Does the prevention paradox apply to various alcohol habits and problems among Swedish adolescents?

The Paradox of Suicide Prevention

The recognition that we cannot use risk stratification (high, medium, low) to predict suicide or to allocate resources has led to a paradigm shift in suicide prevention efforts. There are challenges in adapting to these new paradigms, including reluctance of clinicians and services to move away from traditional risk categorisations; and conversely, the risk of a pendulum swing in which the focus of care swings from one approach to determining service priority and focus (e.g., diagnosis, formulation, risk and clinical care) to a new focus (e.g., suicide specific and non-clinical care), potentially supplanting the previous approach. This paper argues that the Prevention Paradox provides a useful mental model to support a shift in paradigm, whilst maintaining a balanced approach that incorporates new paradigms within the effective aspects of existing ones. The Prevention Paradox highlights the seemingly paradoxical situation where the greatest burden of disease or death is caused by those at low to moderate risk due their larger numbers. Current planning frameworks and resources do not support successful or sustainable adoption of these new approaches, leading to missed opportunities to prevent suicidal behaviours in healthcare. Adopting systems approaches to suicide prevention, such as the Zero Suicide Framework, implemented in a large mental health service in Australia and presented in this paper as a case study, can support a balanced approach of population- and individual-based suicide prevention efforts. Results demonstrate significant reductions in re-presentations with suicide attempts for consumers receiving this model of care; however, the increasing numbers of placements compromise the capacity of clinical teams to complete all components of standardised pathway of care. This highlights the need for review of resource planning frameworks and ongoing evaluations of the critical aspects of the interventions.

The Evolution of Gambling-Related Harm Measurement: Lessons from the Last Decade

Jurisdictions around the world have a self-declared mandate to reduce gambling-related harm. However, historically, this concept has suffered from poor conceptualisation and operationalisation. However, recent years have seen swift advances in measuring gambling harm, based on the principle of it being a quantifiable decrement to the health and wellbeing of the gambler and those connected to them. This review takes stock of the background and recent developments in harm assessment and summarises recent research that has validated and applied the Short Gambling Harms Screen and related instruments. We recommend that future work builds upon the considerable psychometric evidence accumulated for the feasibility of direct elicitation of harmful consequences. We also advocate for grounding harms measures with respect to scalar changes to public health utility metrics. Such an approach will avoid misleading pseudo-clinical categorisations, provide accurate population-level summaries of where the burden of harm is carried, and serve to integrate gambling research with the broader field of public health.

The prevention paradox applies to some but not all gambling harms: Results from a Finnish population-representative survey

BACKGROUND AND AIMS

The Prevention Paradox (PP) suggests that a large proportion of aggregate harm from gambling occurs to people who do not have a gambling disorder. However, it has not yet been tested using a population-representative sample. We aimed to test whether the PP applies to gambling in Finland. The prevalence rates of diverse harmful consequences from gambling were surveyed amongst a population-representative sample of past-year gamblers.

METHODS

The study used first wave data (N = 7,186) of Finnish Gambling Harms survey, collected via online and postal surveys in 2017. A subset of 3,795 adults (≥18 years), who had gambled at least monthly in 2016, were selected for analysis.

MEASUREMENTS

Gambling-related harms were evaluated with the 72-item Harms Checklist. Problem and Pathological Gambling Measure (PPGM) measured respondents' probable disordered gambling from the subset of items for impaired control (4 questions) and other issues (3 questions).

FINDINGS

Consistent with previous findings, the majority of harms were reported by those in the less severe PPGM categories (i.e. scoring <5). However, considering each domain separately, this was true only for financial, emotional/psychological, and work/study harms. The PP was not supported for health, relationship, or social deviance harms.

CONCLUSIONS

The population prevalence of the most serious harms (e.g. unsafe living conditions) is concentrated among those with severe impaired control issues. However, even excluding the ∼15% of harms occurring to occasional gamblers, most financial, emotional and work/study impacts occur to those with lower levels of control issues. Efforts at harm reduction should focus on the entire spectrum of issues that people experience from their gambling.

Epidemiology visualized: the prosecutor's fallacy

The "prosecutor's fallacy" (the assumption that Pr [probability] (A|B) = Pr (B|A)) arises often in epidemiology but is often unrecognized as such, in part because investigators do not have strong intuitions about what the fallacy means. Here, we help inform such intuitions and remind investigators of this fallacy by using visualizations. In figures, we demonstrate the prosecutor's fallacy, as well as show conditions under which Pr (A|B) can be assumed to be equal to Pr (B|A). Visualizations can help build intuition around statistical concepts such as the prosecutor's fallacy and should be more widely considered as teaching tools.