Social norms research shows that the behavior of college students are influenced by what they perceive to be normal among their peers. Students tend to overestimate negative behavior while underestimating positive behavior relating to health issues ranging from smoking and binge drinking to risky sexual practices and wearing seat belts. How can social norms campaign highlight the differences between perceptions and reality that influence young people to improve their actions and ultimately their health. You are listening to ReachMD, the Channel for Medical Professionals. Welcome to the Clinicians Roundtable. I am your host, Dr. Jennifer Shu, Practicing General Pediatrician and Author. Our guest is Dr. James Turner, President elect of the American College Health Association, Executive Director of the National Social Norms Institute, and a Professor of Internal Medicine at the University of Virginia School of Medicine.
DR. JENNIFER SHU:
Welcome Dr. Turner.
DR. JAMES TURNER:
Thank you Jennifer. Thank you for having me.
DR. JENNIFER SHU:
Now let's just start with the basics. If you could tell us a little bit about what the theory is behind the Social Norms Model?
DR. JAMES TURNER:
Perceptions of what normative behavior are, are very powerful in determining how someone is going to behave and perceptions can be accurate or they can be inaccurate, and to give you some examples that practitioners might be familiar with is, is a common misperception is that the Flu shot will give people the flu and therefore they may not seek a Flu shot, or being out in the cold and getting wet might actually cause you to get cold or the flu. Those are very, very common misperceptions that drive behavior, and as you noted earlier in your introduction with college students every study we have ever done about college students and their perceptions of drinking is they grossly overestimate the degree to which their peers drink and they underestimate the degree to which their peers practice protective behaviors.
DR. JENNIFER SHU:
So now the whole issue of perceptions is not a new idea, in fact, Thomas Jefferson himself once said, "by oft repeating an untruth, men come to believe it themselves". So this is a couple of 100 years old but why do you think it is that these perceptions and even misperceptions can be so powerful in influencing people's behavior?
DR. JAMES TURNER:
Well you know Mr. Jefferson actually was plagued with a lot of rumors that circulated in the muck raking press back in those days during his political career, and so many lies were published about him as again people started believing it, and in the context of alcohol use among college students those kinds of misperceptions perpetuate themselves in the eyes of the media, for example the kinds of coverage that circulate around college drinking. One it's glamorized in the movies; animal house is a great example. When a death occurs on a college campus obviously that's tragic but the press picks up with it and portrays it as if every college student is drinking to the point of alcohol poisoning. I think many adults try to perpetuate the myths of being a heavy drinker in college and either sharing with their kids or with their friends about how great the good old days were when the drinking was out there, and then you know finally college students they go to a party and there is a 100 kids at a fraternity party and 1 or 2 are grossly intoxicated and are in trouble or fighting, the kids are going to remember those 1 or 2 people who were behaving poorly, but they will not remember the 98 who might have been there drinking responsibly. So these are the kinds of things that cause these misperceptions to perpetuate themselves.
DR. JENNIFER SHU:
So now over a 6-year span you did some extensive student surveys, what were some of the findings?
DR. JAMES TURNER:
Well first of all we confirmed that there were really significant misperceptions among the UVA students, for example, they overestimated the quantity and frequency of the drinking of their peers, in fact, they estimated that the average number of drinks per week consumed by an upper class man was 10 when in actuality when you ask them how much they actually drink, it was 5, so it is almost a double in overestimating. There was an overestimation of the degree to which the seniors participated in a bizarre tradition of drinking a fifth of bourbon during the last home football game; in fact, only 16% participated. It was really concerning to me. We heard from students saying that they were fearful of going to the emergency room at a university hospital with an intoxicated friend or themselves going in for an alcohol related problem. They were fearful the police would be called, parents would be called, or the university would be notified, and this was alarming to me because it told me that the kids were not appropriately seeking care, and none of those things happen. The only time a family member is called if the student's life is in imminent danger and fortunately that is very rare. So that was a very important misperception and also students didn't appreciate the degree to which their friends counted drinks, monitored their BAC, and watched out for their friends. So we developed an information and media campaign that served to try to correct these misperceptions.
DR. JENNIFER SHU:
So what kind of things that you do in this campaign?
DR. JAMES TURNER:
Well first of all we put our revolving posters in every dormitory, bathroom stall, and urinals and there are 797 urinals and bathroom stalls in our residents all.
DR. JENNIFER SHU:
You have the number well.
DR. JAMES TURNER:
Yes and these posters were there for about 3 weeks and they had information about correcting these misperceptions. We had posters that ran in all of the buses on campus, we had tabletops in the cafeterias, we had peer health educators, students who went out and met with sororities, fraternities, dormitories, we ran ads in the student newspaper, we just blanketed the campus with all of this information, and then over the 6 years we studied whether or not the perceptions were correcting and the behaviors correcting as well.
DR. JENNIFER SHU:
And one other thing I want to mention is you also did what alcohol content card is that correct?
DR. JAMES TURNER:
Yeah and that was a big part of it. We had credit card sized Blood Alcohol Concentration cards that if you knew how many standard drinks you consumed over a period of time, and of course you knew your gender and weight, you could calculate or estimate what your Blood Alcohol Concentration was, and the idea was try to minimize rapid rises in the BAC and it encourages students to count their drinks and to think of drinks in terms of standard amount,. and that's very, very important in teaching young people more responsible consumption. So it was very well received. We thought initially it might be controversial but I personally speak to all parents during summer orientation and in 8 or 9 years I have only had 1 parent object giving their underage student a BAC card. Thousands of these, I think 30 or 40,000 have been distributed over the years and frequently the parents are picking them up at orientation and giving them to their kids.
If you have just joined us, you are listening to the Clinicians Roundtable on ReachMD, the Channel for Medical Professionals. I am your host, Dr. Jennifer Shu. Our guest is Dr. James Turner, President elect of the American College Health Association. We are discussing changing misperceptions and behavior among young people using social norms research.
DR. JENNIFER SHU:
Now you have mentioned that after the 6th year survey you collected some data about changes in people's behavior, what did you find?
DR. JAMES TURNER:
Yeah, well first of all as a baseline during this 6-year period on a National Level there had been no change in binge drinking rates or rates of negative consequences as studied by the American College Health Association using the national survey. So, as a baseline nationally no changes whatsoever. What we found were actually rather stunning findings. Over a 6-year period we looked at 10 different negative consequences and every single one of them decreased statistically significantly, for example, the probability of being injured as a result of alcohol in the preceding year declined by 65%; students admitting on these surveys that they had driven a car and had been drinking dropped by 52%, missing class and poor performance on test dropped by 50-55%, taking advantage of someone sexually dropped by 65%. So it was really rather dramatic decreases, and during this time I have been tracking emergency room records and emergency room visits doubled during this time, and people say see that doesn't really sound all that good, well in fact the number of serious injuries and alcohol poisonings dropped during this time and the number of visits for minor trauma and minor illness related to alcohol went up, which told us that as a result of our educational campaigns students were seeking care more appropriately than they had been, and I think if there is anything that's come out of this research is that we have encouraged students to seek care for themselves and others much more appropriately to have a lower threshold for seeking care.
DR. JENNIFER SHU:
And you mentioned earlier about the perception of violence on college campuses. What about after the Virginia Tech shootings and other violent campus act? Was there then a perception that violence was very common in schools?
DR. JAMES TURNER:
Well, I mean absolutely. First of all what a horrific thing had happened at Virginia Tech and we were all just impacted tremendously. But even if you include the Virginia Tech homicides in the national data you are actually safer related to homicide and violence on a college campus than you are in your own home. I want to reassure your listeners that college campuses are very, very safe. We have an occasional outlier, but in general they are very safe. But you are absolutely right all of that media coverage created this perception that college campuses were very, very unsafe.
DR. JENNIFER SHU:
In your capacity as the American College Health Association liaison to the ACIP or advisor committee on immunization practices at CDC, I was wondering what your thought was regarding meningitis infections on college campuses as well meningitis vaccination rate?
DR. JAMES TURNER:
We had 5 cases of meningococcal disease her at UVA in the mid 1990's and that's how I got involved with this, and ACHA was out in front 1997 recommending that students consider getting the polysaccharide vaccine at that time, which was somewhat controversial but we worked with CDC to come up with research that clearly identified that college students particularly those living in dorms were at a 5-6 fold greater increase of contracting invasive meningococcal disease, and as of course since the meningococcal conjugate came out there is now a recommendation that all young people between 11 and 18 and people freshman in colleges receive meningococcal conjugate. In the last 6 years the percent of college matriculates who have been immunized has gone from less than 10% to almost 60% of all college freshman entering school now are vaccinated against meningococcal disease, and the incidence of meningococcal disease nationally is at it's lower point than it has been ever in recorded history, and curiously serogroup B now is the most common cause of the meningococcal disease and the vaccine preventible serotype such as YW135 and C have dropped to really low levels. And it's probably too early to know for sure but I have a hunch having a hugely vaccinated cohort of adolescents is likely leading to some sort of herd immunity for the general population and hopefully is going to protect Americans from coming down with the disease. Also, I am anecdotally, I hear about all these cases nationwide and it's usually some poor student that's been at a fraternity party, or some other private off-grounds party has been drinking heavily that comes down with meningococcal disease and I suspect either aspirate secretions or in the process of sharing drinking glasses or random kissing and sharing cigarettes they get exposed to meningococcal infection. So it's kind of interesting the link between binge drinking and meningococcal disease.
DR. JENNIFER SHU:
I hadn't thought about that!
DR. JAMES TURNER:
Yeah, we have made great, great headway in getting college freshman vaccinated; it's been terrific.
DR. JENNIFER SHU:
We have been mostly talking about college students, but what about using social norms marketing for the general population. You know because as a pediatrician I know that there is a lot of negative media regarding vaccines, yet the vast majority of parents are getting their children vaccinated on time and according to schedule. Do you see any use for social norms marketing in this regard?
DR. JAMES TURNER:
Yes I do. I definitely think that it's a wide-open field, and I think that social norms marketing should be used. There was a spot on NPR a week or so ago with Paul Offit from the University of Pennsylvania and they were interviewing a celebrity mother who actually supported vaccinating children. She was from the Los Angeles area, tried to counter this negative publicity that celebrity mothers had brought about vaccines. But it's definitely an area that can be used. social norms marketing has been used in Australia to encourage people filing their tax returns. It's been used in California to encourage recycling and green environmental initiatives. So there are limitless possibilities for the use of social norms marketing. And in fact you know it's really nothing more than a population based brief motivational intervention, something that we as physicians do with an individual patient all the time but we are just applying the same principles on a population basis. So intuitively when I heard about this several years ago, it just really made sense for dealing with populations of people such as college students.
DR. JENNIFER SHU:
And finally can you let our listeners know where they can go to get more information about Social Norms Research?
DR. JAMES TURNER:
Yeah our website, the National Social Norms Institute at the University of Virginia has lots of information. The website is socialnorms.org, www.socialnorms.org and it's got all of the latest research and links to other resources.
I would like to thank our guest Dr. James Turner. We have been discussing changing misperceptions and behavior among young people using Social Norms Research. I am Dr. Jennifer Shu. You have been listening to the Clinicians Roundtable on ReachMD, the Channel for Medical Professionals. Please visit our website at ReachMD.com, which features on-demand podcasts of our entire library.
Thank you for listening.
