How to Support Prison Workers’ Perceived Readiness to Identify and Respond to Possible Gambling Problems: a Pilot Study from Two Finnish Prisons

Problem gambling is known to be prevalent among prisoners. However, it is not systematically screened and often remains undetected. This pilot study explores prison workers’ (N = 21) knowledge, views, and opinions about problem gambling in two Finnish prisons with a view to improving training and to developing better guidelines for identifying and responding to gambling problems. Four-fifths (81%) of prison workers considered problem gambling a serious issue in Finland. During the past year, more than nine in ten (94.1%) had encountered a prisoner with a gambling problem. Problem gambling was identified in connection with discussions about prisoners’ illegal activity (50%), financial situation (25%), or other problems (25%). Nearly half of the participants felt they did not have adequate training or information about problem gambling and related issues and expressed an interest in continuing education. This pilot study provides important direction for the development of tailored training programs for prison workers. The next step is to increase awareness of gambling programs in a wider national context and to develop and evaluate the effectiveness of training programs.

The Criminal Sanctions Agency operates 26 prisons across Finland. There are two types of prisons, viz. closed prisons and open institutions. From the beginning of 2016, the Criminal Sanctions Agency's Health Care Unit was renamed as the Prisoners' Health Care Unit and transferred under the supervision of the National Institute for Health and Welfare (THL). The purpose of the reorganization was to integrate prisoners' health care more closely with wider health care services and to improve the monitoring of health care provision. This will guarantee that prisoners have the same rights to health care as the general population (e.g., Turner 2017).
This current study stems from our earlier findings which showed that professionals in different social work and health care settings and in the addiction field in particular regard problem gambling as a more serious concern than the general public (Castrén et al. 2016;Salonen and Raisamo 2015). Professionals also thought that gambling problems had increased more than the general public did (Castrén et al. 2016;Salonen and Raisamo 2015). This may reflect the lay perception of gambling as a harmless hobby (Campbell et al. 2011), whereas professionals have a keener awareness of the potential problems involved. Our findings furthermore showed that professionals had gaps in their knowledge about problem gambling, but were interested in attending continuing education , which is in line with another Finnish study (Castrén et al. 2016) and two studies from other countries (Derevensky et al. 2013;Temcheff et al. 2014). Our earlier work prompted greater interest among professionals in problem gambling and in continuing education in the form of tailored workshops with supportive materials (e.g., Hodgins and Makarchuk 2002).
In this study, we address problem gambling in a Finnish prison setting. Our aim is to increase awareness among prison workers about gambling problems and to provide guidelines to support their intervention efforts. The present pilot study was designed to gauge prison workers' views and opinions about prisoners' problem gambling, the nature of problem gambling in the prison setting, their knowledge, skills, and readiness to provide support for individuals with gambling problems, and their interest in continuing education.

Participants and Procedure
The data were collected between December 2017 and January 2018 in two Finnish prisons, one closed high-security prison and one open prison. The two prisons represent two different types of penitentiaries, both in the criminal sanctions region of Western Finland. Turku prison is a closed high-security prison with a capacity of 255 prisoners. Vanaja is an open prison with a capacity of about 100 inmates in two units, one in Vanaja for women and one in Ojoinen for men. Such open prisons are often the last step of a prison sentence before inmates make the transition back to regular life. The prison workers recruited for the study were to work closely with prisoners or be involved in their sentence planning (criminal sanctions managers, counselors, guards, prison chaplains, and prison directors). The researchers (KL, SC) visited the prisons personally to promote the study. The structured questionnaires were collected in sealed ballot boxes to ensure confidentiality and the boxes were placed in suitable and selected places (lunch and break room) in both prisons chosen by the prison heads as the preferred method of data collection. All participants received written information about the principles of confidentiality and voluntary participation in the study.
This study used a questionnaire modified from an earlier survey we had developed for purposes of assessing professionals' knowledge, skills, and readiness to provide support for problem gambling and their interest in continuing education about problem gambling and related issues (Castrén et al. 2016). Replicating a question from the Finnish Gambling population survey (e.g., Salonen and Raisamo 2015), we asked how they thought the prevalence of problem gambling had developed recently and how concerned they were about the trend. The total number of targeted professionals working in these two prisons was 27. The response rate was 78%.

Views and Opinions about Problem Gambling
Awareness about problem gambling was examined with two questions: "Is problem gambling a serious concern in Finland?" (response options yes, no, do not know) and "Have gambling problems increased, remained the same, or decreased during the past years?" (response options increased, remained the same, decreased, do not know). These same questions were used in the epidemiological Finnish Gambling 2015 survey (n = 4515) (Salonen and Raisamo 2015).

Encountering Prisoners with Possible Gambling Problems
Participants were asked how many prisoners with possible gambling problems they had encountered during the past year (response options 1 = none, 2 = 1-3, 3 = 4-10, 4 = 11-20, 5 = more than 20). They were also asked to identify the type(s) of game that in their view were causing problems to prisoners. The specified game types included electronic gambling machines (EGMs), betting games provided by the Finnish monopoly operator, horse race betting games, casino games, online poker, and other games. Furthermore, an item was included concerning the specific context in which problem gambling was identified (six response options: appointment focused on problem gambling; appointment focused on social and relationship issues with family members or significant others; assessment of some other health issues; discussions about financial issues; discussions about underlying illegal activity; or some other situation).

Confidence in Ability to Provide Services and Needs for Continuing Education
Skills and qualifications as well as readiness to provide support for gambling problems were inquired with the question: "How would you define the skills and qualifications you gained in your training: are they sufficient to provide adequate support to individuals with problem gambling and their significant others?" (response options: very sufficient, rather sufficient, neither sufficient nor insufficient, rather insufficient, very insufficient, do not know). The participants' current knowledge about problem gambling was inquired with the question: "Is your current knowledge about problem gambling very sufficient, rather sufficient, neither sufficient nor insufficient, rather insufficient, very insufficient, don't know." We also asked whether the participants had attended any continuing education regarding problem gambling. In addition, the participants were asked about their willingness to receive continuing education about problem gambling and related issues: "Please rank the following topics in order of interest, with 1 being the most interesting topic and 6 indicating no interest". The topics listed were the following: information about problem gambling (prevalence, causes, consequences); tools for recognizing, screening, and assessing problem gambling; treatment of problem gambling; information about support and help services, something else, no interest.

Descriptive Information
Background information was collected on gender, age, educational level, work organization, position at work, and work experience.

Ethics
The study was conducted in accordance with the ethical standards of the Declaration of Helsinki. The Ethics Committee of the National Institute for Health and Welfare, Finland, approved the research protocol (THL/1701/6.02.01/2017). Additional approval was obtained from the Criminal Sanctions Agency. Potential participants received written and verbal information about the study and the principles of voluntary participation.

Data Analysis
The data were analyzed using SPSS 25 software (SPSS, Inc., Chicago, IL, USA) and summarized using descriptive statistics.

Participants
Three-quarters (76.2%) of the 21 prison workers who took part in the study were women and 14.3% were men; gender information was missing in two cases (9.5%). The participants' mean age was 49.63 years (SD 9.36). Over half (52.4%) had a university education, 14.3% had a higher university degree, 23.8% had a vocational level education, and 4.8% indicated that they had not yet completed their education. Over one-third (38.1%) of the participants worked in the closed high-security prison and 61.9% in the open prison. The participants occupied the following positions: criminal sanctions manager (4.8%); rehabilitation team counselor (14.3%); rehabilitation special counselor (33.3%); guard (19.0%); other counselor (9.5%); and three participants were prison directors and prison chaplains who were categorized as other (14.3%). Table 1 describes the participants' work experience in years.

Views and Opinions About Problem Gambling
The vast majority, 85% (n = 18) of the participants regarded problem gambling as a serious issue in Finland. The same number felt that gambling problems have increased; one participant (4.8%) thought there had been no change; no one thought that gambling problems had decreased; and two (9.5%) did not know whether gambling problems had increased, remained the same, or decreased. Prison workers were more likely to regard problem gambling as a serious concern than any other group of professionals or the general public (85.7% as compared to 75.0% of social work professionals, 66.7% of addiction medicine professionals, and 44.8% of the general public). Prison workers also felt that gambling problems had increased more than other professionals (prison workers 85.7%, social work professionals 72.4%, addiction medicine professionals 65.0%, and general public 46.6%) (Castrén et al. 2016;Salonen and Raisamo 2015) (Table 2).

Encountering Prisoners with Possible Problem Gambling
Participants were asked how many prisoners with possible gambling problems they had encountered during the past year. Eight (38.1%) prison workers said they had encountered 1-3 individuals with possible gambling problems; seven (33.3%) had encountered 4-10 individuals with possible gambling problems; and one (4.8%) had encountered 11 or more inmates with gambling problems. The types of game identified as the major cause of these problems were EGMs (50.0%), betting games provided by Veikkaus (the national gambling operator) (43.8%), horse betting games (12.5%), casino games (31.3%), online poker games 50%, and other games 43.9%. Six participants (37.5%) indicated that possible problem gambling was identified by the prison worker in the context of discussions about underlying illegal activity, and 18.7% said it was identified in connection with the assessment of health or financial issues (Table 3).

Confidence in Ability to Provide Services and Needs for Continuing Education
Four participants (19.0%) felt that the skills and qualifications they had acquired in their training was sufficient (very/rather); six (28.6%) thought they were insufficient; 10 (47.6%) said they did not feel well equipped to support prisoners with gambling problems and their significant others; and one (4.8%) did not know. Sixteen (76.2%) had not participated in any continuing education regarding problem gambling. Three participants had attended gamblingrelated lectures, others had participated in training days or seminars (n = 1), attended a problem gambling course (n = 1), a problem gambling workshop (n = 1), and none of the participants had taken an online course related to problem gambling. Nine prison workers (42.9%) (n = 9) described their current knowledge about problem gambling as very/rather sufficient; seven (33.3%) (n = 7) felt their knowledge was neither sufficient nor insufficient; and five (23.8%) rated their knowledge as rather or very insufficient (Table 4).

Discussion
To the best of our knowledge, this is the first study that explores prison workers' views and opinions about problem gambling among prisoners, the nature of problem gambling in the prison setting, prison workers' knowledge, skills, and readiness to provide support for individuals with possible problem gambling, and their interest in continuing education. In order to increase prison workers' awareness about problems gambling and to develop suitable training programs for prison workers, it is important to have a basic understanding of how professionals see the problem.

Views and Opinions about Problem Gambling
The prison workers in our study regarded gambling as a serious problem in Finland: they took a more critical view than social and health care professionals (Castrén et al. 2016) and informants in other earlier studies (Table 2), including the Finnish Gambling 2015 population survey (Salonen and Raisamo 2015).
The prison workers in this study thought that gambling problems had increased in Finland. However, population surveys indicate that the prevalence of problem gambling has in fact been unchanged (Salonen et al. 2019a, b;Castrén et al. 2018). On the other hand, the severity of gambling-related harms has escalated among help-seeking gamblers over the past couple of years, as noted by Silvennoinen and colleagues (Silvennoinen et al. 2017) and Salonen and colleagues (Salonen et al. 2019a, b), which has resulted in their becoming visible at an earlier stage in certain services. It seems that social workers, prison workers, and professionals in the field of addiction medicine are more convinced than others that the problems have increased. This may reflect an overall increase in awareness among these groups (Silvennoinen et al. 2017).

Encountering Prisoners with Possible Problem Gambling
Most of our participants had encountered a prisoner with gambling problems during the past year. Gambling problems had been identified in connection with discussions about underlying illegal activities or assessments of either health or psychosocial issues. Both of those situations in which problem gambling was identified in prisons are clearly identified as gambling-related harms . Gambling-related crime is most often motivated by the need to finance gambling or to pay off gambling debts (Turner et al. 2009;Lind et al. 2015).
Excessive gambling often causes problems in social life and it can also impact health (Griffiths 2004;Langham et al. 2016) and prevent holistic recovery. It is reported that inmate gambling is occurring rather frequently (Turner et al. 2013;Lind et al. 2019) and that prison officers and staff members are aware of it (McEvoy and Spirgen 2012). Prison environment facilitates natural recovery from alcohol and drug addictions simply by limiting the availability of the substance. Incarceration obviously sets heavy restrictions also to gambling. However, due to wide availability of EGMs in Finland, in open prisons, legal gambling is still possible even when imprisoned, e.g., during supervised visits to the supermarket. Prisoners are also able to make bets via telephone (by ordering someone to make the bet for them) from the prison and to play, for example, money, food, or cigarettes with other inmates (McEvoy and Spirgen 2012). The extent of such activity is not known. In any case, untreated gambling problem is likely to increase the risk of reoffending and to impact their re-entry into society. On the other hand, incarceration, where legal gambling is not permitted, may serve as a boost for a change or "natural recovery," where recovery from gambling occurs using informal strategies (Vasiliadis and Thomas 2018) or without active treatment (i.e., Hodgins and El-Guebaly 2000). Early detection (screening) of possible problem gambling is essential in a prison setting in order to be able to tailor specific support for those in need or are motivated to make a change in their gambling behaviors or give support to prevent a relapse (O'Neil 2017) when released from prison or while incarcerated.
In Finland, there are currently no standard screening practices in place for the detection of problem gambling when people enter the correctional system, nor any systems for those in need of support or treatment (see also Turner et al. 2017). A formal screening and assessment procedure in connection with the prisoner intake process, for instance, might be able to highlight the need for specific areas of support and contribute to a more efficient process of developing "health plans" for prisoners (Cuardrado and Lieberman 2012). The difficulty in recognizing problem gambling often lies in its invisibility. Problem gambling includes comorbid problems, such as depression and other mental health issues, shame, and the lack of motivation or willingness to seek help (Lorains et al. 2011;Suurvali et al. 2009;Turner et al. 2017;Manning et al. 2017) and therefore effective intervention requires evidence-based treatment approaches as well as training for prison workers so that they can tackle the problem while working closely with existing rehabilitation programs.

Confidence in Ability to Provide Services and Needs for Continuing Education
One in five participants indicated that they had sufficient skills and training to deal with gambling problems. Almost half, on the other hand, felt that they were not well enough equipped to support prisoners with possible gambling problems and their significant others. These results are in line with earlier findings (Castrén et al. 2016;Temcheff et al. 2014), indicating that there is a lack of content regarding problem gambling in the current curriculum for social and health care workers. At the same time, though, our own earlier study showed that professionals with a background in social work and addiction medicine felt more prepared than others to address gambling-related issues at work (Castrén et al. 2016), which probably reflects their overall interest in the topic and the specific nature of their clientele. As reported, gambling is frequent and widespread activity in prisons (i.e., Turner et al. 2013;McEvoy and Spirgen 2012); therefore, concrete tools and guidelines ought to be introduced in staff training programs and further implemented into practice.
Although the participants showed some readiness to provide support to those suffering from problem gambling, the necessary know-how is still clearly lacking. Professionals working in a prison setting were particularly interested in developing (a) their know-how about the screening and assessment of gambling problems, and (b) their knowledge about the support and treatment options available for individuals with possible problematic gambling behavior. The participants also expressed an interest in attending tailored training programs and having access to case consultation. They were not familiar with the wide range of online courses currently available free of charge through the National Institute for Health and Welfare, Finland. The promotion of these services will require greater input in the future.
Our results suggest that professionals working in prisons are well aware of gambling problems and recognize the need for support, but there is no systematic framework for the identification of individuals with possible problem gambling and a shortage of supportive resources for their treatment. Training courses organized at different levels in the prison setting could have important benefits. Guards, ministers, and probation officers, for instance, have regular and close contact with inmates. These groups of professionals would certainly benefit from tailored training programs dealing with problem gambling and gambling-related harms and the different types of support and treatment available. Counselors, for their part, would benefit from more comprehensive tailored training on how to treat problem gamblers. It is crucial that screening and assessment tools as well as services and treatments are tailored to the needs and situation of the individuals concerned. Incarcerated gamblers are one of the subgroups that will require special focus so that the impact of problem gambling on future criminal activity can be effectively mitigated (O'Sullivan 2001). The detection of possible gambling problem or at-risk gambling is therefore paramount. It is known that for justice systems, however, problem gambling still remains something of a blind spot (Turner et al. 2017;Williams et al. 2005). As prisoners do seek help and are willing to accept support (Riley et al. 2017;Lind et al. 2019), courts could encourage prisoners to seek help. An even better solution would be to screen all offenders entering the criminal justice system to identify those in need for help as early as possible.
Sentence plans are drawn up for all prisoners with the ultimate aim of preventing recidivism. The plans provide the basis for all measures and decisions taken during the prison sentence, taking into account all the factors that might contribute to reoffending. Sentence plans include rehabilitation measures aimed at reintegrating the prisoner into society (Act on Imprisonment 767/2005). Most sentence plans are based on a risk and needs assessment which considers the inmate's psychosocial situation and the key factors leading to their current crime. However, the frequency and accuracy of these assessments may vary between different prisons. It would be crucial to better recognize problem gambling in these risk and needs assessments. Screening and support for gambling problems should be organized and integrated into prisoner health care (Obstbaum et al. 2016).
Our experiences from this and another pilot study (Lind et al. 2019) conducted in the same two prisons have been extremely positive. The preliminary results of both studies were presented to staff members in these prisons in June 2018. Feedback was collected at the same time. Our efforts follow up on the earlier work that has been started with the Gambling Clinic and Peluuri (a nationwide helpline and online service for gamblers, significant others, and professionals). The clinic and the helpline have been in talks with a view to launching tailored training programs for prison workers focused on the recognition, screening, and assessment of problem gambling, using a brief intervention model (Hodgins and Makarchuk 2002) and treatment approach Lachance 2007a, Ladouceur andLachance 2007b) modified in the prison context, noting comorbidities ). These training programs will take place in the autumn in the open prison in focus in the present study. We hope and expect that these initiatives will pave the way to more effective treatment of problem gambling and related issues in prison settings.

Strengths and Limitations
This is the first Finnish study on problem gambling to target prison workers. The response rate was very high (78%), probably reflecting the importance that prison workers attach to the topic. Our study was conducted in two types of prisons (open and closed), which meant we obtained data from two different prison settings. Having said that, our data comes from just two out of a total of 26 prisons in Finland. The sample of our study is too small for accurate quantitative analysis, and it is clear that the results cannot be generalized to prison workers in the whole country. The Criminal Sanctions Agency has a staff of around 2600, roughly half of whom have guarding and supervision duties. Our comparisons with previous studies (Salonen and Raisamo 2015;Castrén et al. 2016) are likewise indicative only. Nevertheless, the results do provide important pointers for the research community, developers, and decision-makers.

Conclusions
The prison workers in this study were clearly well aware of problem gambling and recognized the importance of tackling this issue seriously. They encountered possible problem gambling in a correctional setting while addressing other issues. There is a need for continuing education regarding problem gambling, its assessment, and ways of supporting and treating people with gambling problems. The next step is to develop and implement tailored training programs for different groups of professionals and to evaluate the effectiveness of these training programs.
Funding This research was funded by the Ministry of Social Affairs and Health, Helsinki, Finland (section 52 of the Appropriation of the Lotteries Act).
Data Availability The datasets generated and/or analyzed during the current study are not publicly available due the sensitivity of the content, but are available from the corresponding author on reasonable request.

Compliance with Ethical Standards
Ethics Approval and Consent to Participate The study was conducted in accordance with the ethical standards of the Declaration of Helsinki. The Ethics Committee of the National Institute for Health and Welfare, Finland, approved the research protocol (THL/1701/6.02.01/2017). Additional approval was obtained from the Finnish Criminal Sanctions Agency's research unit. Potential participants received written and verbal information about the study and the principles of voluntary participation.
Constraints on Publishing None.

Conflict of Interest
The authors declare that they have no conflict of interest.
Disclaimer The Ministry of Social Affairs and Health, Helsinki, Finland, had no role in the study design, analysis, or interpretation of the results nor in any phase of the publication process.
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