Estonia Successfully Cuts Alcohol Consumption with First Web-Based Program
In 2020, Estonia’s National Institute for Health Development, a member national public health institute of IANPHI, began rolling out a self-help online program called Selge, aimed to reduce alcohol consumption among the Estonian population. Selge was hailed a key public health success in the European region by the IANPHI General Assembly.
Promotional visual for Estonia’s self-help program Selge, which supports the reduction of alcohol consumption (“Selge! A new free program to help reduce alcohol consumption.”)
Europe is the region with the world’s highest level of alcohol consumption, one of the leading risk factors for population health. A European adult consumes on average 9.5 liters of pure alcohol in a year. In 2019, it was estimated that alcohol use was responsible in the region for about 800 deaths a day.
Estonia has the third highest alcohol-attributable mortality rate in the region, behind its two Baltic neighbors, Latvia and Lithuania. Between 2010 and 2019 the country achieved one the largest decreases in alcohol use in the region – about 3 liters of pure alcohol per adult – thanks to a combination of alcohol reduction policy measures, including advertising restrictions, excise tax policies and awareness raising. Despite these measures, 15% of Estonian adults still consumed alcohol at health-threatening or damaging levels as of 2018. Those levels are defined as consuming over 140 grams of pure alcohol per week for men (about 10 drinks), and over 70 grams for women (about 5 drinks). However, only 1.9% of these adults were being treated for alcohol abuse.
Estonia’s National Institute for Health Development (Tervise Arengu Instituut or TAI), which leads health promotion activities in the country, has been working to address the issue and improve alcohol-related health outcomes. In 2018, TAI health promotion experts identified a need for a treatment plan outside of the normal healthcare system, which would be anonymous and easily accessible. They wanted to be able to reach individuals who were hesitant because of the stigma associated with excessive alcohol consumption or because of the perceived restrictions they could face by coming forward with the disorder (e.g., restrictions on ability to obtain permits, loss of driver’s license).
Our strategy was to find an existing, successful program, not to develop a new one. The most time-consuming part of the project was to find a suitable program that would meet all our requirements, including financial and legal ones.
A colleague of Karin Kilp, Triin Ülesoo, conducted a study to have an overview of the effectiveness of web-based intervention programs used in other countries to support change in alcohol consumers’ behavior in reducing excess consumption of alcohol. She found 14 suitable long-term, multisession programs for adaptation in Estonia, five of which fit the quality criteria set by TAI – Alkoholhjalpen, Balance, CBT4CBT, Down Your Drink and Take Care of You. Take Care of You, a self-help program created by the Swiss Institute for Addiction and Health Research at the University of Zurich and its scientific director Dr. Michael P. Schaub, was ultimately found to be the most appropriate for Estonia and selected by TAI.
How Selge was developed and tested
The adaptation process of Take Care of You and development of the new program, which was named Selge (“clear” in Estonian), began in 2018 with the support of Dr. Schaub and his team. “During the adaptation process we reviewed all the content, adapted texts, produced new video and audio content,” said Kilp.
The Selge program consists of 10 self-guided online modules supporting the reduction of alcohol consumption and combatting issues related to depression through the use of cognitive-behavioral therapy and motivational interviewing. Program participants are guided by a virtual coach through each module, which include a mix of self-analyses, exercises and recording of personal experiences, and asked to keep a running consumption diary. Learning how and when to say “no”, understanding the reasons that trigger alcohol consumption and what influences the mood and feelings, and creating plans for the future are some of the topics covered in Selge.
In order to assess the impact and effectiveness of Selge before opening it to the population, Karin Kilp and her colleagues conducted a randomized control trial between March and October 2019. The study included 589 participants who were randomly assigned to either complete the Selge modules or continue with standard of care (no program). Participants were given an Alcohol Use Disorder Identification Test (AUDIT) score at enrollment, directly after completing the modules (two months after enrollment), and six months after enrollment. The study protocol was published in BMC Public Health and the results in Addiction, two peer-reviewed journals.
The results of the trial showed that Selge was successful in reducing alcohol consumption among participants, including reducing the number of alcohol units per week and increasing the number of alcohol-free days. Specifically, the preliminary study report found that participants who completed the program modules in the recommended 8-week period consumed 12.17 fewer alcohol units per week and had 1.2 more days of alcohol-free time than before. They also had a significantly larger decrease in AUDIT scores and 35% reduced their consumption levels to below a dangerous level (as compared to 19% among those who did not complete the program modules).
By the time of the six-month follow-up survey, the rate of change of these parameters had slowed; however, their weekly alcohol intake remained lower and the number of alcohol-free days higher than in the control group. Additionally, satisfaction among members of the intervention group was high. Out of 182 respondents [1], 87% were satisfied with their decision to join while 76% rated the use of the web environment as convenient. Two out of three participants (66%) said that the program helped them reduce their alcohol consumption.
A timely launch at the beginning of the COVID-19 pandemic
When the program launched to the public in April 2020, it came at a timely moment. By then, the COVID-19 pandemic had hit and would result in a 1.7% increase of the overall alcohol consumption in 2020 compared to 2019. By March 2022, over 4,750 people had registered for Selge.
TAI uses a set of channels to reach out to alcohol consumers and encourage them to sign up. “We target alcohol consumers directly via social marketing campaigns,” said Karin Kilp. “Also, in the last five years, we have developed services for alcohol consumers, including screening and brief interventions via general practitioners – Selge is just one link in the chain of care. Health professionals and social workers are an additional channel to reach our target group.” TAI’s primary objectives are now to increase the number of program users, encourage them to seek help from health care system, and continue to raise awareness of the program among health professionals and social workers.
“Selge offers an accessible opportunity to change the life of Estonians and help them use less alcohol,” said Karin Kilp. “According to our research, our program is effective and we recommend it to anyone who is considering reviewing their consumption habits and drink less as a support on their journey. We get dozens of thankful letters from users whom our program has helped to change their life, and this is what makes us most happy.”
If you are interested in learning more about this project from Estonia’s National Institute for Health Development, please reach out to Karin Kilp, health marketing account manager (karin.kilp@tai.ee), and Helen Noormets, head of communications (helen.noormets@tai.ee). If you would like to receive more details about the study, please contact Esta Kaal, research expert (esta.kaal@tai.ee).
"Estonia is a good example of how a country can take steps to reduce alcohol consumption through large-scale implementation of various cost-effective interventions. Between 2009 and 2019 we showed largest decrease in alcohol use in the region, achieved by progressive adoption of measures of comprehensive national alcohol policy. These measures have directed implementation of legislative changes and activities of various sectors in the country.
However, despite the relatively good progress made in reducing absolute alcohol consumption per adult person, further efforts are still needed because the positive trend seems to have stopped. There are still untapped opportunities to limit the availability of alcohol by either municipalities or the state.
But there is also a clear need to strengthen individual services to provide support to reduce alcohol consumption among different population groups. TAI develops and advocates a whole-of-society approach in provision of services, with a focus on the individual in the context of family and wider community. Over the past 10 years, TAI has made significant contributions to the training of primary health care professionals as well as developed an alcohol disorder treatment service in health care system.
We need to do more and develop innovative approaches to deliver services not only in an overburdened healthcare system, but also provide people with tools to help them cope with mental health problems on their own."
[1] Kaal E, Vorobjov S. Alkoholitarvitamise vähendamisele suunatud veebipõhise eneseabiprogrammi „Selge“ mõju-uuringu aruanne. Tallinn: Tervise Arengu Instituut; 2020. https://www.tai.ee/sites/default/files/2021-03/15909923064_Alkoholitarvitamise_vahendamisele_suunatud_veebipohise_eneseabiprogrammi_Selge_mojuuuringu_aruanne_.pdf