Prevention norms across socio-ecological levels and their relationship to PrEP-intention among men who have sex with men: a structural equation model.

backgroundSocial norms around PrEP act as both barriers to and stimulants of the use of PrEP across a wide range of target populations, yet remain relatively understudied. To stimulate theoretical innovation and provide a quantitative check for qualitative findings, we integrate norm types from the Behavioral Models (BM) and the Social Norms Approach (SNA) into the socio-ecological model (SEM) and analyze their relationship with PrEP-intention. We include attitude and role belief at the individual level, injunctive norms at the interpersonal level and descriptive norms and self-comparison to peers at the community level.

methodsThe data were drawn from a survey on sexual health distributed on social media by Flemish MSM community organizations from October 19

resultsAt the individual level, attitude towards PrEP was positively and moderately to strongly associated with intention, while role belief that 'It is inappropriate for someone with my relationship(s) to use PrEP' was negatively and moderately to strongly associated with intention. At the interpersonal level, injunctive norms, the expectation of a positive reaction to the respondent's PrEP use, were positively and moderately to strongly associated with intention. At the community level, descriptive norms, thinking more peers use PrEP, were positively and weakly associated with intention. While self-comparison to peers, estimating one's own sexual behaviour as safer than peers, was negatively and weakly associated with intention.

conclusionAll norm types included in the analysis, at the individual level (attitude and role belief), interpersonal level (injunctive norms), and the community level (descriptive norms and self-comparison to peers), were associated with PrEP-intention among MSM. Most PrEP interventions target cognition, while our analysis shows significant untapped potential for norm-based interventions to increase intention to use PrEP.