Macau parents’ perceptions of underage children’s gambling involvement

The study examined Macau parents’ perceptions of underage children’s gambling involvement, and parents’ attitudes towards help seeking if their children had a gambling problem. The parents’ gambling behavior in the past year was also investigated.

Methods
This is a parent survey using a self-administered questionnaire. A convenience sample of 311 Macau parents (106 fathers and 205 mothers) with underage children aged 3–17 years was recruited. The response rate is 77.8%. The participants were asked if they had ever approved or taught their underage children to gamble, and how did they award their children when they won in gambling games. The parents were also asked if they had gambled in the previous 12 months, and their gambling behavior was assessed by the Chinese Problem Gambling Severity Index (CPGSI).

Results
Half of the parents surveyed (52%) did not approve underage gambling but 81% taught their underage children to play different gambling games. Children were awarded with money (55%), praises (17.5%), toys (15%) and food (12.5%) when they won in games. One-fifth (20.6%) were distressed with their children’s gambling problem. Many (68.8%) were willing to seek help to cope with children’s gambling problems. Only 21.2% (n = 66) of the parents reported gambling in the past year. Using the CPGSI, 4.5% of these gamblers could be identified as problem gamblers, and 16.7% were moderate-risk gamblers.

Gambling behavior among Macau college and university students

This survey investigated gambling behavior among Chinese students studying in Macau colleges and universities. It also aimed to examine the relationship between problem gambling, affect states and sensation seeking propensity. A convenience sample of 999 students (370 men, 629 women) filled a self-administered questionnaire consisted of the Problem Gambling Severity Index (PGSI) (Ferris and Wynne in The Canadian problem gambling index: User manual. Canadian Centre on Substance Abuse, Toronto 2001a), the 8-item Brief Sensation Seeking Scale (BSSS-8) (Hoyle et al. Pers Individ Diff 32(3): 401–414, 2002), Bradburn’s Affect Balance Scale (BABS) (Bradburn in The structure of psychological well-being. Aldine, Chicago 1969) and questions on gambling activities. The response rate is 65%. Results indicate 32.3% (n = 323) of the survey participants wagered on mahjong (61.8%), soccer matches (40.2%), Mark Six lottery (37.2%), card games (28.1%), land-based casino gambling (13.1%), slot machines (7.5%) and online casino games (2.0%). The average monthly stake was MOP $411. Seeking entertainment (18.7%), killing time (12.5%) and peer influence (11.1%) were the three main reasons for gambling. Using the PGSI, 3.6 and 5.3% of the students could be identified as moderate-risk and problem gamblers respectively. Men were significantly more vulnerable to gambling problems (X2(1) = 35.00, p < 0.01) than women. Most of the problematic gamblers (76%) made their first bet before 14 years. The PGSI scores are significantly correlated with the BSSS-8 scores (r = 0.23, p < 0.01) but not with the overall ABS scores (r = −0.06, p > 0.05). The study findings inform campus prevention programs and future research.

Background
Youth is susceptible to gambling involvement and gambling problems. College and university students are a particularly vulnerable group (Koross 2016; Moore et al. 2013; Mubarak and Blanksby 2013; Weinstock et al. 2008). Many students have free time, money, increased freedom, accessibility and interest to play different gambling games. Approximately, 42–80% of college and university students reported gambling in the previous six to twelve months (Burger et al. 2006; LaBrie et al. 2003: Moore et al. 2013; Stinchfield et al. 2006; Weinstock et al. 2007). Oster and Knapp (1998) reported 97% of male college students at the University of Nevada, Las Vegas and 91% of females gambled over the course of their lifetime.

Research data indicate around 6–8 percent of these young people have a serious gambling problem worldwide (Derevensky and Gupta 2007; George et al. 2016; Moore et al. 2013; Mubarak and Blanksby 2013). Nowak (2014) conducted a comprehensive literature review of 72 studies involving 41,989 university students and student athletes worldwide. The estimates of pathological and problem gambling among the university (college) students were 6.13 and 10.23% respectively. Problem gambling would interfere with study, damage relationships and health, cause financial disaster, lead to illegal acts and affect future work prospects.

There is a paucity of research on gambling behavior among the college and university students in Macau where legalized gambling is widely available and accessible. Macau is famed as the Las Vegas of the East. There were 36 casinos in such a small city of only 30.4 square meters in 2015. In the recent decade, the Macau government has provided more resources to support gambling research to increase evidence-based data on Macau citizens’ gambling behavior and problem gambling. For example, prevalence studies on gambling behavior of Macau adolescents and adults were conducted almost every three years to update the estimates of gambling involvement and addiction in Macau. Around 50% of the Macau residents aged 15–64 years gambled in the previous year (University of Macau 2003, 2010, 2013a). The latest government-commissioned study (University of Macau 2013) revealed that 0.9% of the 2158 Macau residents surveyed could be identified as probable pathological gamblers, while 1.9% could be defined as problem gamblers using the DSM-IV criteria.

The past-year estimates of pathological gambling and problem gambling among Macau adolescent high school students are higher than those of the adults, ranging from 5 to 8% (University of Macau 2003, 2010, 2013a; Wong 2009). Our understanding of gambling behavior among the college and university students is inadequate because research is scarce. Current available evidence-based data on Macau university students’ gambling behavior were generated from a very small number of studies.

Wong et al. (2008) conducted a survey targeted 198 Macau undergraduate students (80 males and 118 females) aged 18–24 years. Results showed that 2.5% of the survey participants were problem gamblers. Problem gamblers often experience serious financial, social, emotional and health consequences. Impulsivity was found positively associated with problem gambling, whereas life satisfaction and knowledge about gambling were negatively correlated to problem gambling.

There was another survey aiming to investigate correlates of problem gambling among 952 community adults and 427 university students (Wu et al. 2014a, b). Online gambling was associated with pathological gambling in both the community and student samples. Significant risk factors of pathological gambling were identified, namely the male gender, materialism, casino employment and life dissatisfaction. Wu (2012) also identified predictors of problem gambling in a sample of 932 Chinese college students aged 18–25 years in Macau and Hong Kong. The predictors are gambling intention and perceived control.

Little gambling research among Macau college and university students has been conducted. We hope this study would help filling the research gap to provide empirical data on these students’ gambling behavior. Correlates of problem gambling would also be examined. Previous studies indicated that problem gambling was associated with affect states (e.g. Atkinson et al. 2012; Matthew et al. 2009; University of Macau 2013b) and sensation seeking propensity (Harris et al. 2013; Zuckerman 2007). We would like to examine if affect states and sensation seeking are also risk factors of problem gambling among Macau college and university students. The study results would have implications for campus gambling awareness activities.

Early student studies discovered a link between problem gambling and affect states. Atkinson et al. (2012) conducted a survey among 448 young adult college students. They found that gambling severity was correlated with negative affect. In another student study with 127 Internet gamblers (Matthew et al. 2009), negative mood states after gambling online and negative mood states generally were the best predictors of problem gambling. While agreeing with the linkage between problem gambling and affect states, Hills et al. (2001) argued that the link was not a causal relationship. We wonder if affect states would also play a role in problem gambling among Macau college and university students.

The role of sensation seeking in problem gambling has been verified in several studies but not yet examined in Macau student gambling surveys. Sensation seeking is a personality trait showing an individual’s desire for experiences and feelings which are novel, complex and intense (Zuckerman 2009). The individual may ignore or tolerate potential risk associated with these experiences. Sensation seeking is often linked to thrill seeking activities such as gambling, smoking and drinking. These activities may provide a lot of stimulation and excitement. The high sensation seekers need plenty of stimulation to obtain optimal level of arousal. Problem gambling is commonly found among high sensation seekers (Gupta and Derevensky 1998a; Powell et al. 1999). For example, in a study conducted among youth and adult gamblers, Harris et al. (2013) found that sensation seeking was positively associated with student pathological gambling. Sensation seeking is also identified as a robust predictor of excessive gambling.

To conclude, this study aimed to fill a research gap by providing evidence-based data on gambling behavior and problem gambling among Macau college and university students. We also attempted to identify the correlates of problem gambling because correlation data would inform preventive measures. Previous western studies indicated that sensation seeking and affect states were associated with youth problem gambling. We tried to explore if sensation seeking and affect states would play a role in student gambling problems across culture. To our knowledge, sensation seeking and affect states have never been examined in Macau’s gambling surveys. We expected that student problem gambling would be associated with affect states and sensation seeking propensity. We also expected gambling would be a male dominated activity, and male student gamblers would be more vulnerable to problem gambling than the women student gamblers. The study findings would throw light on campus education and preventive programs.

Methods
Procedures
This was a student survey. Ethics approval for conducting the study was granted by the institution’s Training and Research Committee before research launch. In early 2014, letters were sent to all the Macau colleges and universities inviting their students to participate in the study. Explanation about survey aims and procedures was included in the letter. Ten Macau colleges and universities agreed to provide support to the study. With the help provided by the college and university teaching staff, the trained research assistants distributed 1548 survey questionnaires to potential survey participants during the recess. Survey participation was voluntary and students were not asked to provide their names. The students were informed that their responses would be kept confidential. A convenience sample of 999 students aged 17–52 years (mean age = 21.6 years, SD = 3.7) filled and returned the questionnaires with the written consent forms. The response rate is 64.5%.

Participants
Among the 999 participants, there were 629 women and 370 men aged 17–25 years (mean age = 21.6 years, SD = 3.7). Many were studying in the first year (n = 413, 41.3%), 20.2% (n = 202) were second year students, 19.0% (n = 190) were third year students, and 17.9% (n = 179) were fourth year students.

Majority received financial support from their parents (n = 707, 70.7%), 45.9% earned an income from jobs (n = 459). Only 2.4% (n = 24) admitted that some of their income came from gambling activities. Many students (n = 399, 39.9%) reported having a monthly income of MOP $1000–$2999, 17.9% (n = 179) had more than MOP $10,000 per month, 17.2% (n = 172) had MOP $4000–$6999 each month and 15.0% (n = 150) had less than MOP $1000 each month.

Measures
The self-administered questionnaire included the following sections:

1.
Demographic information on age, sex, incomes and year of study;

2.
Questions on gambling reasons, gambling frequency, monthly amount wagered on gambling, and types of gambling activities preferred in the past year;

3.
The 9-item Problem Gambling Severity Index (PGSI) (Ferris and Wynne 2001a) assessed the severity of gambling problems. The PGSI measures gambling involvement, problem gambling and harmful consequences. The PGSI is reliable (Cronbach’s alpha > 0.70) and has good construct validity (Sharp et al. 2012) with a unidimension of problem gambling. The PGSI has been widely used in many countries including the United Kingdom (Orford et al. 2010), Australia (McMillen and Wenzel 2006), Singapore (Arthur et al. 2008) and Canada (Ferris and Wynne 2001b). The students’ responses to the PGSI were rated on a four-point scale (0 = never, 1 = sometimes, 2 = most of the time and 3 = almost always). Total scores ranged from 0 to 27. Higher the PGSI scores, greater the risk of problem gambling. The results were interpreted as follows: (a) a score of “0” implied non-problem gambling, (b) a score of 1–2 indicated low-risk gambling with few or no negative consequences, (c) a score of 3–7 suggested moderate-risk gambling leading to some substantial negative consequences, and (d) a score of 8 or more indicated problem gambling with harmful consequences and a possible loss of control over gambling.

4.
Sensation seeking was assessed by the 8-item Brief Sensation Seeking Scale (BSSS-8) (Hoyle et al. 2002). The BSSS-8 is reliable with Cronbach’s alphas ranging from 0.60 to 0.79 (Aluja et al. 2004; Hoyle et al. 2002; Stephenson et al. 2007). The BSSS-8 also has good construct validity. It retains Zuckerman’s (1976, 1994) conceptualization that sensation seeking as a personality trait is composed of four components (Ferrando and Chico 2001), namely thrill and adventure seeking, experience seeking, disinhibition and boredom susceptibility. The scale includes 2 items for each component. Using a four-point scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree), total scores range from 0 to 32. Higher the BSSS score, greater the desire to seek sensation.

5.
The Bradburn’s Affect Balance Scale (ABS) (Bradburn 1969) was used to assess the students’ affect states. There are 10 items in the scale. Five items explore positive affect, while the other five items examine negative affect. The students’ affect states were measured as a net balance of negative affect (5 items) and positive affect (5 items). Participants were asked if they had experienced certain emotions in the previous four weeks (e.g. feeling “bored” or “on top of the world”). Responses were made in a “yes” and “no” format but only each affirmative answer would be given one score. The overall “Affect Balance Score” (ABS) comes from subtracting the negative affect score from the positive affect score. Higher ABS scores suggest more positive affect is being experienced. The ABS has been tested to be a reliable and valid instrument (Bradburn 1969). Internal consistency reliabilities for Negative Affect scores range from 0.61 to 0.73; for Positive Affect scores range between 0.55 and 0.73. Factor analyses indicated that positive and negative affect were distinct dimensions with small associations between them (0.04–0.15).

Results
Gambling participation and problem gambling
As shown in Table 1, almost one-third (n = 323, 32.3%) of the survey participants (143 men and 180 women) gambled in the past year. Using the PGSI (Ferris and Wynne 2001a), 19.6% (n = 196) of the 999 survey participants were identified as non-problem gamblers, 3.8% (n = 38) were low-risk gamblers, 3.6% (n = 36) were moderate risk gamblers, and 5.3% (n = 53) could be classified as problem gamblers.

Table 1 Gambling participation and problem gambling among the survey participants (n = 999)
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Gender difference in gambling participation and problem gambling
Since more women than men were recruited in this study, there were more female gamblers (n = 180, 55.7%) than male gamblers (n = 143, 44.3%) (Table 2). There were also more female low-risk gamblers (n = 25, 65.8%) than male low-risk gamblers (n = 13, 34.2%). However, more men (n = 63) than women (n = 26) obtained a score of 3 or more on the PGSI. The threshold of moderate-risk gambling is a score of three. The sex difference in moderate and problem gambling is significant (X2 (1) = 35.0, p < 0.01). As shown in Table 2, 61.1% of the moderate-risk gamblers were males, and 38.9% were females. Similarly, 77.4% of the problem gamblers were males, and 22.6% were women.

Table 2 Sex difference in gambling participation and problem gambling (n = 999)
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Reasons for gambling
The five most frequently reported reasons for gambling were entertainment (n = 121, 37.5%), killing time (n = 81, 25.1%), peer influence (n = 72, 22.3%), affordability due to acceptance of small stakes (n = 57, 17.6%) and perceiving gambling activities as a challenge (n = 55, 17.0%).

Preferred gambling forms
The preferred gambling forms were mahjong (38.1%), soccer betting (25.4%), Mark Six lottery (22.9%), card games (17.3%), stocks (9.0%), land-based casino gambling (8.0%), slots (5.0%) and online casino games (1.2%). With the exception of mahjong, men outnumbered women in all these gambling activities.

Gambling frequency
Among 96 gamblers who answered the question on gambling frequency, 42.7% (n = 41) gambled once a month, 20.8% (n = 20) played 2–3 times a month, 18.8% (n = 18) played 1–2 times a week, 12.5% (n = 12) played once a day, 4.2% (n = 4) played 3–4 times a week, and one gambler (1.0%) played 5–6 times a week.

Money wagered on gambling
On average, the gamblers wagered MOP $411 a month on gambling activities. The highest stake reported was MOP $10,000. On average, the gamblers spent 3.88 h (SD = 3.41) on a gambling activity. The longest gambling duration reported by a gambler was 12 h.

Age of first gambling
Among the 323 gamblers, the mean age of first gambling of was 14.5 years (SD = 4.7). Most of the problematic gamblers (i.e. combining the cases of moderate-risk and problem gamblers) (n = 67, 76.1%) placed their first bet before 14 years. Only 23.5% (n = 46) of the non-problem gamblers did so. The difference is significant [X2 (2) = 66.1, p < 0.01].

Gambling debts
Only five (1.5%) of the 323 gamblers reported having gambling debts. All of them were problematic gamblers who obtained a score of 3 or more on the PGSI.

Family problem gambling
Among the fifty-three problem gamblers, twenty (37.7%) reported that their family members had a gambling problem in the previous twelve months, while the majority (n = 33, 62.3%) did not have the same problem.

Sensation seeking among the gamblers
The gamblers’ desire for seeking sensation was measured by the 8-item Brief Sensation Seeking Scale (Hoyle et al. 2002). Higher the BSSS-8 scores, greater the need to seek sensation. As indicated in Table 3, the problem gamblers obtained the highest mean BSSS-8 score of 22.3 (SD = 4.4). The low-risk gamblers’ mean BSSS-8 score is 21.1 (SD = 2.9) which is the second highest score. The non-problem gamblers’ mean BSSS-8 score is 20.1 (SD = 3.4) which is slightly higher than the mean BSSS-8 score of 19.9 (SD = 3.6) obtained by the moderate-risk gamblers. In short, the problem gamblers were most fond of seeking sensation than the other three types of gamblers.

Table 3 Student gamblers’ scores on the 8-item Brief Sensation Seeking Scale (n = 323)
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To enhance further comparison of the mean BSSS-8 scores between the gamblers with and without severe negative consequences, the gamblers were re-classified as the “non-problematic gamblers” (i.e. the cases of non-problem and low-risk gamblers were combined), and the “problematic gamblers” (i.e. the cases of moderate-risk and problem gamblers were combined). The former experienced few or no harmful consequences, and the latter had experienced serious adverse consequences. The mean BSSS-8 score for these two groups of gamblers are 20.3 (SD = 3.3) and 23.1 (SD = 4.2) respectively, implying the problematic gamblers were more fond of sensation seeking than the non-problematic gamblers. The difference is significant (t = 5.1, p < 0.01).

Affect states of the gamblers
Bradburn’s Affect Balance Scale (1969) (ABS) was used to measure the gamblers’ emotional well-being. Higher overall ABS score suggests more positive affect. As shown in Table 4, the low-risk gamblers obtained a mean ABS score of 0.87 (SD = 1.6) which is the highest score found in these four types of gamblers. The non-problem gamblers had a mean score of 0.79 (SD = 1.6) which is the second highest score. The moderate-risk gamblers and the problem gamblers obtained a much lower mean ABS score of 0.50 (SD = 2.0) and 0.67 (SD = 1.7) respectively.

Table 4 Student gamblers’ scores on the Bradburn’s Affect Balance Scale (n = 323)
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To enhance further comparison of the mean ABS scores between the gamblers with and without serious negative gambling harms, the gamblers were re-classified as the “non-problematic gamblers” and the “problematic gamblers”. The former experienced no or few adverse gambling harms, while the latter might have experienced serious negative consequences. The mean ABS score for these two groups of gamblers are 0.81 (SD = 1.6) and 0.61 (SD = 1.8) respectively, suggesting that the non-problematic gamblers did experience more positive affect than the problematic gamblers as their mean ABS score is higher but the difference is not statistically significant (t = 0.8, p > 0.05).

Correlates of problem gambling
Table 5 summarizes the correlation findings generated from the Pearson product moment test. Problem gambling was significantly correlated with age of first gambling (r = −0.8, p < 0.05), age of the gamblers (r = 0.24, p < 0.01), the BSSS-8 scores (r = 0.23, p < 0.01) and gambling frequency (r = 0.17, p < 0.05) but not with the ABS scores (r = −0.06, p > 0.05).

Table 5 Correlations between PGSI scores and other key variables
Full size table
Discussion
Gambling participation and problem gambling
The students’ past-year gambling participation rate in this study is only 32.3%. Compared with the rates of 40–50% found in previous Macau studies (e.g. University of Macau 2013a, b; Wu et al. 2014a, b), this gambling participation rate is relatively low. However, the estimate of problem gambling (5.3%) is close to the rates of 6–8% reported in many western studies (Derevensky and Gupta 2007; George et al. 2016; Moore et al. 2013; Mubarak and Blanksby 2013; Nowak 2014).

Interestingly, the rates of problem gambling (5.3%) and moderate-risk gambling (3.6%) found in this survey are slightly higher than those noted in previous Macau studies (Wong et al. 2008; Wu 2012; Wu et al. 2014a, b). For example, Wong et al. (2008) reported that 2.5% of the 198 Macau undergraduates were problem gamblers. Wu and her researchers (2015) also reported a similar problem gambling rate of 2.1% among 427 Macau university students. More research is needed to increase evidence-based data of gambling involvement and problem gambling among Macau college and university students.

Sex difference and age correlate of problematic gambling
The survey results replicated previous research findings on gender difference in student problematic gambling (i.e. the cases of moderate-risk and problem gambling were combined) (e.g. George et al. 2016; Koross 2016; LaBrie et al. 2003). More male gamblers (n = 63) than females (n = 26) scored three or more on the PGSI. Men were significantly more vulnerable to problematic gambling than women.

Gamblers’ age is positively associated with the PGSI scores (r = 0.23, p < 0.01). Older age gamblers had higher risk of problematic gambling because they might have increased freedom from parental supervision to engage in gambling activities. Campus preventive education should target the male and older students.

Sensation seeking and problem gambling
In line with previous studies (e.g. Gupta and Derevensky 1998a; Harris et al. 2013; Powell et al. 1999), the survey results have confirmed that sensation seeking is positively correlated to problem gambling severity (r = 0.23, p < 0.01). Problematic gamblers obtained a significantly higher mean BSSS-8 score (mean = 23.1, SD = 4.2) than the non-problematic gamblers (mean = 20.3, SD = 3.3) (t = 5.1, p < 0.01). In short, the problematic gamblers exhibited a stronger desire for seeking sensation than the non-problematic gamblers. In Macau it is very convenient for these high sensation seekers to play gambling games at different gambling venues (e.g. the casinos, the pokies halls, the horse racing course) or via the Internet. Gambling is widely available and accessible in Macau. Gambling might also have fulfilled their need for entertainment and killing time.

Affect states and problem gambling
As expected, the low-risk and non-problem gamblers experienced more positive affect (ABS score = 0.81, SD = 1.6) than the problematic gamblers (ABS score = 0.61, SD = 1.8) but the difference is not statistically significant. However, contrary to past research results (Atkinson et al. 2012; Matthew et al. 2009), problem gambling severity is not correlated to both negative and positive affect states. More research is needed before conclusion can be made as this is the only study to explore the role of affect states in problem gambling among Macau college and university students. Western studies have provided evidence to support a link between problem gambling and negative affect states (Atkinson et al. 2012; Matthew et al. 2009).

Early gambling and problem gambling
Many previous studies have also documented early gambling as a risk factor of problem gambling (e.g. George et al. 2016; Griffiths 1995; Gupta and Derevensky 1998b; Wong 2010; Wu et al. 2014a, b). The correlation data confirm that early gambling is negatively correlated to problem gambling severity. Among the four significant correlates of problem gambling found in this study, early gambling is the strongest factor of association. Prevention of early and problematic gambling should begin in primary schools. This study discovered that many problematic gamblers (76.1%) wagered with money before 14 years while only 23.5% of the non-problematic gamblers did so. We suggest prevention programs should begin early before adolescence years but should continue after admission to college and university.

Campus gambling prevention programs
In line with western research data, the problem gambling rate in Macau colleges is around three times greater than that of the general population (e.g. Mubarak and Blanksby 2013; Nowak 2014; Volberg 1998). Problem gambling would disrupt the students’ study and even their future career prospects. However, little attention has been paid to campus gambling problems in Macau. Shaffer et al. (2000) reported that forty percent of the American institutions failed to recognize gambling as a major problem for their students. We find similar situation in Macau. Without evidence-based information on campus gambling problems, it is not a surprise that Macau institution administrators would not believe their students have gambling problems, not to mention developing appropriate measures to address this health hazard on campus. We hope that the high problematic gambling rate found in this study would attract the attention of the government, the institution administrators and the campus student office. They should work together to prevent student gambling problems and to provide professional help to the problematic gamblers.

Conclusion
The major weakness of this study is the research data were collected by the convenience sampling strategy. Hence, the power to generalize the study results to the population of Macau college and university students would be adversely affected. Future research should consider using random samples if feasible to enhance data representation.

Despite the weakness, the survey has increased our understanding of the students’ gambling involvement and addiction. The college and university students could be identified as a vulnerable group for gambling problems. It seems that Macau Chinese male and older students who have started gambling early to seek sensation are particularly at risk for problematic gambling. The study results confirm that gender, age, early gambling and sensation seeking propensity are common risk factors across culture. Campus prevention programs should target these high risk students whereas primary prevention measures (e.g. information pamphlets, warning messages and awareness seminars) may be beneficial to all the students. There is a paucity of gambling research targeting the college and university students. It is necessary to conduct more research to investigate the college students’ gambling behavior, and to examine their resiliency and risk for gambling addiction. Systematic evaluation of the current preventive programs is also recommended. Only evidence-based information would inform and improve campus education and intervention programs.

Development and validation of the Pachinko/Pachi-Slot Playing Ambivalence Scale

A scale aimed at measuring ambivalence among people with pachinko/pachi-slot playing disorder, the Pachinko/Pachi-Slot Playing Ambivalence Scale (PPAS), was developed and its reliability and validity ascertained.

Methods
A total of 522 participants (average year: 48.0) who were residing in Tokyo Metropolitan Area, and had played pachinko within the previous year completed questions relating to demographics, four gambling-related scales (including South Oaks Gambling Screen) and two general ambivalence scales (including Ambivalence over Emotional Expressiveness Questionnaire).

Results
Internal consistency (α = 0.87) and test–retest reliability (r = 0.66) were confirmed. The PPAS’s score was associated with each related scale’s score (r = 0.37–0.62).

Conclusions
The PPAS was shown to be consistent with previous scales and useful in clinical settings.

Background
The lifetime prevalence of gambling disorders around the world has been reported to be about 1.5% (Gowing et al. 2015), similar to that of schizophrenia and bipolar disorder. Not only gambling disorder promotes depression and suicide (Petry and Kiluk 2002), but it has been linked to social problems such as child abuse and severe indebtedness (Grant et al. 2010). Therefore, the development of intervention guidelines based on appropriate diagnostic and assessment measures has become a pressing issue.

Existing gambling disorder assessment scales can broadly be divided into: (a) scales for evaluating treatment effectiveness by measuring principal symptoms such as a craving and (b) diagnostic scales providing a comprehensive assessment of problems; for example, in cognition, behavior, and interpersonal relationships. The former type includes the Gambling Symptom Assessment Scale (G-SAS) (Kim et al. 2009) and the Yale-Brown Obsessive Compulsive Scale-modified for Pathological Gambling (PG-YBOCS) (Pallanti et al. 2005). The latter type includes assessment instruments such as the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) (American Psychiatric Association 2013), the South Oaks Gambling Screen (SOGS) (Lesieur and Blume 1987), the Alberta Gaming Research Institute (AGRI) Short Version (Volberg and Williams 2011), the Problem Gambling Severity Index (PGSI) (Ferris and Wynne 2001), and the Lie–Bet Screen (Johnson et al. 1997). These diagnostic scales (b) enable assessment of problem severity, based on several different pathological concepts in a given case. In other words, these scales focus not on a single pathological concept but on multiple pathological concepts such as psychopharmacology of substance use disorder, psychodynamics, and interpersonal model (Stinchfield 2013). For example, the nine items of DSM5 consist of four different pathological concepts, namely psychopharmacology, psychodynamics, interpersonal and socio-economics model. Similarly, Lie–Bet Screen consists of two concepts, interpersonal model and psychopharmacology. On the other hands, scales, which focus on a single pathological concept, have been developed. For example, the Gambling Functional Assessment-Revised measures psychopharmacological dependency, namely positive and negative reinforcement such as resistance and withdrawal (Weatherly et al. 2011); whereas Gamblers’ Beliefs Questionnaire measures cognitive distortions such as neglecting of randomness (Steenbergh et al. 2002).

Although various useful scales for gambling disorders have been developed, it is not clear if these scale measure core symptoms that explain the basic mechanism of gambling disorder.

The importance of the concept of ambivalence, being that “alcoholics simultaneously want to quit and do not want to quit,” has been raised in substance addiction research (Walker et al. 2011), because it has been found to be a predictor of relapse in drinking behavior (including heavy drinking) and drug abuse (Lipkus et al. 2001; Oser et al. 2010), and of relapse in ex-smokers (Menninga et al. 2011). Additionally, ambivalence regarding alcoholism is an important determinant of drinking behavior in the same way that craving for alcohol is (Dawn et al. 2014). In many instances, ambivalence acts as an inhibitory factor in recovery (Armitage 2003).

Bleuler, who first coined the concept of ambivalence, encompassed two different ideas. He pointed out that ambivalence can be a symptom of pathology because two opposite psychological phenomena continue to exist in parallel, or it can have the common meaning of tying different psychological phenomena together via consistent values (Bleuler 1914/1997; Hitomi 2011). Therefore, in the assessment of ambivalence, these two aspects must be covered. The former is a psychopathological finding, which reveals failure of solution to conflicts, such as “parallel existence of expectation, emotion, and reason” (Bleuler 1914/1997, p. 136). On the other hand, the latter reveals a self-oriented, rational response after conflictive behaviors, such as regret.

When assessing ambivalence, one either assesses structural ambivalence by differentiating and measuring two conflicting factors such as feelings, thoughts and behaviors, or subjective ambivalence by assessing the psychological state that arises when two conflicting factors coexist (Priester and Petty 1996). For example, Drinking Ambivalence Scale (DAS) (Dawn et al. 2014) measures structural ambivalence; whereas, General Ambivalence Scale (Thompson et al. 1995) and a six-item ambivalence scale for smoking (Lipkus et al. 2001) focus on subjective ambivalence. However, Conner and Sparks (2002) report there is a significant correlation between two assessment methods.

Currently, no scale has been developed for this concept in gambling. Thus, in this study, we developed a scale to measure ambivalence towards gambling behavior. In Japan, pachinko/pachi-slot playing disorder accounts for nearly 90% of all gambling disorders (Toyama et al. 2014; Komoto 2014). Pachinko and pachi-slot constitute private gambling involving use of a device similar to a recreational arcade game. There are many pachinko/pachi-slot parlors in every downtown area in Japan. Therefore, we first developed the Pachinko/Pachi-Slot Playing Ambivalence Scale (PPAS), and tested its reliability and validity. Improving classification (severity/subtype) and prediction of prognosis are not the only reasons for the incorporation of ambivalence into the diagnosis and treatment of gambling disorder. A better understanding of ambivalence by those providing support to people with gambling disorders may enhance their understanding of the recovery process that may face frequent relapses. In addition, for the gambler, better understanding could provide an opportunity to think about the cravings that drive his/her urge to gamble (Komoto and Sato 2014).

Methods
Participants
Initial survey
Using an online survey company, we recruited members registered as internet-shopping customers residing in Tokyo, in Saitama, Chiba, or in Kanagawa Prefectures, who had played pachinko or pachi-slot within the previous year. A total of 522 people agreed to participate in the survey, comprising the ambivalence scale and an impression management subscale (Paulhus 1991).

Of the 522 participants, 446 (85.4%) were men and most were in their 40 s (35.8%) or 50 s (28.0%). The majority of the participants were individuals who had at least graduated from college (77.4%), lived with a family (not be single) (72.8%), and had an annual household income of ¥4–10 million (60.4%; the so-called “middle economical class” in Japan).

Retest survey
We used the same online survey company and asked the 522 from the initial survey to participate again in the survey. Sixty-six participants (12.6%) of the original sample (n = 522) agreed to answer the retest questionnaire.

Measures
Playing frequency, duration, and expenditure
The frequency of playing pachinko/pachi-slot and expenditure (i.e., “money lost”) over the previous 12 months were measured. Responses regarding frequency were rated on a 9-point scale from 1 (less than once a year) to 9 (more than 4 times a week). Playing duration was measured through average playing duration per day, on an 8-point scale, from 1 (less than 1 h) to 8 (8 h or more). Expenditure on playing was measured through the average amount of money lost per month, on a 7-point scale from 1 (I do not lose) to 7 (more than ¥200,000). A response indicating the lowest expenditure in this regard was allocated 1 point. Responses to “I do not lose” were merged with those to “less than ¥10,000,” with either option assigned 1 point.

The Pachinko/Pachi-Slot Playing Ambivalence Scale (PPAS)
Several congresses were held by three psychiatrists and four researchers specializing in psychology, education, neuroscience, and sociology to develop items of the PPAS. All psychiatrists were specialists of addictive disorders. Three researchers were experienced researchers of universities, and one researcher of sociology was also a specialist of statistics. During this process, the six-item ambivalence scale for smoking (Lipkus et al. 2001) and other existing ambivalence-related scales were used for reference (Dawn et al. 2014; King and Emmons 1990; Lipkus et al. 2005; Nagano et al. 2001). This six-item ambivalence scale for smoking consisted of the following six self-descriptive assessments: (1) “I have strong feelings both for and against smoking”; (2) “I have conflicting thoughts and feelings about smoking; sometimes I think that smoking is good, while at other times I think that it is bad”; (3) “My gut feeling and my thoughts do not seem to agree on whether I should smoke”; (4) “I find myself feeling torn between wanting and not wanting to smoke”; (5) “My gut feeling about whether to smoke agrees perfectly with what my mind tells me” (a reversed question); and (6) “I have equally strong reasons for wanting and not wanting to smoke.” Although this scale has good internal consistency and prognosis-predictive ability, some items are abstract, with terms such as “good,” “bad,” and “gut.” Therefore, we created the PPAS, with more concrete and clear expressions and consisting of two factors and nine items, as follows: three items concerning “regret” (e.g. “After losing money playing pachinko/pachi-slot, I wished that I had spent it on something delicious to eat.”) and six items concerning “parallel expectations, emotions, and reasons” (e.g. “When I was playing pachinko or pachi-slot, I felt both happy and distressed or “In my mind, I want to quit playing pachinko/pachi-slot and at the same time, I want to play.”).

The rating was on a 4-point scale, as follows: (1) “Not true,” (2) “Maybe not true,” (3) “Maybe true,” and (4) “True.” The total score range was 9–36. Participants were asked to consider the questions regarding their gambling behavior only in the previous 12 months.

Factor analysis of the PPAS
We conducted an exploratory factor analysis (EFA) of nine items of the PPAS. Because all factors were considered dependent upon each other, the factor solution was sought after Promax rotation, which is an oblique rotation. The number of factors was determined through the scree plot (Cattell 1966). To create subscales of the PPAS, we extracted items for each subscale if they yielded a loading of >0.3 on a particular factor, but of <0.3 on other factors.

Thereafter, using maximum likelihood estimation, some factor structures including one derived from the EFA were confirmed through confirmatory factor analysis (CFA) among the same group of 522 participants. The fit of each data model was examined through the goodness of fit index (GFI), adjusted goodness of fit index (AGFI), comparative fit index (CFI) and root mean square error of approximation (RMSEA). According to conventional criteria, GFI > 0.9, AGFI > 0.9, CFI > 0.95, and RMSEA < 0.08 indicate an acceptable fit (Schermelleh-Engel et al. 2003).

Additionally Cronbach’s alpha for the hypothesized subscales was calculated to examine the internal reliability of the PPAS. The acceptable standards for alpha values are ranging from 0.70 to 0.95. (Tavakol and Denneck 2011).

Scales used to test concurrent validity
To examine concurrent validity, we used both the general ambivalence and gambling scales.

General ambivalence scales
The Short Interpersonal Reactions Inventory (SIRI)—Japanese version (Grossarth-Maticek and Eysenck 1990; Nagano et al. 2001).

This scale is a self-administered scale, with its reliability for use in Japan having been confirmed. Participants were required to answer “Yes”/“No” items related to the “ambivalent object-dependent type” characterized by an ambivalent attitude. We selected only the most representative three items to shorten a questionnaire. The items were as follows: “I alternate to a great degree between positive and negative evaluation of people and situations”; “With people I love, I oscillate between them at a great distance to stifling dependence, and from stifling dependence to excessive distancing”; “As soon as someone becomes emotionally close to me, I tend to place contradictory demands on them, such as ‘Don’t ever leave me’ and ‘Get away from me.’” The score range for these items was from 3 to 6.

Ambivalence over Emotional Expressiveness Questionnaire (AEQ) (King and Emmons 1990).The AEQ is a self-administered scale consisting of 28 items, used to assess ambivalence in emotional expressiveness in interpersonal relations. Since there is no Japanese version, the scale’s reliability and validity have not been confirmed for use in Japan. To shorten a questionnaire, we selected the following four items, referring to Cronbach’s alpha, which were rated on a 5-point scale, e.g. 0 (strongly disagree) to 4 (strongly agree): “Often I find that I cannot tell others how much they really mean to me”; “I want to tell someone people when I love them, but it is difficult to find the right words”; “After expressing anger at someone, it bothers me for a long time”; and “I feel guilty after having expressed anger at someone.” The possible range of the scale scores varied from 0 to 16.

Measures of gambling disorder
In all of the gambling disorder’s items, the word “gambling” was replaced with the word “pachinko/pachi-slot playing.”

The Diagnostic and Statistical Manual of mental Disorders-5 (DSM-5)
Nine items were adapted from the Japanese version of the nine DSM-5 criteria for gambling disorder (American Psychiatric Association 2013). The original DSM-5 wording was changed to make the items relevant to the questionnaire context and easier for respondents to understand. For example, “In a 12-month period…” became “In the last 12 months….” Moreover, the criteria regarding experiences of emotions and problems were expressed in a “Yes”/”No” question format. Upon scoring, a “Yes” response was assigned one point, so that the total possible score range was 0–9. We used the DSM-5 severity levels and simply translated the number of criteria met into points; in other words, mild severity was 4–5 points, moderate was 6–7 points, and severe was 8–9 points.

The South Oaks Gambling Screen (SOGS)
We translated 19 of the SOGS’s 20 items (Lesieur and Blume 1987) into Japanese. We omitted translating the item concerning the writing of bad checks to cover gambling debt, as it is not relevant in the Japanese context. The answers were scored on the basis of Lesieur and Blume’s (1987) method. Scores were determined by adding up the number of questions which show an “at risk” response. Nineteen questions were scored 0 or 1. Therefore the score range was 0–19.

The Problem Gambling Severity Index (PGSI)
The PGSI is a 9-item scale requiring the respondent to think about the past 12 months (Ferris and Wynne 2001), with questions such as, “Have you bet more than you could really afford to lose?,” using a scale of 1 (“never”) to 4 (“almost always”). The score range was 9–36.

The Alberta Gaming Research Institute (AGRI) Short Screen
The AGRI Short Screen is a 5-item scale requiring the respondent to think about the past 12 months (Volberg and Williams 2011) and reply with “Yes” or “No” to questions such as, “Would you say you have been preoccupied with gambling?” (as adapted for this study). A score of 1 was assigned to each “Yes” answer. The score range was 0–5.

A gambling dependency diagnosis status
Participants were asked the question, “During the past year, have you ever been told by a medical or treatment support facility that you suffer from gambling dependence?,” to which they were to respond “Yes,” “No,” or “Don’t wish to answer.” A score of 1 was assigned for “Yes,” and 0 for “No”; “Don’t wish to answer” was treated as missing data. The score range was 0–1.

Social desirability
In order to check for the possibility of responses having been biased by the respondents’ desire for social approval, we included the 12-item Impression Management subscale from the Balanced Inventory of Desirable Responding. Respondents were asked to rate each item (e.g., “I sometimes tell lies if I have to.”) on a scale of 1–4, with 1 indicating “Not true” and 4 indicating “Very true” (Paulhus 1991; Tani 2008). The score range was 12–48.

Procedure
Data for the initial and retest surveys were collected via self-administered online questionnaires at an interval of approximately two weeks in February 2015.

Statistical analysis
To determine validity, we observed the correlations between the PPAS and the scales presented in the preceding sub-sections, playing frequency, the gambling dependency diagnosis status, and social desirability by using Pearson’s correlation coefficients. To test for reliability, we observed the correlations between the initial data and the retest data. Significance was set at p < 0.05.

Ethics
The study procedures were carried out in accordance with the Declaration of Helsinki. The Institutional Review Board of Ochanomizu University approved the study. All subjects were informed about the study and all provided informed consent. Participant data were treated as strictly confidential and anonymous.

Results
Playing frequency and expenditure
With regard to playing frequency, 23.2% of the participants played 2–3 times per week, followed by 21.5%, who played 2–3 times per month. Moreover, 21.0% had played ≤4 times within the past year and 5.4% had played ≥4 times per week. Most of the participants (n = 150, 28.7%) played for 2–3 h, followed by 22.6%, who played for 3–4 h. In total, 8.0% played for ≥6 h. With regard to monthly expenditure, 28.0 and 26.2% of the participants reported losing less than ¥10,000 and ¥20,000–¥50,000, respectively. However, 6.3% reported never losing and 5.3% reported a loss of ¥100,000 or more.

PPAS
The mean total score (SD) of PPAS was 21.3 (6.25). More “Very true” or “True” responses were given for “regret” (26.4–33.1%), as compared to “paralleling” (5.7–18.2%).

EFA
The entire log-transformed items of the PPAS were entered into an EFA. This suggested a two-factor structure. Factor 1 was loaded by three items (1–3), which expressed “regret” for gambling. Regret is a conflictive reaction after an inconsistent behavior, because feeling regret meant that gamblers recognized that the food, goods, and friendship were more important to them than gambling was. Factor 2 was loaded by six items that expressed coexistence of opposite thoughts, feelings and motivations, e.g. “a desire to gamble and a desire to quit gambling”.

A two-factor structure was suggested in PPAS (Table 1).

Table 1 Exploratory factor analysis (EFA) for the PPAS
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CFA
Three models were tested. The first model to be examined was a one-factor model in which all nine items were predicted to load onto a single factor generally reflecting the ambivalence of disordered gamblers. The analysis showed that the single-factor solution was not a good fit for the data. All fitted indices were less than the acceptable value of 0.9.

The second model to be examined was the two-factor model, which was extracted in the EFA. Although this model was a better fit than the one-factor model, the fit was not adequate, as the AGFI value was less than 0.9. Moreover, the RMSEA value fell outside the accepted value, further suggesting that the two-factor model was not the best fit for the data.

The third model was the four-factor model, which was assumed logically. The parallel factor, which was one factor of the two-factor model, could be divided into three sub-factors, namely, parallel expectation (items 4–5; e.g. “when I am playing pachinko/pachi-slot, thoughts run through my mind that I could get rich, but also that I could go bankrupt.”), parallel emotion (items 6–7; e.g. “In my mind, I want to quit plying pachinko/pachi-slot and at the same time, I want to play.”), and parallel reasons (items 8–9; e.g. “The reason I play pachinko/pachi-slot is to win and also to lose.”). The analyses showed that this four-factor model was a good fit for the data, as all fit indices were greater than 0.9 (GFI = 0.967; AGFI = 0.929; CFI = 0.975). Furthermore, the RMSEA value was in the accepted range (0.074).

Three models were tested and four-factor model was a best fit for the data, as all fit indices were greater than 0.9 Table 2.

Table 2 CFA of the PPAS
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Reliability
Internal consistency (Cronbach’s alpha)
Internal consistency coefficients (Cronbach’s alpha) for the overall scale and each factor were as follows: α = 0.87 for the total score, α = 0.92 for “regret,” α = 0.79 for “parallel expectations,” α = 0.80 for “parallel emotions,” and α = 0.48 for “parallel reasons.”

Test–retest reliability (n = 66)
Pearson’s correlation coefficients for the initial and retest scores were 0.66 for the total score, 0.62 for “regret,” 0.42 for “parallel expectations,” 0.56 for “parallel emotions,” and 0.50 for “parallel reasons.” All were significant at p < 0.01.

Validity
Correlations with related scales
Scales related to the PPAS showed significant positive correlations with the PPAS and with each of its subscales.

Total score and sub score of PPAS correlated with other gambling- and ambivalent- related scales Table 3.

Table 3 The PPAS’s correlations with related scales
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Next, we divided the participants into four groups according to the DSM-5 severity score (none, mild, moderate, and severe) and compared the mean PPAS scores across severity groups. For the procedure, we performed a one-way analysis of variance on the means for the four groups and found a significant between-group effect [F(3, 518) = 78.58, p < 0.001]. Differences between the mean values were then assessed using the Bonferroni comparison procedure. The results showed that the scores increased with severity.

Mean total score of PPAS correlated with severity assessed by DSM5 Table 4.

Table 4 A comparison of PPAS total scores by DSM5-severity group
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Correlations with a gambling dependency diagnosis status
The correlations of a gambling dependency diagnosis status with the PPAS and its subscales were as follows: 0.21 for the total score, 0.09 for “regret,” 0.21 for “parallel expectations,” 0.16 for “parallel emotions,” and 0.24 for “parallel reasons.” The correlation for “regret” was significant at p < 0.05, and the rest at p < 0.01.

Correlations with playing frequency and expenditure (convergent validity)
There were significant positive correlations (p < 0.01) between the total PPAS score and “frequency” (0.20), “playing duration” (0.17), and “money lost” (0.37).

Discriminant validity
Correlations with the social desirability scale
Significant negative correlations (p < 0.01) were found between social desirability and the total PPAS score (−0.30), “regret” (−0.20), “parallel expectations (−0.33), “parallel emotions” (−0.22), and “parallel reasons” (−0.18).

Correlations with demographic factors
No significant differences were found in the total PPAS score according gender, education level (higher or lower than college-graduate level) and family structure (single or not single). Similarly, no significant results were found for the correlation between household income and the total PPAS and subscale scores. Significant negative correlations were found between age group and the total PPAS score and each sub score (p < 0.05).

No significant differences were found in the total PPAS score according gender Table 5.

Table 5 The PPAS’s difference concerning demographic factors (gender)
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No significant differences were found in the total PPAS score according education level Table 6.

Table 6 The PPAS’s difference concerning demographic factors (education)
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No significant differences were found in the total PPAS score according family structure Table 7.

Table 7 The PPAS’s difference concerning demographic factors (family structure)
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Significant negative correlations were found between age group and the PPAS score (p < 0.05). On the other hand, no significant results for the correlation were found between household income and the PPAS Table 8.

Table 8 The PPAS’s correlations with demographic factors (household income and age group)
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Discussion
The PPAS’s reliability
The scale’s reliability was confirmed. Despite the low Cronbach’s alpha value for “parallel reasons,” at 0.48, those for the total scores and other three factors’ scores were 0.79–0.92, demonstrating the scale’s high internal consistency. Moreover, the test–retest correlation coefficients were 0.64 for the overall scale and between 0.42 and 0.62 for the subscales. Regarding parallel reasons, item 9 has a wider concept beyond ambivalence. Namely, changing the reason is not always associated with ambivalent attitude. Therefore the factor “parallel reasons” demonstrated the relative low internal consistency.

The PPAS’s validity
Construct validity
Results revealed that the four factors model reflected the classical distinctions drawn by Bleuler in defining regret.

Concurrent validity
There were significant positive correlations (0.37–0.62) between the total PPAS score and those of the related general scales (SIRI, AEQ) and gambling scales (SOGS, DSM-5, AGRI Short Screen, PGSI). Moreover, the correlations for the parallel factors tended to be higher than those for the regret factor. Additionally, there were small but significant positive correlations between the gambling dependency diagnosis status and the PPAS’s total score and its paralleling-factor scores. Thus, the PPAS’s concurrent validity was confirmed.

Convergent validity
The PPAS scores showed small to medium positive correlations with playing frequency and expenditure. In particular, stronger correlations were observed with money lost than with playing frequency. This confirmed the PPAS’s convergent validity. This may reflect ambivalent gambling leads to the unintentional repetitive incurrence of losses.

Discriminant validity
No significant correlation was found between PPAS scores and demographic factors, except being younger. This may be a reflection of the instability in the self-identity of young people. For that reason, when researching young people, one needs to be cautious about their overestimation of themselves. Meanwhile, a negative correlation with social desirability was found. A possible explanation for these results is that ambivalent people are susceptible to anxiety because they become introspective in response to reality. To avoid anxiety, a denial mechanism serves to protect them from a negative self-image and, as a result, they tend to answer based on unrealistic images of themselves. In sum, some of the responses to the scale may be biased. On the other hand, similar results have been reported for the SOGS, suggesting that this may be a limitation of self-administered scales (Kuentzel et al. 2008). Therefore, depending on the situation, use of a social desirability scale may be necessary when using the PPAS.

The utility of the PPAS
While this study showed that some caution may be required when using the PPAS, its reliability and validity were ascertained. Further, the PPAS’s scores showed that the degree of ambivalence correlated with the scores of the DSM5 as the comprehensive severity-assessment scale. Therefore, this study revealed that ambivalence as measured by the PPAS may reflect a core aspect of the condition of a gambling disorder patient. Namely, the PPAS can be considered a useful measure for the assessment for gambling disorders.

Limitations and suggestions for further research
The recruitment of participants for this study was limited to people registered with an online survey company. As a result, the sample may have been biased and not representative of the general population of pachinko or pachi-slot players in Japan. However, the study’s sample may be considered appropriate, overall, because it consisted mainly of married, middle-class, middle-aged men, which is consistent with the characteristics of most Japanese people who are diagnosed with gambling disorder (Komoto 2014; Toyama et al. 2014). Moreover, participation was limited to people who had played pachinko or pachi-slot only within the previous year. Next, we selected PPAS’s items by not statistic method but specialists’ conferences. As result, inclusion criteria of scale items somewhat became arbitrary. Additionally, to better understand the efficacy of ambivalence to predict prognosis, longitudinal studies are needed. While acknowledging these limitations, the further development and validation of this ambivalence scale for gambling disorder, for use in clinical settings, is recommended.