Social-Contextual Factors Interact with Masculinity to Influence College Men's HPV Vaccination Intentions: The Role of Descriptive Norms, Prototypes, and Physician Gender

"Theoretically-anchored research is needed to understand college men's HPV vaccination decision-making and inform interventions."

College men are particularly vulnerable to human papillomavirus (HPV) due to both high rates of risky sexual activity and low vaccination rates, yet only 49-50% of college men in the United States (US) are vaccinated against HPV. Inaccurate beliefs that the HPV vaccine is a female health intervention and both peer and physician influences play a role in HPV vaccination decisions among college men. This paper uses the Prototype Willingness Model to examine the influence of gendered social-contextual factors (male descriptive norms, prototypes, and physicians) on unvaccinated US college men's HPV prevention cognitions across two studies.

In contrast to theories that focus primarily on rational cognitions about behavioural consequences (e.g., perceived risk), the Prototype Willingness Model positions social cognitions (cognitions about people doing a behaviour) as important behavioural drivers. On this model, descriptive norms capture prevalence perceptions of behavioural participation in social referent groups (e.g., "Most of my male friends got the HPV vaccination.") and serve as a behavioural guide during uncertain or new circumstances, like getting a new vaccine. Prototypes are defined as images of a typical person who engages in a behaviour (e.g., "The typical college man who gets the HPV vaccination is healthy and smart.") and predict both health-risk and health-promotive behaviour. Descriptive norms and prototypes inform two decision-making cognitions: behavioural intentions and behavioural willingness. Behavioural intentions are predictive of vaccination uptake and reflect a more planful decision cognition. Behavioural willingness represents an openness to engage in a behaviour given opportunity and is more predictive of risk behaviors and socially influenced behaviors.

Study 1 cross-sectionally investigated whether social cognitions from the Prototype Willingness Model - that is, male descriptive norms and male vaccinator prototypes - were associated with HPV vaccination decision cognitions. College men (N = 130; white = 58.1%) reported their social cognitions (male-referent descriptive norms and prototypes), self-reliance masculinity ideology, and vaccination intentions. Higher descriptive norms (believing more male college students had been vaccinated against HPV) and more favourable prototypes (rating the typical guy your age who has received the HPV vaccination as being attractive, confident, popular, and exciting) were both significantly associated with higher HPV vaccination intention. In addition, more favourable prototypes were significantly associated with higher willingness to vaccinate for HPV.

In Study 2, college men (N = 106; white = 61.3%) were randomly assigned to receive HPV vaccination information from a man or woman physician-avatar. They were shown either a male or female physician photograph paired with identical, factual information about HPV risks and prevention behaviour (risk of contracting HPV from sex without barrier protection (e.g., condomons) and the availability of vaccination). This study found that men with higher self-reliance masculinity (on a scale that captures norms of traditional masculinity ideologies) had higher HPV vaccination intentions with a man physician and when they perceived greater vaccination among men. Men higher in self-reliance masculinity had lower HPV vaccination intention when they received the vaccination recommendation from a woman physician. Also, although physician gender did not influence behavioural willingness for unprotected sex, more masculine men were more willing to engage in sex that would put them at risk for HPV, which is consistent with former research on masculinity and risky sexual behaviour.

Thus, the results show that descriptive norms are associated with behavioural intentions, perhaps because these norms provide cues for demonstrating manhood and inform men's behavioural decision-making to align with their perceptions of the group. (However, descriptive norms did not significantly relate to vaccination willingness.) Favourable male prototypes also related to higher HPV vaccination decision cognitions. College men may engage in a social comparison process by using perceptions of a confident and exciting male vaccinator prototype, thus integrating these characteristics into sense of self. "In sum, the influence of descriptive norms and prototypes suggest that the Prototype Willingness Model is a useful framework for exploring social influence on vaccination decision cognitions."

The finding that men with higher self-reliance masculinity had greater vaccination intentions when they received HPV vaccination information from a male physician parallels past research demonstrating that more masculine and sexist men prefer men physicians. Thus, "gender concordant medical interactions could lead self-reliant masculine men to greater adherence to medical recommendations." Masculinity could also be a predictor for behaviour that puts men at risk for HPV outside of the physician's office (unprotected sex).

Informed by the study's findings, practitioners may want to consider health messaging for college men and the HPV vaccine that harnesses social-contextual influence, such as highlighting men's participation, promoting positive male prototypes, including messages with both men and women physicians, and positioning HPV vaccination as a form of self-reliance by taking charge of one's health.

Future research to understand the social forces that shape descriptive norms and prototypes might include looking at social media as a source of norms messaging. One study found that descriptive norms of female-referent social media users influence Chinese and American women's HPV vaccination intentions. Health behaviour prototypes are also informed by culture, advertisements, and media representation/social media. Future studies could investigate whether social media influences college men's HPV vaccination decisions via masculinity, norms, and prototypes.

In conclusion: "Creative interventions are urgently needed to achieve the Healthy People 2030 target of 80% HPV vaccination coverage...Addressing the gender disparity head on by harnessing social–contextual influence via descriptive norms, prototypes, and gender-diverse physicians has the potential to rectify HPV vaccination under-uptake, prevent cancer, and save men's lives."