Structural gaps in referral and treatment pathways for gambling-related harm: a systematic review of health system responses using the antecedents-decision-outcomes framework.

INTRODUCTION

Gambling-related harm is increasingly recognized as a public mental health concern, yet referral pathways into formal treatment and support services remain poorly understood. Weak or absent referral structures may delay engagement with care and limit coordination across health and support systems. This review aimed to map structural and system-level factors shaping referral and treatment pathways for gambling-related harm. Particular attention was given to mechanisms influencing help-seeking, healthcare system readiness, and the extent to which gambling environments facilitate transitions into formal care.

METHODS

A systematic review was conducted across multiple databases covering literature published between 2014 and 2024. Studies were included if they examined help-seeking, referral pathways, service engagement, or system-level responses to harmful gambling. From an initial pool of 8,178 studies, 5,230 were screened, and 39 met the inclusion criteria. Findings were analyzed using ADO-guided thematic synthesis as the primary analytical approach, complemented by abstract-based descriptive bibliometric mapping.

RESULTS

Ten core themes were identified across the ADO phases. Antecedent-level findings highlighted barriers related to service visibility, system readiness, and the framing of responsibility. Decision-phase themes included help-seeking triggers, digital interventions, and the role of referral gatekeepers. Outcome themes focused on treatment engagement, dropouts, and user experiences of treatment. Across the included peer-reviewed literature, few studies reported structured referral pathways between gambling platforms and healthcare services, which shows an important gap in the documented evidence base. Responsibility framing emerged as a cross-cutting influence shaping how institutions recognize and respond to gambling-related harm.

CONCLUSION

The evidence base remains limited, with most studies descriptive in nature. The findings highlight structural weaknesses in current referral and treatment ecosystems, particularly the absence of formalized pathways linking gambling environments to healthcare systems. Addressing these gaps will require stronger coordination between gambling operators, healthcare services, and regulators, alongside implementation research to develop and evaluate system-level referral models.