The global economic and health burden of alcohol use disorders is widely recognized [1
], as is the need for effective public health interventions to substantially reduce this burden [2
]. Since the dawn of the new millennium, broad public access to the Internet and e-self-help has become a reality, and this has opened new avenues to reach out to the large, but relatively hidden, group of problem drinkers in the community [4
]. Problem drinkers are defined as individuals who consume alcohol beyond the guideline for low-risk drinking. Different gradations of alcohol use disorders may underlie this excess in alcohol consumption. (See and Textbox 1
for an overview of specified alcohol use disorders.) Ample meta-analyses have shown face-to-face screening and brief interventions (SBIs) to be effective [5
], particularly in primary care [6
] and college settings [7
]. The wide-scale dissemination of SBIs in routine practice is hampered, however, by implementation barriers, including inadequate supporting policies and resources (time, money, and professional skills) in the health care sector [8
] and by meager uptake by problem drinkers themselves [9
]. E-self-help may provide a welcome extension to these SBIs. E-self-help interventions are available in both brief and more extended formats. Single session e-personalized normative feedback
is a phrase used to describe a brief type of self-help delivered over the Internet. Personalized feedback refers to the provision of individualized observations on each drinker’s alcohol consumption patterns in comparison with the recommended low-risk drinking guidelines. Normative feedback is often an important component of these interventions, enabling problem drinkers to compare their own alcohol use (in terms of frequency, quantity, or other measures) to the level of their own cohort or peer group [10
Selected characteristics of studies (N = 9)
Alcohol use disorders
Alcohol use disorders from the lexicon of alcohol and drug terms published by the World Health Organization [41
- Abstinence is defined as refraining from drinking alcoholic beverages.
- Moderate drinking is the consumption of alcohol that does not exceed guidelines for moderate drinking in terms of volume or quantity per occasion.
- Heavy drinking is defined as drinking in excess of the standard of moderate drinking(see moderate drinking, above).
- Hazardous use (Internation
al Classification of Disease, Tenth R
evision [ICD-10] code Z72.1) is a pattern of heavy drinking and/or binge drinking that carries with it a risk of harmful consequences to the drinker. These consequences may be detrimental to physical or mental health, or have adverse social consequences to the drinker or others. Other potential consequences include worsening of existing medical conditions or psychiatric illnesses, injuries caused to self or others, due to impaired judgment after drinking, high risk sexual behavior while intoxicated, and worsening of personal or social interactions.
- Harmful drinking (ICD-10 code F10.1) is a pattern of drinking that is causing damage to health. The damage may be either physical (eg, liver cirrhosis from chronic drinking) or mental (eg, depressive episodes secondary to drinking). Harmful patterns of use are often criticized by others and are sometimes associated with adverse social consequences of various kinds. Harmful drinking has persisted for at least 1 month or has occurred repeatedly over the past 12-month period; subject does not meet criteria for alcohol dependence.
- Alcohol dependence (ICD-10 code F10.2) is defined as drinking that meets at least 3 of the following criteria: tolerance; withdrawal symptoms; impaired control; preoccupation with acquisition and/or use; persistent desire or unsuccessful efforts to quit; sustains social, occupational, or recreational disability; use continues despite adverse consequences.
A more extended form of e-self-help consists of protocol-driven treatments based on principles of behavioral self-control [11
], cognitive-behavioral therapy [12
], motivational interviewing [13
], or a combination of these. The recommended time of use of the extended self-help interventions is 6 weeks, as this is the expected time period in which changes in problematic alcohol use are appearing [14
]. Potential benefits have already been illustrated in studies on e-self-help interventions that induce behavioral change in the use of substances such as alcohol or tobacco [15
] or that treat mental health disorders like depression and anxiety [16
The chief advantages of e-self-help interventions include their potential to reach broad groups of problem drinkers independent of time or geographical distance and at relatively low dissemination costs [19
]. A recent review by Vernon and colleagues [20
] has pinpointed similar reasons why users themselves find the interventions attractive, that is, they are timely, anonymous, accessible 24/7, and mostly free of charge. This is especially true of e-self-help interventions that participants can work through without involvement of a professional (defined here as no-contact
interventions) that are offered for problem drinkers in the general population [21
] or directed at students in college settings [22
Studies investigating the effectiveness of e-self-help interventions among youth have been evaluated mostly in student settings in the United States and Australia and more recently in Europe [23
]. In a meta-analysis conducted in 2009, Carey and colleagues [26
] found a favorable impact of computer-based interventions on student alcohol consumption as compared with no-intervention controls. This favorable impact was also shown in a recent systematic review conducted in 2010 by White and colleagues [27
] on the effectiveness of online programs for college and adult problem drinking. However, evaluation studies on e-self-help for student problem drinking in low- and middle-income countries (LMICs) are lacking.
Studies investigating the effectiveness of e-self-help interventions among adult problem drinkers are fewer in number, but they show promising results as well. Many can be characterized as feasibility studies with pretest-posttest designs [28
], but the number of randomized controlled studies is on the rise [20
]. The availability of evidence-based e-self-help interventions is growing in many high-income nations, including European countries [21
], the United States [4
], Canada [31
], and Australia [32
]. These countries have high Internet penetration rates and a strong public health focus on problem drinking.
We would argue for several reasons that e-self-help interventions could also benefit LMICs. First of all, the majority of people with alcohol use disorders in LMICs are not in treatment, and the many problem drinkers are not exposed to public health interventions at all because no appropriate strategies are in place [33
]. The estimated treatment gap of 78% for people with alcohol use disorders in these countries serves to illustrate the many unmet needs [34
]. Second, LMICs have meager health resources in terms of both finances and trained health professionals [33
]. For countries with minimal resources and increasing problem drinking, such as India and China, low-cost e-self-help interventions might help to fill this public health gap [1
]. Third, despite the promising results reported by a limited number of studies on face-to-face brief interventions in countries like Brazil [36
], India [37
], and Taiwan [38
], LMICs still experience major obstacles to the full implementation of these SBIs, even more so than affluent countries [33
]. Fourth, the high level of anonymity provided by self-help Internet interventions could be of value to problem drinkers in those LMICs, where face-to-face help for alcohol problems may be hampered by religious or cultural values that scorn alcohol use or professional help-seeking [40
Before the scope of e-self-help interventions can be broadened in any type of country, their effectiveness needs to be evaluated beyond the individual studies that have been carried out so far on adult problem drinking. We have therefore conducted a meta-analysis of the currently available studies. As Web-based self-help interventions were preceded by CD-ROM interventions, we include studies on these as well. These CD-ROM studies used PC’s for the delivery of the intervention and applied recruitment strategies similar to the Web-based studies developed at a later stage. We hypothesized that e-self-help without professional guidance would prove effective in reducing problem drinking as compared with control groups that receive no interventions. Next, we examined whether a number of study characteristics impact the primary outcome measure of alcohol consumption. To the best of our knowledge, this paper is the first meta-analysis to report on the effectiveness of no contact e-self-help among adult problem drinkers.