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. Author manuscript; available in PMC: 2015 Jul 13.
Published in final edited form as: Drug Alcohol Depend. 2013 Oct 12;134:218–221. doi: 10.1016/j.drugalcdep.2013.10.002

An examination of associations between social norms and risky alcohol use among African American men who have sex with men

Karin Tobin 1,*, Melissa Davey-Rothwell 1, Cui Yang 1, Daniel Siconolfi 1, Carl Latkin 1
PMCID: PMC4499778  NIHMSID: NIHMS531940  PMID: 24210770

Abstract

Background

Research has indicated associations between risky alcohol consumption and sexual risk behavior, which may in turn present risk of HIV acquisition or transmission. Little is known about social determinants of problematic alcohol use among African American MSM (AA MSM), a risk group disproportionately affected by HIV. The present study sought to explore associations between risky alcohol use and perceived peer norms of alcohol use among a sample of urban African American men who have sex with men (AA MSM).

Methods

A cross-sectional survey was administered to 142 AA MSM in Baltimore, Maryland, recruited using active and passive methods. Risky and hazardous alcohol use was assessed using the Alcohol Use Disorders Identification Test (AUDIT) and participants self-reported descriptive and injunctive peer norms regarding frequency and quantity of alcohol consumption.

Results

Nearly half reported hazardous or high risk consumption of alcohol. Perceived peer alcohol norms, both descriptive and injunctive, were associated with alcohol use, including hazardous use.

Conclusions

The findings highlight the role of social factors on problematic alcohol use among AA MSM. Results indicate that AA MSM's use of alcohol is associated with their perceptions of peer alcohol use. Potential interventions could include norms-based campaigns that seek to reduce risky alcohol consumption among AA MSM as well as programs to screen and identify individuals with problematic alcohol use.

Keywords: African American men who have sex with men, social norms, alcohol use, AUDIT

1. INTRODUCTION

Studies have shown high rates of alcohol use and abuse among men who have sex with men (MSM; Stall et al., 2001; Woolf and Maisto, 2009; Reisner et al., 2010; Pollock et al., 2012). Factors associated with problematic alcohol use among MSM include depression (Reisner et al., 2010), lower socio-economic status, history of incarceration, frequenting gay bars (Wong et al., 2008), HIV positive status (Deiss et al., 2013) and non-gay sexual identity (Agronick et al., 2004).

Alcohol use is also associated with increased HIV risk among MSM (Woolf and Maisto, 2009; Reisner et al., 2010), specifically, engaging in transactional sex (Deiss et al., 2013), increased number of recent and lifetime sexual partners, unprotected anal intercourse (UAI) and sex under the influence of alcohol (Purcell et al., 2001; Colfax et al., 2004; Parsons et al., 2005). Additionally, HIV seropositive MSM who frequently engage in sex under the influence of alcohol are more likely to report an increased UAI with casual partners (Purcell et al., 2001). Understanding factors associated with problematic alcohol use among MSM is necessary to expand development of appropriate interventions targeting alcohol-related risk. Alcohol use is typically a social behavior, yet little is known about social determinants of problematic alcohol use among African American MSM (AA MSM), a risk group disproportionately affected by HIV.

Social norms are a component of the social context of alcohol use and are strong predictors of behavior (Neighbors et al., 2007; Rimal, 2008; Rosenquist et al., 2010; Teunissen et al., 2012). Perceptions of others’ behavior (termed descriptive norms) and perceptions of others’ disapproval for a certain behavior (termed injunctive norms) have been associated with heavy episodic consumption drinking and alcohol-related problems (Larimer et al., 2004). Studies of alcohol-related social norms, predominately conducted with heterosexual college-aged populations, have shown that greater alcohol use is associated with perceptions that peers are excessively consuming alcohol (Perkins et al., 2005; Perkins, 2007; Bertholet et al., 2011). One study among college aged students found that the association between descriptive social norms on individual drinking behavior was stronger for men than it was for women (O'Grady et al., 2011). In another study, among a sample of predominately white young men who have sex with men, the increased number of friends who drank heavily was associated with individual alcohol use (Paschall et al., 2005). Furthermore, a study of multi-ethnic sample of young MSM, found that heavy episodic drinking was associated with a greater number of peers who engaged in drug, alcohol or sex risk behavior (Wong et al., 2008).

Along these lines, social norms approaches have been utilized to address hazardous drinking among college populations (Borsari and Carey, 2003; DeJong et al., 2006, 2009). Some of these interventions show promise (DeJong et al., 2006), though not all have been found to be effective (Dejong et al., 2009). If norms are associated with alcohol consumption patterns among African American MSM, then norms-based interventions could be designed to address problem drinking and subsequent risky sexual behaviors.

The purpose of this study was to examine associations between descriptive and injunctive norms of alcohol use and alcohol risk level among an urban sample of African American men who have sex with men.

2. METHODS

Data for this study came from a cross-sectional survey of AA MSM conducted from March, 2012 to July, 2012 in Baltimore, Maryland. Participants were recruited using a variety of methods, including street-based outreach by trained field recruiters, word of mouth referrals, collaborations with community-based agencies that provide services to AA MSM, and internet-based postings on Craigslist.org. Inclusion criteria were self-reported age 18 years old or older, African American race/ethnicity, and sex with a male in the prior 90 days. Interested participants were screened via phone or in person by a trained research assistant. Of n=196 who were screened, 22% were ineligible. No participants who contacted the research study refused or declined screening. Eligible participants provided written informed consent and completed a baseline survey administered in a private office by a trained research assistant. Participants were remunerated $50 for completing the survey. All study procedures were approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.

2.1. Measures

2.1.1. Outcome

Alcohol Use Risk The Alcohol Use Disorders Identification Test (AUDIT) was used to assess alcohol use, hazardous drinking, and risk for alcohol dependence (Saunders et al., 1993; Babor et al., 2001). The AUDIT has been validated in numerous populations and measures frequency of drinking, drinking behavior, dependence, and problems and consequences related to drinking. AUDIT scores range from 0-40, with a higher score indicating more hazardous or risky drinking. For each participant, a total score was calculated and categorized for level of Alcohol Use Risk (AUR) measured as 0=no use of alcohol, 1= AUDIT score 0-7 (low-risk drinking), 2= AUDIT score 8-15 (hazardous drinking), and 4= AUDIT score 16 or higher (high-risk drinking, and likely dependent on alcohol).

2.1.2. Descriptive alcohol use norms

were assessed by asking “How many of your friends drink three or more times a week” (i.e., frequency) and “How many of your friends have five or more drinks in one sitting?” (i.e., quantity) The response choices for both items were: none, a few, half, or most/all.

2.1.3. Injunctive alcohol use norms

were assessed by asking “How many of your friends would disapprove if you were to drink three or more times a week” (i.e., frequency) and “How many of your friends would disapprove if you had five or more drinks in one sitting?” (i.e., quantity) The response choices for both items were: none, a few, half, or most/all.

2.1.4. Socio-demographic variables

Participants self-reported age, highest level of educational attainment, current employment status (full-time, part-time, not working, and not working due to disability), whether they had health insurance (yes/no), had been homeless at any time during the past 6 months, and their HIV status (positive, negative, unsure). Sexual identity was assessed with the question, “Which best describes your sexual identity (homosexual/gay, bisexual, heterosexual/straight, other)?”

2.1.5. Analyses

were conducted to examine bivariate associations between socio-demographic variables and perceived alcohol norms and Alcohol Use Risk categories using chi-square and Fishers chi-square statistics for categorical variables and ANOVA for continuous variables. To assess independent associations between perceived alcohol norms and Alcohol Use Risk, logistic regression was conducted, controlling for age, HIV status and sexual identity. For modeling using logistic regression, a dichotomous variable was created to indicate 0=”no or low alcohol risk” versus 1=”hazardous or high alcohol risk.”

3. RESULTS

The final sample included n=142 AA MSM whose median age was 43 (SD=10.9; IQR=31-49). The majority of participants (57%) reported no use or low risk use of alcohol; distribution of Alcohol Use Risk (AUR) was 20% reporting no use of alcohol, 37% in the low risk category, 22% in the hazardous category and 21% in the high risk/likely dependent category (Table 1). Results from the bivariate analysis indicate that a greater proportion of men who did not drink alcohol were older (p<0.01), not working due to disability (p=0.02), and of “not sure/questioning” sexual identity (p=0.03) compared to the other AUR groups. AUR did not vary based on self-reported HIV status or homelessness.

Table 1.

Associations between perceived alcohol norms and AUDIT risk level among African American men who have sex with men (n=142).

AUDIT score
Total sample
N=142		 No alcohol use in prior 90 days
N=29 (20%)		 <=7 (Low risk)
N=52 (37%)		 8-15 (Risky/Hazardous)
N=31 (22%)		 >=16 (High risk)
N=30 (21%)		 p-value
Median age (SD) 43 (10.9) 47.0 (8.76) 34 (11.3) 45 (10.7) 43 (10.2)
(IQR) (31-49) (42-51) (27-47) (31-49) (35-42) <0.01
Education
    ≤11 years 28 (20) 6 (21) 10 (19) 6 (19) 6 (20)
    12/GED 67 (47) 13 (45) 18 (35) 21 (68) 15 (50)
    ≥some college 47 (33) 10 (34) 24 (46) 4 (13) 9 (30) 0.01
Employment
    Full time 17 (12) 3 (10) 13 (25) 1 (3) 0 (0)
    Part-time 23 (16) 3 (10) 11 (21) 5 (16) 4 (13)
    Not working 52 (37) 10 (34) 13 (25) 14 (45) 15 (50)
    Disability 50 (35) 13 (45) 15 (29) 11 (35) 11 (37) 0.02
Health insurance
    yes 114 (80) 26 (90) 40 (77) 23 (74) 25 (83) 0.41
Sexual identity
    Gay 64 (45) 10 (34) 32 (62) 12 (39) 10 (33)
    Bisexual 48 (34) 8 (28) 13 (25) 12 (39) 15 (50)
    Heterosexual 16 (11) 5 (17) 2 (4) 5 (16) 4 (13)
    other 14 (10) 6 (21) 5 (10) 2 (6) 1 (3) 0.03
Self-reported HIV+
    Yes 59 (42) 14 (48) 23 (44) 11 (35) 11 (37) 0.70
Homeless in past 6 months
    Yes 32 (23) 6 (21) 10 (19) 5 (16) 11 (37) 0.24
How many friends drink alcohol >=3 times a week
    None 17 (12) 5 (17) 11 (21) 0 (0) 1 (3)
    A few 56 (39) 15 (52) 19 (37) 13 (42) 9 (30)
    >=50% 69 (49) 9 (31) 22 (42) 18 (58) 20 (67) <0.01
How many friends drink >=5 drinks in one sitting
    None 39 (27) 15 (52) 19 (37) 3 (10) 2 (7)
    A few 54 (38) 7 (24) 19 (37) 15 (48) 13 (43)
    >=50% 49 (35) 7 (24) 14 (27) 13 (42) 15 (50) 0.001
How many would disapprove if you drank alcohol >=3 times a week
    None 42 (30) 8 (28) 10 (19) 12 (39) 12 (40)
    A few 38 (27) 2 (7) 17 (33) 8 (26) 11 (37)
    >=50% 62 (44) 19 (66) 25 (48) 11 (35) 7 (23) <0.01
How many would disapprove if you drank >=5 drinks in one sitting
    None 34 (24) 6 (21) 10 (19) 8 (26) 10 (33)
    A few 31 (22) 4 (14) 9 (17) 8 (26) 10 (33)
    >=50% 77 (54) 19 (66) 33 (63) 15 (48) 10 (33) 0.16
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Both descriptive alcohol norms items were statistically associated with AUR (Table 2). As perceptions of friends drinking frequently and in greater quantities increased, AUR category increased (e.g. risk hazardous drinking and/or dependence). The injunctive norm item on frequency of alcohol use was also statistically associated with AUR, such that as AUR increased, the proportion of friends who would disapprove decreased. There was a trend of association between injunctive norms on quantity of alcohol consumed such that as AUR score increased, perceptions that peers would disapprove of 5 or more drinks in a sitting decreased, but this did not achieve statistical significance in bivariate analysis.

Table 2.

Independent associations between perceived alcohol norms and high risk versus low/no risk alcohol use among African American men who have sex with men (n=142)

Model AOR (95% CI)*
Consumption frequency subjective norm
“How many friends drink alcohol >=3 times a week?”
    None Ref
    A few 11.4 (1.39-93.9)
    >=50% 20.1 (2.49-161.6)
Consumption quantity subjective norm
“How many friends drink >=5 drinks in one sitting?”
    None Ref
    A few 9.37 (3.03-28.9)
    >=50% 10.3 (3.34-31.8)
Consumption frequency injunctive norm
“How many would disapprove if you drank alcohol >=3 times a week?”
    None Ref
    A few 0.66 (0.26-1.64)
    >=50% 0.28 (0.12-0.66)
Consumption quantity injunctive norm
“How many would disapprove if you drank >=5 drinks in one sitting?”
    None Ref
    A few 1.19 (0.43-3.27)
    >=50% 0.41 (0.18-0.96)
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*

adjusting for age, HIV status, sexual identity

Results from multivariable logistic regression analysis of associations between alcohol norms and alcohol use risk (low versus high) indicated that high risk drinking was associated with perceptions that peers were drinking frequently and in high quantities after adjusting for HIV status, age and sexual identity. Furthermore, high risk drinking was associated with lower odds that half or more of peers would disapprove of frequent or high quantity alcohol use.

4. DISCUSSION

Consistent with extant alcohol norms literature (Perkins et al., 2005; Perkins, 2007; Real and Rimal, 2007), AA MSMs’ perceptions of peer alcohol use was associated with greater use and hazardous use. Findings from this study suggest the potential value of public health interventions that aim to alter and correct perceptions about problematic alcohol use as an approach to decrease alcohol use behaviors among AA MSM. One such approach could include a media campaign featuring messages on the prevalence of moderate drinking among African American males, as observed in the present study where 57% scored in the no to low risk category.

A critical element to improve effectiveness of norms based interventions is selection of the referent group. Findings from a study of college students (Lewis et al., 2010) suggest that effectiveness of interventions focused on descriptive and injunctive norms can be tailored based on the extent of drinking behavior and identification with a similar peer. Peer approval of risky behavior was protective to light drinkers who did not identify with this peer. Little research has been conducted with AA MSM to determine the referent group that is most influential on drinking behavior. It is unclear whether norms-based interventions tailored for AA MSM should include referent groups based on sexual identity, level of MSM disclosure or HIV status. Assessments of the social network can illuminate relevant referent groups (Davey-Rothwell et al., 2010). Future research with AA MSM should aim to describe salient, referent individuals and utilize this information in norms-based interventions.

In this sample of urban AA MSM, we report that nearly half (43%) scored in the risky alcohol use categories. Our findings are comparable to other studies on alcohol use among MSM in Los Angeles and Massachusetts (Reisner et al., 2010) and underscore the need for accessible alcohol use treatment tailored for AA MSM (Reisner et al., 2010). For example, screening, brief interventions, and referral to treatment (SBIRT) is one approach can be implemented in diverse settings, including healthcare sites (e.g., community-based health clinics) and community events (e.g., Gay Pride; Moyer et al., 2002; Babor et al., 2010). SBIRT programs have empirical support for reducing alcohol consumption or alcohol-related problems (Moyer et al., 2002; Kaner et al., 2007).

Problematic alcohol use and heavy episodic consumption (defined as 5 or more drinks in one sitting) has been identified as a key determinant of HIV risk and other health problems among MSM. There is preliminary evidence that on-premise brief interventions, delivered shortly before venue entry (e.g., bars), can reduce consumption among MSM who planned to drink heavily (Croff et al., 2012). As AA MSM bare a disproportionate burden of HIV infection, this also suggests the importance of integrating alcohol screening and intervention with HIV prevention and treatment efforts. Developing interventions to address both sexual- and alcohol-risk behaviors in an integrated manner may be potent, and presents an avenue for future intervention research.

The results of this study must be interpreted within context of its limitations. First, alcohol use was assessed using self-report, and thus alcohol use may have been under-reported due to social desirability bias. The cross-sectional study design limits our ability to determine the causal direction between perceived norms and alcohol use. Furthermore, the norms measures assess norms among friends which may not be one's relevant referent group. It is also plausible that referent groups vary by context, such that peers in alcohol consumption environments differ from peers in other contexts. Finally, as the median age of the sample was 43 years old, findings from this study may not be generalizable to younger African American men who have sex with men or MSM who are not African American.

Despite these limitations, this study highlights the role of social factors on problematic alcohol use, specifically the role of both descriptive and injunctive norms. Altering perceived social norms among AA MSM may cultivate an environment within which behavior change is supported and sustained (Latkin and Knowlton, 2005).

Acknowledgements

this research was funded by The National Institute of Health – Eunice Kennedy Shriver National Institute of Child Health 1K01HD061269

Role of funding source: This research was funded by a grant from the National Institutes of Health – National Institute of Child Health and Human Development 1 K01HD061269-04.

Footnotes

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Contributors:
  1. Karin Tobin conceptualized the study, led the analysis and development of the manuscript.
  2. Melissa Davey-Rothwell assisted with the development of the manuscript and offered expertise on alcohol norms literature.
  3. Cui Yang assisted with the development of the manuscript and offered expertise on data analysis
  4. Daniel Siconolfi assisted with the development of the manuscript and offered expertise on SBIRT interventions
  5. Carl Latkin assisted with the development of the manuscript and offered expertise on social networks and prevention approaches

Conflict of Interest: no conflict declared

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