title: Impacts of casinos on key pathways to health: qualitative findings from American Indian gaming communities in California.
abstract: Three decades ago, casino gaming on sovereign American Indian lands was legalized with differential economic and social implications. While casinos have improved the incomes of tribal communities, there have been both positive and negative findings in relation to health impacts. We sought to understand the perceived pathways by which casinos impact individual and community health through voices of the community.
  
  
  
  We conducted semi-structured, interviews with tribal leaders (n =12) and tribal members (n =24) from tribal communities (n = 23) representing different regions of California. We inductively analyzed textual data drawing from Grounded Theory, first using line-by-line coding to identify analytic categories from emergent themes in consideration of the study objective. Then, focused codes were applied to identify salient themes, which we represented through exemplar quotes and an overall conceptual framework. Data were managed and coded using Dedoose software.
  
  
  
  American Indian-owned casinos are perceived to influence the health of tribal communities through three pathways: 1) improving the tribal economy 2) altering the built environment, and 3) disrupting the the social landscape. Forming these pathways are a series of interrelated health determinants. Improvement of the tribal economy, through both job creation for tribal members and improved tribal cash flow, was perceived by participants to both influence health. Specifically, improved cash flow has resulted in new wellness programs, community centers, places for recreation, and improved social services. Higher disposable incomes have led to better financial stability, increased access to healthy food, and more opportunities for physical activity. Yet, higher disposable incomes were perceived to also contribute to negative health behaviors, most notably increased drug and alcohol abuse. Casinos were also perceived to alter built environments, resulting in increased availability and access to unhealthy food. And to a lesser extent, they were perceived to disrupt the social landscape of communities with impacts on tribal community value systems.
  
  
  
  Casino environments improve economic conditions of tribal communities, but present important social and public health challenges. Policy makers at federal, state, and tribal levels should consider the perceptions of tribal members and leaders when determining policies in light of casino development.
authors.affiliation: Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA. skodish@hsph.harvard.edu.
authors.forename: Stephen R
authors.initials: SR
authors.lastname: Kodish
authors.affiliation: Department of International Health, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA.
authors.forename: Joel
authors.initials: J
authors.lastname: Gittelsohn
authors.affiliation: Department of International Health, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA.
authors.forename: Vanessa M
authors.initials: VM
authors.lastname: Oddo
authors.affiliation: Department of International Health, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA.
authors.forename: Jessica C
authors.initials: JC
authors.lastname: Jones-Smith
mesh_terms: D000328:Adult; D002140:California; D005260:Female; D005715:Gambling; D006293:Health Promotion; D006304:Health Status; D006801:Humans; D007198:Indians, North American; D007407:Interviews as Topic; D008297:Male; D010067:Ownership; D011634:Public Health
keywords: American Indian health; Built environment; Casinos; Health impacts; Nutrition; Physical activity; Qualitative research; Social policy