Prevention norms across socio-ecological levels and their relationship to PrEP-intention among men who have sex with men: a structural equation model.
5 affiliations
- 1Centre for Population, Family and Health, University of Antwerp, Antwerp, Belgium. [email protected].
- 2University of the Western Cape, Cape Town, South Africa.
- 3Brussels Institute for Social and Population Studies, Vrije Universiteit Brussel, Brussels, Belgium.
- 4Centre for Population, Family and Health, University of Antwerp, Antwerp, Belgium.
- 5Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa.
Abstract
Background
Social 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.Methods
The data were drawn from a survey on sexual health distributed on social media by Flemish MSM community organizations from October 19th, 2022, to December 19th, 2022, resulting in a total convenience sample of 610. Structural Equation Modelling analyses, including confirmatory factor analysis of the latent variables and path analysis of the relationship between norm types and PrEP intention, were conducted on a convenience sample of 350 Belgian MSM who were not living with HIV.Results
At 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.Conclusion
All 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.
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BibTeX
@article{thunnissen2026prevention,
title = {{Prevention norms across socio-ecological levels and their relationship to PrEP-intention among men who have sex with men: a structural equation model.}},
author = {Estelle Thunnissen and Jeroen De Man and Veerle Buffel and Edwin Wouters},
journal = {BMC public health},
year = {2026},
month = jul,
doi = {10.1186/s12889-026-28207-1},
url = {https://europepmc.org/article/MED/42894168},
note = {CC BY},
}
RIS
TY - JOUR
TI - Prevention norms across socio-ecological levels and their relationship to PrEP-intention among men who have sex with men: a structural equation model.
AU - Estelle Thunnissen
AU - Jeroen De Man
AU - Veerle Buffel
AU - Edwin Wouters
PY - 2026
DA - 2026/07/01
JO - BMC public health
DO - 10.1186/s12889-026-28207-1
UR - https://europepmc.org/article/MED/42894168
AB - Background Social 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.Methods The data were drawn from a survey on sexual health distributed on social media by Flemish MSM community organizations from October 19th, 2022, to December 19th, 2022, resulting in a total convenience sample of 610. Structural Equation Modelling analyses, including confirmatory factor analysis of the latent variables and path analysis of the relationship between norm types and PrEP intention, were conducted on a convenience sample of 350 Belgian MSM who were not living with HIV.Results At 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.Conclusion All 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.
SN - 1471-2458
ER -