Feb 12, 2017 - are provided with free text boxes to elaborate on their assessment. These free text ... program on management inclination to approach an employee about ... clear which single item responses are testing which hypotheses (i.e., it is not ... only conditionâ that need correcting and spelling and grammar errors.
PEER REVIEW HISTORY BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form (http://bmjopen.bmj.com/site/about/resources/checklist.pdf) and are provided with free text boxes to elaborate on their assessment. These free text comments are reproduced below.
ARTICLE DETAILS TITLE (PROVISIONAL) AUTHORS
Effects of a Workplace Prevention Program for Problem Gambling: Study Protocol for a Cluster Randomized Controlled Trial Rafi, Jonas; Ivanova, Ekaterina; Rozental, Alexander; Carlbring, Per VERSION 1 - REVIEW
REVIEWER
REVIEW RETURNED
Alun C Jackson Formerly Problem Gambling Research and Treatment Centre, University of Melbourne 12-Feb-2017
GENERAL COMMENTS
This is a timely study. The design is appropriate and the authors acknowledge the limitations appropriately.
REVIEWER
Eva Alvarez-Moya Benito Menni CASM, St Boi de Llobregat Barcelona (Spain) 16-Mar-2017
REVIEW RETURNED
GENERAL COMMENTS
This paper describes a prevention project for pathological gambling at workplace. The article is well written and ideas are clearly developed. I have only some minor concerns: -Page 2, Strengths and limitations, 3rd point: please specify whom abilities -Page 5, Intervention: When describing the first component of the intervention ("policy implementation"), please specify to whom is adressed (managers only? employees too?) -Statistical analyses: please specify which specific variables and indices will be analysed -Limitations: given that the intervention will be addressed to working people, the results will not be generalizable to the general population. We have to take into account that unemployed people are a risk group that will not be considered, so this limitation of generalizability should be acknowledged. -Bibliographic references: if possible, swedish titles should be translated into english (added in brackets)
REVIEWER REVIEW RETURNED
Simone Rodda University of Auckland 20-Mar-2017
GENERAL COMMENTS
This manuscript is a protocol for a RCT investigating the effects of a
workplace prevention program for problem and disordered gambling in Sweden. The manuscript identifies a large gap in the literature specifically related to prevention programs for problem gambling in the workplace. The study investigates the impact of a workplace program on management inclination to approach an employee about problem gambling as well as 5 other secondary outcomes (e.g., confidence in responding to problem gambling). Overall the manuscript is interesting but further elaboration and clarification on measures is required to aid comprehensiveness of the protocol. Introduction The title refers to disordered gambling but there is no further mention of this in the manuscript. There have been multiple Swedish peer reviewed reports on prevalence studies and comorbidity so perhaps refer to this instead of the Swedish language references [5,6]. It is unclear what reference 9 refers to or which population. I presume it is a Swedish study but this is not clear from the manuscript or citation. Reference 10 is not really suitable in terms of saying „not all gamblers benefit from treatment‟. The citation is specific to internet based CBT (self-directed programs) and was across multiple different conditions. Page 1, line 17 requires citations and more specific evidence provided Page 1, line 26 does not appear correct. There are many structured interventions for problem gambling. Perhaps the authors mean specific workplace interventions. There have been multiple studies and reviews examining workplace interventions that have not been discussed by this manuscript. While many are gambling venue employees specific they provide a rationale for the current study and would be better included. The hypotheses I think need further clarification. The primary hypothesis does not appear derived from the literature as the background section is quite brief. Some of the secondary hypotheses are vague. For example, what is meant by „sustainable gambling practices.‟ The fourth hypothesis seems counter-intuitive to the study „fewer managers and employees reported PG'. Perhaps the authors mean fewer incidents of PG? If so, it is not made clear how this could be the case given the intervention is delivered to managers and not employees. Hypothesis 5 refers to an increased number of early identifications by the measures do not collect number of identification (only yes/no response). Hypothesis 6 refers to support in the workplace but the measure directly testing this is not obvious and this item does not appear in the intervention description. Furthermore, between the aims and the measures section there is a disconnect between the hypotheses and the measures and it is not clear which single item responses are testing which hypotheses (i.e., it is not clear what is addressing which hypotheses and whether they are all single items). (note psychometric have not been reported – see measures) Methods The intervention is not entirely clear from the study description. The first component of the intervention is described as implementation of a workplace gambling policy. Both related citations [17,18] are Swedish language resources and it is therefore not easy to get a
sense of what the intervention entails (or if they were peer reviewed publications). Perhaps the manuscript could contain a table outlining exactly what the first component of the intervention involved. Similarly the checklist that is offered to managers as part of the intervention is not easily available (also in Swedish language) (page 6) Measurement The primary outcome is managers inclination to engage in a conversation with an employee about gambling. There are no psychometrics provided for this item and it is difficult to get a sense of exactly what it is measuring. Perhaps the background (which is quite brief) could build the rationale for this primary outcome and provide evidence that it is likely to indicate better outcomes for gamblers. There are no psychometrics provided for the PGSI or its translation into Swedish (or use with this population). Furthermore, there is no indication of scoring system used for the PGSI in this study. Similarly the other secondary measures listed do not have any psychometrics or information on how the items were developed (e.g., were they focus tested or piloted, were they based on other surveys/screens?). Each of the items should include the response options (currently in the supplementary file but not the manuscript). There is also no rationale provided for some of the secondary outcomes. For example, „know about someone in the workplace who gambles‟ or „their own gambling habits‟. The items measuring „own gambling habits‟ has no psychometric or information provided on the source of these items. Given the number of brief screening tools available it would be better to administer a tool that did have psychometric information. Recruitment – it is not clear whether the researchers will have access to individual email addresses Randomisation is a little confusing. It reads as if the 10 organisations involved were randomised to a condition (i.e., “for pragmatic reasons, randomizing was done at the workplace level”). It is not clear the order in which organisations were recruited and how they were then randomised and by whom. Perhaps a rationale needs to be provided on why randomisation occurred at the organisation level and not at the managerial level. This approach will have significant impact on outcomes given the range of different settings and numbers of employees. No rationale provided for the sample size in terms of previous literature. There is reference to qualitative analysis but no indication in the aims/hypotheses what the qualitative analysis will be answering. Discussion: The reference to Monaghan pop-up study is a very strange citation for rates of treatment seeking. There have been many studies conducted specifically on treatment seeking and this is not one of them. Overall there are some Swedish-English translational errors (e.g., the use of „stand-by‟ to indicate wait-list control in the „assessment only condition‟ that need correcting and spelling and grammar errors (e.g., page 6, line 43)
VERSION 1 – AUTHOR RESPONSE Reviewer #1 (No adjustments requested). Thank you for sharing your enthusiasm for this study. We also believe this is an important subject to investigate.
Reviewer #2: 1) Page 2, Strengths and limitations, 3rd point: please specify whom abilities Page 2, row 34-35: To increase clarity, we changed “their” to “the managers”. 2) Page 5, Intervention: When describing the first component of the intervention ("policy implementation"), please specify to whom is addressed (managers only? employees too?) Page 5, row 17: Added clarification that the policy implementation component is aimed towards HRmanagers. 3) Statistical analyses: please specify which specific variables and indices will be analyzed. Thank you for noticing this. On page 9, row 4, we have now added the following text: “Each outcome corresponds to a questionnaire question (see measures section), and the change in each corresponding question from baseline to post and follow-up will be analyzed”. 4) Limitations: given that the intervention will be addressed to working people, the results will not be generalizable to the general population. We have to take into account that unemployed people are a risk group that will not be considered, so this limitation of generalizability should be acknowledged. Added generalizability limitation on page 10, row 29. 5) Bibliographic references: if possible, Swedish titles should be translated into English (added in brackets) Added English translations of reference titles.
Reviewer #3 1) The title refers to disordered gambling but there is no further mention of this in the manuscript. Thank you for pointing this out. To minimize confusion, we have removed the term “disordered gambling” from the title. 2) There have been multiple Swedish peer reviewed reports on prevalence studies and comorbidity so perhaps refer to this instead of the Swedish language references [5,6]. Thank you for pointing this out. The reference on comorbidity amongst individuals with PG have been changed to a meta-analysis by Lorains (2011) on page 3, row 6. The reference on PG prevalence in Sweden [6] have been changed to Abbot, Romild & Volberg (2014), on page 3, row 8. Both of these articles are written in English and are peer-reviewed. 3) It is unclear what reference 9 refers to or which population. I presume it is a Swedish study but this is not clear from the manuscript or citation. Thank you for noticing this. On page 3, line 10-11, we have clarified that the referenced paper is a systematic review conducted by the Public Health Agency of Sweden. 4) Reference 10 is not really suitable in terms of saying „not all gamblers benefit from treatment‟. The citation is specific to internet based CBT (self-directed programs) and was across multiple different conditions
Thank you for commenting on this. The review on treatment for disordered gambling by Hodgins and Yakovenko (2016) has been added, on page 3, row 13. 5) Page 1, line 17 requires citations and more specific evidence provided Thank you for your input. Specifications and citations has been added on row 14. 6) Page 1, line 26 does not appear correct. There are many structured interventions for problem gambling. Perhaps the authors mean specific workplace interventions. Thank you for your input. Assuming you mean row 19 (“Despite being important in…”), the lack of structured interventions refers to preventive interventions. The section now reads (Page 3, line 19): ”Despite being important in public health matters, preventive interventions aimed at PG are scarce [1] and the fundamental aspects of effective preventive interventions are not yet defined [13, 14].” 7) There have been multiple studies and reviews examining workplace interventions that have not been discussed by this manuscript. While many are gambling venue employees specific they provide a rationale for the current study and would be better included. Thank you for highlighting this issue. Most gambling workplace studies are indeed specific to gambling venue employees. Furthermore, they generally investigate and report on risk- and protective factors. While the studies indeed are highly relevant in the context of problem gambling prevention, we don‟t see how they provide rationale for the current intervention and would be thankful if you could elaborate on this matter. We are not aware about a workplace intervention apart from those specific to gambling venues. If you happen to know of that kind of interventions, we would be very grateful if you could share your knowledge with us.” 8) The hypotheses I think need further clarification. The primary hypothesis does not appear derived from the literature as the background section is quite brief. Thank you for noticing this important aspect. We have made changes in the background section in order to clarify the importance of the manager‟s inclination to engage in a conversation on harmful use with their employees. Page 3, line 27: “For instance, Pidd, Kostadinov, and Roche [18] showed that the presence of alcohol and drug policies at Australian workplaces were associated with lower odds for the presence of alcohol and drug problems, even more so when it comes to policies focusing on the use of substances as well as on getting assistance following the identified use. Although the authors conclude that they cannot be sure whether the lower odds were caused by the policy interventions or some other variable, the findings are, in combination with the increased demand for evaluating preventive interventions, worth exploring. An interview study, conducted by Binde [19], has shown that professionals in the field of prevention and treatment of harmful use see clear workplace policies for both managers (for engaging in a conversation and following a specific action plan) and non-managerial employees (for reporting about one‟s suspicions of a colleague‟s harmful use) as potentially useful tool to implement in a workplace setting.”
9) Some of the secondary hypotheses are vague. For example, what is meant by „sustainable gambling practices. Thank you for pointing this out, this has been clarified on page 4 line 13: “managers and employees engaging in more sustainable gambling practices as measured by sum of PGSI scores”. 10) The fourth hypothesis seems counter-intuitive to the study „fewer managers and employees reported PG'. Perhaps the authors mean fewer incidents of PG? If so, it is not made clear how this could be the case given the intervention is delivered to managers and not employees. Thank you for noticing this. You are correct that the intention was to refer to fewer cases of PG.
Policies are generally implemented to affect employee behavior, not the behavior of the managers who implement the policies. 11) Hypothesis 5 refers to an increased number of early identifications by the measures do not collect number of identification (only yes/no response). Hypothesis 6 refers to support in the workplace but the measure directly testing this is not obvious and this item does not appear in the intervention description. Thank you for pointing this out. Since the questionnaire item corresponding to this hypothesis only asked for where one might get help (not what kind of help), the formulation of the hypothesis has been corrected to reflect that. 12) Furthermore, between the aims and the measures section there is a disconnect between the hypotheses and the measures and it is not clear which single item responses are testing which hypotheses (i.e., it is not clear what is addressing which hypotheses and whether they are all single items). (note psychometric have not been reported – see measures) We appreciate the highlighting of this problem. The section on secondary measures has been completely re-written, and the order of the secondary hypothesis have been re-arranged to create a clear link. Also, the number of items per hypothesis has been clarified. 13) The intervention is not entirely clear from the study description. The first component of the intervention is described as implementation of a workplace gambling policy. Both related citations [17,18] are Swedish language resources and it is therefore not easy to get a sense of what the intervention entails (or if they were peer reviewed publications). Perhaps the manuscript could contain a table outlining exactly what the first component of the intervention involved. Similarly, the checklist that is offered to managers as part of the intervention is not easily available (also in Swedish language) (page 6) We understand this concern. A short explanation of what the policy component includes have been added. The checklist is only available in Swedish, but a brief summary of the checklist can be found at page 6. Apart from what is already outlined, there is not much more to add. However, we will consider having the checklist translated into English at a later stage in the project. 14) The primary outcome is managers‟ inclination to engage in a conversation with an employee about gambling. There are no psychometrics provided for this item and it is difficult to get a sense of exactly what it is measuring. Perhaps the background (which is quite brief) could build the rationale for this primary outcome and provide evidence that it is likely to indicate better outcomes for gamblers. The decision to value the managers‟ inclination to engage in a conversation with an employee about gambling is based on Alnas preferences and aim with their intervention rather on theoretical grounds. This has been clarified on page 5. 15) There are no psychometrics provided for the PGSI or its translation into Swedish (or use with this population). Furthermore, there is no indication of scoring system used for the PGSI in this study. We have made modification according to your suggestion. The section I question now reads: Page 7, line 12: “Furthermore, the PGSI will be used to investigate levels of gambling problems among employees and managers (hypothesis 5), where the total score of 0 points indicating nonproblem gambling, 1 to 2 points – low-risk gambling, 3 to 7 points – moderate-risk gambling, 8 and above – problem gambling. PG is defined as a PGSI score of 8. The PGSI has shown good psychometric properties [24, 25] and is being used in the Swedish national longitudinal epidemiological study [26].” 16) Similarly, the other secondary measures listed do not have any psychometrics or information on how the items were developed (e.g., were they focus tested or piloted, were they based on other
surveys/screens?). Each of the items should include the response options (currently in the supplementary file but not the manuscript). Response options, development, and pilot-testing information added to page 7. 17) There is also no rationale provided for some of the secondary outcomes. For example, „know about someone in the workplace who gambles‟ or „their own gambling habits‟. See point 14. 18) The items measuring „own gambling habits‟ has no psychometric or information provided on the source of these items. Given the number of brief screening tools available it would be better to administer a tool that did have psychometric information. Thank you for your comment. The questions regarding gambling habits have been adopted from the Swedish Longitudinal Gambling Study to enable comparison. This has been clarified on page 7. 19) Recruitment – it is not clear whether the researchers will have access to individual email addresses. This has been clarified on page 7, row 41. 20) Randomization is a little confusing. It reads as if the 10 organizations involved were randomized to a condition (i.e., “for pragmatic reasons, randomizing was done at the workplace level”). It is not clear the order in which organizations were recruited and how they were then randomized and by whom. Perhaps a rationale needs to be provided on why randomization occurred at the organization level and not at the managerial level. This approach will have significant impact on outcomes given the range of different settings and numbers of employees. That is correct, the organizations are randomized to a condition. Because the intervention is given at the organizational level, randomizing at the individual level would not have been possible without contamination between the intervention and wait-list group. This has been clarified on page 8. 21) No rationale provided for the sample size in terms of previous literature. Power analyses are justified based on the simulation study by Heo & Leon (2009), as mentioned in the section on sample size. 22) There is reference to qualitative analysis but no indication in the aims/hypotheses what the qualitative analysis will be answering. In the original manuscript, the aims of the qualitative was only briefly described in the secondary outcomes section. In the revised manuscript, the purpose (explorative analyses of managers experience of the intervention program) has been clarified in the section on qualitative analyses. 23) The reference to Monaghan pop-up study is a very strange citation for rates of treatment seeking. There have been many studies conducted specifically on treatment seeking and this is not one of them. The section on rates of treatment seeking has been rewritten. 24) Overall there are some Swedish-English translational errors (e.g., the use of „stand-by‟ to indicate wait-list control in the „assessment only condition‟ that need correcting and spelling and grammar errors (e.g., page 6, line 43) “Being on stand-by” has been changed to “being on hold”. Other minor grammar errors have been corrected (e.g. line 1 on page 8):
VERSION 2 – REVIEW REVIEWER
REVIEW RETURNED
Professor Alun Jackson Formerly, Problem Gambling Reseacrha nd Treatment Centre, Australia 03-May-2017
GENERAL COMMENTS
The authors have responded appropriately to the reviewers' comments and publication is now recommended.
REVIEWER
Simone Rodda University of Auckland 29-May-2017
REVIEW RETURNED
GENERAL COMMENTS
This is a re-review of a protocol for a workplace problem gambling intervention. The authors have addressed all of my comments and I thank them for considering my feedback.
