By conducting semi-structured interviews among American Indian tribal members and leaders throughout California, we were able to generate an understanding of how this population perceived gaming operations to impact their environment, behaviors, and health. Participants in this study perceived casinos to both positively and negatively impact several important determinants of their community and individual health, through economic, environmental, and social pathways.
Pathways to health through improving the tribal economy
Most notably, tribal leaders and members described the gaming operations and their stimulation to the tribal economy positively, highlighting increased job creation and improved tribal cash-flow, which tribal councils reportedly allocate toward per capita payments, new wellness programs & community centers, and for improved social services, such as health insurance subsidies.
Tribal members underscored the positive impact of
per capita payments on individual and household levels of
disposable income, which participants said have allowed them and their children to more easily engage in positive-health behaviors. This finding is aligned with quantitative estimates of improved health indicators and health-related behaviors corresponding with improved tribal member income from American Indian gaming operations between 1988 and 2003 nationwide [
27]. Improvements in physical and emotional health, in particular, and as a result of increased economic resources, are plausible considering that tribal members in our study discussed their use of casino profits for paying bills, acquiring better or more stable housing, buying healthier foods, such as “
organic products”, and enrolling their children in sports. The positive health behaviors reported among our study sample are consistent with findings that a casino presence on tribal lands was associated with decreased probability of overweight among American Indian children, also in California, and with findings of reduced probability of obesity and diabetes among American Indian adults nationwide [
9,
21].
On the other hand, tribal members and leaders stressed that
higher disposable incomes from
per capita payments, as opposed to
higher disposable incomes from
job creation, may also negatively influence individual health behaviors. For example, excess drinking and drug abuse were frequently noted as unintended behavioral consequences from
per capita payments with direct negative consequences for the physical and mental health of communities. These findings are consistent with ethnographic research conducted by Bruckner and colleagues [
11] who noted that participants from the Eastern Band of Cherokee Indian community frequently cited spending per capita payments on drugs and alcohol, as well as on new motor vehicles. The authors speculate that the combination of these activities could be producing more accidental deaths in association with the timing of casino payments. However, other research from a nationwide sample showed that smoking and heavy alcohol use actually decreased in association with higher incomes from gaming [
9].
Tribal leaders in our study perceived the casino environment to be largely unhealthy, and as a facilitator of
gambling, drugs, and alcohol abuse. These observations are supported by data showing that neighborhood access to gambling opportunities was associated with an increased odds of gambling behaviors, over and above individual characteristics, although these findings where not specific to American Indians [
40]. Gambling is a known risk factor for a variety of mental and physical health conditions [
41]. And although
job creation for tribal members was perceived positively by our study participants, a salient concern emerged in relation to worries about
second-hand smoke exposure as a result of finding a casino job. Secondhand smoke is a major occupational hazard in casino environments where increased levels of it exist, and where elevated levels of tobacco-specific biomarkers in non-smokers’ blood, urine, and saliva have been found [
42,
43].
To explain these discrepant findings, it is important to consider that the emotionality of one’s experience is a key factor influencing memory and recall [
44]. So because the purpose of our qualitative interviews was to gather in-depth personal experiences and narratives [
30,
32], participants potentially were more apt to discuss their own memorable experiences during the interviews. While such findings are reflective of individual-level perceptions, and can be useful for informing policy planning, they may not be reflective of overall population trends and likely vary by individual and tribal characteristics. Also, individual perceptions of casino benefits and costs is not a straightforward issue: Casino development data suggest that tribal members who are likely to receive substantial personal benefits from gambling development, such as new construction of a wellness center or hefty per capita payouts, are more likely to believe that positive benefits outweigh costs [
45]. This fact is pertinent to our study because some respondents received larger positive economic-related benefits than others due to their specific community and individual situations, thus likely influencing their perceptions toward gaming and narratives during our interviews. However, even more disparate findings may be found in other states where redistribution policies (e.g., RSTF) are not in place to provide non-gaming tribes with similar benefits from gaming. At the same time, seeing one friend or family member turn to drug use as a result of increased disposable income can stand out as a salient experience for an entire community despite the vast majority of other community members not having the same experience.
Pathways to health from altering the built environment
A number of changes to the built environment, most prominently characterized by improvements to the physical activity environment were described. Specifically, participants perceived improvements to programs and services, as well as to community centers and health and wellness facilities as a result of casino development. If true, then this finding has positive implications for community health and makes a strong argument for gaming operations to play a positive role in addressing chronic disease prevention efforts, such as those for diabetes, on tribal lands. Barriers to physical activity among American Indian children have been reported in qualitative studies to include a lack of access to and availability of health and wellness facilities, adequate equipment, and trained staff personnel [
46,
47]. Tribal members in our study highlighted the use of
improved tribal cash flow for improving the physical activity environment by addressing all of these barriers, at least among participants of casinos with greater economic resources (i.e., >1,000 slots).
This finding has positive implications for child health on tribal lands. Gordon-Larsen and colleagues [
48] illustrated an association between community availability of physical-activity facilities in the built environment and disparities in population activity and overweight patterns. Among American Indian school-aged children, higher level physical activity levels in second grade have been shown to be associated with lower levels of percentage body fat among the same children in fifth grade [
49], an example from the larger body of well-established literature illustrating important physical health benefits from physical activity during childhood.
On the contrary, tribal members in our study perceived changes to their food environments from casinos that offer
more unhealthy food establishments nearby casinos and
greater availability of unhealthy foods within casinos. Bachar and colleagues [
50] found similar changes to the food environment among the Eastern Band of Cherokee Indians in North Carolina. They concluded that as family income increased from casinos, the array of fast food choices also increased, with 19 fast food restaurants available in just 3 miles of one district center. So our findings, and those of Bachar et al. [
50], agree that although casinos and casino profits can have positive impacts on individual or household incomes, they may also have negative effects on the food environment and food-related behaviors due to additional disposable income available for eating out.
However, it is noteworthy that in our data set, participants indicated that while disposable incomes rose as a result of
per capita payments, they were not only used for eating out but also for making healthier food-related decisions, such as “
buying organic.” In fact, in our study, parents largely put the onus on good parenting to ensure their children’s healthful dietary behaviors, a finding similar to one by Akee and colleagues [
51], who believed parental quality to be a mechanism for better educational attainment and decreased chances of committing a crime in the face of casino environments. Good parenting has been shown to be a protective factor from several health issues important to good adolescence development [
52], including weight and weight-related behaviors [
53] as well as tobacco and alcohol abuse [
54]. Also, because the local food environment of a community is associated with indicators of nutritional status, such as obesity prevalence [
55], there is a need for additional research in other settings to understand how casinos may be modifying those food environments, related dietary behaviors, and nutritional health of tribal members in tribes with similar characteristics.
Pathways to health by disrupting the social landscape
Participant explanations of increased drug and alcohol abuse, troublesome gambling behaviors, and unhealthy casino environments were focused on individual-level health impacts. The emergent themes in this pathway may be due in part to the memorable and emotion-evoking impressions left by vivid accounts of alcohol and drug abuse on individual memories. There is evidence to suggest that one’s perceived likelihood of risk is related to personal experience [
56], which people typically use as a heuristic to filter information and evaluate risks, health or otherwise [
57], and likely emerged so explicitly during interviews for that reason.
However, casino impacts on social health were also expressed strongly by some participants who provided insights about their communities as a whole. Our data are in line with other research that examined community leader perceptions of social and economic impacts on tribal communities, finding that overall economic impacts were perceived positively, but social concerns were important to people [
58]. For instance, in our study, tribal leaders suggested that large
per capita payments contributed to attitudes of entitlement and general dependency on handouts, negatively impacting the younger generation. Negative perceptions do not always exist in relation to casino development though. Momper and Dennis [
59] found that community-level relations between tribal members and non-members improved as a result of casino operations opening on tribal land in the United States Midwest. Our data did not reveal any emergent themes in relation to such relationships; however, our semi-structured interview guide did not have a focus on this particular topic either.
Some tribal members also talked about feelings of cultural identity loss, in part, due to gaming activities, comparing the current casino environment to the past when people would help each other more often in a more unified community dynamic. This finding is similar to that from a case study examining the social impact that American Indian gaming had on one reservation in Minnesota, where tribal members expressed concern that American Indian values were being replaced by materialism [
60]. Because data suggest that the traditional cultural identify of American Indians may be a protective factor for gambling behaviors and alcohol abuse [
61], our findings about identity loss may highlight shifting social norms and casino environments where negative health-related behaviors are more prevalent. This phenomenon will have to be studied in more detail, however, to more fully understand the relationship between cultural identity and practices in relation to casino development and tribal community health. Understanding unique cultural constructs of health and the social environment in American Indian communities is important to inform decision making for community-level health prevention [
62].
Limitations
This study has some limitations. First, we employed a stratified purposive sampling strategy in order to identify participants from different geographic regions of California, varying tribal sizes, and gaming or non-gaming affiliation. However, in doing so, the number of participants within some strata is small, despite having a relatively large total sample of participants for this type of qualitative work. For instance, tribal leaders from casinos with fewer economic resources (<350 slots) are better represented and therefore findings may be unique to those types of casinos in this particular state. While this qualitative study did not aim to be generalizable to all tribal communities in California or elsewhere, and should not be interpreted as such, the transferability of our findings may still be further limited to casinos with similar economic resources (and thus community needs) and related gaming operations [
63]. Our sample included individuals who lived outside of tribal lands and therefore may have received fewer benefits of the casino; however, we feel this perspective is important to include when considering overall perceptions toward casinos. Finally, the American Indian gaming situation in California is unique in its establishment of the RSTF, whereby even non-gaming tribes are receiving monies from casino profits. This further limits the transferability of our findings, but still can provide useful insights about such programs. Also, findings may have been interpreted differently had we applied methodological triangulation to this study by using another data collection method, such as secondary food environment data, in order to corroborate results and offer potentially new perspectives [
31]. It is also possible that participant narratives were somehow shaped by the interviewer affiliation to a school of public health within a university.