Don’t Let an Opportunity Go by: Validation of the EIGHT Gambling Screen

Don’t Let an Opportunity Go by: Validationof the EIGHT Gambling Screen

Sean Sullivan

Received: 3 January 2007 /Accepted: 15 March 2007 /Published online: 17 April 2007# Springer Science + Business Media, LLC 2007

Abstract The EIGHT Screen is a brief problem gambling screen originally designed foruse by family doctors. Its wider use indicated the need for further validation. A triangulatedapproach used a range of measures in different settings in both the current study andfindings from a number of earlier projects, and reviewed current use. The EIGHT Screenhad acceptable correlations with the SOGS (r=74–90%) and with the NODS-12 monthsScreen (r=62.4%). Measurements remained relatively constant amongst a range of cultures,settings, age and gender, while few false positives were produced by the screen. TheEIGHT Screen appears to be a valid tool for untrained users to identify Level 2 and 3problem gambling in a wide range of cultures and settings.

Keywords Eight screen . Problem gambling . Screen validation . Brief screen

Introduction

Currently there appear to be at least 25 screens developed to identify problematic gambling(Abbott et al. 2004), with earlier screens focussing upon the identification of the mostsevere level, Pathological Gambling Disorder (PGD). More recent screens have also sought,in addition to PGD or Level 3 problem gambling, to identify more moderate gamblingproblems, currently referred to as Level 2 gambling (Shaffer et al. 1997). This can offer theadvantage of identifying an earlier stage of problem gambling with the possibility ofreducing progression of the gambling behaviour to Level 3. Early stage problems may existwithout the gambler’s full awareness and may be identified in opportunistic situations thatmay be health settings that are not for gambling treatment (such as alcohol treatmentservices) or even social settings (such as budgeting or justice services). Those screening inthese services are often constrained by time and by competing demands, and are unlikely touse a screen that is long, complex, or difficult to score. The EIGHT Screen, an acronym for

Int J Ment Health Addiction (2007) 5:381–389DOI 10.1007/s11469-007-9064-x

S. Sullivan (*)Auckland Medical School, University of Auckland, PO Box 90710,Auckland Mail Centre, Auckland, New Zealande-mail: [email protected]

Early Intervention Gambling Health Test, was initially developed at the University ofAuckland Medical School (Sullivan 1999a; part of a PhD thesis) as a tool specifically forfamily doctors, and designed to be self-completed by patients within approximately oneminute. The screen was provided to approximately 1,000 patients in primary health settingsand to over 200 clients of specialist problem gambling treatment services. These earlyfindings identified a 74% correlation with the SOGS and a high sensitivity for diagnosedPGD. Its internal reliability was high (Cronbach’s alpha 0.97) and with test–retestreliability. The four cut-off for a ‘case’ was agreed by analysis (ROC) and from a Delphiprocess with 63 problem gambling specialists from NZ and overseas. The eight questionstested emotional, behavioural and cognitive dimensions of problem gambling.

Subsequently the screen has been used in a range of other settings, including websites asa self-testing survey (see below). A score of four or more out of a possible eight indicatesLevel 2 or 3 problematic gambling is occurring.

The EIGHT screen has been used in a number of research studies in New Zealand (NZ) andin some overseas studies. It has also been accepted as an appropriate tool in NZ and overseasfor both self-identification of problematic gambling (e.g. Cape et al. 2002; Lemay et al. 2006)and as a resource in clinical settings (e.g. The Bridge, alcohol and drug treatment programme,personal communication). These studies and use in clinical, health promotion and social settingswere assessed as part of a triangulated research approach to validation of the screen.

The current project was to further validate the EIGHT Screen in a range of settings andcultures, to accumulate published and unpublished research using the screen, and to identifyits current use.

The findings of the triangulated research approach were allocated to the aspectsidentified by Neal et al. (2005) necessary to validate a screening tool.

In the specialist gambling setting the EIGHT Screen and NODS 12-month Screen(National Opinion Research Center 1999) were provided contemporaneously, while in theAOD and family doctor settings, the EIGHT and SOGS screens were provided.

Results of the Current Study

A total of 1,333 clients or patients participated in the current further validation projectcomprising 341 clients of specialist problem gambling treatment (‘specialist gambling’)services, 315 patients of family doctors, and 676 clients of alcohol or other drug treatment(‘AOD’) services.

AOD and Family Doctor Settings

The correlation between the SOGS and EIGHT Screen in the AOD setting was high at83.9% (Spearman’s rho p<0.01 two-tailed) and 81.3% in the family doctor setting(Spearman’s rho p<0.01 two-tailed). At a four cut-off on the EIGHT Screen, bothsensitivity (90%) and specificity (95%) were similar when compared with a five cut-off forthe SOGS (probable pathological gambling).

Specialist Gambling Setting

In the specialist gambling setting the correlation between the EIGHT and NODS 12-monthscreen was 62.4% (Spearman’s rho p<0.01 two-tailed). At a six cut-off 96.5% of NODS12-month Level 3 gamblers would be identified.

382 Int J Ment Health Addiction (2007) 5:381–389

Gender

Correlation between the SOGS and EIGHT Screens for females was 84.5% (p<0.01) andfor males 87% (p<0.01). Reliability of the EIGHT Screen for both females (Cronbach’salpha 0.960) and males (Cronbach’s alpha 0.956) was high.

Youth

For youth (under 25 years), the EIGHT and NODS 12-month Screens correlated at 70%(p<0.01; n=29) and for the EIGHT and SOGS Screens correlated at 78% (p<0.01; n=148).

Ethnicity

For Maori (indigenous New Zealanders) the EIGHT Screen and SOGS correlated at 83%(p<0.01; n=222). For the NODS 12-month and EIGHT Screens, correlation was 56%(p<0.01; n=94). The area under the ROC (usefulness of the screen) was 98%.

For Pacific peoples, the correlation between the EIGHT Screen and SOGS was 88%(p<0.01; n=167) and for the EIGHT Screen and NODS 12-month 44% (p<0.01; n=15).The area under the ROC for Pacific was 96%.

For New Zealand Europeans, the EIGHT Screen and SOGS correlated at 78% (p<0.01;n=329) and for the EIGHT Screen and NODS 12-months 60% (p<0.01; 186). The areaunder the ROC was 98%.

Inter-item Reliability

The internal consistency of the EIGHT Screen (question items measuring the sameconstruct should be moderately correlated at Cronbach’s 0.70 or above—Neal et al. 2005)was calculated at 0.958 (n=1,290). This was also true for the subgroups of settings, genderand ethnicity.

(a) Reliability for different settingsThe reliability of the EIGHT Screen for AOD settings (Cronbach’s alpha 0.947),family doctor settings (Cronbach’s alpha 0.927) and specialist gambling settings(Cronbach’s alpha 0.692) were within acceptable limits.

(b) Reliability for genderThe EIGHT Screen’s reliability was high for both females (Cronbach’s alpha 0.96)and males (Cronbach’s alpha 0.956).

(c) Reliability for ethnic groupsReliability was high for Maori (Cronbach’s alpha 0.956), Pacific (Cronbach’s alpha0.944) and NZ European (Cronbach’s alpha 0.956).

Test–Retest

Participants at AOD or specialist gambling settings were provided the EIGHT Screen at asession and asked to re-complete the screen at a following session. Seventy of 73participants (96%) were either positive (n=67) on the test and re-test or negative (n=3) onboth. Two participants scored four on the test and two on the retest, and one scored five onthe test and three on the retest. This compared to a 95% test/retest conformity in the screendevelopment (Sullivan 1999b).

Int J Ment Health Addiction (2007) 5:381–389 383

False Positives

Some suggestion has been made that because the EIGHT Screen is designed to minimisefalse negatives, it may have a propensity to produce false positives, and therefore reduce itsvalue as a diagnostic screen. It was noted that in the settings where both the SOGS andEIGHT Screens were provided, similar numbers of clients were identified as negative forLevel 2 or above gambling (663 scored 2 or less by the SOGS; 668 scored 3 or less by theEIGHT Screen). A score of 3 or 4 on the SOGS has been generally accepted as problemgambling, and 5 or more as probable pathological gambling (Table 1).

The sensitivity of a four or higher score on the EIGHT Screen for a three or higher scoreon the SOGS (‘problem’ or ‘probable pathological gambling’) is 81% and the specificity is97%. The sensitivity of a four or higher score on the EIGHT Screen for a five or higher scoreon the SOGS Screen (‘probable pathological gambling’) is 93% and the specificity is 94%.

The specialist gambling setting is not perhaps an appropriate setting for identifying thespecificity of a screen in that there will be few screen negatives while those in treatmentmay have reduced their criteria (for Pathological Gambling Disorder) over the last12 months, the period measured by the NOD-12 month screen. In addition, the EIGHTScreen is designed to measure Level 2 and Level 3 gambling at a four cut-off. Thus therewill be small numbers of negatives for Level 3 problem gambling which will skewspecificity calculations and some Level 3 negatives for the NODS-12 months Screen willstill be positives for the EIGHT Screen at this cut-off.

The sensitivity of a four or higher score on the EIGHT Screen for a one or higher scoreon the NODS-12 months Screen (Level 2 or Level 3 problem gambling) is 97% and thespecificity is 33%. The sensitivity of a four or higher score on the EIGHT Screen for a fiveor higher score on the NODS-12 months Screen (Level 3 problem gambling) is 100% andthe specificity is 13%. Some 2.6% (n=8) of these participants in the problem gamblingsetting were positives for the EIGHT Screen at a four cut-off but were negatives for eitherLevel 2 or Level 3 problem gambling under the NODS 12-month Screen. Theseparticipants may have been either false positives for problem gambling (yet had electedto attend a specialist problem gambling service) or had been reporting symptoms prior to12 months from completing the screens when they were problem gamblers under theEIGHT Screen but no longer exhibiting the problem gambling criteria identified by theNODS 12-month Screen during the last 12 months (Table 2).

Discussion of Current Study and other EIGHT Screen Findings

In the absence of a gold standard to measure either Level 2 or Level 3 gambling against thetriangulated approach appeared to be the best approach to determine the validity of the

Table 1 SOGS Levels of Problem Gambling by EIGHT Screen in AOD and Family Doctor Settings(N=811)

SOGS Level 1 SOGS Level 2 SOGS Level 3 Total

Score <3 Score 3 or 4 Score ≥5

EIGHT positive (score ≥4) 16.1% (23) 14.0% (20) 69.9% (100) 143EIGHT negative (score <4) 95.8% (640) 3.0% (20) 1.2% (8) 668Total 663 40 108 811


EIGHT Screen. Neal et al. (2005) identified several aspects of a screen’s validation values,and the current study reported above, together with other evidence, provided evidencetowards assessing the validity of the EIGHT Screen in a triangulated approach.

Reliability of the EIGHT Screen

The retesting of participants both in the screen development study (Sullivan 1999b) and thecurrent study (n=128) identified that between 95 and 96% of participants would eitherremain positives or negatives under the EIGHT Screen. In addition, the internal reliabilityof the EIGHT Screen considerably exceeded the baseline 0.70 level usually set, withCronbach’s alpha in the development study being 0.97 and in the current study 0.96. Thishigh reliability has also been identified by other researchers (Cape et al. 2002).

It would appear that wording of the screen is not ambiguous and that each screenquestion is not highly correlated with the others.

Internal Validity

a. Construct validity: As Neal et al. (2005) affirm, a valid screen should capture the ‘truenature of problem or pathological gambling’ p58, but this is not an easy concept toidentify. It is shaped by a definition for that gambling (and there are several), that thecriteria can be viewed as symptoms of the problem gambling and not the problemgambling itself, and lastly the difficulty of differentiating between problem gamblingand non-problem gambling. This last issue increases as the differentiation expands toLevel 2 problem gambling, and is not restricted to (the easier categorisation)Pathological Gambling Disorder and those not meeting these criteria. The bio-psycho-social perspective taken in the development of the EIGHT Screen identified arange of these factors in the eight questions. Both behaviours and consequences areincluded while a continuum approach is taken. In the development of the screen, 63practitioners and specialist researchers from New Zealand and overseas were surveyedas to question suitability, weighting and cut-off to identify a point at which gamblingwas becoming a problem and an intervention warranted (Level 2; Sullivan 1999b). Thiswas presented at a range of international overseas for feedback. In the current study,participating practitioners were invited to provide feedback from both their experiencesand their clients’ responses. There was strong support that the screen identified clientswith gambling problems and that the practitioners considered, upon discussion, thatgambling problems existed. This supported feedback from family doctors in an earlierstudy using the screen (Sullivan et al. 2006).

b. Classification accuracy: The absence of a gold standard prevents an estimation of a truesensitivity and specificity for the EIGHT Screen. However, comparison with a range ofmeasures, none of which by itself can be considered a true classification, can provide

Table 2 NODS Levels of Problem Gambling by EIGHT Screen (N=318)

NODS Level 1 NODS Level 2 NODS Level 3 Total

Score 0 Score 1–4 Score ≥5

EIGHT positive (score ≥4) 2.6% (8) 22.9% (70) 74.5% (228) 306EIGHT negative (score <4) 4 8 0 12Total 12 78 228 318


an indication that the EIGHT Screen does provide a measure of accuracy. The originaldevelopment study provided a consensus between practitioners working in the fieldthat a four cut-off classified a problem gambler. An ROC analysis using SOGS as thecriteria and the EIGHT Screen produced a high area under the curve at 92.7%identifying the EIGHT Screen as a useful measure. In a subsequent study, the EIGHTScreen responses of prison inmates were compared with a DSMIV based diagnosis byexperienced assessors with the EIGHT Screen identifying 91% of inmates meetingPathological Gambling Disorder. This compared with the SOGS which identified 82%of these inmates (Sullivan et al. 2007). In an Australian university degree thesis study, theEIGHT Screen correlated with the SOGS at 90.6% (Shandley 2001) while the currentstudy identified high correlations with the SOGS in a number of settings and satisfactorycorrelation with the NODS 12-month Screen in a specialist gambling setting.

c. Appropriate validation samples: A suitable range of settings have been tested in boththe current and other studies drawn together in a triangulated research approach. Theseinclude family doctors (Sullivan 1999b; Sullivan et al. 2006), problem gamblingtreatment settings (Sullivan 1999b; the current study), casino gamblers (Cape et al.2002), Australian public and treatment clients (Shandley 2001), inmates at a mediumsecurity prison (Sullivan et al. 2007), and alcohol and other drug treatment settings asin the current study. These include subgroups of male, female, Maori, Pacific peoples,Asian and New Zealand Europeans. The screen has therefore been tested with a rangeof samples and returned effective validity measures in each.

d. Dimensionality: All questions should relate to the same concept, and the analysis ofinternal consistency above identified that the questions identified with the total score.The overlap between many dimensions in the screen has caused difficulty in ascertainingwhether a single factor (ideally) explains much of the variability between items and furtherwork in this area may be warranted. An Oblique Principal Component Cluster analysisconducted during the development of the screen was unsuccessful (Sullivan 1999b) andsuggests a need for further enquiry for dimension analysis.

e. External validation: The extent to which the EIGHT Screen correlates with other issuesthat also correlate with problem gambling can assist in confirming the validity of ascreen. Problem gambling has been found to correlate with suicidal ideation,depression, poverty, alcohol misuse and be elevated in Maori. Elevated positiveEIGHT Screen findings have been found amongst depressed patients of family doctors(Sullivan et al. 2006; Sullivan 2003), in foodbank clients (Hutson and Sullivan 2004),in a prison population (Sullivan et al. 2007), amongst Maori (Sullivan 2005a), patientsadmitted to a hospital after a suicide attempt (Penfold et al. 2006a, 2006b) and inclients of alcohol and drug treatment services (Sullivan and Steenhuisen 2007).

f. Concurrent validity: The EIGHT Screen has been found to correlate with other problemgambling screens (Table 3), although, as Neal et al. (2005) state ‘an obvious limitationwith this method is that it assumes that the older methods are necessarily valid’ (p. 61).

g. Item variability: Questions in the EIGHT Screen do not vary in their likelihood of beingchosen (or not) by problem and non-problem gamblers. No question was rarely chosen byproblem gamblers, nor often chosen by non-problem gamblers (Cape et al. 2002).

h. Practicality: Neal et al. (2005) identify three aspects of practicality. These are brevitywhich enhances practicality for multiple uses, ease of administration in applicationtraining, scoring and interpretation, and whether the screen is free to access. In eachcase, the EIGHT Screen meets these criteria. It is brief, provides only two responses,requires little training to administer, score and interpret, and is within the publicdomain and free of cost.


i. Applicability: The degree the screen can be used for subgroups within a population(especially gender, age and culture), and is seen by them as relevant is an aspect ofvalidity. Different interpretation by subgroups may affect internal consistency andreliability, while ability to translate the screen into different languages with little or nochanges may indicate the screen’s level of applicability. In the above current study andothers the EIGHT Screen was found to provide high levels of usefulness in differentsubgroups as identified by the ROC findings and in levels of internal consistency asidentified by Cronbach’s alpha (Table 4).

Table 3 EIGHT Screen Correlation with Other Problem Gambling Screens

Study Result

Screen Development Study(Sullivan 1999b)

Correlation with SOGS in a number of NZ settings 74%

Youth EIGHT Screen-Y Study(Sullivan 2005b)

EIGHT-Y and SOGS-RA correlation 64%; and with DSM-JR 53%

Prison Study (Sullivan et al. 2007) Correlation with SOGS in a prison setting 83%Correlation with DSM assessment by therapist 91% sensitivity

Australian university study(Shandley 2001)

EIGHT Screen and SOGS correlated at 90%

Current Validation Study EIGHT Screen and SOGS correlated at 86% and with 12 monthsNODS 62%

Table 4 Applicability of the EIGHT Screen to Different Subgroups

Group Reliability Areaunder ROC

Internal Consistency(Cronbach’s alpha)

Other

Females 0.973 0.960Males 0.892 0.956Maori 0.976 0.956Pacific 0.957 0.944NZ European 0.976 0.960AOD 0.965 0.947 Used in various AOD

non-government organisationsFamily doctors 0.960 0.927Problem gamblingservices

0.958 0.692a

Youth 0.955 Used in Iwi-based organisationsYouth version correlates with youthversions of SOGS and DSM screens

Adult (25 years+) 0.958Prison inmates(Sullivan et al. 2007)

EIGHT Screen identified 91% ofdiagnosed with PGD

Adopted as the gambling screen forNZ Corrections

a At limit of recognised acceptance level


In addition, the EIGHT Screen is being used widely as a resource for those accessingInternet websites. These websites include NZ Corrections, Victorian Commission forGambling Regulation, Caritas AG (in English and Chinese), South Australian Departmentof Human Resources, and several NZ NGO websites. It has also been adopted as a writtenresource, such as a doctors’ (general or family) professional development resource(Australian Federal Government (Dept of Health & Aging) handbook), a resource forolder people (Ontario Ministry of Health and Long Term Care), and by the gamblingindustry (South Australian Lotteries and Dunedin Casino).

Validation Conclusions

The data and feedback from a number of studies that have used the EIGHT Screen asproblem gambling measure, and measured its performance against a number of recognisedvalidity standards indicate that the EIGHT Screen has acceptable psychometric properties tomeasure problem gambling. Some criticism arising from earlier conference presentations bythe screen designer that an emphasis has been upon minimising false negatives has beentaken to imply that its diagnostic properties may be weakened through excessive falsepositive findings by the screen. These statements appear not to have followed research thathas shown that the EIGHT Screen doesn’t produce excessive false positives. Indeed, in theabove current study, the numbers of Level 2 and 3 problem gamblers identified by theSOGS were similar in numbers to those identified by the EIGHT Screen. Also, in the prisonstudy lower false negatives for diagnosed PGD were found for the EIGHT Screen than theSOGS. When compared with the DSM based NODS-12 months Screen, only 2.6% ofEIGHT Screen positives were not Level 2 or 3 problem gamblers.

Many of the studies identified have been involved the EIGHT Screen designer as eitherthe researcher or co-researcher, and have focussed upon mostly NZ populations.Independent studies by researchers other than the screen designer, both in NZ andespecially outside of NZ will assist to confirm the psychometric properties and acceptanceof the screen in other settings.

The EIGHT Screen is a briefer screen than all of the 25 or more problem gamblingscreens in existence except perhaps one other (the Lie/Bet Screen for pathologicalgambling; Johnson et al. 1997), and focuses upon early stage problems in addition topathological gambling. It is arguably the briefest and simplest gambling screen (to score) inassessing Level 2 and Level 3 gambling problems, important factors in acceptance by oftenbusy health and social services not specialising in addressing problem gambling. Its abilityto be completed within one minute, on average, and to be quickly scored (four or more outof a possible eight being positive) was an important goal of the screen’s development,which required that there were fewer items than almost all other gambling screens, andreduced response options (essentially yes or no).

The screen was originally designed as a tool for family doctors and, as with otherscreens such as the SOGS, has been used in many other settings. This validation study hasprovided some evidence that the EIGHT Screen retains its properties in a wide range ofsettings. Its brevity and simplicity although it was designed for family doctors, is alsoadaptable for non-specialist use. It is this latter ability that may enhance the EIGHTScreen’s future use, such that more opportunities may arise in the future through screeningpeople in social and non-specialist gambling treatment settings, through the availability of avalid, simple and brief problem gambling tool.


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Don’t Let an Opportunity Go by: Validation of the EIGHT Gambling Screen

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