Health, Risk & Society

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A systematic review of psychosocial risks for

gambling and problem gambling in the Nordic
countries

Johanna Nordmyr & Anna K. Forsman

To cite this article: Johanna Nordmyr & Anna K. Forsman (2020) A systematic review of
psychosocial risks for gambling and problem gambling in the Nordic countries, Health, Risk &
Society, 22:3-4, 266-290, DOI: 10.1080/13698575.2020.1796929

To link to this article: https://doi.org/10.1080/13698575.2020.1796929

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Health, Risk & Society, 2020
Vol. 22, Nos. 3–4, 266–290, https://doi.org/10.1080/13698575.2020.1796929

A systematic review of psychosocial risks for gambling and problem

gambling in the Nordic countries
Johanna Nordmyr* and Anna K. Forsman

Faculty of Education and Welfare Studies, Health Sciences, Åbo Akademi University, Vaasa,
Finland

Gambling is a relatively common activity in the Nordic countries, while the incidence
and prevalence of problem gambling is relatively stable in this context. Social net­
works and relationships (e.g., gambling activities among family members and peers)
have been put forward as relevant factors to consider when monitoring the epide­
miological pathways in regard to gambling and problem gambling. The research on
gambling and functional or qualitative aspect of networks and relationships (here
labelled psychosocial factors), is however an important emerging area, warranting
a synthesis of the evidence. We systematically reviewed the evidence on psychosocial
risk factors in relation to gambling and problem gambling in Nordic gambling
research. Included articles were identified through systematic searches in 10 scientific
databases, covering the time period January 2000–July 2019. Following a systematic
screening procedure, the final data set consisted of 21 original studies applying
various statistical, interview or narrative methods. The review highlights both less
researched psychosocial phenomena and also synthesises the evidence on the most
commonly featured psychosocial factors in the included publications – loneliness and
social support – evidencing conflicting findings in relation to gambling activities and
problem gambling. Although few studies carried evidence to corroborate causal
inferences, the risk factors and related epidemiological pathways we identify high­
light focal areas that should be considered in both future prevention research and
practice, broadening the arena for prevention strategies targeting new health
challenges.
Keywords: Gambling; psychosocial; problem gambling; Nordic countries; systematic
review

Introduction
In this study we systematically review the quantitative and qualitative evidence on
psychosocial factors in Nordic gambling studies, assessing the associations, influences
or articulated experiences of psychosocial risks in relation to gambling activities and
problem gambling reported in the Nordic research literature. We focus on the Nordic
context given the prevalent gambling activity and relatively low problem gambling
prevalence in these countries, aiming to shed further light on the evidence on psychoso­
cial risk and/or protective factors related to gambling and problem gambling, which
could support primary and secondary prevention strategies.

*Corresponding author. Email: jnordmyr@abo.fi

© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives
License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in
any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
 Health, Risk & Society 267

Gambling in the Nordic countries

Gambling is a fairly common leisure activity in the Nordic countries, with past-year
gambling participation rates varying between around 60% and 80% among adults
(Nordic Welfare Centre, 2017). While past-year problem gambling prevalence rates in
the Nordic countries are at the same level as the global standardised average rate of 2.3%
or lower (Williams, Volberg et al., 2012), the broader societal impact of gambling-related
harm has been highlighted in the Nordic and international literature (see, for example,
Riley et al., 2018; Salonen et al., 2016). Hence, the Nordic context shows a relatively
high frequency of gambling in the population and – from a public health point of view –
relatively low and stable problem gambling rates. The question is whether, looking at the
Nordic research base, the risk of incidence and prevalence with regard to gambling and
problem gambling is influenced by social circumstances ̶ looking at inter-personal
psychosocial factors in particular ̶ and in what ways?

Problem gambling from a risk perspective

A public health viewpoint on gambling considers gambling behaviour and related
problems on a continuum, with subsequent impacts (be it positive or negative) on the
individual, inter-personal, and societal levels (Korn et al., 2003; Latvala et al., 2019).
Factors that can influence gambling behaviour and the risk of a problem gambling
development can similarly be viewed on different levels (Abbott et al., 2018) ranging
from, for example, gambling environment and forms of gambling, to individual factors
such as gender, age and socio-economic status. Here, influences of interpersonal net­
works and relationships, such as gambling activities in one’s family and peer group, also
seem to play a role.
Wardle et al. (2018) have earlier presented a socio-ecological model depicting how
both harm caused by gambling and also the determinants for problem gambling can be
experienced and shaped on individual, family, community and societal levels.
Interpersonal harm includes relationship disruption, social isolation and erosion of trust
from family, friends and community. The model, integrating both consequential harms
and risks, highlights how factors on the interpersonal level such as family or peer
gambling culture, but also more general interpersonal factors such as experiences of
social support, can be affected by and also influence a person’s gambling engagement
and eventual problems. The element of this model encompassing experiences related to
one’s social network and relationships, such as perceived social support, will be the focus
of this article – here labelled as psychosocial factors or phenomena.

Psychosocial risks and gambling

When considering risk and protective factors for health, a psychosocial framework places
emphasis on the pathways and mechanisms mediating the influences of the social
determinants on health, more specifically the experience surrounding one’s social net­
work and interpersonal relationships. Martikainen et al. (2002) propose that psychosocial
factors are best considered as influences acting primarily between social structural
factors and individual-level psychological characteristics. They describe how a social
network may provide both instrumental or material aid as well as social contacts and
emotional support – but that the contacts and emotional support would qualify as
psychosocial. In this study, psychosocial factors are viewed as the functional or
268 J. Nordmyr and A.K. Forsman

qualitative aspect of networks and relationships – such as positive experiences of social

support and belonging or negative experiences of loneliness – as opposed to structural
factors such as the number of people in one’s network or marital status (Cohen & Wills,
1985; Thoits, 2011).
Studies from outside the Nordic setting have highlighted various psychosocial factors
in relation to gambling initiation, and development of activities and eventual problems
over time (Nuske et al., 2016; Reith & Dobbie, 2011, 2013). An earlier review of risk
and protective factors for problem gambling development in longitudinal studies
(Dowling et al., 2017) included a few studies looking at psychosocial factors; however,
these studies were not included in the synthesis of the findings due to their low number.
Further, Sharman et al. (2019) included some studies focusing on psychosocial factors
(as defined in our study) in a review study, but overall their use of the psychosocial
concept was much broader encompassing, for example, mental and physical ill-health,
and the study was limited to focusing specifically on certain risk groups.

Methodology
Included and excluded studies
This review study synthesises the research on psychosocial factors and their links to
gambling activities and related problems. Studies were included in this review based on
publication type (original studies included, review studies, editorials and similar
excluded) and study content. Regarding content, studies focusing on factors, outcomes
or – in the case of interview or narrative studies – themes or categories, related to
a person’s social network and relationships are included, in line with the psychosocial
concept outlined in the article introduction. Studies focusing on biomedical perspectives
of problem gambling, regulatory and legislative issues related to gambling and other
topics unrelated to psychosocial themes are excluded from this review.

Database searches and screening

The original search strategies were implemented within the scope of a review exercise
(Nordmyr & Forsman, 2018) aiming to map (Curran et al., 2007; Daudt et al., 2013)
Nordic gambling studies. Included studies were identified through systematic searches
performed in 10 international scientific databases, covering the time period
January 2000–July 2019: CINAHL; Academic Search Premier; PsycInfo, Web of
Science; Pubmed; ScienceDirect; Sociological Abstracts; Social Services Abstracts;
ASSIA: Applied Social Sciences Index Abstracts; International Bibliography of the
Social Sciences. The database selection and search strategies are found in the supple­
mental online material. The number of identified studies in the selected databases and the
study screening and selection process can be viewed in Figure 1. Based on title, abstract
and key word information, the first author performed an initial screen of identified
studies, where articles clearly irrelevant in relation to the review scope were excluded
and original studies potentially focusing on psychosocial factors were identified.
Potentially relevant studies or studies where the content remained unclear after the initial
screening were thereafter scanned in full text versions for inclusion by both authors. All
identified publications reporting on studies applying interview or narrative methods were
reviewed in full-text to assess their relevance.
 Health, Risk & Society 269

Figure 1. PRISMA flow diagram illustrating the performed identification and screening process.

Data extraction and synthesis

We considered the following descriptors for the included records: study design (data/
psychosocial measure or dimension/analyses); key findings (emerged themes in interview
studies or results of statistical analyses). When reporting on statistical findings, the results of
the most advanced analyses are reported. For studies where participants from countries
outside the Nordics were also represented, we report on findings applying to the Nordic
participants. For studies applying interview or narrative approaches, surfaced themes had to
have a comprehensive (thematic) focus on social components. This follows the synthesising
or meta-aggregation process outlined by Pearson (2004) where findings in the forms of
themes, categories and similar from included review studies are collated.
Quality assessment was performed for the included studies utilising the recognised
NICE checklists, with separate systematic guidelines for quantitative and qualitative
270 J. Nordmyr and A.K. Forsman

studies (National Institute for Health and Care Excellence, 2012a, 2012b, based on
Jackson et al., 2006; Spencer et al., 2003). Study quality was assessed by one author
and unclear cases were discussed between the authors. Internal and external study
validity was coded as ++, +, or -. ++ indicated a high-quality score, with all or most
checklist criteria fulfilled (where these had not been fulfilled, the conclusions of the
study were unlikely to alter, had this been the case). + indicated moderate quality for
internal and external validity, where some checklist criteria had been fulfilled, and where
they had not been fulfilled (or adequately described), study conclusions were unlikely to
alter. – indicated a low-quality score, with few or no of checklist criteria fulfilled and the
conclusions of the study could be easily altered.

Findings
Twenty-one publications fulfilled the review inclusion criteria, focusing on psychosocial
factors or themes in relation to gambling or problem gambling. The heterogeneity in, for
example, research design and outcome measures applied in the studies meant that this
review takes the form of a narrative evidence synthesis rather than a meta-analysis. The
key findings of all studies are available in Table 1. In the following, we present the
collected evidence on the psychosocial factors which have been studied in the included
gambling articles.

Psychosocial phenomena with a limited evidence base in Nordic research

The collected studies encompassed analysis of several psychosocial phenomena where the
evidence is limited to a single study. In one article (Hanss et al., 2015), family cohesion was
not associated with gambling nor risk-problem gambling among 17-year-old Norwegians.
Similarly, Svensson and Sundqvist (2019), did not find family satisfaction to be associated
with past-year gambling or frequent gambling among Swedish adolescents. In another study
(Lyk-Jensen, 2010), respondents’ retrospective views on their childhood and adolescence
experiences related to feeling solitary and left out and feeling understood did not differentiate
at-risk gamblers from no-risk gamblers (persons experiencing problem gambling were not
included in the study). Further, one cross-sectional study (Nordmyr et al., 2016) of a Finnish
population sample showed a positive association between low levels of neighbourhood trust
and problem gambling, but no risk associated with general trust.
Finally, three studies applying interview and narrative methods reported on ‘sense of
belonging’ and related features. In an interview study by Svensson (2011), the theme
Gambling – lifestyle and identity encompassed the relevant subtheme Electronic and
virtual friends, where the author stated that the participants ‘gambling seems to be
influenced by their search for belonging and fellowship’. Under the theme Rituals of
belonging and self-determination, Matilainen and Raento (2014) noted how the studied
narratives reflected feelings of togetherness, belonging. Kristiansen et al. (2015) also
mentioned maintaining a sense of belonging to a social community under the theme Peer
groups, and feelings of community under the theme Family, in their results.

The collected evidence on experienced loneliness – quantitative findings

Several studies in the synthesised material looked at experienced loneliness in relation to
gambling activities and problem gambling, evidencing mixed results. In one Finnish
 Health, Risk & Society 271

population study (Castrén et al., 2013) loneliness was associated with problem gambling
in regression analysis, interestingly however it was not associated with more severe
gambling-related problems (such as gambling disorder). In another cross-sectional
Finnish study looking at a population sample (Nordmyr et al., 2016), loneliness was
associated with problem gambling. Sirola et al. (2019) found that excessive gambling
was higher among young Finns who reported higher levels of loneliness, with loneliness
also positively moderating the association between excessive gambling and daily online
gambling community participation in one of the included study samples. On the other
hand, a Finnish study did not show loneliness to be associated with at-risk or problem
gambling among young men or women in the most comprehensive models applied in the
study (Edgren et al., 2016). Further, a study looking at loneliness in relation to gambling
or risk-problem gambling among Norwegian youth evidenced no significant results
(Hanss et al., 2015). Another Norwegian study (Sagoe et al., 2017) similarly showed
that neither loneliness at age 19 nor at age 17 were associated with gambling or risk-and
problem gambling. Loneliness was, however, associated with lower odds of risk-or
problem gambling, compared to no gambling, among 17-year-olds. In a population
study by Castrén et al. (2018) loneliness was not included in regression analyses
predicting gambling expenditure in order to avoid multi-collinearity.

The collected evidence on experienced loneliness – qualitative findings

An interview and observation study (Lalander, 2006) exploring social dimensions of
Swedish gambling machine environments specifically mentioned loneliness in the results
section under the theme The gamblers and the staff/owners of restaurants: ‘For the
customer, who might otherwise have felt lonely, this social contact nonetheless had great
importance’. In the group interview material studied by Pöysti and Majamäki (2013), an
emerged theme was Social and situational pathways. Here, Finnish and French recrea­
tional gamblers expressed the view that social and situational issues such as loneliness
and relationship problems were risk pathways that may lead to problem gambling.
Finally, interview data from the longitudinal Swedish Swelogs study (Samuelsson
et al., 2018) showed that important life events (many of them of a social nature such
as relationship breakdown) and Lack of supportive network and meaningful employment
were identified as factors increasing the risk for increased gambling engagement and
related problems. Here the authors specifically mention that ‘Loneliness, unemployment,
and problems with social relations were also reported as reasons for gambling taking
precedence in life’ (p. 518).

The collected quantitative evidence on experienced social support

The results concerning social support – either from parents, peers or other people, e.g.,
teachers – were mixed. A Finnish study (Räsänen et al., 2016a) found that social support
from parents and school staff decreased gambling among both boys and girls, whereas social
support from friends increased boys’ gambling (no association for girls). Räsänen et al.
(2016b), utilising the same data, mirrored these results for boys and girls with regard to
support from parents and school personnel and also the positive association between boys
gambling and social support from friends. However, for girls, social support from friends
was negatively associated with gambling. Another study (Oksanen et al., 2019), found that
weaker social support from close people was associated with competent gambling among
272 J. Nordmyr and A.K. Forsman

young Finns, while higher perceived social support was associated with entertainment
gambling. In another Finnish study, no direct associations were found between social support
from close people and problem gambling, while high levels of social support did moderate
the association between peer group identification and problem gambling (Savolainen et al.,
2019). On the other hand, Fröberg et al. (2013) did not find social support to be associated
with gambling among young Swedes, and Nordmyr et al. (2016) did not find social support
to be associated with problem gambling in a Finnish sample. A Swedish longitudinal
population study similarly found that social support did not predict online gambling
(Svensson & Romild, 2011).

The collected qualitative evidence on experienced social support

Looking at longitudinal interview data, Samuelsson et al. (2018) found that factors
increasing gambling included important life events (many of them of a social nature),
and Lack of supportive network while Support from significant others also appeared
when looking at factors decreasing gambling and helping a person abstain from
gambling.

Research design of the included studies

When reviewing study quality (see Table 1), the majority of included studies were rated
as being of good quality. Six of the included studies applied different interview, observa­
tion or narrative methods while the remaining 15 studies applied statistical approaches.
Considering the studies applying statistical methods, most were of a cross-sectional
nature utilising representative population survey data. Four publications utilised data
from one or more waves of longitudinal or follow-up studies (Kristiansen et al., 2015;
Lyk-Jensen, 2010; Sagoe et al., 2017; Samuelsson et al., 2018). Regarding measurement
of a psychosocial dimension, several standardised instruments and scales were used
alongside single-item questions (see Table 1 for full range of measures), for example,
Roberts’s 8-item loneliness scale (Roberts et al., 1993); the Oslo 3-item Social Support
Scale (OSS-3, Brevik & Dalgard, 1996); and the six-item Family Relations/Cohesion
scale (as described in Oregon Mentors, 2019). Statistical methods used can be found in
Table 1.
Within the cluster of studies applying a qualitative design, varying individual and
focus group approaches, ethnographic observations and elicited written data methods
were used. Further information on the analyses and common themes generated from the
collected data can be viewed in Table 1.

Discussion
In this review, we focused on psychosocial factors – functional or qualitative aspect of
networks and relationships – in relation to gambling and problem gambling; an under-
explored research area. The heterogeneity in research design and outcome measures used
in the included studies meant that this review takes the form of a narrative evidence
synthesis. We limited our review to studies carried out in Nordic contexts where lone­
liness and social support emerged as the most commonly studied psychosocial phenom­
ena. The included studies also encompassed analysis of psychosocial phenomena such as
family cohesion or family satisfaction, where the evidence is limited to a single study
Table 1. The methods and key findings of the included studies (n = 21).
Author (year) Country
Quality appraisal Data
Castrén et al. (2013) -Cross-sectional population survey
Finland (Finnish Gambling 2011)
Overall quality score:+ -Computer-assisted telephone interview
Internal validity score:+ survey
External validity score:++ -Original sample size 16,000 15–74-year
olds, random sample
-Past-year gamblers (n = 3451) selected
from total respondents (n = 4484),
53.2% males, mean age 44.3
Castrén et al. (2018) -Cross-sectional population survey
Finland (Finnish Gambling 2015)
Overall quality score:+ -Computer-assisted telephone interview
Internal validity score:+ survey
External validity score:++ -Original sample size 7400 15–74-year
olds, random sample, response rate 62%
(n = 4515)
-Past-year gamblers (n = 3251) selected
from total respondents: 1418 females
(mean age 47.6), 1833 males (mean age
45.1)
Edgren et al. (2016) -Cross-sectional population survey
Finland (Finnish Gambling 2011)
Overall quality score:+ -Computer-assisted telephone interview
Internal validity score:+ survey
External validity score:+ -Study sample (n = 822) selected from
total respondents (n = 4484)
-16–28-year olds, 49.3 per cent female
Design
Psychosocial measure/
dimension Analyses Key findings
Loneliness (single-item Multinomial regression Loneliness associated with
question) analyses problem gambling
(OR 3.47, CI 1.98–6.05,
p < 0.001) compared to
non-problem gamblers and
people experiencing
gambling disorder
Loneliness (single-item Multiple log-linear Loneliness and past-year
question) regression, likelihood game types gambled
ratio test removed from regression
models predicting
gambling expenditure to
avoid multi-collinearity
Loneliness (single-item Binary logistic regression Loneliness did not predict at-
question) models, calculated risk and problem gambling
separately for males/ for males or females in the
females most comprehensive model
Health, Risk & Society
(n.s).
273
(continued )
 274

Table 1. (Continued ).

Design

Author (year) Country Psychosocial measure/

Quality appraisal Data dimension Analyses Key findings

Fröberg et al. (2013) -Cross-sectional population survey Social support Multinomial logistic Social support did not predict
Sweden (Swedish National Public Health Defined by two questions regression analyses gambling or problem
Overall quality score:+ Survey) that were collapsed gambling compared to
Internal validity score:+ -Postal questionnaire, national register non-gambling among
External validity score:++ variables linked to data women (not analysed for
J. Nordmyr and A.K. Forsman

-Average response rate 60.1 per cent men) (n.s).

(years 2004–07)
-Study sample, n = 19,016 (16–24-year
olds, 55.6% female) selected from
2004–07 pooled data (total n = 170,327,
age range 16–84)
Hanss et al. (2015) -Cross-sectional population survey of 17- Loneliness Fisher’s Exact tests, Loneliness did not predict
Norway year old Norwegians Robert’s UCLA multinomial logistic gambling or risk-problem
Overall quality score:++ -Postal questionnaire with online option Loneliness Scale regression analyses gambling compared to
Internal validity score:++ -3000 recipients, randomly selected, (8-items) (Roberts et al., non-gambling (n.s).
External validity score:++ response rate 70.4% 1993) Family cohesion did not
-n = 2059 (52.9% female) Family Relations/ predict gambling or risk-
Cohesion problem gambling
Six-item Family Relations/ compared to non-gambling
Cohesion scale (Oregon (n.s.)
Mentors, 2019)
(continued )
Table 1. (Continued ).

Design

Author (year) Country Psychosocial measure/

Quality appraisal Data dimension Analyses Key findings

Kristiansen et al. (2015) -Interview study Semi-structured -Theory-driven and data- Themes
Denmark -Data stemming from wave I of interviews. Interview driven coding. Focus onFamily
Overall quality score:+ a qualitative longitudinal prospective schedule contained social learning processes Feelings of community
Internal validity score:+ study of gambling behaviour among themes: initial gambling involving relationships, specifically mentioned
External validity score:+ Danes aged 12–20 experiences, current family and peer group Peer groups
-Recruitment from schools in the Aalborg gambling behaviour, interactions Maintaining a sense of
region, 1034 respondents completed self-perceived gambling -Cross-sectional and belonging
a questionnaire, volunteer interview abilities, friends, and within-case analysis to a social community
participants recruited from these social networks specifically mentioned
respondents. Snowballing technique also
applied
-People with a range of gambling
experiences included
-n = 52, ages 12–20
Lalander (2006) -Interview and observational study Core questions: What type Thematic analysis of social Themes
Sweden -18 interviews conducted in 2 Swedish of sociality does the dimensions of gambling The gamblers and the staff/
Overall quality score:+ cities (5 locations) Jack Vegas environment machine environments. owners of restaurants
Internal validity score:+ -9 informants recruited at gaming create? What types of Description of gambler Loneliness specifically
External validity score:+ locations, 6 via personal contacts, 3 gamblers develop in types in relation to mentioned
through associations for compulsive these environments? earlier research
gamblers
-Selection criterion: experienced regular
gamblers (Jack Vegas machines)
-130 participatory observations made (the
Health, Risk & Society

researcher played the game alongside

players)
(continued )
275
 276

Table 1. (Continued ).

Design

Author (year) Country Psychosocial measure/

Quality appraisal Data dimension Analyses Key findings

Lyk-Jensen (2010) -Cross-sectional national survey (two
Denmark waves)
Overall quality score:+ -Interviews conducted by phone and face-
Internal validity score:+ to-face
External validity score:+ - 11,737 Danes aged 18–74 randomly
selected, first wave response rate ~70%
(n = 8153)
The second wave included: Logistic regression Negative childhood and
Conditions in respondent’s analyses adolescence experiences
childhood and did not differentiate at-risk
adolescence gamblers from no-risk
Questions on for example, gamblers in t-test, variable
-Solitary and left out not included in regression
feelings analyses (n.s.)
J. Nordmyr and A.K. Forsman

-Second wave subsample n = 453, -Felt understood

response rate ~63% (items specified in Bonke,
Current non-gamblers and problem 2007)
gamblers excluded – first wave
subsample n = 4932 current non-
problem gamblers (4790 no-risk, 142 at-
risk), second wave subsample n = 379
current non-problem gamblers (295 no-
risk, 84 at-risk)
Matilainen and Raento -Narrative study (elicited written data) Narratives in which Data triangulation. Data Themes
(2014) -Two sets of narratives: 230 respondents respondents address complemented with Rituals of belonging and self-
Finland (1061 pages), 28 respondents (250 their first contacts with authors’ auto- determination
Overall quality score:+ pages) gambling selected ethnographic The described feelings of
Internal validity score:+ -40 narratives on hobby gambling by observations. togetherness, belonging
External validity score:+ gamblers born between 1922–1982 Content and discourse
selected (25% women, average age analyses
57 years)
(continued )
Table 1. (Continued ).

Design

Author (year) Country Psychosocial measure/

Quality appraisal Data dimension Analyses Key findings

Nordmyr et al. (2016) -Cross-sectional postal questionnaire Loneliness (single-item Stepwise logistic Loneliness predicted problem
Finland survey (2011 Western Finland Mental question) regression analyses gambling:
Overall quality score:+ Health Survey) Social support Experiencing loneliness
Internal validity score:+ -10,000 recipients randomly selected, age Oslo 3-item Social seldom OR1.68 (95% CI
External validity score:+ range 15–80, 2011 response rate 46.2% Support Scale, OSS-3 1.00–2.84)
(n = 4624, 57.1% women) (Brevik & Dalgard, Experiencing loneliness often
1996) OR 3.02 (95% CI
Trust 1.77–5.16)
Trust in people in one’s Low trust in neighbourhood
neighbourhood predicted problem
General trust gambling
OR 1.92 (95% CI 1.21–3.05)
General trust did not predict
problem gambling (n.s.)
Social support did not predict
problem gambling (n.s.)
Oksanen et al. (2019) -Cross-sectional survey (YouGamble Social support (single-item Principal component Weak social support
Finland online survey) question) analysis, ordinary least associated with competent
Overall quality score:+ -Participants recruited from pool of squares regression gambling (B – 0.30, SE
Internal validity score:+ volunteer respondents provided by 0.13, β –.06, p =.018)
External validity score:+ Survey Sampling International, sample High social support
stratified associated with
-n = 1200, age range 15–25 (mean age entertainment gambling (B
21.3), 50% female 0.17, SE 0.06, β.08,
p =.007)
Pöysti and Majamäki -Interview study Discourses focusing on Reception Analytical Themes
(2013) -14 group interviews conducted in processes leading to Group Interview Social and situational
Finland Finland, 14 in France problem gambling (RAGI) method pathways
Health, Risk & Society

Overall quality score:+ -Self-identified recreational gamblers coded Problems with relationships
Internal validity score:+ recruited from gambling venues or lack thereof mentioned
External validity score:+ -110 gamblers participated (54 women) as a potential pathway,
277

loneliness specifically
mentioned
(continued )
Table 1. (Continued ).
278

Design

Author (year) Country Psychosocial measure/

Quality appraisal Data dimension Analyses Key findings

Räsänen et al. (2016a) -Cross-sectional, population survey Social support Kruskall – Wallis test, Support in relation to
Finland (School Health Promotion Study) Social support from Mann-Whitneys’ u-test, frequent gambling (Boys)
Overall quality score:+ -In 2010, 78% of Finnish 8th and 9th friends (one item) Path analysis School staff
Internal validity score:+ graders surveyed, in 2011 81% of 8th Social support from school 8th grade β – 0.11
External validity score:++ and 9th graders participated personell (five variables (p < 0.001)
-102,545 8th and 9th grade students, 51% created sum variable) 9th grade β–0.13 (p < 0.001)
girls Social support from Parents
-Total n = 62,956. Adolescents who had parents (four variables) 8th grade β – 0.13
not gambled during the previous year (p < 0.001)
J. Nordmyr and A.K. Forsman

(37.3%) or who did not answer the 9th grade β–0.10 (p < 0.001)
question concerning gambling (1.3%) Friends
excluded 8th grade β 0.09 (p < 0.001)
9th grade β 0.08 (p < 0.001)
Support in relation to
frequent gambling (Girls)
School staff
8th grade β – 0.07
(p < 0.001)
9th grade β–0.09 (p < 0.001)
Parents
8th grade β – 0.08
(p < 0.001)
9th grade β–0.07 (p < 0.001)
Friends (n.s.)
Social support did not act as
a mediator between poor
health and gambling or
between health risk-taking
and gambling (n.s.)
(continued )
Table 1. (Continued ).

Design

Author (year) Country Psychosocial measure/

Quality appraisal Data dimension Analyses Key findings

Räsänen et al. (2016b) -Cross-sectional population survey (School Social support Mann-Whitney U test, Support in relation to
Finland Health Promotion Study) Social support from structural equation frequent gambling (Boys)
Overall quality score:+ -In 2010, 78% of Finnish 8th and 9th friends (one item) modelling School staff
Internal validity score:+ graders surveyed, in 2011 81% of 8th Social support from school 8th grade β – 0.11
External validity score:++ and 9th graders surveyed personnel (five variables (p < 0.001)
-In total, 102,545 8th and 9th grade created sum variable) 9th grade β–0.13 (p < 0.001)
students participated, 51% girls Social support from Parents
-Total n = 62,956. Adolescents who had parents (four variables) 8th grade β – 0.09
not gambled during the previous year (p < 0.001)
(37.3%) or did not answer gambling- 9th grade β–0.08 (p < 0.001)
related question (1.3%) excluded. Friends
8th grade β 0.07 (p < 0.001)
9th grade β 0.04 (p < 0.001)
Support in relation to
frequent gambling (Girls)
School staff
8th grade β – 0.06 (p < 0.01)
9th grade β–0.11 (p < 0.001)
Parents
8th grade β – 0.10
(p < 0.001)
9th grade β–0.06 (p < 0.001)
Friends
8th grade β – 0.08 (p < 0.01)
9th grade β–0.09 (p < 0.001)
Indirect effects indicated that
social support mediated the
relationship between
Health, Risk & Society

problem behaviour and

gambling frequency, with
the exception of social
279

support from friends

(continued )
 280

Table 1. (Continued ).

Design

Author (year) Country Psychosocial measure/

Quality appraisal Data dimension Analyses Key findings

Sagoe et al. (2017) -Longitudinal survey study of young Loneliness Latent class analysis Loneliness at age 17
Norway Norwegians Robert’s UCLA associated with lower odds
J. Nordmyr and A.K. Forsman

Overall quality score:++ -Self-completion questionnaire Loneliness Scale of belonging to risky-and

Internal validity score:++ -3000 individuals aged 17 randomly
External validity score:++ selected, final sample n = 2055, females
53.0 per cent. Response rate 70.4%
-2012 respondents contacted again in 2013
(aged 18 years). In the second wave, 1
334 individuals responded (females
58.7%, retention rate 64.9%)
-First wave respondents contacted again in
2014 (aged 19 years). 1277 individuals
responded (females 61.7%, retention
rate 62.1%)
(8-items) (Roberts et al., problem gambling class
1993) compared to no gambling
(OR 0.30, 95% CI 0.12 to
0.75, p ˂ 0.011)
Loneliness not associated
with gambling compared
to non-gambling (n.s).
At age 19 loneliness not
associated with gambling
or risky-and problem
gambling compared to
non-gambling (n.s).
(continued )
Table 1. (Continued ).
Author (year) Country
Quality appraisal Data
Samuelsson et al. (2018) -Longitudinal study (The Swedish
Sweden longitudinal gambling study Swelogs)
Overall quality score:++ -The study comprised an epidemiological
Internal validity score:++ track and an in-depth track, an
External validity score:++ epidemiological track sub-sample
followed
-Study inclusion criteria: having gambled
at least monthly during the past
12 months, having participated in at
least three Swelogs epidemiological
track studies, having a minimum of
a three-point difference in PGSI scores
between two data collections. Among
those who met these criteria, 102
individuals sampled, 40 gamblers
interviewed (19 women, 21 men, mean
age 37)
Design
Psychosocial measure/
dimension Analyses Key findings
Semi-structured interview -Cases categorised based Themes
guide, covering current on extent of harm, Factors increasing gambling:
and previous gambling, gambling intensity over Important life events
personal circumstances, time, stability versus Lack of supportive network
negative consequences, change, pace of change and meaningful
reasons for changes in -Using framework employment (loneliness
gambling behaviour and matrices, broad themes specifically mentioned)
problems and categories identified These two themes only for
within and across cases, fluctuating and increasing
resulting in four gambling intensity:
configurations of change periodic gambling with
and harm. moderate harm and high-
Configurations frequency gambling with
constructed on four substantial harm
dimensions: pattern of Factors decreasing
change, harm level, gambling:
gambling motives, Important life events
factors of importance This theme for: high-
for change frequency gambling with
occasional harm and periodic
gambling with
moderate harm
Criticism, demands and
support from significant
others
This theme for high-
frequency gambling with
occasional harm; periodic
Health, Risk & Society
gambling with
moderate harm; high-
frequency gambling with
281
substantial harm
(continued )
 282

Table 1. (Continued ).

Design

Author (year) Country Psychosocial measure/

Quality appraisal Data dimension Analyses Key findings

Savolainen et al. (2019) -Cross-sectional survey (YouGamble Social support (single-item Linear regression analysis, High perceived social support
Finland online survey) question) moderation and slope not associated with lower
Overall quality score: - -Finnish and U.S. participants recruited difference analysis problem gambling (n.s)
Internal validity score: + from volunteer pool administered by High perceived social
J. Nordmyr and A.K. Forsman

External validity score:- Survey Sampling International support moderated the

-1200 Finnish young people aged 15–25 association between
(mean age 21.3, 50% female) problem gambling and
peer group identification
with both offline peers
(B = −.22, SE =.10, t
(1199) = −2.27, p =.024)
and online peers (B = −.27,
SE =.10, t(1199) = −2.61,
p =.009)
Slope difference test results
not country-specified (not
reported on here)
(continued )
Table 1. (Continued ).
Author (year) Country
Quality appraisal Data
Sirola et al. (2019) -Cross-sectional survey (YouGamble
Finland online survey)
Overall quality score:+ -Finnish and US participants
Internal validity score:++ -Finnish sample 1 (n = 1 200) recruited
External validity score:- from pool of volunteer respondents
administrated by Survey Sampling
International
-Age 15–25 (mean 21.3, 50% female)
-Finnish sample 2 (n = 230) recruited from
Finnish social networking site
(convenience sampling)
-Age 15–30 (mean 24.3, 53.5 per cent
female)
Svensson and Romild -Longitudinal survey (Swelogs population Social support
(2011) study conducted in 2008/09, waves
Sweden I and II)
Overall quality score:++ -Stratified sample, computer-based
Internal validity score:++ telephone interviews
External validity score:++ -Age range 16–84
-Response rate phase I 63% (n = 8165),
weighted response rate phase II 80%
(n = 6017)
Design
Psychosocial measure/
dimension Analyses Key findings
Loneliness Multivariate logistic Excessive gambling higher
Three-Item Loneliness regression analysis among those reporting
Scale higher level of loneliness
in Sample 1 (OR 1.75,
p < .001, 95% CI
1.47–2.09.) and Sample 2
(OR 1.81, p =.003
95 per cent CI 1.22–2.69)
Loneliness moderated the
association between
excessive gambling and
daily online gambling
community participation in
Finnish Sample 1
(OR = 1.20, z = 2.74,
p =.006), Sample 2 (n.s)
Multivariate logistic Social support not associated
(instrumental and regression models with incident Internet
emotional) gambling (n.s.)
(Items detailed in Romild
et al., 2014)
Health, Risk & Society
(continued )
283
Table 1. (Continued ).

Design
284

Author (year) Country Psychosocial measure/

Quality appraisal Data dimension Analyses Key findings

Svensson and Sundqvist -Cross-sectional survey (2014 annual
(2019) Swedish school survey)
Sweden -Paper-and-pen questionnaire
Overall quality score:+ -Annual samples comprise ~9000
Internal validity score:+ individuals (roughly equal number of
External validity score: boys/girls)
+ -2014 sample: Grade 9 (n = 4763, girls
2272), Grade 11 (n = 3720, girls 1842)
-Response rate 85% (Grade 9), 83%
(Grade 11)
Family satisfaction (single- Poisson multivariate Family satisfaction not
item question) regression models associated with past-year
gambling or past-year
frequent gambling,
variable not included in
final analyses (n.s.)
J. Nordmyr and A.K. Forsman

Svensson (2011) -Interview study, participants two males Analyses of young
Sweden
Overall quality score:-
Internal validity score:-
External validity score:-
and one female aged 17–19
No information available Themes
people’s gambling and Gambling – lifestyle and
gambling careers as identity
a part of their Relevant subtheme
internalisation of adult Electronic and virtual friends
habits Search for belonging and
fellowship specifically
mentioned
Young people’s gambling
careers
Relevant subthemes:
The first phase of the
gambling career –
gambling within the family
The second phase of the
gambling career –
gambling with one’s peers
outside of the family
No psychosocial phenomena
specifically mentioned
under these themes
 Health, Risk & Society 285

applying quantitative methods. The evidence on feelings of belonging and togetherness

was on the other hand limited to interview studies.
The results regarding experienced loneliness and social support are mixed, with varying
evidence concerning the role and direction of psychosocial pathways, in part due to most of
the included studies being of a cross-sectional nature. Here studies applying qualitative
approaches serve to highlight the inherent complexity of psychosocial phenomena. As earlier
highlighted by Holdsworth et al. (2015), psychosocial factors may constitute risk and
protective factors in themselves, they can be the result of problems related to gambling,
and they can also have a mediating/moderating effect on the links between various factors
and gambling or problem gambling through functioning as resiliency factors and in influen­
cing coping (for example, social support). In the study by Savolainen et al. (2019), no direct
associations were found between social support and problem gambling, while social support
moderated the association between peer group identification and problem gambling. Among
Finnish young people, problem gambling was more common among those who strongly
identified with an online peer group but experienced low social support.
Reith and Dobbie (2013) have earlier highlighted inter- and intra-individual variance in
positive or negative consequences of life events and social networks for both reducing and
increasing gambling behaviour. The Swedish longitudinal study by Samuelsson et al.
(2018) echoes these findings and illustrates well the complexity in the role of psychosocial
factors as both risk and supportive factors. This can help explain the differing, arguably
contradictory, results of some studies. Räsänen et al. (2016a), for example, showed that
gambling among boys was correlated with positive social support from friends (as opposed
to negative correlations with support from parents or school staff). This result can be
considered in light of an earlier study showing that young people who get along with, and
are liked by, their peers were found to be more at risk for problem gambling (Yücel et al.,
2015). On the other hand, the study by Sagoe et al. (2017) included in this review found
loneliness among 17-year-olds as a factor decreasing the risk of problem gambling.
Given these aforementioned examples of the complexity of psychosocial phenomena,
it is viewed as a particular strength that the multi-level model of Wardle et al. (2018)
highlights how risk factors on interrelated levels can act as determinants of problem
gambling and also how harms can be experienced across these levels. Our review
findings support the recognition of not only structural factors related to an individuals’
social networks and relationships in this model, but also related experiences, as risk (but
also in some instances protective) factors to consider in relation to the onset, occurrence
or reoccurrence of problem gambling. While social support is the only psychosocial
factor (as labelled in this review) included in the model, our findings highlight loneliness
as a factor also evidencing some research support. As emphasised by Wardle and
colleagues and also Abbott et al. (2018), a sole focus on personal characteristics in
relation to problem gambling overlooks relevant contextual features. The findings of this
review support and strengthen this notion that prevention should not concentrate exclu­
sively on risk and protective factors at the individual or societal and communal levels,
but also action to influence and mitigate risks at the inter-personal level.
Together with other approaches to health epidemiology such as life course
approaches, the psychosocial approach directs more research emphasis to the risk and
protective pathways and mechanisms mediating the influences of multi-level social
determinants on health and health problems. While it is established that social factors
on the macro-level, shaped by socioeconomic and political context, as well as individual-
level circumstances and socioeconomic position contribute to a person´s experience of
286 J. Nordmyr and A.K. Forsman

health and wellbeing (e.g., Marmot et al., 2012), individual-level psychosocial factors are
increasingly recognised as influencing these effects (Aldabe et al., 2011; Moor et al.,
2014, 2017). The findings from these large-scale studies highlight psychosocial factors
such as social support as a target for prevention interventions to decrease broad health
inequalities due to their direct and indirect impacts on health.
In the context of gambling activities and related potential risks more specifically, the
limited but growing evidence on psychosocial pathways offers a basis for new
approaches, warranting new multi-professional cooperation in both the implementation
and evaluation of prevention initiatives. This should be considered in relation to the field
of primary and secondary prevention interventions targeting problem gambling, where
the majority of existing interventions aim to control the gambling environment and the
promotion of responsible gambling by individuals (McMahon et al., 2019; Williams,
West et al., 2012). Factors such as support networks, provide a framework on which
prevention and support interventions can be based (Holdsworth et al., 2015).

Study limitations
Common limitations in review methodology concern for example, journal indexing or
bibliographical information records affecting the screening process. It is considered
a strength that the search strategies focused on gambling studies broadly, limiting the risk
of missing studies due to narrow interpretations or labelling of psychosocial concepts by the
reviewers. As this review is limited to publications in international scientific journals,
potentially relevant studies published in more limited fora (in terms of e.g., language) are
not included. The strength of limiting the review to these publications is increased rigour
through e.g., systematic and detailed information in publication coding in research databases
as well as improved possibilities for study replication. As database searches were not limited
to certain study designs or methods, studies applying various interview or narrative
approaches were screened for inclusion. It can be noted that the number of Nordic gambling
studies applying interview or narrative methods is limited in number compared to those
applying statistical methods – a gap in the field in itself.
The overall quality of the studies included in the review was overall high. We do not
consider that the removal of three studies with a higher level of perceived limitations
would have drastically altered our review findings.
This review was limited to the Nordic context. From the risk approach perspective, it is
justified to focus on the unique welfare state context that the Nordic countries constitute (e.g.,
Esping-Andersen, 1990). The Nordic context simultaneously exhibits high prevalence of
gambling activities and, from a public health point of view, relatively low rates of problem
gambling within the population (Nordic Welfare Centre, 2017). This motivates the study of
social circumstances and especially the under-researched psychosocial risk factors eviden­
cing influences on, or associations with, gambling or problem gambling in this context.
Apparent differences in three included studies encompassing comparative elements with
participants from the U.S. (Savolainen et al., 2019; Sirola et al., 2019) and France (Pöysti &
Majamäki, 2013) mean that the applicability of review results to other contexts is cautioned.

Conclusion
Our research contributes to synthesising the limited evidence base on psychosocial risks and
pathways in relation to gambling-related issues in the Nordic context where gambling is
 Health, Risk & Society 287

prevalent. The findings highlight lesser researched psychosocial phenomena and synthesise
the evidence on the most commonly featured psychosocial factors in the included publica­
tions – loneliness and social support. Although few studies carried evidence supporting
causal inferences, the review findings highlight focal areas that should be considered in
future research and practice, broadening the concept of social factors and circumstances by
including also inter-personal psychosocial factors in the understanding of the risk pathways
and related prevention strategies targeting problem gambling.

Disclosure statement
No potential conflict of interest was reported by the authors.

Supplementary material
Supplemental data for this article can be accessed here.

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