A Rural-Urban Comparison of Healthcare Access for Gambling Disorder in the United States: A Hurdle Model Approach

Background and Purpose: Rural populations face significant barriers to accessible treatment and recovery services when compared with their urban counterparts. The changing epidemiology of Gambling Disorder has significant public health impacts that require social workers receive specialized training in prevention and treatment, particularly in underrepresented communities. Greater gambling availability is associated with an increase in participation and subsequent increases in at-risk and problem gambling prevalence rates. Legal sports betting in many states and the ease of access to online/mobile casinos likely exacerbate these outcomes in rural communities, in part due to shortages in treatment and recovery services. The goal of the current study was to provide a robust estimate of the relative availability of services for gambling problems for rural counties compared with urban counties.

Methods: Data for the current project were collected from public facing website databases from the International Gambling Counselor Certification Board (IGCCB) counselor directory and Gamblers Anonymous (GA) 12-step program meeting rooms. Gambling services availability was measured by the number of IGCCB counselors per 100,000 residents and number of GA rooms per 100,000 residents at the county level for all 3144 counties in the United States. County Rural Urban Continuum Codes (RUCCs) were used to distinguish between three levels of rurality: urban (RUCCs = 1 – 3), micropolitan rural (RUCCs = 4 – 7), and remote rural (RUCCs = 8 – 9). The current study applies zero-inflated hurdle models to predict probability of health service access and estimate the relationships between service availability and county characteristics to adjust for the large proportion of counties that have no services. Zero-inflated hurdle models were selected to deal with large number of counties with no services. Models also included county characters including, percentage estimates for sex, age, having no health insurance, having no internet access and living in poverty, and USDA Economic Research Service county designations for low educational attainment, population loss and low employment.

Results: IGCCB counselors and GA rooms, per 100k availability were significantly higher in rural counties when such services were present, but the odds of having no services at all were also substantially higher. For example, remote rural counties with IGCCB counselors had 18.13 times higher access per 100k than urban counties when services were present, but also had 13.58 higher odds of having no IGCCB counselors at all. Several county characteristics were also associated with absence of recovery services, including the proportion of the county identifying with a racial category other than white, the proportion of the population without health insurance, and counties with low education attainment and population loss.

Conclusions and Implications: The authors found that counties designated as rural have far greater odds of lacking services relevant for those experiencing gambling problems and that these odds increase as rurality increases. These disparities are discussed in the context of larger challenges for Social Work in addressing inequities in mental healthcare access faced by rural communities.