harms [ 3 ] [ 2 ]. These new data show that the economic and public health burden of harm attributable to gambling is extremely significant, is rising in its frequency, and is impacting not just people who score above recognised screening thresholds for harm, but also extends to people who gamble at levels below those set out in the International Classification of Diseases-11 or the American Psychiatric Association’s Diagnostic and Statistics Manual-5 [ 1 ]. This has important implications for public health policy and practice around gambling harms, as individuals are likely to seek help for the often severe consequences of their gambling behaviour (suicidality, loss of work, damaged relationships, debt, or criminality) without their gambling behaviour being formally identified or addressed, particularly where conventional screening tools are not designed to fully capture severity of harm in non-clinical or community settings [ 1 ]. The most serious harm, suicide, is estimated to account for more than 400 deaths annually in the UK, marking it as a sentinel indicator of severity rather than an isolated outcome [ 4 ]. Meanwhile, the spillover effects of harmful gambling, such as criminality, intimate partner violence or loss of housing, affect family members and the wider community, meaning gambling harms are a population-level burden operating through the wider determinants of health, and one that likely affects some communities with greater severity than others [ 5 ] [ 6 ]. Gambling harms have been described as an invisible or hidden problem, because there are no direct physical symptoms associated with this behaviour, compared with for example alcohol dependency or drug use [ 7 ] [ 8 ]. One facet of the invisibility of gambling harm is the difficulty family and friends face in identifying the gambling in the harm experienced (i.e. “connecting the dots”). Another is the significant stigma associated with experiences of gambling harm [ 9 ] [ 10 ] [ 11 ]. In the case of gambling, stigma operates as a structural barrier to recognition, acceptance and care, shaping both individual disclosure and institutional responses [ 12 ] [ 13 ]. Consequently, gambling-related harms persist alongside very low rates of gambling-specific help-seeking [ 1 ] [ 14 ] [ 15 ]. As a result, harms can spiral, impacting other aspects of a person’s life (e.g., suicidal ideation, relationship problems, financial issues, criminality etc.). Indeed, these downstream impacts may (and in this study, do) then present as primary, rather than secondary harms [ 16 ] [ 1 ]. When help is sought for a secondary impact while gambling harms remaining hidden, the risk is that services cannot intervene or support effectively. Further compounding this risk, limited specialist knowledge, training, or lack of access to screening tools within those settings, then creates potential for missed opportunities in addressing harms [ 17 ]. Overlaying all the above issues are the related issues of prevalence of gambling harm, and their distribution across segments of society. With respect to the former, it is important to understand the scale of contemporary gambling harms, as part of constructing a proportionate response programme within and beyond public health [ 18 ]. This represents an ongoing, dynamic issue because prevalence estimates are contingent on regulatory context, industry form, and measurement methodology [ 19 ] [ 20 ]. However, from a public health perspective, it is not only overall prevalence but the distribution of gambling harms across places, services, and populations that is critical to delivering effective interventions [ 21 ]. An overall prevalence estimate can also be highly misleading if considered without context [ 1 ]. That is, regardless of whether gambling harms are rare at a population level, there can be a large and significant concerns in particular, or specific environments. [ 22 ] [ 23 ] It is useful to note sex differences are expected in gambling harms prevalence and distribution, with a pattern of higher gambling harm in men, although numbers of women experiencing harm from their own gambling are increasing [ 1 ] [ 2 ]. Gambling harm is disproportionately concentrated among socioeconomically disadvantaged populations [ 22 ] [ 23 ] [ 6 ]. Therefore, the aim of this study was to examine if gambling harms were experienced by significant numbers of people using a foodbank to cope with a crisis and whether a volunteer-led service could effectively and routinely screen those seeking support. This study had two closely connected aims. Establish the prevalence of gambling-related harm within a socioeconomically deprived, help-seeking population. Evaluate the viability and utility of brief, volunteer-administered gambling harm screening tools in a non-clinical welfare setting, to better understand the benefits of harm identification in both signposting to treatment and managing ongoing support needs The study was designed in response to a request from a linked Foodbank and Money Advice Service, who felt gambling harms were an underlying and unidentified driver of need among some of their clients. Given the role of debt as indicative of gambling harm [ 14 ], we suspected that both people experiencing debt and foodbank users, as help-seeking and emotionally vulnerable populations in financial crisis, may have a higher than population-level risk of experiencing gambling related harms. The study therefore sought to establish both whether hidden gambling-related harm was present at significant levels within this help-seeking population, and whether brief, non-specialist screening tools could be feasibly implemented by volunteers in busy welfare settings where such harms would otherwise remain invisible. Our work contributes to public health practice by generating the first empirical evidence of gambling-related harm prevalence in a foodbank setting, revealing substantial unmet need in a community not typically associated with gambling services. We also highlight the 'prevention paradox', whereby a significant burden of gambling-related harm is borne by individuals below clinical screening thresholds, and demonstrate that even where harm is identified, referral to treatment services may be declined. Together, these findings underscore the importance of community-based identification and awareness as foundations for planning new routes to treatment and building partnerships between public health teams and the wider network of welfare and support organisations engaged in gambling-harm prevention and recovery. Thus, the current project provides important empirical evidence on gambling harm by drawing from a large community-based sample experiencing multiple indices of deprivation. In so doing, we confirm that routine screening for gambling-related harm in community support services is both feasible and useful and as a result, we reveal substantial unmet need in settings where gambling harms are not usually discussed, opening routes to raise awareness of the hidden harms of gambling. Methods Participants and Design The study examined the extent to which gambling-related harms could be identified within help-seeking (in-need) populations accessing community support and mental health services, rather than aiming to estimate population prevalence. Ethical approval was obtained for all aspects of the reported data, which were collected January 2023 - December 2023. Participants provided signed consent in connection with the Lie/Bet/Debt data (protocol with ethics approval IRAS322860. Participants provided verbal consent in connection with the Problem Gambling Severity Mini / Short (PGSI-Mini/Short) data (protocol with separate ethics approval, FASSLUMS-2023-3623). In this study we focus on a help-seeking community living in a deprived Lower-layer Super Output Area (LSOA) - fewer than 1% of neighbourhoods in England are more deprived using Indices of Deprivation Measures. We define 'help-seeking' behaviour here as the process of actively seeking support from trusted community services when distressed or presented with difficult situations such as needing food, experiencing housing insecurity, requiring money advice, or seeking family support [ 24 ]. The project deployed a modified version of the two-question Lie/Bet Gambling Screen [ 25 ] originally developed to identify the most severe and debilitating forms of gambling harms [ 26 ]. We used this instrument for multiple reasons. First, it is very quick to administer. Second, the questions are simple to present and understand. Third, responding “Yes” to any question triggers a triage process – no data aggregation or threshold is required. The Lie/Bet/Debt screen did not collect demographic data due to the need for a rapid and volunteer-administered screening process in a time-pressured context. Our modification was the addition of a third debt question, based on previous findings that intractable debt is a significant, and possibly, the primary, marker of gambling harm [ 14 ]. This created the Lie/Bet/Debt questionnaire. Complementary relevant data were then available via the short form of the Problem Gambling Severity Index (PGSI Mini / PGSI short) [ 27 ] which was in use for internal audit processes within the foodbank and which included demographic data. A total of 1,247 participants were approached through Blackburn Foodbank and their associated Oaks Money Advice Centre and took part in the study. Moreover, 21 NHS patients also participated through the LSCFT NHS mental health services crisis team. To be enrolled in the study, respondents had to be over 18 years old, be able to consent for themselves, and access the study either via Blackburn Foodbank, Blackburn Oaks Money Advice Centre, or the LSCFT NHS mental health services. Participation in this study was entirely voluntary, and clear signposting to appropriate support and rapid access to treatment services was available for any participant who was identified as experiencing gambling-related harms. Materials Lie/Bet/Debt questionnaire. Participants completed a 3-item questionnaire (Table 1 ). It is based on the original two-question Lie/Bet assessment [ 25 ]. We introduced an additional third question, adapted from the previous research that indicated that gambling-related debt is a key identifiable characteristic of individuals who suffer from problem gambling [ 14 ]. The ‘Lie/Bet/Debt Questionnaire’ is intended as a useful starting point in determining or additional assessment is needed. Each item receives a yes or no response. If the participant answers 'No' to all three questions there is no indication from this screen of gambling-related harm requiring further follow-up. However, a 'Yes' response to any item indicates gambling-related harm may be present and additional evaluation is needed. Table 1 3-item Lie/Bet/Debt Screening Tool Modified Lie/Bet Questionnaire 1. Have you had to lie to people important to you about how much you gambled? 2. Have you ever felt the need to bet more and more money? 3. Has your gambling activity led you [to] get into debt? Note : Answer with “Yes” or “No” Procedure Staff members from the organisations undertook data collection, after brief training on the screening tool itself and post-questionnaire support. After obtaining consent, the staff member verbally guided participants through the three-item Lie/Bet/Debt screener, with questions read aloud and clarification provided where required to support comprehension, including for participants with English as an Additional Language. The entire process including consent took approximately 10 minutes per participant (the screener itself can be completed in less than 1 minute). Results Project data, analysis scripts etc. can be accessed from the repository at: https://osf.io/ufqe2/ Lie/Bet/Debt . 1,247 participants took part. One person declined to answer the questions, leaving 1,246 valid responses. Forty-two of these individuals answered “yes” to at least one of the three questionnaire items. Accordingly, 3.37% of the responses evidenced severe gambling-related harm , 95% CI [2.44, 4.53]. We use the term “severe” in this context to reflect the intended purpose of the Lie/Bet/Debt screen as a brief identifier of major gambling harm, rather than as a diagnostic classification (Johnson et al., 1997). Table 2 provides additional scrutiny of the 42 Lie/Bet/Debt responses in which at least one question was answered “yes” is provided in Table 2. Half of the responses reflected endorsement of all three items . Only 12 individuals (28%) gave a single “yes” response, and only three “yes” responses were attributable solely to the additional debt question. Accordingly, 3.1% of respondents would have been identified as experiencing gambling harm from the original-form 2-item screen – it is evident that the inclusion of the debt question did not substantially alter the overall response pattern . It is also apparent that the majority of positive screens reflected endorsement of multiple indicators of gambling-related harm. Table 2 , Response taxonomy on the 3 questions of the Lie/Bet screener Response profile No. of individuals %age of all positive responses “Yes” to all 3 questions 21 50 “Yes” to 2 of the 3 questions 9 21.4 “Yes” to Question 1 (only) 2 4.8 “Yes” to Question 2 (only) 7 16.7 “Yes” to Question 3 (only) 3 7.1 PGSI-Mini . Concurrent with these research data. the foodbank administered the short-form PGSI [PGSI-Mini], as part of an internal assessment process. Standard screener instructions were deployed , as part of routine service activity , but explicit written consent was not sought since this was not initially implemented as a research exercise . Insofar as the data were collected both independently of the Lie/Bet/Debt and each was entirely anonymous, we cannot match individual responses between instruments. Nonetheless, we assume that these datasets are broadly drawn from the same population , and there is no indication of systematic differences in recruitment processes or participant profiles across the two screening activities . Table 3 describes the PGSI-Mini assessment. Table 3. PGSI-Mini Screening Tool In the last 12 months: Have you gambled in a casino, bookmakers, online, at sports venue… etc.? (Yes/No) If yes: 1. Have you gambled more than you can afford to lose? 2. Have people criticised your gambling or told you that you had a gambling problem (regardless of whether you thought it was true)? 3. Have you felt guilty about the way you gamble or what happens when you gamble? Have you been affected by another person as a result of their gambling in a casino… etc.? (Yes/No) Note : Final Score from 3 questions (score for each: Never=0, Sometimes=1, Most of the time=2, Almost Always=3) ranges 0-9. We examined 1922 responses from the PGSI-Mini. Table 4 describes the score profile Table 4 . PGSI-Mini score distribution. PGSI score 0 1 2 3 4 5 6 7 8 9 Frequency 1830 31 15 16 9 6 6 7 0 2 Accordingly, Table 4 confirms 46 individuals categorised as at risk of gambling-related harm [i.e. PGSI-Mini score 1–2] (2.39%, 95% CI [1.76, 3.18]) and a further 46 individuals categorised as experiencing gambling-related harm [i.e. PGSI-Mini score of 3 or more] (2.39%, 95% CI [1.76, 3.18]). Moreover, in response to the final question, “In the past 12 months, have you been affected by another person as a result of their gambling?”, there were 78 “yes” responses and 1,780 “no” responses (64 missing responses). This represented 4.20% of respondents reporting harm from the perspective of being an affected other , 95% CI [3.33, 5.21]. Data on age, sex, and respondent ethnicity were obtained alongside the PGSI-Mini. However, these (non-research) data were inconsistently recorded . Most frequently when any variable was missing, all three variables were missing , In some cases, however, one or two responses were missing for an individual. Overall, where participant sex was recorded, there were slightly more male (890) than female (675) respondents. Therefore, males were overrepresented by a ratio of 1.32:1 . However, within the group screened as experiencing gambling-related harm , there were many more males (27) than females (7), with males overrepresented by a ratio of 3.86:1 . However, in response to the question about being affected by the gambling of others, 36 females and 31 males recorded a positive response; a ratio of 1.16:1 . Thus, although males outnumbered females in the overall sample by a ratio of 1.32:1, this pattern was inverted among those reporting harm from another person's gambling. This pattern is consistent with evidence that women are more frequently affected by the gambling harm of others, while men more frequently report harm from their own gambling behaviour [5]. The mean age of the overall respondent sample was 41.6 years, similar to the mean age of those screened as experiencing gambling-related harm , at 38.4 years. Where data was available, 44.5% of the sample self-identified with the label “White British”. Among respondents screened as experiencing gambling-related harm , 80% used this label. 19.6% of the sample reported the term “British (vs. 10% of the gambling-harm respondents). 6.42% of the sample reported Pakistani heritage and a further 6.86% of the sample reported Asian or Indian heritage (vs. 5% of gambling harm respondents identified as Pakistani or British Pakistani and 5% as Asian or Mixed Asian. These patterns should be interpreted with caution given the extent of missing demographic data. Discussion This study highlights a central public health challenge in relation to gambling harms: that at an individual level they are frequently not identified at all [ 28 ]. In line with existing evidence, our findings confirm that individuals experiencing gambling-related harms are more likely to seek support for the consequences and comorbidities of gambling, such as debt, threats of repossession, food insecurity, psychological distress, or relationship difficulties, without disclosing gambling as an underlying cause, often due to stigma [ 29 ] [ 14 ] [ 9 ] [ 13 ]. Other factors preventing disclosure include internalised minimisation of the problems being experienced as a result of gambling [ 30 ] [ 31 ] or, as Fulton (2019) found, a desire to keep their gambling secret, often as a means to continue gambling unpressured to stop by external sources [ 32 ]. Within these complex contexts, the identification of gambling harm depends less on individuals presenting for gambling-specific support, and more on whether a wider range of systems and services are equipped to recognise harm when it surfaces indirectly and can then begin a conversation about gambling that might otherwise not take place. The percentage of gambling-related harm identified in this study – 3.4%- is notably high, reinforcing evidence that gambling harm is concentrated in socioeconomically disadvantaged populations and often remains unrecognised within welfare settings and that harm may remain hidden even within populations experiencing acute financial and social stress [ 33 ]. This reinforces the importance of community and welfare settings as critical points for public health action, where brief, pragmatic prompts can increase the visibility of an otherwise hidden public health issue [ 34 ] [ 35 ]. Consistent with the effect of stigma on limiting both disclosure and help-seeking among people experiencing gambling harm, organisations involved in this study reported that although individuals identified as experiencing gambling-related harms were signposted to free and confidential specialist services, none chose to access this support at the time. This was despite continuing long-term engagement with the welfare organisations they had initially approached. However, embedding initiatives around the identification of gambling harm in community settings may also support wider recognition of gambling harm among affected others, or the general discussion of gambling harm, extending the potential benefits of identification beyond those who gamble themselves. Furthermore, being made aware of treatment options, even if they are not adopted may lead people to seek help in future. From a public health perspective, our findings underscore that the value of community-based identification of gambling harm can best be maximised if it is accompanied by robust efforts to share information about gambling harms across a wide range of community contexts, so as to normalise conversations about harmful gambling. An awareness-driven approach allows locally trusted, community-based services such as foodbanks and money advice organisations to not only identify hidden gambling-related harms but also create a climate in which communities can understand that gambling harms are a commercially determined harm, rather than an individual fault [ 37 ]. Thus, they are not only identifying people experiencing gambling harm but are raising awareness that harm is built into the games people access, providing a route to discuss gambling harms openly as a legitimate and potentially solvable contributor to wider financial and social difficulties. Alongside the work reported here, a parallel arm of the project also sought to explore the presence of gambling-related harms among individuals referred to the mental health crisis team for support within Lancashire & South Cumbria NHS Trust. Where individuals seeking acute mental health support are experiencing gambling-related harms that are not identified or recorded, their mental health presentation and associated risks may not be fully understood, and opportunities for appropriately targeted support may be missed. At present, gambling-related harms are not routinely identified across NHS services. Sampling within the mental health crisis service was necessarily limited, with data collected from 21 patients between January and July 2023. This component of the study is therefore reported as exploratory, intended to showcase potential signals of unmet gambling-related need rather than to generate prevalence estimates. Four of the 21 individuals answered “yes” to at least one of the three questionnaire items, indicating potentially significant gambling-related harm. This corresponds to 19.1% of this small pilot sample (95% CI [5.45, 41.91]). While the wide confidence intervals underline the considerable interpretative caution required, this outcome is remarkable as a potential flag for unmet gambling-related need within crisis mental health settings and is consistent with the broader recognition within the National Institute for Health and Clinical Excellence (NICE) NG248 that gambling-related harms may be relevant across a range of health contexts [ 36 ]. Rather than implying a public health prevention role for mental health services, these findings highlight how gambling-related harms that remain unidentified upstream, for example, in community settings, may then surface within acute clinical contexts, where they may complicate assessment, risk management, and care planning. We argue that it is therefore vital to further explore gambling-related harms within this population, both to inform clinical understanding and to reinforce the importance of earlier identification within community and public health settings. Our data focus primarily on individuals experiencing more severe gambling-related harms, as identified by the modified Lie/Bet/Debt screener or higher scores on the PGSI-Mini. However, in line with recent research by Wardle et al, (2024) we believe a substantially larger group of individuals are experiencing material gambling-related harms below these clinical or screening thresholds [ 1 ]. Indeed, the PGSI-Mini data indicate that the number of individuals categorised as ‘at risk’ of gambling harm is at least as large as the number categorised as experiencing gambling-related harm. This finding has been previously reported discussed as the ‘prevention paradox’ (p.8) whereby the majority of aggregated gambling-related harm in a population is borne by individuals who do not meet diagnostic or high-threshold screening criteria (pp. 9–10) [ 1 ]. Paradoxically, without support or intervention there is a risk of problem escalation. The importance of this sub-clinical or ‘at-risk’ population to public health provision is particularly acute in community settings, because communities seeking help with food and debt are extremely sensitive to even small financial shocks [ 38 ]. As Wardle et al (2024) emphasise, even relatively modest gambling losses can have disproportionate consequences for individuals and households already experiencing socioeconomic stress, contributing to cycles of debt, insecurity, and deteriorating wellbeing (pp. 12–14) [ 1 ]. In such contexts, gambling behaviours that might be categorised as ‘low’ or ‘moderate’ risk in general population surveys can nevertheless generate substantial harm and need the provision of joined up services and information sharing between voluntary community welfare services, NHS and public health teams to reduce harm and limit the impact of the prevention paradox. Accordingly, we expect our data actually under-estimates the true extent of gambling-related harm within help-seeking populations. First, because they rely on self-report of a highly stigmatised behaviour - the immediate social incentive would be to downplay personal contributors for economic distress. Second, these short, simple screener instruments target only the most severe and direct aspects of gambling-harm spectrum. Third, any prevalence measure is constrained by both sensitivity and specificity [ 39 ] - the likelihood of false positive and false negatives- and we expect more of the latter than the former. From a public health perspective, this further highlights the importance of community-based identification, joined up services, and early intervention strategies that engage with gambling harm across the full spectrum of risk, rather than focusing solely on individuals who already meet clinical or diagnostic criteria. Practice-based feedback from volunteers and staff involved in data collection indicated that sometimes the PGSI-Mini was perceived as confusing or ambiguous, both for screen administrators and for some participants, particularly in busy, non-clinical settings (eg. distinguishing response levels “Never”, “Sometimes”, “Most of the time”. In contrast, the simplicity of the Lie/Bet/Debt was consistently reported as being effective and appreciated. Importantly, it is also obvious and straightforward to work with in terms of next steps (i.e.. any positive response warrants support signposting – no scoring and response amalgamation is required). Similar feedback has also been reported to us in other community and welfare settings where gambling screening has been introduced. In this context, it is important to bear in mind that for the current project (and other potential scenarios) screen administrators were not research staff but community workers or volunteers who, despite having received brief training, did not have specialist expertise in either gambling-related harm structured assessment tools. Responding to a time-crunched situation, staff are focused on addressing immediate and tangible needs such as food insecurity, debt, or housing instability. Instrument characteristics such as ease and rapidity of use are important characteristics of a screening tool. From a public health perspective, implementation characteristics are likely to influence not only feasibility but also the quality and completeness of data collected in community settings. In this study, observed differences in the proportion of individuals identified by different screening tools may reflect challenges in data acquisition and deployment in real-world contexts, rather than differences in the underlying prevalence or severity of gambling-related harm. More generally it is important to recognise that psychometric properties, and instrument functionality in the wild, are not always isomorphic. The PGSI-Mini screening tool includes a question about affected others (‘In the past 12 months, have you been affected by another person as a result of their gambling?’). The proportion of respondents answering “yes” to this item (4.2%) was almost double the proportion self-reporting gambling-related harm (2.39%). While the scope of these questions is not directly comparable, since the affected-others item captures harm experienced by a wider network of people, including partners, family members, dependants or even friends, this discrepancy is nevertheless informative in a community screening context. Our findings show males were overrepresented in self-reported gambling harm, and females were slightly overrepresented in reporting harm from others' gambling. While not researching underlying causes of foodbank use, we believe it is important for help-providing organisations to consider whether females may be presenting at the foodbank partly as a consequence of a partner or family member's gambling. Given the high level of stigma associated with gambling-related harm, disclosure about the gambling behaviour of unnamed others may be easier than disclosure about one’s own behaviour, and such disclosures may offer a route to provide information and advice for those affected directly by gambling harms. As such, the observed gap between self-reported gambling harm and reports of harm experienced through others is consistent with under-disclosure or under-recognition of personal gambling harm, particularly in non-clinical settings. From a public health perspective, this suggests that designing screening questions which allow individuals to disclose concern indirectly may increase the visibility of gambling-related harm within community services. This insight has already informed local public health practice. Working with the research team, Blackpool Council has further adapted our Lie/Bet/Debt screener for use across a wide range of community and welfare settings by adding a fourth question asking whether individuals are worried about the gambling of someone they know. This four-item version is now used in approximately 14 community contexts, including housing services, advice organisations, recovery-led groups, and voluntary sector providers. Such adaptations reflect an emerging recognition that community-based identification of gambling harm benefits from prompts that capture both direct and indirect experiences of harm, particularly in populations where self-disclosure may be constrained by or uncertainty about what constitutes harmful gambling [ 11 ]. Despite these emerging local adaptations, researchers have limited empirical understanding of how gambling-related harm contributes to demand across local service systems, including health, housing, family support, advice services, and the criminal justice sector, meaning public health teams do not have access to information that will support them in planning and delivering services to reduce gambling harms [ 40 ]. Our findings indicate the importance of recognising gambling harm as a cross-cutting public health issue that generates pressures beyond specialist gambling services, and one that is likely to be most acutely felt within communities already experiencing social and economic disadvantages. Limitations Although the sample, this study mainly comprises a single foodbank and associated money advice service in one deprived LSOA of NW England. We note that this may limit generalisability of our findings. The sociodemographic profile of the setting; within the most deprived 1% of neighbourhoods in England, means prevalence estimates should not be taken as representative of foodbank users in less deprived areas, or those accessing different types of community-based support. Studies across a wider range of volunteer-led support settings are needed to allow generalisations to be made. The Lie/Bet/Debt screen used in this study does not include a question about concern for the gambling of a significant other, meaning harm experienced by affected others may be under-identified. The PGSI-Mini data, in which 4.2% of respondents reported being affected by another person's gambling indicates that the Lie/Bet/Debt screen, as trialled in this study, may underestimate the true burden of gambling-related harm within the community by missing those affected by another's gambling This limitation has since been addressed in a local adaptation developed with and rolled out by Blackpool Council. The adaptation adds a fourth question asking whether the individual is worried about someone else's gambling. The 4-item Community Use Gambling Screen (CUGS-4) is now in use across approximately 14 community settings in Blackpool, with data being collected to enable robust evaluation of the tool. The mental health crisis service element of the study was limited in scale. This work should be interpreted as exploratory and is not sufficient basis for prevalence estimation. Recruitment in this setting was constrained by operational and clinical factors. Nevertheless, the finding that 19.1% of this small sample screened positive for gambling-related harm is striking, and consistent with emerging evidence that gambling harm is disproportionately present among individuals experiencing mental health crises. Our pilot suggests the importance of larger-scale investigation of gambling-related harm within NHS mental health settings, where unidentified gambling harm may complicate both risk assessment and care planning Conclusions Gambling harms are a significant and unevenly distributed public health concern. In welfare or advice environments involving individuals experiencing acute financial or personal stress, our findings indicate that the prevalence of severe gambling-related harm is substantially higher than estimates derived from general population surveys. The contribution of this study is not to demonstrate that gambling harm is socially patterned, this is a long-established finding, but to show how this patterning manifests in community welfare settings, remains largely unrecognised in routine practice, and can be made visible through pragmatic public health approaches to identification. However, our findings also highlight a critical limitation of current responses: identification does not reliably translate into engagement with specialist support. Across the settings involved in this study, no individual identified as experiencing significant gambling-related harm chose to access readily available treatment services, despite continued engagement with the welfare organisations they initially approached. However, emerging data from a second year of implementation and from the Blackpool CGS-4 rollout suggest treatment uptake may be improving, with approximately 10–12% of identified individuals accepting referral, representing a meaningful shift from baseline. This pattern is consistent with the hypothesis that sustained community-based identification alongside normalisation of conversations about gambling harm may gradually reduce the stigma to help-seeking over time. From a public health perspective, this underscores the need for approaches that extend beyond detection alone. Reducing stigma, normalising conversations about gambling-related harm, and embedding supportive responses within trusted community settings are likely to be essential if identification is to lead to meaningful benefit. Strengthening community-based identification must therefore be accompanied by public health strategies that address stigma and improve the acceptability and accessibility of support, if preventable gambling-related harms are to be reduced and inequalities addressed. Abbreviations CUGS-4 4-item Community Use Gambling Screen DSM-5 Diagnostic and Statistical Manual of Mental Disorders, 5th edition ESRC Economic and Social Research Council ICD-11 International Classification of Diseases, 11th edition IRAS Integrated Research Application System LSCFT Lancashire and South Cumbria NHS Foundation Trust LSOA Lower-layer Super Output Area NICE National Institute for Health and Care Excellence PGSI Problem Gambling Severity Index Declarations Ethics approval and consent to participate Research ethics approvals were granted via the Lancashire and South Cumbria NHS Foundation Trust Study (reference IRAS322860) and Lancaster University for the Blackburn Foodbank / Oak Money Advice Trust Study (reference FASSLUMS-2023-3623), both conducted in accordance with the Declaration of Helsinki and the UK Policy Framework for Health and Social Care Research. In both studies, a short training programme was prepared for NHS Staff and Volunteers administering the screen. This covered taking consent from participants and screen administration. All participants received a participant information sheet in plain English and signed a consent form. In the latter case, volunteer staff also collected PGSI Mini data for organisation administrative purposes, following screen guidance. Consent for publication Not applicable (no individual data/images). Funding This work was supported by an ESRC Impact Acceleration Account (2022-3) award to CD “Implementation of Modified Lie/Bet Gambling Screen in Blackburn with Darwen and Lancaster Mental Health Referral Settings ” in partnership with Lancashire and South Cumbria NHS Foundation Trust Author Contribution CD designed the study, supported data analysis and drafted the discussion, limitations and conclusion of the manuscript and provided feedback on the methods and results sectionsJT supported study design, led on data analysis, drafted the methods and results section and provided feedback on the discussion and conclusion sectionsAG supported study design and provided critical feedback on the paperGK supported study design and data analysis and prepared figuresSN supported data analysis Acknowledgement We appreciate the help and support of the Oaks Money Advice Centre in facilitating data collection and Claire Birdsall in particular. We appreciate data processing contributions from Focus Chen and constructive feedback on an earlier draft from Dr Andrew Harding Data Availability All data and materials are available in the Open Science Framework (OSF) repository on https://osf.io/ufqe2/ References Wardle H, Degenhardt L, Marionneau V, Reith G, Livingstone C, Sparrow M, Tran LT, Biggar B, Bunn C, Farrell M, Kesaite V. The Lancet Public Health Commission on Gambling. Lancet Public Health. 2024;9(11):e950–94. Gambling Commission. Review of the Gambling Survey for Great Britain [Internet]. 2025 [cited 2026 Feb 5]. Available from: https://osr.statisticsauthority.gov.uk/wp-content/uploads/2025/05/Review-of-the-Gambling-Survey-for-Great-Britain.pdf Office for Health Improvement and Disparities, Public Health England. Gambling-related harms evidence review: summary [Internet]. London: GOV.UK. 2023 [cited 2025 Feb 3]. Available from: https://www.gov.uk/government/publications/gambling-related-harms-evidence-review/gambling-related-harms-evidence-review-summary Karlsson A, Hakansson A. Gambling disorder, increased mortality, suicidality and associated comorbidity: a longitudinal nationwide register study. J Behav Addict. 2018;7(4):1091–9. Tulloch C, Browne M, Hing N, Rockloff M, Hilbrecht M. How gambling harms the wellbeing of family and others: a review. Int Gambl Stud. 2022;22(3):522–40. Raybould JN, Larkin M, Tunney RJ. Is there a health inequality in gambling related harms? A systematic review. BMC Public Health. 2021;21(1):305. Ladouceur R, Gambling. The hidden addiction. Can J Psychiatry. 2004;49(8):501–3. Page S, Pointon L, Plimley S. Gambling in caseloads: Can you spot the harms? Probat J. 2025:02645505251364192. Hing N, Holdsworth L, Tiyce M, Breen H. Stigma and problem gambling: current knowledge and future research directions. Int Gambl Stud. 2014;14(1):64–81. Livingstone C, Rintoul A. Gambling-related suicidality: stigma, shame, and neglect. Lancet Public Health. 2021;6(1):e4–5. Lloyd J, Penfold K, Nicklin LL, Martin I, Martin A, Dinos S et al. Stigmatisation and discrimination of people who experience gambling harms in Great Britain: synthesis report [Internet]. 2025 [cited 2026 Feb 7]. Available from: https://natcen.ac.uk/sites/default/files/2025-06/Synthesis%20Report.pdf Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;27(1):363–85. Quigley L. Gambling disorder and stigma: opportunities for treatment and prevention. Curr Addict Rep. 2022;9(4):410–9. Downs C, Woolrych R. Gambling and debt: the hidden impacts on family and work life. Community Work Fam. 2010;13(3):311–28. Sanju G, Gerada C. Problem gamblers in primary care: can GPs do more? Br J Gen Pract. 2011;61(585):248–9. Metcalf O, Lawrence-Wood E, Baur J, Van Hooff M, Forbes D, O'Donnell M, et al. Prevalence of gambling problems, help-seeking, and relationships with trauma in veterans. PLoS ONE. 2022;17(5):e0268346. Sharman V. Gambling-related harms: what community nurses can do. J Community Nurs. 2024;38(2). P.56. Bowden-Jones H, Hook RW, Grant JE, Ioannidis K, Corazza O, Fineberg NA, et al. Gambling disorder in the UK: key research priorities and the urgent need for independent research funding. Lancet Psychiatry. 2022;9(4):321–9. Sturgis P, Kuha J. How survey mode affects estimates of the prevalence of gambling harm: a multisurvey study. Public Health. 2022;204:63–9. Williams RJ, Williams HA. The trajectory, chronicity, and etiology of problem gambling: a synthesis of longitudinal research. Curr Addict Rep. 2025;12(1):5. Adeniyi O, Brown A, Whysall P. Spatial concentration of gambling opportunities: an urban scale perspective. Cities. 2023;140:104386. Wheaton J, Collard S, Nairn A. Experience, risk, harm: what social and spatial inequalities exacerbate gambling-related harms? Bristol: Bristol Hub for Gambling Harms Research, University of Bristol; 2024. Saunders M, Rogers J, Roberts A, Gavens L, Huntley P, Midgley S. Using geospatial mapping to predict and compare gambling harm hotspots in urban, rural and coastal areas of a large county in England. J Public Health. 2023;45(4):847–53. Rickwood D, Thomas K. Conceptual measurement framework for help-seeking for mental health problems. Psychol Res Behav Manag. 2012;5:173–83. 10.2147/PRBM.S38707 . Johnson EE, Hamer R, Nora RM, Tan B, Eisenstein N, Engelhart C. The Lie/Bet questionnaire for screening pathological gamblers. Psychol Rep. 1997;80(1):83–8. Götestam KG, Johansson A, Wenzel HG, Simonsen IE. Validation of the lie/bet screen for pathological gambling on two normal population data sets. Psychol Rep. 2004;95(3):1009–13. Williams RJ, Volberg RA. Developing a short form of the PGSI: report to the Gambling Commission. Birmingham: Gambling Commission; 2012. Bijker R, Booth N, Merkouris SS, Dowling NA, Rodda SN. Global prevalence of help-seeking for problem gambling: a systematic review and meta-analysis. Addiction. 2022;117(12):2972–85. Clarke D, Abbott M, DeSouza R, Bellringer M. An overview of help seeking by problem gamblers and their families including barriers to and relevance of services. Int J Mental Health Addict. 2007;5(4):292–306. Rolando S, Ferrari C, Beccaria F. To me, it was just a vice: stigma and other barriers to gambling treatment in Piedmont, Italy. J Gambl Stud. 2023;39(4):1909–25. Suurvali H, Cordingley J, Hodgins DC, Cunningham J. Barriers to seeking help for gambling problems: a review of the empirical literature. J Gambl Stud. 2009;25(3):407–24. Fulton C. Secrets and secretive behaviours: exploring the hidden through harmful gambling. Libr Inf Sci Res. 2019;41(2):151–7. Brennan-Tovey K, Board EM, Fulton J. Counteracting stigma-power: an ethnographic case study of an independent community food hub. J Contemp Ethnogr. 2023;52(6):778–98. Whitman A, De Lew N, Chappel A, Aysola V, Zuckerman R, Sommers BD. Addressing social determinants of health: examples of successful evidence-based strategies and current federal efforts. Off Heal Policy. 2022;1:1–30. McGorry PD, Mei C, Chanen A, Hodges C, Alvarez-Jimenez M, Killackey E. Designing and scaling up integrated youth mental health care. World Psychiatry. 2022;21(1):61–76. National Institute for Health and Care Excellence (NICE). 2025. Gambling-related harms: identification, assessment and management. Reference number: NG248. Published: 28 January 2025. Available on https://www.nice.org.uk/guidance/NG248 last accessed 7 Feb. 2026. Reith G, Wardle H. The framing of gambling and the commercial determinants of harm: challenges for regulation in the UK. In: Nikkinen J, Marionneau V, Egerer M, editors. The global gambling industry: structures, tactics, and networks of impact. Wiesbaden: Springer Fachmedien Wiesbaden; 2022. pp. 71–86. Bufe S, Roll S, Kondratjeva O, Skees S, Grinstein-Weiss M. Financial shocks and financial well-being: what builds resiliency in lower-income households? Soc Indic Res. 2022;161(1):379–407. Rogan WJ, Gladen B. Estimating prevalence from the results of a screening test. Am J Epidemiol. 1978;107(1):71–6. Johnstone P, Regan M. Gambling harm is everybody's business: a public health approach and call to action. Public Health. 2020;184:63–6. Footnotes Contemporary terminology surrounding gambling-harm has evolved considerably. In this article, we attempt as far as feasible to frame discussion around gambling-harm , whilst recognising previous, cited research, has sometimes used a different lexicon (see https://www.grg.scot/resources/2024/08/Words-Matter_main_digital-file.pdf ). This impacts the precision with which previous findings can be represented Output Areas (OAs) are the lowest level of geographical area for census statistics and were first created following the 2001 Census. Lower layer Super Output Areas (LSOAs) are made up of groups of OAs, usually four or five. They comprise between 400 and 1,200 households and have a usually resident population between 1,000 and 3,000 persons. https://www.ons.gov.uk/methodology/geography/ukgeographies/censusgeographies/census2021geographies Indices of Deprivation are calculated across seven domains https://www.gov.uk/government/statistics/english-indices-of-deprivation-2025/english-indices-of-deprivation-2025-frequently-asked-questions The instrument was originally developed as an index of “pathological gambling”. Terminological choices aside, the measure was evidently designed to screen for much more than risk of gambling harm , A production error omitted “[to]” on printed copies of this question. When presented verbally, the required minor alignment was made in situ by the administrator. We present the original form for transparency, whilst also signalling how the questions were heard to respondents. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 24 Apr, 2026 Editor invited by journal 31 Mar, 2026 Editor assigned by journal 30 Mar, 2026 Submission checks completed at journal 30 Mar, 2026 First submitted to journal 12 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9106160","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":634328038,"identity":"9d55c7b7-81ef-4141-8404-4fe9dce735a9","order_by":0,"name":"Carolyn Downs","email":"","orcid":"","institution":"Liverpool Business School, Liverpool John Moores University","correspondingAuthor":false,"prefix":"","firstName":"Carolyn","middleName":"","lastName":"Downs","suffix":""},{"id":634328040,"identity":"0ec4bf56-94af-4d79-ba8e-acedfd800498","order_by":1,"name":"John Towse","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIie2RsWrDMBBATwjkRalXlaT2L8gI3CX0WxQMySJ3CYRsVQlcpu7+jf5BQub2H0xXD84SMiikpN5arGTsoLccd8fj7jiAQOAfQmwXk7tfDe1R6E9UrMvldQWgUyZ4s0JtvP3ibjzD6GPbHp1LHi2tW4JT32JUDXBaIn8u7t9QqtGGKUHQ+BQ2LO2uRDA5DKycVAA5EFz6FePOMxY3OXFOvlQQHW5Q2EYzYXLKmdQC+GWKZ7EVVeqERYaiUcMHVFlF+Vzoz/7zs/VrXVfuKY1jk+0bl6QiWr+37aLoV1Z/SpdH6V4BIPX0AoFAINDxDedcRMnbcoY8AAAAAElFTkSuQmCC","orcid":"","institution":"Lancaster University","correspondingAuthor":true,"prefix":"","firstName":"John","middleName":"","lastName":"Towse","suffix":""},{"id":634328043,"identity":"06f87ba4-2548-43b4-b338-06070710a7b1","order_by":2,"name":"Abhishek Goli","email":"","orcid":"","institution":"Greater Manchester Mental Health NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Abhishek","middleName":"","lastName":"Goli","suffix":""},{"id":634328045,"identity":"6d56d9b1-a6db-45d3-8b71-0c3854ec2070","order_by":3,"name":"Georgia Kritikaki","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Georgia","middleName":"","lastName":"Kritikaki","suffix":""},{"id":634328046,"identity":"ee68210c-ec2b-4c58-be69-9a95f53eaf6b","order_by":4,"name":"Stephanie Ng","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Stephanie","middleName":"","lastName":"Ng","suffix":""}],"badges":[],"createdAt":"2026-03-12 14:53:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9106160/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9106160/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108804861,"identity":"2f3a409e-6c8b-414b-bf2b-6128e1b7c352","added_by":"auto","created_at":"2026-05-08 15:24:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":276949,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9106160/v1/17c7ce4f-35b7-4927-b010-4d1a064bf6d6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Gambling-Harm in a Community Foodbank Setting: Exploring the Feasibility and Utility of a Brief Non-Clinical Screening Approach","fulltext":[{"header":"Background","content":"\u003cp\u003eAs noted by the Lancet Public Health Commission on Gambling [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], harms to individuals, families and communities generated by widespread availability and accessibility of gambling are both substantial and widespread. The notion of gambling disorder has accordingly been expanded to include a substantial range of gambling harms, which affect many people, beyond those individuals who actually gamble.\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e\u003c/p\u003e \u003cp\u003eThe most recent national data, presented in the Gambling Survey for Great Britain (2025) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] incorporates methodological changes recognising more effectively the complexity of gambling harms [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These new data show that the economic and public health burden of harm attributable to gambling is extremely significant, is rising in its frequency, and is impacting not just people who score above recognised screening thresholds for harm, but also extends to people who gamble at levels below those set out in the International Classification of Diseases-11 or the American Psychiatric Association\u0026rsquo;s Diagnostic and Statistics Manual-5 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This has important implications for public health policy and practice around gambling harms, as individuals are likely to seek help for the often severe consequences of their gambling behaviour (suicidality, loss of work, damaged relationships, debt, or criminality) without their gambling behaviour being formally identified or addressed, particularly where conventional screening tools are not designed to fully capture severity of harm in non-clinical or community settings [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The most serious harm, suicide, is estimated to account for more than 400 deaths annually in the UK, marking it as a sentinel indicator of severity rather than an isolated outcome [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Meanwhile, the spillover effects of harmful gambling, such as criminality, intimate partner violence or loss of housing, affect family members and the wider community, meaning gambling harms are a population-level burden operating through the wider determinants of health, and one that likely affects some communities with greater severity than others [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGambling harms have been described as an invisible or hidden problem, because there are no direct physical symptoms associated with this behaviour, compared with for example alcohol dependency or drug use [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. One facet of the invisibility of gambling harm is the difficulty family and friends face in identifying the gambling in the harm experienced (i.e. \u0026ldquo;connecting the dots\u0026rdquo;). Another is the significant stigma associated with experiences of gambling harm [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In the case of gambling, stigma operates as a structural barrier to recognition, acceptance and care, shaping both individual disclosure and institutional responses [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Consequently, gambling-related harms persist alongside very low rates of gambling-specific help-seeking [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. As a result, harms can spiral, impacting other aspects of a person\u0026rsquo;s life (e.g., suicidal ideation, relationship problems, financial issues, criminality etc.). Indeed, these downstream impacts may (and in this study, do) then present as primary, rather than secondary harms [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. When help is sought for a secondary impact while gambling harms remaining hidden, the risk is that services cannot intervene or support effectively. Further compounding this risk, limited specialist knowledge, training, or lack of access to screening tools within those settings, then creates potential for missed opportunities in addressing harms [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverlaying all the above issues are the related issues of \u003cem\u003eprevalence\u003c/em\u003e of gambling harm, and their \u003cem\u003edistribution\u003c/em\u003e across segments of society. With respect to the former, it is important to understand the scale of contemporary gambling harms, as part of constructing a proportionate response programme within and beyond public health [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This represents an ongoing, dynamic issue because prevalence estimates are contingent on regulatory context, industry form, and measurement methodology [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, from a public health perspective, it is not only overall prevalence but the distribution of gambling harms across places, services, and populations that is critical to delivering effective interventions [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. An overall prevalence estimate can also be highly misleading if considered without context [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. That is, regardless of whether gambling harms are rare at a population level, there can be a large and significant concerns in particular, or specific environments. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] It is useful to note sex differences are expected in gambling harms prevalence and distribution, with a pattern of higher gambling harm in men, although numbers of women experiencing harm from their own gambling are increasing [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGambling harm is disproportionately concentrated among socioeconomically disadvantaged populations [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Therefore, the aim of this study was to examine if gambling harms were experienced by significant numbers of people using a foodbank to cope with a crisis and whether a volunteer-led service could effectively and routinely screen those seeking support.\u003c/p\u003e \u003cp\u003eThis study had two closely connected aims.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEstablish the prevalence of gambling-related harm within a socioeconomically deprived, help-seeking population.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEvaluate the viability and utility of brief, volunteer-administered gambling harm screening tools in a non-clinical welfare setting, to better understand the benefits of harm identification in both signposting to treatment and managing ongoing support needs\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe study was designed in response to a request from a linked Foodbank and Money Advice Service, who felt gambling harms were an underlying and unidentified driver of need among some of their clients. Given the role of debt as indicative of gambling harm [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], we suspected that both people experiencing debt and foodbank users, as help-seeking and emotionally vulnerable populations in financial crisis, may have a higher than population-level risk of experiencing gambling related harms. The study therefore sought to establish both whether hidden gambling-related harm was present at significant levels within this help-seeking population, and whether brief, non-specialist screening tools could be feasibly implemented by volunteers in busy welfare settings where such harms would otherwise remain invisible.\u003c/p\u003e \u003cp\u003eOur work contributes to public health practice by generating the first empirical evidence of gambling-related harm prevalence in a foodbank setting, revealing substantial unmet need in a community not typically associated with gambling services. We also highlight the 'prevention paradox', whereby a significant burden of gambling-related harm is borne by individuals below clinical screening thresholds, and demonstrate that even where harm is identified, referral to treatment services may be declined. Together, these findings underscore the importance of community-based identification and awareness as foundations for planning new routes to treatment and building partnerships between public health teams and the wider network of welfare and support organisations engaged in gambling-harm prevention and recovery.\u003c/p\u003e \u003cp\u003eThus, the current project provides important empirical evidence on gambling harm by drawing from a large community-based sample experiencing multiple indices of deprivation. In so doing, we confirm that routine screening for gambling-related harm in community support services is both feasible and useful and as a result, we reveal substantial unmet need in settings where gambling harms are not usually discussed, opening routes to raise awareness of the hidden harms of gambling.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eParticipants and Design\u003c/p\u003e \u003cp\u003eThe study examined the extent to which gambling-related harms could be identified within help-seeking (in-need) populations accessing community support and mental health services, rather than aiming to estimate population prevalence. Ethical approval was obtained for all aspects of the reported data, which were collected January 2023 - December 2023. Participants provided signed consent in connection with the Lie/Bet/Debt data (protocol with ethics approval IRAS322860. Participants provided verbal consent in connection with the Problem Gambling Severity Mini / Short (PGSI-Mini/Short) data (protocol with separate ethics approval, FASSLUMS-2023-3623).\u003c/p\u003e \u003cp\u003eIn this study we focus on a help-seeking community living in a deprived \u003cem\u003eLower-layer Super Output Area\u003c/em\u003e (LSOA) - fewer than 1% of neighbourhoods in England are more deprived using Indices of Deprivation Measures.\u003ca class=\"FNLink\" href=\"#Fn2\" id=\"#FNLinkFn2\"\u003e\u003c/a\u003e We define 'help-seeking' behaviour here as the process of actively seeking support from trusted community services when distressed or presented with difficult situations such as needing food, experiencing housing insecurity, requiring money advice, or seeking family support [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe project deployed a modified version of the two-question Lie/Bet Gambling Screen [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] originally developed to identify the most severe and debilitating forms of gambling harms [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003ca class=\"FNLink\" href=\"#Fn3\" id=\"#FNLinkFn3\"\u003e\u003c/a\u003e We used this instrument for multiple reasons. First, it is very quick to administer. Second, the questions are simple to present and understand. Third, responding \u0026ldquo;Yes\u0026rdquo; to any question triggers a triage process \u0026ndash; no data aggregation or threshold is required. The Lie/Bet/Debt screen did not collect demographic data due to the need for a rapid and volunteer-administered screening process in a time-pressured context. Our modification was the addition of a third debt question, based on previous findings that intractable debt is a significant, and possibly, the primary, marker of gambling harm [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This created the Lie/Bet/Debt questionnaire. Complementary relevant data were then available via the short form of the Problem Gambling Severity Index (PGSI Mini / PGSI short) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] which was in use for internal audit processes within the foodbank and which included demographic data.\u003c/p\u003e \u003cp\u003eA total of 1,247 participants were approached through Blackburn Foodbank and their associated Oaks Money Advice Centre and took part in the study. Moreover, 21 NHS patients also participated through the LSCFT NHS mental health services crisis team. To be enrolled in the study, respondents had to be over 18 years old, be able to consent for themselves, and access the study either via Blackburn Foodbank, Blackburn Oaks Money Advice Centre, or the LSCFT NHS mental health services. Participation in this study was entirely voluntary, and clear signposting to appropriate support and rapid access to treatment services was available for any participant who was identified as experiencing gambling-related harms.\u003c/p\u003e \u003cp\u003eMaterials\u003c/p\u003e \u003cp\u003eLie/Bet/Debt questionnaire.\u003c/p\u003e \u003cp\u003eParticipants completed a 3-item questionnaire (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). It is based on the original two-question Lie/Bet assessment [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. We introduced an additional third question, adapted from the previous research that indicated that gambling-related debt is a key identifiable characteristic of individuals who suffer from problem gambling [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The \u0026lsquo;Lie/Bet/Debt Questionnaire\u0026rsquo; is intended as a useful starting point in determining or additional assessment is needed.\u003c/p\u003e \u003cp\u003eEach item receives a yes or no response. If the participant answers 'No' to all three questions there is no indication from this screen of gambling-related harm requiring further follow-up. However, a 'Yes' response to any item indicates gambling-related harm may be present and additional evaluation is needed.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003e3-item Lie/Bet/Debt Screening Tool\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eModified Lie/Bet Questionnaire\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHave you had to lie to people important to you about how much you gambled?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHave you ever felt the need to bet more and more money?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHas your gambling activity led you [to] get into debt?\u003ca class=\"FNLink\" href=\"#Fn4\" id=\"#FNLinkFn4\"\u003e\u003c/a\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cem\u003eNote\u003c/em\u003e: Answer with \u0026ldquo;Yes\u0026rdquo; or \u0026ldquo;No\u0026rdquo;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eProcedure\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eStaff members from the organisations undertook data collection, after brief training on the screening tool itself and post-questionnaire support. After obtaining consent, the staff member verbally guided participants through the three-item Lie/Bet/Debt screener, with questions read aloud and clarification provided where required to support comprehension, including for participants with English as an Additional Language. The entire process including consent took approximately 10 minutes per participant (the screener itself can be completed in less than 1 minute).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eProject data, analysis scripts etc. can be accessed from the repository at: https://osf.io/ufqe2/\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLie/Bet/Debt\u003c/em\u003e. 1,247 participants took part. One person declined to answer the questions, leaving 1,246 valid responses. Forty-two of these individuals answered “yes” to at least one of the three questionnaire items. Accordingly,\u0026nbsp;\u003cstrong\u003e3.37% of the responses evidenced severe gambling-related harm\u003c/strong\u003e, 95% CI [2.44, 4.53]. We use the term “severe” in this context\u0026nbsp;\u003cstrong\u003eto reflect the intended purpose of the Lie/Bet/Debt screen as a brief identifier of major gambling harm, rather than as a diagnostic classification\u003c/strong\u003e (Johnson et al., 1997).\u003c/p\u003e\n\u003cp\u003eTable 2 provides additional scrutiny of the 42 Lie/Bet/Debt responses in which at least one question was answered “yes” is provided in Table 2. Half of the responses reflected endorsement of \u003cem\u003eall three items\u003c/em\u003e. Only 12 individuals (28%) gave a single “yes” response, and only three “yes” responses were attributable solely to the additional debt question. Accordingly, 3.1% of respondents would have been identified as experiencing gambling harm from the original-form 2-item screen\u0026nbsp;\u003cstrong\u003e– it is evident that the inclusion of the debt question did not substantially alter the overall response pattern\u003c/strong\u003e. It is also apparent that the majority of positive screens reflected endorsement of multiple indicators of gambling-related harm.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003cem\u003e, Response taxonomy on the 3 questions of the Lie/Bet screener\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Response profile\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;No. of individuals\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;%age of all positive responses\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e“Yes” to all 3 questions\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;21\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;50\u003c/p\u003e\n\u003cp\u003e“Yes” to 2 of the 3 questions\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;9\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;21.4\u003c/p\u003e\n\u003cp\u003e“Yes” to Question 1 (only)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;2\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;4.8\u003c/p\u003e\n\u003cp\u003e“Yes” to Question 2 (only)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;7\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;16.7\u003c/p\u003e\n\u003cp\u003e“Yes” to Question 3 (only)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;3\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;7.1\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePGSI-Mini\u003c/em\u003e. Concurrent with these research data. the foodbank administered the short-form PGSI [PGSI-Mini], as part of an internal assessment process. Standard screener instructions were deployed\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eas part of routine service activity\u003c/strong\u003e\u003cstrong\u003e, but\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eexplicit written consent was not sought since\u0026nbsp;\u003c/strong\u003ethis was\u0026nbsp;\u003cstrong\u003enot initially implemented as a research exercise\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInsofar as the data were collected both independently of the Lie/Bet/Debt and each was entirely anonymous, we cannot match individual responses between instruments. Nonetheless,\u0026nbsp;\u003cstrong\u003ewe assume that these datasets are broadly drawn from the same population\u003c/strong\u003e, and\u0026nbsp;\u003cstrong\u003ethere is no indication of systematic differences in recruitment processes or participant profiles across the two screening activities\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 describes the PGSI-Mini assessment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e\u003cem\u003e\u0026nbsp;PGSI-Mini Screening Tool\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIn the last 12 months:\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHave you gambled in a casino, bookmakers, online, at sports venue… etc.? (Yes/No)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cu\u003eIf yes:\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1. Have you gambled more than you can afford to lose?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2. Have people criticised your gambling or told you that you had a gambling problem (regardless of whether you thought it was true)?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3. Have you felt guilty about the way you gamble or what happens when you gamble?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHave you been affected by another person as a result of their gambling in a casino… etc.? (Yes/No)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote\u003c/em\u003e: Final Score from \u003cstrong\u003e3 questions\u003c/strong\u003e (score for each: Never=0, Sometimes=1, Most of the time=2, Almost Always=3) ranges 0-9.\u003c/p\u003e\n\u003cp\u003eWe examined 1922 responses from the PGSI-Mini. Table 4 describes the score profile\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e\u003cem\u003e. PGSI-Mini score distribution.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePGSI score\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;0\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;1\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;2\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;3\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;4\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;5\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;6\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;7\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;8\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;9\u003c/p\u003e\n\u003cp\u003eFrequency\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;1830\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;31\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;15\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;16\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;9\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;6\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;6\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;7\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;0\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;2\u003c/p\u003e\n\u003cp\u003eAccordingly, Table 4 confirms\u0026nbsp;\u003cstrong\u003e46 individuals categorised as at risk of gambling-related harm\u003c/strong\u003e [i.e. PGSI-Mini score 1–2] (2.39%, 95% CI [1.76, 3.18]) and\u0026nbsp;\u003cstrong\u003ea further 46 individuals categorised as experiencing gambling-related harm\u003c/strong\u003e [i.e. PGSI-Mini score of 3 or more] (2.39%, 95% CI [1.76, 3.18]). Moreover, in response to the final question, “In the past 12 months, have you been affected by another person as a result of their gambling?”, there were 78 “yes” responses and 1,780 “no” responses (64 missing responses). This represented\u0026nbsp;\u003cstrong\u003e4.20% of respondents reporting harm from the perspective of being an affected other\u003c/strong\u003e, 95% CI [3.33, 5.21].\u003c/p\u003e\n\u003cp\u003eData on age, sex, and respondent ethnicity were obtained alongside the PGSI-Mini. However,\u0026nbsp;\u003cstrong\u003ethese (non-research) data were inconsistently recorded\u003c/strong\u003e. Most frequently when any variable was missing,\u0026nbsp;\u003cstrong\u003eall three variables were missing\u003c/strong\u003e, In some cases, however, one or two responses were missing for an individual.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOverall, where participant sex was recorded, there were slightly more male (890) than female (675) respondents. Therefore, males were overrepresented by\u0026nbsp;\u003cstrong\u003ea ratio of 1.32:1\u003c/strong\u003e. However, within the group\u0026nbsp;\u003cstrong\u003escreened as experiencing gambling-related harm\u003c/strong\u003e, there were many more males (27) than females (7), with males overrepresented by\u0026nbsp;\u003cstrong\u003ea ratio of 3.86:1\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e However, in response to the question about being affected by the gambling of others, 36 females and 31 males recorded a positive response;\u0026nbsp;\u003cem\u003ea ratio of 1.16:1\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e Thus,\u0026nbsp;\u003cem\u003ealthough males outnumbered females in the overall sample by a ratio of 1.32:1, this pattern was inverted among those reporting harm from another person's gambling. This pattern is consistent with evidence that women are more frequently affected by the gambling harm of others, while men more frequently report harm from their own gambling behaviour [5].\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; The mean age of the overall respondent sample was 41.6 years, similar to the mean age of those\u0026nbsp;\u003cstrong\u003escreened as experiencing gambling-related harm\u003c/strong\u003e, at 38.4 years.\u003c/p\u003e\n\u003cp\u003eWhere data was available, 44.5% of the sample self-identified with the label “White British”. Among respondents\u0026nbsp;\u003cstrong\u003escreened as experiencing gambling-related harm\u003c/strong\u003e, 80% used this label. 19.6% of the sample reported the term “British (vs. 10% of the\u003cstrong\u003e\u0026nbsp;gambling-harm\u003c/strong\u003e respondents). 6.42% of the sample reported Pakistani heritage and a further 6.86% of the sample reported Asian or Indian heritage (vs. 5% of gambling harm respondents identified as Pakistani or British Pakistani \u0026nbsp;and 5% as Asian or Mixed Asian.\u0026nbsp;\u003cstrong\u003eThese patterns should be interpreted with caution given the extent of missing demographic data.\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study highlights a central public health challenge in relation to gambling harms: that at an individual level they are frequently not identified at all [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In line with existing evidence, our findings confirm that individuals experiencing gambling-related harms are more likely to seek support for the consequences and comorbidities of gambling, such as debt, threats of repossession, food insecurity, psychological distress, or relationship difficulties, without disclosing gambling as an underlying cause, often due to stigma [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Other factors preventing disclosure include internalised minimisation of the problems being experienced as a result of gambling [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] or, as Fulton (2019) found, a desire to keep their gambling secret, often as a means to continue gambling unpressured to stop by external sources [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Within these complex contexts, the identification of gambling harm depends less on individuals presenting for gambling-specific support, and more on whether a wider range of systems and services are equipped to recognise harm when it surfaces indirectly and can then begin a conversation about gambling that might otherwise not take place.\u003c/p\u003e \u003cp\u003eThe percentage of gambling-related harm identified in this study \u0026ndash; 3.4%- is notably high, reinforcing evidence that gambling harm is concentrated in socioeconomically disadvantaged populations and often remains unrecognised within welfare settings and that harm may remain hidden even within populations experiencing acute financial and social stress [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. This reinforces the importance of community and welfare settings as critical points for public health action, where brief, pragmatic prompts can increase the visibility of an otherwise hidden public health issue [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Consistent with the effect of stigma on limiting both disclosure and help-seeking among people experiencing gambling harm, organisations involved in this study reported that although individuals identified as experiencing gambling-related harms were signposted to free and confidential specialist services, none chose to access this support at the time. This was despite continuing long-term engagement with the welfare organisations they had initially approached. However, embedding initiatives around the identification of gambling harm in community settings may also support wider recognition of gambling harm among affected others, or the general discussion of gambling harm, extending the potential benefits of identification beyond those who gamble themselves. Furthermore, being made aware of treatment options, even if they are not adopted may lead people to seek help in future.\u003c/p\u003e \u003cp\u003eFrom a public health perspective, our findings underscore that the value of community-based identification of gambling harm can best be maximised if it is accompanied by robust efforts to share information about gambling harms across a wide range of community contexts, so as to normalise conversations about harmful gambling. An awareness-driven approach allows locally trusted, community-based services such as foodbanks and money advice organisations to not only identify hidden gambling-related harms but also create a climate in which communities can understand that gambling harms are a commercially determined harm, rather than an individual fault [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Thus, they are not only identifying people experiencing gambling harm but are raising awareness that harm is built into the games people access, providing a route to discuss gambling harms openly as a legitimate and potentially solvable contributor to wider financial and social difficulties.\u003c/p\u003e \u003cp\u003eAlongside the work reported here, a parallel arm of the project also sought to explore the presence of gambling-related harms among individuals referred to the mental health crisis team for support within Lancashire \u0026amp; South Cumbria NHS Trust. Where individuals seeking acute mental health support are experiencing gambling-related harms that are not identified or recorded, their mental health presentation and associated risks may not be fully understood, and opportunities for appropriately targeted support may be missed. At present, gambling-related harms are not routinely identified across NHS services.\u003c/p\u003e \u003cp\u003eSampling within the mental health crisis service was necessarily limited, with data collected from 21 patients between January and July 2023. This component of the study is therefore reported as exploratory, intended to showcase potential signals of unmet gambling-related need rather than to generate prevalence estimates. Four of the 21 individuals answered \u0026ldquo;yes\u0026rdquo; to at least one of the three questionnaire items, indicating potentially significant gambling-related harm. This corresponds to 19.1% of this small pilot sample (95% CI [5.45, 41.91]). While the wide confidence intervals underline the considerable interpretative caution required, this outcome is remarkable as a potential flag for unmet gambling-related need within crisis mental health settings and is consistent with the broader recognition within the National Institute for Health and Clinical Excellence (NICE) NG248 that gambling-related harms may be relevant across a range of health contexts [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Rather than implying a public health prevention role for mental health services, these findings highlight how gambling-related harms that remain unidentified upstream, for example, in community settings, may then surface within acute clinical contexts, where they may complicate assessment, risk management, and care planning. We argue that it is therefore vital to further explore gambling-related harms within this population, both to inform clinical understanding and to reinforce the importance of earlier identification within community and public health settings.\u003c/p\u003e \u003cp\u003eOur data focus primarily on individuals experiencing more severe gambling-related harms, as identified by the modified Lie/Bet/Debt screener or higher scores on the PGSI-Mini. However, in line with recent research by Wardle et al, (2024) we believe a substantially larger group of individuals are experiencing material gambling-related harms below these clinical or screening thresholds [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Indeed, the PGSI-Mini data indicate that the number of individuals categorised as \u0026lsquo;at risk\u0026rsquo; of gambling harm is at least as large as the number categorised as experiencing gambling-related harm. This finding has been previously reported discussed as the \u0026lsquo;prevention paradox\u0026rsquo; (p.8) whereby the majority of aggregated gambling-related harm in a population is borne by individuals who do not meet diagnostic or high-threshold screening criteria (pp. 9\u0026ndash;10) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Paradoxically, without support or intervention there is a risk of problem escalation.\u003c/p\u003e \u003cp\u003eThe importance of this sub-clinical or \u0026lsquo;at-risk\u0026rsquo; population to public health provision is particularly acute in community settings, because communities seeking help with food and debt are extremely sensitive to even small financial shocks [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. As Wardle et al (2024) emphasise, even relatively modest gambling losses can have disproportionate consequences for individuals and households already experiencing socioeconomic stress, contributing to cycles of debt, insecurity, and deteriorating wellbeing (pp. 12\u0026ndash;14) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In such contexts, gambling behaviours that might be categorised as \u0026lsquo;low\u0026rsquo; or \u0026lsquo;moderate\u0026rsquo; risk in general population surveys can nevertheless generate substantial harm and need the provision of joined up services and information sharing between voluntary community welfare services, NHS and public health teams to reduce harm and limit the impact of the prevention paradox.\u003c/p\u003e \u003cp\u003eAccordingly, we expect our data actually under-estimates the true extent of gambling-related harm within help-seeking populations. First, because they rely on self-report of a highly stigmatised behaviour - the immediate social incentive would be to downplay personal contributors for economic distress. Second, these short, simple screener instruments target only the most severe and direct aspects of gambling-harm spectrum. Third, any prevalence measure is constrained by both sensitivity and specificity [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] - the likelihood of false positive and false negatives- and we expect more of the latter than the former. From a public health perspective, this further highlights the importance of community-based identification, joined up services, and early intervention strategies that engage with gambling harm across the full spectrum of risk, rather than focusing solely on individuals who already meet clinical or diagnostic criteria.\u003c/p\u003e \u003cp\u003ePractice-based feedback from volunteers and staff involved in data collection indicated that sometimes the PGSI-Mini was perceived as confusing or ambiguous, both for screen administrators and for some participants, particularly in busy, non-clinical settings (eg. distinguishing response levels \u0026ldquo;Never\u0026rdquo;, \u0026ldquo;Sometimes\u0026rdquo;, \u0026ldquo;Most of the time\u0026rdquo;. In contrast, the simplicity of the Lie/Bet/Debt was consistently reported as being effective and appreciated. Importantly, it is also obvious and straightforward to work with in terms of next steps (i.e.. any positive response warrants support signposting \u0026ndash; no scoring and response amalgamation is required). Similar feedback has also been reported to us in other community and welfare settings where gambling screening has been introduced.\u003c/p\u003e \u003cp\u003eIn this context, it is important to bear in mind that for the current project (and other potential scenarios) screen administrators were not \u003cem\u003eresearch staff\u003c/em\u003e but community workers or volunteers who, despite having received brief training, did not have specialist expertise in either gambling-related harm structured assessment tools. Responding to a time-crunched situation, staff are focused on addressing immediate and tangible needs such as food insecurity, debt, or housing instability. Instrument characteristics such as ease and rapidity of use are important characteristics of a screening tool. From a public health perspective, implementation characteristics are likely to influence not only feasibility but also the quality and completeness of data collected in community settings. In this study, observed differences in the proportion of individuals identified by different screening tools may reflect challenges in data acquisition and deployment in real-world contexts, rather than differences in the underlying prevalence or severity of gambling-related harm. More generally it is important to recognise that psychometric properties, and instrument functionality in the wild, are not always isomorphic.\u003c/p\u003e \u003cp\u003eThe PGSI-Mini screening tool includes a question about affected others (\u0026lsquo;In the past 12 months, have you been affected by another person as a result of their gambling?\u0026rsquo;). The proportion of respondents answering \u0026ldquo;yes\u0026rdquo; to this item (4.2%) was almost double the proportion self-reporting gambling-related harm (2.39%). While the scope of these questions is not directly comparable, since the affected-others item captures harm experienced by a wider network of people, including partners, family members, dependants or even friends, this discrepancy is nevertheless informative in a community screening context.\u003c/p\u003e \u003cp\u003eOur findings show males were overrepresented in self-reported gambling harm, and females were slightly overrepresented in reporting harm from others' gambling. While not researching underlying causes of foodbank use, we believe it is important for help-providing organisations to consider whether females may be presenting at the foodbank partly as a consequence of a partner or family member's gambling. Given the high level of stigma associated with gambling-related harm, disclosure about the gambling behaviour of unnamed others may be easier than disclosure about one\u0026rsquo;s own behaviour, and such disclosures may offer a route to provide information and advice for those affected directly by gambling harms.\u003c/p\u003e \u003cp\u003eAs such, the observed gap between self-reported gambling harm and reports of harm experienced through others is consistent with under-disclosure or under-recognition of personal gambling harm, particularly in non-clinical settings. From a public health perspective, this suggests that designing screening questions which allow individuals to disclose concern indirectly may increase the visibility of gambling-related harm within community services.\u003c/p\u003e \u003cp\u003eThis insight has already informed local public health practice. Working with the research team, Blackpool Council has further adapted our Lie/Bet/Debt screener for use across a wide range of community and welfare settings by adding a fourth question asking whether individuals are worried about the gambling of someone they know. This four-item version is now used in approximately 14 community contexts, including housing services, advice organisations, recovery-led groups, and voluntary sector providers. Such adaptations reflect an emerging recognition that community-based identification of gambling harm benefits from prompts that capture both direct and indirect experiences of harm, particularly in populations where self-disclosure may be constrained by or uncertainty about what constitutes harmful gambling [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite these emerging local adaptations, researchers have limited empirical understanding of how gambling-related harm contributes to demand across local service systems, including health, housing, family support, advice services, and the criminal justice sector, meaning public health teams do not have access to information that will support them in planning and delivering services to reduce gambling harms [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Our findings indicate the importance of recognising gambling harm as a cross-cutting public health issue that generates pressures beyond specialist gambling services, and one that is likely to be most acutely felt within communities already experiencing social and economic disadvantages.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eAlthough the sample, this study mainly comprises a single foodbank and associated money advice service in one deprived LSOA of NW England. We note that this may limit generalisability of our findings. The sociodemographic profile of the setting; within the most deprived 1% of neighbourhoods in England, means prevalence estimates should not be taken as representative of foodbank users in less deprived areas, or those accessing different types of community-based support. Studies across a wider range of volunteer-led support settings are needed to allow generalisations to be made.\u003c/p\u003e \u003cp\u003eThe Lie/Bet/Debt screen used in this study does not include a question about concern for the gambling of a significant other, meaning harm experienced by affected others may be under-identified. The PGSI-Mini data, in which 4.2% of respondents reported being affected by another person's gambling indicates that the Lie/Bet/Debt screen, as trialled in this study, may underestimate the true burden of gambling-related harm within the community by missing those affected by another's gambling This limitation has since been addressed in a local adaptation developed with and rolled out by Blackpool Council. The adaptation adds a fourth question asking whether the individual is worried about someone else's gambling. The 4-item Community Use Gambling Screen (CUGS-4) is now in use across approximately 14 community settings in Blackpool, with data being collected to enable robust evaluation of the tool.\u003c/p\u003e \u003cp\u003eThe mental health crisis service element of the study was limited in scale. This work should be interpreted as exploratory and is not sufficient basis for prevalence estimation. Recruitment in this setting was constrained by operational and clinical factors. Nevertheless, the finding that 19.1% of this small sample screened positive for gambling-related harm is striking, and consistent with emerging evidence that gambling harm is disproportionately present among individuals experiencing mental health crises. Our pilot suggests the importance of larger-scale investigation of gambling-related harm within NHS mental health settings, where unidentified gambling harm may complicate both risk assessment and care planning\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eGambling harms are a significant and unevenly distributed public health concern. In welfare or advice environments involving individuals experiencing acute financial or personal stress, our findings indicate that the prevalence of severe gambling-related harm is substantially higher than estimates derived from general population surveys. The contribution of this study is not to demonstrate that gambling harm is socially patterned, this is a long-established finding, but to show how this patterning manifests in community welfare settings, remains largely unrecognised in routine practice, and can be made visible through pragmatic public health approaches to identification.\u003c/p\u003e \u003cp\u003eHowever, our findings also highlight a critical limitation of current responses: identification does not reliably translate into engagement with specialist support. Across the settings involved in this study, no individual identified as experiencing significant gambling-related harm chose to access readily available treatment services, despite continued engagement with the welfare organisations they initially approached. However, emerging data from a second year of implementation and from the Blackpool CGS-4 rollout suggest treatment uptake may be improving, with approximately 10\u0026ndash;12% of identified individuals accepting referral, representing a meaningful shift from baseline. This pattern is consistent with the hypothesis that sustained community-based identification alongside normalisation of conversations about gambling harm may gradually reduce the stigma to help-seeking over time.\u003c/p\u003e \u003cp\u003eFrom a public health perspective, this underscores the need for approaches that extend beyond detection alone. Reducing stigma, normalising conversations about gambling-related harm, and embedding supportive responses within trusted community settings are likely to be essential if identification is to lead to meaningful benefit. Strengthening community-based identification must therefore be accompanied by public health strategies that address stigma and improve the acceptability and accessibility of support, if preventable gambling-related harms are to be reduced and inequalities addressed.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCUGS-4\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e4-item Community Use Gambling Screen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDSM-5\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDiagnostic and Statistical Manual of Mental Disorders, 5th edition\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eESRC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEconomic and Social Research Council\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICD-11\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Classification of Diseases, 11th edition\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIRAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntegrated Research Application System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLSCFT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLancashire and South Cumbria NHS Foundation Trust\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLSOA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLower-layer Super Output Area\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNICE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Institute for Health and Care Excellence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePGSI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProblem Gambling Severity Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eResearch ethics approvals were granted via the Lancashire and South Cumbria NHS Foundation Trust Study (reference IRAS322860) and Lancaster University for the Blackburn Foodbank / Oak Money Advice Trust Study (reference FASSLUMS-2023-3623), both conducted in accordance with the Declaration of Helsinki and the UK Policy Framework for Health and Social Care Research. In both studies, a short training programme was prepared for NHS Staff and Volunteers administering the screen. This covered taking consent from participants and screen administration. All participants received a participant information sheet in plain English and signed a consent form. In the latter case, volunteer staff also collected PGSI Mini data for organisation administrative purposes, following screen guidance.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable (no individual data/images).\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was supported by an ESRC Impact Acceleration Account (2022-3) award to CD \u0026ldquo;Implementation of Modified Lie/Bet Gambling Screen in Blackburn with Darwen and Lancaster Mental Health Referral Settings\u003cb\u003e\u0026rdquo;\u003c/b\u003e in partnership with Lancashire and South Cumbria NHS Foundation Trust\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eCD designed the study, supported data analysis and drafted the discussion, limitations and conclusion of the manuscript and provided feedback on the methods and results sectionsJT supported study design, led on data analysis, drafted the methods and results section and provided feedback on the discussion and conclusion sectionsAG supported study design and provided critical feedback on the paperGK supported study design and data analysis and prepared figuresSN supported data analysis\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe appreciate the help and support of the Oaks Money Advice Centre in facilitating data collection and Claire Birdsall in particular. We appreciate data processing contributions from Focus Chen and constructive feedback on an earlier draft from Dr Andrew Harding\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data and materials are available in the Open Science Framework (OSF) repository on https://osf.io/ufqe2/\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWardle H, Degenhardt L, Marionneau V, Reith G, Livingstone C, Sparrow M, Tran LT, Biggar B, Bunn C, Farrell M, Kesaite V. The Lancet Public Health Commission on Gambling. Lancet Public Health. 2024;9(11):e950\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGambling Commission. Review of the Gambling Survey for Great Britain [Internet]. 2025 [cited 2026 Feb 5]. 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An overview of help seeking by problem gamblers and their families including barriers to and relevance of services. Int J Mental Health Addict. 2007;5(4):292\u0026ndash;306.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRolando S, Ferrari C, Beccaria F. To me, it was just a vice: stigma and other barriers to gambling treatment in Piedmont, Italy. J Gambl Stud. 2023;39(4):1909\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuurvali H, Cordingley J, Hodgins DC, Cunningham J. Barriers to seeking help for gambling problems: a review of the empirical literature. J Gambl Stud. 2009;25(3):407\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFulton C. Secrets and secretive behaviours: exploring the hidden through harmful gambling. Libr Inf Sci Res. 2019;41(2):151\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrennan-Tovey K, Board EM, Fulton J. Counteracting stigma-power: an ethnographic case study of an independent community food hub. J Contemp Ethnogr. 2023;52(6):778\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhitman A, De Lew N, Chappel A, Aysola V, Zuckerman R, Sommers BD. Addressing social determinants of health: examples of successful evidence-based strategies and current federal efforts. Off Heal Policy. 2022;1:1\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGorry PD, Mei C, Chanen A, Hodges C, Alvarez-Jimenez M, Killackey E. Designing and scaling up integrated youth mental health care. World Psychiatry. 2022;21(1):61\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Institute for Health and Care Excellence (NICE). 2025. \u003cem\u003eGambling-related harms: identification, assessment and management.\u003c/em\u003e Reference number: NG248. Published: 28 January 2025. Available on \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nice.org.uk/guidance/NG248\u003c/span\u003e\u003cspan address=\"https://www.nice.org.uk/guidance/NG248\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e last accessed 7 Feb. 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReith G, Wardle H. The framing of gambling and the commercial determinants of harm: challenges for regulation in the UK. In: Nikkinen J, Marionneau V, Egerer M, editors. The global gambling industry: structures, tactics, and networks of impact. Wiesbaden: Springer Fachmedien Wiesbaden; 2022. pp. 71\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBufe S, Roll S, Kondratjeva O, Skees S, Grinstein-Weiss M. Financial shocks and financial well-being: what builds resiliency in lower-income households? Soc Indic Res. 2022;161(1):379\u0026ndash;407.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRogan WJ, Gladen B. Estimating prevalence from the results of a screening test. Am J Epidemiol. 1978;107(1):71\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnstone P, Regan M. Gambling harm is everybody's business: a public health approach and call to action. Public Health. 2020;184:63\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Contemporary terminology surrounding gambling-harm has evolved considerably. In this article, we attempt as far as feasible to frame discussion around \u003cem\u003egambling-harm\u003c/em\u003e, whilst recognising previous, cited research, has sometimes used a different lexicon (see \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.grg.scot/resources/2024/08/Words-Matter_main_digital-file.pdf\u003c/span\u003e\u003cspan address=\"https://www.grg.scot/resources/2024/08/Words-Matter_main_digital-file.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). This impacts the precision with which previous findings can be represented\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Output Areas (OAs) are the lowest level of geographical area for census statistics and were first created following the 2001 Census. Lower layer Super Output Areas (LSOAs) are made up of groups of OAs, usually four or five. They comprise between 400 and 1,200 households and have a usually resident population between 1,000 and 3,000 persons. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ons.gov.uk/methodology/geography/ukgeographies/censusgeographies/census2021geographies\u003c/span\u003e\u003cspan address=\"https://www.ons.gov.uk/methodology/geography/ukgeographies/censusgeographies/census2021geographies\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Indices of Deprivation are calculated across seven domains \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gov.uk/government/statistics/english-indices-of-deprivation-2025/english-indices-of-deprivation-2025-frequently-asked-questions\u003c/span\u003e\u003cspan address=\"https://www.gov.uk/government/statistics/english-indices-of-deprivation-2025/english-indices-of-deprivation-2025-frequently-asked-questions\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e The instrument was originally developed as an index of \u0026ldquo;pathological gambling\u0026rdquo;. Terminological choices aside, the measure was evidently designed to screen for much more than \u003cem\u003erisk of gambling harm\u003c/em\u003e,\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e A production error omitted \u0026ldquo;[to]\u0026rdquo; on printed copies of this question. When presented verbally, the required minor alignment was made in situ by the administrator. We present the original form for transparency, whilst also signalling how the questions were heard to respondents.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Gambling harms, food insecurity, foodbanks, advice services, gambling screening, short PGSI, lie/bet screen, voluntary services","lastPublishedDoi":"10.21203/rs.3.rs-9106160/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9106160/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eGambling is a significant public health issue, with recent prevalence data confirming that people who have gambled in the previous 12 months experience severe consequences including bankruptcy, relationship breakdown and suicide ideation. There is a critical need to assess and respond to the distribution of problems across population subsets and communities, especially in non-clinical, volunteer-administered, time-limited contexts. This study aimed to assess the prevalence of gambling harm in a foodbank setting and to evaluate the feasibility of brief, volunteer-administered screening tools.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAll foodbank users accessing a service in NW England over 2023 were screened using two gambling harm tools. Positive screen responses were recorded based on responses from a mixed sex sample to a modified Lie/Bet screen (n\u0026thinsp;=\u0026thinsp;1247) and PGSI-Mini (n\u0026thinsp;=\u0026thinsp;1922).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOver 3% of respondents reported experiences of severe gambling-related harm, with males substantially over-represented among positive screens. However, despite signposting to rapidly available support and treatment delivered via a variety of formats (face-to-face, telephone or online) no individual identified as experiencing severe gambling harm accepted a referral.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe argue that rolling out rapid, community-based screening using tools accessible to non-clinical and volunteer staff can support earlier identification of gambling harms and inform a public health approach that better reflects where and how gambling-related distress is experienced. Although support and treatment was often refused, knowledge of the source of distress equips help providing organisations to better target support for gambling harms within their own settings while screening in community settings could offer new delivery points for treatment services.\u003c/p\u003e","manuscriptTitle":"Gambling-Harm in a Community Foodbank Setting: Exploring the Feasibility and Utility of a Brief Non-Clinical Screening Approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-05 19:31:20","doi":"10.21203/rs.3.rs-9106160/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-24T07:36:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-31T11:14:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-30T09:15:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-30T09:15:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-03-12T14:47:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bde3dd20-45f2-4908-bb44-7f39054b28b7","owner":[],"postedDate":"May 5th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T19:31:21+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-05 19:31:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9106160","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9106160","identity":"rs-9106160","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}