1. Alcohol Education is Working: 10 years of declining negative consequences and mortality rates. American College Health Association June 3, 2010 * Philadelphia, PA James Turner, MD & jennifer bauerle, Ph.D. University of Virginia www.socialnorms.org

2. Successful Interventions Have the following characteristics: –Express empathy –Offer no argumentation –Support self-efficacy –Recognize discrepancy between individual’s behavior & normative behavior in population

3. Social Norms Approach: Revealing Gap Between Perception & Norm Q.: How many alcoholic drinks did you have/do you think the typical student at your school had the last time they “partied” or socialized? NCHA, Spring 2009, n= 87,105 web & paper surveys

4. What is a Norm?

5. Perception of Norms

6. Why Do Misperceptions Matter? Misperceived norms can be as powerful as actual norms in influencing behavior Famous Misperceptions: –Getting cold & wet predisposes you to cold or flu –All college students are drinking

7. Examples of misperceptions among UVa students Quantity The Fourth Year Fifth University policies Underestimation

8. How Do Misperceptions Occur

10. In health promotion, sometimes we normalize what we are trying to prevent!

11. The Normative Version of the Ad Thanks for Not Smoking!

12. Whatever we focus on expands How many times do the people in the white shirts pass the basketball to each other?

13. Social Norms Approach “I begin with an idea and then it becomes something else.” - Picasso Various ways to implement normative approach Paradigm Shift –towards positive or majority Fact-Based messages are corrected, behavior changes

14. Social Norms Approach Social Norms practice is based on long-term relationships –Sandboxes Social Norms Practitioners Intended Audience

15. PIE Components Positive: beneficial, constructive, affirmative Inclusive: embracing, involving, comprehensive Empowering: energy, authority, strength

16. Don’t Turn A Night Out Into A Nightmare Campaign Goals of the Campaign “Increase perceptions of the possibility of personally experiencing negative.” *Australia has 2.8 million 15- 24 year olds *rate of 7.4 per 100K

17. Normative Version of Campaign Most Australian Youth Get Home Safely From A Night Out. Thanks, Aussies

18. New UVa Social Norms Marketing Programs 1999-2008 Campus Wide Campaign Weekly Campus Posters, newspaper ads, BAC cards, & E-mails, Annual music event, Facebook 2002-2006 Primary Campaign Monthly Dorm Posters 1999 Small Group Norms For Athletes, Fraternities & Sororities 2003 Social Norms Programs Intended Audience First Year Students All UndergradsAt Risk Students Supplemental Social Norms Programs Parents Orientation Normative statistics 2002

19. Social norms marketing incorporated into longstanding programs RA (240) training and orientation Lectures to two substance abuse classes each year (250 students) –Results in class projects, web based presentations, newspaper articles Collaboration with Dean of Students, UVa Police, and ER staff. Peer Health Educators

20. Social Norms at UVA Use normative data to highlight positive, healthy behaviors of majority Encourage protective behaviors, safety, & responsibility through empathy and support self- efficacy Develop discrepancies –correct misperceptions between perceived and actual norms Avoid health terrorism (no arguing) Resonates with students and encourages behavioral change

21. Stall Seat Journal

22. Quantity and Frequency

24. * Signs of alcohol poisoning or injury * Caring for an intoxicated friend * Using the ER

25. Need to go the hospital? UVa officials, Dept. of Student Health clinicians, and ER doctors do not notify police for alcohol related incidents. Parents or guardians are not notified without student permission unless a situation is deemed life threatening. Whenever an emergency 911 call is made on Grounds, University police officers are dispatched to assist with the response. On occasion, follow up and investigation will take place if deemed necessary….

26. Hoo Knew

30. Stall Seat Journal

31. Does it work?

32. Alcohol-related Negative Consequences Over Ten Years at UVa Interventions since 1999: Social norms marketing, BMI in clinic, other UVa educational initiatives (CASE) Data source: Annual Health Promotion Survey: stratified random sample Statistical analysis: Odds ratios compare the probability of experiencing a negative consequence in the most recent year to the probability in the first year (2001): –Less than 1: less probable –1: no change in probability –Greater than 1: more probable Computed within logistic regression equations that standardize the years in regards to: –Gender –Race/ethnicity –Class year –U.S.A. citizenship

33. Negative Consequences All UVa Undergraduates 2001-2010.40*.47*.37*.68**.72** Odds Ratios *p<.001 **p<.01

34. .24*.38*.19*.51*.55** Odds Ratios *p<.001 **p<.01 Negative Consequences All UVa Undergraduates 2001-2010

35. UVa Health Promotion Surveys 2001-2010: Female Undergraduate Drinkers: Protective Behaviors for Self Used Usually or Always * * * *p<.005 *

36. UVa Health Promotion Surveys 2001-2010: Male Undergraduate Drinkers: Protective Behaviors for Self Used Usually or Always *p<=.01 * * * * *

37. UVa Undergraduates: Mean eBAC & 99% CI

38. Campaign exposure predicts outcomes First Year Undergraduates 2001-2006 (Internal Control Group) Multivariate Analysis: First year students exposed to the UVa campaign had 24% lower odds of having a BAC ≥.08 (p = 0.024) First year students exposed to the UVa campaign had 22% lower odds of suffering two of ten possible negative consequences (p=0.002) Turner, Perkins, Bauerle. J. Am. Coll. Health. 2008. 57:85-93.

39. Emergency room visits at UVa SNM project has encouraged friends caring for friends and using the ER ER visits are up > 100% Hospital admissions are (closed head trauma, alcohol poisoning) decreased Incident rate of injury has declined mirroring declines in self-reported injury “More students are seeking appropriate care for themselves and friends.”

40. Annual ER Experience Undergraduates

41. -34%*-48%**-60%-68%** (18-24 year olds) Submitted JACH. 2010. Turner, Keller, Bruce. * P= 0.03 99/09 vs. 89/99. ** P< 0.001 vs. state and national data.

42. Outbreak of Health? 2010 compared to 2001:  2741 fewer students suffered injuries  2883 fewer students drove under the influence  711 fewer students had unprotected sex 2001 to 2010:  23,300 more students over 10 years no negative consequences related to alcohol.  Significant increases in use of protective behaviors. Increased use of emergency services, less severe conditions Twenty Year Trend of decreasing mortality rates due to alcohol-related unintentional injury

43. Use experts…ask for feedback EARLY