Biopsychosocial vs. Biomedical Model

SPECIAL ISSUE: PHYSICAL HEALTH OF MEN AND BOYS

Men’s Health-Risk and Protective Behaviors: The Effects of Masculinity and Masculine Norms

Dawn M. Salgado, April L. Knowlton, and Brianna L. Johnson Pacific University

Previous research has examined men’s health in relation to women’s functioning and compared mor- bidity and mortality rates among specific subgroups of men using demographic features. More recent research expands these approaches by also examining how men’s thoughts, attitudes, and behaviors influence health-related attitudes and behaviors. The endorsement and internalization of masculinity is generally associated with more negative health behaviors and engagement in fewer health-protective behaviors. However, research to date does not offer a clear and consistent conceptualization of those specific masculine norms that might facilitate or act as a barrier to men adopting healthier behaviors. The current study examines data from 376 men between the ages of 18 and 25 to determine whether health-risk and protective behaviors are predicted by specific masculine norms, when controlling for demographic variables. Findings suggest men’s endorsement of specific masculine norms predicted more health-protective than health-risk behaviors, although the proportion of the variance explained by specific masculine norms was higher for health-risk behaviors than health-protective behaviors. Demographic variables also predicted both health-risk and protective factors. Results from the current study are presented within the context of two previous studies (Levant & Wimer, 2014; Levant, Wimer, & Williams, 2011), highlighting both similarities and additional contributions. Results provide a strong rationale for considering the influence of masculine norms on men’s health behaviors, especially within the context of health promotion, prevention, and intervention programs by healthcare providers and clinicians.

Keywords: men’s health, masculinity, masculine norms, health-risk behaviors, health-protective behaviors

“The body . . . is inescapable in the construction of masculinity, but what is inescapable is not fixed” (Connell, 1995, p. 56).

The current study addresses the ways health-risk and protective behaviors are uniquely influenced by men’s internalization and endorsement of masculine norms within society. Men’s life expec- tancy is shorter than women’s by 5 to 7 years (Mahalik, Burns, & Syzdek, 2007; National Center for Health Statistics, 2013). Health behaviors play an important role in men’s morbidity and mortality. Men not only engage in about 30 different health behaviors asso- ciated with risk of injury, disease, or death (Courtenay, 2000a) but also underutilize available medical services, engage in fewer pre- ventive care practices, and delay treatment when symptoms of illness or injury arise (Addis & Mahalik, 2003; Courtenay, Mc-

Creary, & Merighi, 2002; Galdas, Cheater, & Marshall, 2005; Hegelson, 1995; Levant, Wimer, Williams, Smalley, & Noronha, 2009). Studies with men indicate the level of engagement in health behaviors may also vary on the basis of race and ethnicity (Cour- tenay et al., 2002; Thorpe et al., 2015), age (Peak & Gast, 2014), socioeconomic status (Dolan, 2014), sexual orientation (Drum- mond, 2005), education and socioeconomic status (Mahalik & Burns, 2011), and marital status (Mahalik et al., 2007).

Masculinity, Masculine Norms, and Health Behaviors

Since the late 1970s, many clinicians, theorists, and researchers have proposed explanations for health disparities beyond biologi- cal or physiological explanations to include factors related to gender roles, ideologies, norms, and internalized conflict associ- ated with being male and masculine (Addis & Mahalik, 2003; Brannon, 1976; Connell, 1995; Courtenay, 2000a, 2000b; de Vis- ser & McDonnell, 2013; Eisler, 1995; Julty, 1979; Levant, 1996; Mahalik et al., 2007; O’Neil, 1981; Pleck, 1981; Pleck, 1995; Sabo, 2001; Smiler, 2004). Parent, Moradi, Rummell, and Tokar (2011) stated that conformity to masculine norms is distinctive from personality dimensions (e.g., conscientiousness), masculine and feminine traits, (e.g., expressiveness), and self-esteem (e.g., global). Within this context, the internalization and endorsement of traditional constructions of masculinity have important conse- quences for men’s engagement in health-risk and protective be-

Dawn M. Salgado, April L. Knowlton, and Brianna L. Johnson, Depart- ment of Psychology, Pacific University.

Preliminary results were presented at the 2016 Annual Convention of the Western Psychological Association in Las Vegas, Nevada. Data discussed in this article were presented at the 2018 Annual Conventions of the Western Psychological Association in Portland, Oregon and the Associa- tion for Psychological Science in San Francisco, California.

Correspondence concerning this article should be addressed to Dawn M. Salgado, Department of Psychology, Pacific University, 2043 College Way, Forest Grove, OR 97116. E-mail: [email protected]

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Psychology of Men & Masculinities © 2019 American Psychological Association 2019, Vol. 20, No. 2, 266–275 1524-9220/19/$12.00 http://dx.doi.org/10.1037/men0000211

266

haviors because they conform to perceptions of how other men normatively behave (Mahalik et al., 2007). These behaviors be- come learned and socialized early on and become reinforced during adolescence and into adulthood (Levant & Wimer, 2014; Levant, Wimer, & Williams, 2011; Mahalik, & Burns, 2011; Mansfield, Addis, & Mahalik, 2003; Pleck, Sonenstein, & Ku, 1993).

Over the past 2 decades, masculinity has been consistently linked to engagement in health behaviors that increase risks asso- ciated with morbidity and mortality (Courtenay et al., 2002; de Visser & McDonnell, 2013; Levant, 1992; Levant & Wimer, 2014; Levant et al., 2011; Mahalik et al., 2007; Mahalik, Good, & Englar-Carlson, 2003; Mansfield et al., 2003; Morrison, 2012; Peralta, Tuttle, & Steele, 2010). Mahalik et al. (2007) reported that men’s support for traditional masculine gender norms was linked to lower rates of engagement in several health-protective behaviors including regular seatbelt use, annual physical exams, seeking psychological help, consuming fruits and vegetables, exercising, and not engaging in fighting or substance use. These findings are consistent with other studies documenting the association between men’s adoption and endorsement of masculine ideals and poorer eating attitudes and practices (Griffith, Metzl, & Gunter, 2011; McShane, Salgado, & Bjordahl, 2015), reduced likelihood of being HIV-tested (Parent, Torrey, & Michaels, 2012), increased steroid use (Parent & Bradstreet, 2017), and fewer annual screenings (Morrison, 2012).

Health-protective behaviors (e.g., preventative treatment, self- care practices, and psychological help-seeking), including the men who engage in them, are typically characterized as “feminine,” “weak,” or “gay,” resulting in a paradox whereby attaining mas- culinity comes at the cost to men’s quality of life, health, and well-being (Bell, 1984; Bjordahl, Salgado, & Johnson, 2015; Boon, 2005; Capraro, 2000; Johnson, McShane, & Salgado, 2015; Mahalik et al., 2003; Mankowski & Maton, 2010; McCusker & Galupo, 2011).

It is important to understand how men’s health behaviors are associated with specific masculine norms to identify dimensions that are particularly beneficial or harmful. Masculine norms are defined as socially constructed attitudes, standards, expectancies, and behavioral tendencies associated with being male and mascu- line (Mahalik et al., 2003). Within the United States, dominant forms of masculinity are characterized by risk-taking, aggressive- ness, competitiveness, dominance, status, and focusing on work, as well as self-reliance, stoicism, having power over women, being a playboy, and being perceived as heterosexual (Mahalik et al., 2003; Parent & Moradi, 2009).

Because health outcomes are behaviorally influenced, Courte- nay (1998, 2000a, 2000b) proposed health behaviors related to preventive care, substance use, and dietary habits should be of primary interest to researchers and providers. To the extent men that endorse masculine norms such as self-reliance, emotional control, and winning, they are found to engage in more health-risk and fewer health-protective behaviors (Courtenay, 2000a, 2000b; Levant et al., 2011; Levant & Wimer, 2014; Mansfield et al., 2003). Substance use is associated with men’s higher endorsement of masculine norms associated with risk-taking, less emotional control, being a playboy, winning, and having power over women (Iwamoto, Corbin, Lejuez, & MacPherson, 2014; Levant et al., 2011; Levant & Wimer, 2014). Anger and Stress were associated

with endorsing masculine norms associated with the primacy of work and self-reliance (Levant et al., 2011) or winning (Levant & Wimer, 2014), although both studies point to the importance of emotional control on the management of anger and stress among men. Himmelstein and Sanchez (2016) reported masculine norms such as self-reliance can negatively affect health behaviors directly as well as indirectly when considering how these function in relation to the minimization of symptoms, doctor distrust, concerns about privacy, and delays in seeking treatment after experiencing symptoms of illness or injury. Engaging in health-protective be- haviors has been linked to less endorsement of masculine norms associated with being a playboy, risk-taking, and competitiveness (Levant et al., 2011, Levant & Wimer, 2014).

Although there are some consistent findings across studies re- garding prediction of health-risk and protective behaviors among men by specific masculine norms, studies by Levant and Wimer (2014) and Gerdes and Levant (2018) point to the need for addi- tional research on this topic. Levant and Wimer (2014) reported that only 33% of the associations between specific masculine norms and dimensions of health-risk and protective factors across two similar studies were replicated, which lowered to 25% (three of 12 significant associations) when looking at masculine norm subscales of the Conformity to Masculine Norms Inventory (i.e., Winning, Playboy, Primacy of Work, Risk-Taking, Self-Reliance, and Emotional Control; Parent & Moradi, 2009; Mahalik et al., 2003). Replicated findings across the two studies indicated that substance use was predicted lower Playboy subscale scores, Anger and Stress were predicted by lower Emotional Control subscale scores, and the Proper Use of Health Care Resources was predicted less. Findings across both Levant studies (Levant et al., 2011; Levant & Wimer, 2014) and the more recent content analysis of associations by Gerdes and Levant (2018) highlight the importance in having additional research to assist in clarifying the predictive nature of masculine norms on various health-risk and protective behaviors.

Current Study

The current study examined the influence of masculine norms on health-risk and protective behaviors in a university and com- munity sample of men while relying on previous research findings (Levant & Wimer, 2014; Levant et al., 2011) as points of com- parison and contrast in three ways. First, the current study pro- poses conformity to masculine norms (46-itemed Conformity to Masculine Norms Inventory [CMNI-46]) would negatively predict engagement in health behaviors (Health Belief Inventory–20 [HBI-20]), as reported in both Levant studies (Levant & Wimer, 2014; Levant et al., 2011). Previous research examining the effects of specific masculine norms on health-risk and protective behav- iors has yielded mixed results (Gerdes & Levant, 2018; Levant & Wimer, 2014; Levant et al., 2011; Mahalik et al., 2003). As a result, the second purpose of the current study is to examine whether associations between specific norms and dimensions of health-risk behaviors found in both Levant studies (Levant & Wimer, 2014; Levant et al., 2011) will be replicated. Within this context, there are three hypotheses:

Hypothesis 1: Substance Use would be predicted by higher Playboy and lower Winning subscale scores.

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267MASCULINITY, NORMS, AND HEALTH BEHAVIORS

Hypothesis 2: Proper Use of Health Care Resources would be predicted by lower Risk-taking subscale scores.

Hypothesis 3: Healthy Diet would not be associated with any of the masculine norm subscales.

The third purpose of the study was to examine whether any additional masculine norms not previously indicated in the empirical literature and not replicated across both Levant studies (Levant & Wimer, 2014; Levant et al., 2011) also predicted men’s health behaviors in general and their health- risk and protective behaviors in particular.

Method

Participants

A total of 376 men between the ages of 18 and 25 (M � 20.80, SD � 2.05) participated in a study on gender and men’s health. A majority of participants were enrolled in college (n � 281, 74.73%), with the remaining identifying as college graduates (n � 70; 18.62%) or high school/noncollege graduates (n � 25, 6.65%). Most participants identified as heterosexual (n � 346, 92.02%), followed by bisexual (n � 18, 4.78%) or gay (n � 11, 2.93%). Participants reported subjective social status ranged from working class (n � 4, 1.06%) to lower middle class (n � 67, 17.82%), middle class (n � 158, 42.02%), upper middle class (n � 132, 35.11%), and upper class (n � 15, 3.99%).

Measures

Demographics. Items assessed participant gender, race/eth- nicity, sexual orientation, educational status, and age. Subjective social status was measured using the MacArthur Scale of Subjec- tive Social Status for Youth (Adler, Epel, Castellazzo, & Ickovics, 2000; Goodman et al., 2001) and asked participants to rate their familial social status within society by placing an “X” on the rung of a ladder, with higher rungs representing higher socioeconomic status. This assessment is valid and appropriate for use for indi- viduals 12 years and older, reflects minimal differences from the adult version, and is recommended for participants who may not be financially independent (Goodman et al., 2001). Previous research suggests higher subjective social status is associated with health and well-being (Adler et al., 2000; Adler & Snibbe, 2003; Good- man et al., 2001).

Health behaviors. The HBI-20 (Courtenay, 1998; Courtenay et al., 2002; Levant et al., 2011) contains 20 items divided into five subscales representing both health-protective and health-risk be- haviors. Health-protective subscales included a Healthy Diet (five items, � � .79, “I limit the amount of fat I eat”), the Proper Use of Health Care Resources (two items � � .78, “I fill my medicine prescriptions immediately”), and Preventive Self-care (seven items, � � .51, “I check my skin for unusual spots or coloring every few months”). The lower internal reliability estimate present in the Preventive Self-care subscale is consistent with previously published findings (Levant et al., 2011, � � .69; Levant & Wimer, 2014, � � .57) and reflects the preference of content validity over scale homogeneity to yield the most representative behavioral items associated with men’s preventative self-care behaviors. Health-risk behaviors included Anger and Stress (three items, � �

.75, “I get angry and annoyed when I am caught in traffic”), and Substance Use (three items, � � .67, “I use recreational drugs”). Participants rated each item on a 7-point Likert scale from 1 (never) to 7 (always), indicating how often they engaged in each behavior. Total scores for each subscale were developed by sum- ming items within each subscale, and a total score (20 items � � .70) was computed by first reverse-scoring risk-behavior items and then adding to health-protective behavior items. Higher scores on the HBI-20 and its subscales reflect more engagement in behav- iors.

Masculine norms. Conformity to masculine norms, defined as the extent to which men endorse thoughts, attitudes, and behav- iors associated with male gender norms, was assessed using the CMNI-46 (Mahalik et al., 2003; Parent & Moradi, 2009, 2011). In addition to the CMNI total score (� � .86), there were nine subscales representing specific masculine norms including, Power over Women (four items, � � .83, “In general, I control the women in my life”), Violence (six items, � � .83; “Sometimes violent action is necessary”), Emotional Control (six items, � � .91, “I tend to keep my feelings to myself”), Winning (six items, � � .88, “In general, I will do anything to win”), Heterosexual Self-Presentation (six items, � � .89, “I would be furious if someone thought I was gay”), Primacy of Work (five items, � � .78, “My work is the most important part of my life”), Risk-Taking (five items, � � .86, “I frequently put myself in risky situations”), Self-reliance (five items, � � .87, “I hate asking for help.”), and Playboy (four items, � � .81, “If I could, I would frequently change sexual partners”). Participants responded to each item on a 4-point Likert-type scale from 1 (strongly disagree) to 5 (strongly agree), and the items were reverse-scored as needed and then summed within and across each masculine norm. Higher scores on the total CMNI-46 and each specific masculine norm reflect higher levels of conformity.

Procedure

After receiving institutional review board approval, participants were recruited through a variety of means, including undergradu- ate psychology courses, Internet websites, social media, and list- servs, to participate in a study on gender- and health-related attitudes and behaviors. They were provided a link to an online survey through Survey Monkey. Interested participants reviewed and signed the informed consent, were asked to verify they met the inclusion criteria for participation (e.g., over 18 and male), and then directed to the survey. The survey took approximately 15 to 20 min to complete, and participants were provided with contact information for the principal investigator of the study and an overview of the study. Participants had the option to be directed to a separate, unlinked questionnaire for entering their contact infor- mation to be entered into a raffle for one of three $50 gift cards, and students were able to print out a certificate of research partic- ipation in the event they were able to receive credit within courses.

Results

Preliminary Analyses

Bivariate correlations between the CMNI-46 and HBI-20 total scores, health-risk behaviors, and health-protective behaviors were

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268 SALGADO, KNOWLTON, AND JOHNSON

conducted (samples sizes ranged from 375 to 376, one-tailed). The CMNI-46 was negatively correlated with HBI-20 total scores, r � �.09, p � .05, and health-risk behaviors (Anger and Stress, r � .34, p � .001; Substance Use, r � .17, p � .001). Mixed results between masculinity and health-protective behaviors were observed with Preventive Self-care being positively correlated (r � .15, p � .001), whereas Healthy Diet and the Proper Use of Health Care Resources were not significant.

Descriptives and correlations between health behaviors, demo- graphics, and masculine norms are shown in Table 1. A Healthy Diet was associated with being older but was not associated with any of the masculine norms. The Proper Use of Health Care Resources was associated with being younger, lower subjective social status, lower Emotional Control and Self-Reliance and higher Winning, Heterosexual Self-presentation, and Primacy of Work subscale scores. Preventive Self-care was associated with being younger, heterosexual, higher Winning, Heterosexual Self-presentation, and Primacy of Work and lower Emotional Control subscale scores. Anger and Stress were not associated with demographics but were correlated with higher Power over Women, Violence, Winning, Heterosexual self- presentation, and Self-reliance subscale scores. Substance Use was associated with identifying as a nonracial/ethnic minority, and higher Violence, Risk-Taking, and Playboy subscale scores.

Bivariate correlations between demographics, HBI-20, and CMNI-46 were also conducted (N � 376, two-tailed). Engagement in healthier behaviors was associated with being heterosexual, r � .10, p � .05, and lower subjective social status, r � �.12, p � .02. CMNI-46 total scale scores were associated with being younger (r � �.14, p � .001), identifying as a racial/ethnic minority (r � .12, p � .001) and as a heterosexual, r � .15, p � .01. Younger men reported higher subscale scores for Risk-Taking, Heterosex- ual Self-presentation, and Primacy of Work than older men in the sample. Compared to men who identified as sexual minorities, heterosexual men reported higher Power over Women and Het- erosexual Self-presentation subscale scores. Individuals identify- ing as racial/ethnic minorities reported higher Power over Women, Heterosexual Self-presentation, and Primacy of Work subscale scores. Higher subjective social status was correlated with lower Primacy of Work subscale scores.

Regression Analyses for HBI-20 Total

Hierarchical multiple regressions were conducted with HBI-20 total scores, as well as health-protective and risk behaviors. For each outcome variable, demographic variables were included in the first step, followed by CMNI-46 total in Step 2. The second set of multiple regressions were also conducted for the same outcomes variables and demographic variables but included the set of mas- culine norms at Step 2 rather than the CMNI total scale score. The current study met the minimum criteria and guidelines for the number of participants and predictors (Green, 1991; Harris, 1985; Wilson VanVoorhis & Morgan, 2007). Multicollinearity diagnos- tics were assessed, and variance inflation factor scores did not exceed 10, and tolerance scores were above .20 across all regres- sions.

For HBI-20 total, the final model resulted in an adjusted R2 � .04, �R2 � .02, F(5, 375) � 4.12, p � .01, and was associated with being younger, being heterosexual, and having lower subjective social status, as well as lower conformity to masculine norms

(CMNI-46). Results from the second set of regressions, which included the set of masculine norms, are shown in Table 2. Total HBI-20 was associated with identifying as heterosexual and a lower subjective social status, as well as lower Self-reliance and higher Playboy and Winning subscale scores.

Regression Analyses on Risk Health Behaviors

Health-risk behaviors were characterized by experiences of An- ger and Stress and Substance Use. In the first set regressions, CMNI-46 total was associated with Anger Stress, as well as Substance Use. For Anger and Stress, the final model resulted in an adjusted R2 � .11, �R2 � .12, F(5, 375) � 10.27, p � .001, and associated with more conformity to masculine norms but was not predicted by demographic variables. For Substance Use, the final model resulted in an adjusted R2 � .05, �R2 � .04, F(5, 375) � 4.56, p � .001, and associated with being a nonracial/ethnic minority and more conformity to masculine norms as well. The second set of regressions are presented in Table 2. For anger and stress, demographics were not significant predictors, whereas Power over Women, Heterosexual Self-presentation, and Self- reliance were predictive. Substance Use was higher among men who did not identify as a Racial/ethnic minority and those who scored higher on the Risk-taking and Playboy subscales. In sum- mary, engagement in health-risk behaviors was associated with higher Power over Women, Heterosexual Self-presentation, Self- reliance, Playboy, and Risk-taking subscale scores. Health-risk behaviors were not associated with the Violence, Primacy of Work, Winning, or Emotional Control subscales.

Regression Analyses on Protective-Health Behaviors

Health-protective behaviors included a Healthy Diet, Proper Use of Health Care Resources, and Preventive Self-care. In the first set of regressions, total CMNI-46 scores did not predict Healthy Diet or the Proper Use of Health Care Resources but predicted more Preventive Self-care. For Healthy Diet, the final model resulted in an adjusted R2 � .03, �R2 � .00, F(5, 374) � 3.25, p � .001, and was only predicted by being older. For Proper Use of Health Care Resources, the final model resulted in an adjusted R2 � .09, �R2 � .00, F(5, 375) � 7.99, p � .001, and associated with being younger, being heterosexual, and having lower subjective social status. For Preventive Self-care, the final model resulted in an adjusted R2 � .04, �R2 � .01, F(5, 375) � 4.18, p � .001, and associated with being younger and higher CMNI-46 scores.

The second set of regressions are shown in Table 3. For Healthy Diet, age was the only significant predictor across all demograph- ics and masculine norms. The Proper Use of Health Care Re- sources was associated with being younger and having lower social status, lower Power over Women and Self-reliance and higher Winning and Heterosexual Self-presentation subscale scores. More engagement in Preventive Self-care behaviors were reported by younger men and participants with lower Emotional Control and Winning subscale scores. Violence, Risk-taking, Pri- macy of Work, and Playboy subscales were not significant across both health-protective behaviors. In summary, more engagement in health-protective behaviors (excluding Healthy Diet) was re- ported among men who were younger, heterosexual, and from a lower socioeconomic status, as well as who scored lower on the

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269MASCULINITY, NORMS, AND HEALTH BEHAVIORS

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270 SALGADO, KNOWLTON, AND JOHNSON

Emotional Control, Power over Women, and Self-reliance and higher Winning subscale scores.

Discussion

The current study examined the predictive effects of masculinity and masculine norms on health behaviors in general, as well as health-risk and protective behaviors while relying on findings from two previous studies (Levant & Wimer, 2014; Levant et al., 2011). This was accomplished in three ways: (a) examining whether conformity to masculine norms (CMNI-46) predicted overall health behaviors, as well as health-risk and protective behaviors, (b) examining whether consistent findings between associations of specific masculine norms and health behaviors reported by Levant & Wimer, 2014 and Levant et al. (2011) were replicated in the current study, and (c) examining whether masculine norms that were previously unreported might predict engagement in health- risk and protective behaviors.

CMNI-46 and Men’s Health Behaviors

We proposed conformity to masculine norms (CMNI-46) would negatively predict engagement in health behaviors (HBI-20), as well as increased engagement in health-risk and decreased engage- ment in health-protective behaviors. Similar to previous studies (Addis & Mahalik, 2003; Courtenay, 2000b; Levant & Wimer, 2014; Levant et al., 2011; Mahalik, Lagan, & Morrison, 2006; Pleck, Sonensterin, & Ku, 1994), conformity to masculine norms (CMNI-46) was negatively associated with health behaviors (HBI- 20). Although conformity to masculine norms (CMNI-46) pre- dicted both health-risk behaviors (i.e., Anger and Stress, Substance

Use), it only predicted one of the three health-protective factors, Preventive self-care. These findings offer new evidence when compared with findings reported in the study Levant and Wimer (2014), who reported health-risk and protective behaviors were not predicted by the conformity to masculine norms (CMNI-46) total score.

Associations Between Specific Masculine Norms and Men’s Health Behaviors

A second purpose of the current study was to examine the three replicated associations between specific norms measured in the CMNI-46 and health-risk and protective behaviors (Levant & Wimer, 2014; Levant et al., 2011). In the two previous studies, (a) Substance Use was associated with higher Playboy subscale scores, (b) Anger and Stress was predicted by higher Emotional Control, (c) the Proper Use of Healthcare Resources was associ- ated with lower Risk-Taking subscale scores, and (d) Healthy Diet was not associated with any of the CMNI-46 subscale scores. Across these three findings, only the first and last results were replicated in the current study.

The third purpose of the study was to provide additional evi- dence on whether masculine norms are more likely to have a protective or detrimental effect on men’s health and to examine whether men’s health-risk and protective behaviors were predicted by specific masculine norms not previously examined or found to be inconsistent (Levant & Wimer, 2014; Levant et al., 2011). Both Gerdes and Levant (2018) and Levant and Wimer (2014) reported that masculine norms, as assessed by total the number of subscale scores, were more likely to predict health-risk behaviors as com- pared with health-protective behaviors. The current study presents

Table 2 Regression Analyses Predicting Health-Risk and Total Health Behavior Inventory by Demographic and Masculine Norms

Anger and Stress Substance Use Total

B SE � t p B SE � t p B SE � t p

Step 1 Age �.06 .07 �.05 �0.89 .38 .05 .06 .04 0.80 .42 �.40 .23 �.09 �1.75 .08†

Heterosexual .17 .51 .02 0.34 .74 �.35 .46 �.04 �0.75 .46 3.56 1.73 .11 2.06 .04�

Racial/ethnic minority .19 .31 .03 0.62 .54 �.62 .28 �.11 �2.19 .03� .77 1.06 .04 0.73 .47 Subjective social status .09 .09 .05 1.01 .31 .03 .08 .02 0.33 .74 �.80 .30 �.14 �2.69 .01�

Adjusted R2 �.00 .01 .03�

F for Step 1 .66 1.61 3.46��

Step 2 Age .00 .06 .00 0.05 .96 .05 .06 .04 0.88 .38 �.35 .22 �.08 �1.54 .12 Heterosexual �.57 .49 �.06 �1.18 .24 �.35 .45 �.04 �0.77 .44 3.55 1.72 .11 2.07 .04�

Racial/ethnic minority �.00 .30 �.00 �0.01 .99 �.53 .27 �.10 �1.94 .05† .28 1.05 .01 0.26 .79 Subjective social status .14 .08 .08 1.65 .10 .02 .08 .01 0.24 .81 �.69 .29 �.12 �2.34 .02�

Power over Women .22 .07 .20 3.29 .00�� �.05 .06 �.04 �0.73 .46 �.48 .24 �.12 �1.98 .05†

Violence .06 .04 .08 1.48 .14 .04 .04 .05 1.02 .31 �.15 .15 �.06 �1.00 .32 Emotional Control �.06 .04 �.08 �1.50 .14 �.01 .03 �.01 �0.22 .83 �.16 .13 �.07 �1.20 .23 Winning .07 .04 .09 1.62 .11 �.02 .04 �.03 �0.44 .66 .37 .15 .14 2.47 .01�

Heterosexual Self-presentation .10 .04 .16 2.60 .01� .02 .03 .03 0.45 .66 .14 .13 .06 1.03 .31 Primacy of Work .02 .06 .02 0.29 .77 �.01 .05 �.01 �0.23 .82 .34 .20 .09 1.70 .09†

Risk-taking .01 .05 .01 0.21 .83 .24 .05 .26 5.17 .00�� �.24 .18 �.07 �1.34 .18 Self-reliance .13 .05 .14 2.55 .01� .09 .05 .10 1.92 .06† �.47 .18 �.15 �2.66 .01�

Playboy .01 .05 .01 0.26 .79 .20 .05 .23 4.36 .00�� �.41 .17 �.13 �2.36 .02�

Adjusted R2 change .16�� .15 .09��

Adjusted R2 full model .14 .14�� .10 F for full model 5.60�� 5.64�� 4.12��

† p � .10. � p � .05. �� p � .01.

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271MASCULINITY, NORMS, AND HEALTH BEHAVIORS

the opposite pattern of results with more significant associations between masculine norms and health-protective behaviors than health-risk behaviors (6 versus 5, respectively). However, it is also worth noting that a higher proportion of the variance in health-risk behaviors was accounted for by masculine norms (i.e., 16% in Anger and Stress and 15% in Substance Use) when compared with that of health-protective behaviors (i.e., 9% in the Proper Use of Health Care Resources and 7% in Preventive self-care services).

Levant and Wimer (2014), and more recently Gerdes and Levant (2018), highlighted findings in which specific masculine norms predicted either health-risk or protective behaviors or both in opposite directions. Results from the current study suggest that health-risk behaviors were uniquely predicted higher Risk-taking and Playboy subscale scores, whereas health-protective behaviors were uniquely predicted by the Winning and Emotional Control subscales. Power over Women and Self-reliance subscale scores predicted not only more engagement with health-risk behaviors but also less engagement with health-protective behaviors. These find- ings suggest these specific masculine norms may be particularly detrimental to men’s health and well-being. Interestingly, Hetero- sexual Self-presentation was the only masculine norm found to predict more engagement in both health-risk and health-protective behaviors.

As reported by Levant and Wimer (2014), most of the associ- ations between men’s health and specific masculine norms were not replicated across their two studies (67% of associations using two measures of masculine norms and 75% of associations using only those norms assessed by the CMNI-46). As a result, the current study provides additional evidence on those specific mas- culine norms most relevant to men’s health-risk and protective

behaviors. Primacy of Work and Violence did not predict health- risk or protective behaviors in men, unlike findings previously published. Anger and Stress were predicted by higher Power over Women, Heterosexual self-presentation, and Self-reliance subscale scores, only the latter of which had been previously reported. Substance Use was predicted by higher Risk-taking subscale scores in both the current study and results from the second study reported by Levant and Wimer (2014). The Proper Use of Health Care Resources was predicted by higher Winning (opposite direc- tion reported in previous research) and lower Self-reliance and Power over Women subscale scores. Preventive Self-care was associated with higher Winning and lower Emotional Control subscale scores.

Taken together, these findings suggest that research on this topic would benefit from reports on the number of specific masculine norms that predicted health-risk as compared with protective be- haviors, the unique proportion of variance explained by the set of masculine norms for each health-risk and protective behaviors, and whether (and in what direction) specific masculine norms uniquely or simultaneously predict health-risk and/or protective behaviors. Research by Himmelstein and Sanchez (2016) suggests that tradi- tional masculine norms act as barriers to men’s engagement in Preventive Self-care, appearing as problem minimization, distrust of health care providers and privacy, and longer delays in seeking treatment after injury or symptoms are experienced.

Limitations

The generalizability of the results in the current study could be strengthened with a more diverse sample population (e.g., race/

Table 3 Regression Analyses Predicting Health Prevention Behaviors by Demographic and Masculine Norms

Healthy Diet Proper Use of Healthcare Resources Preventive Self-care

B SE � t p B SE � t p B SE � t p

Step 1 Age .40 .11 .19 3.72 .00�� �.60 .13 �.23 �4.54 .00�� �.20 .07 �.16 �3.05 .00��

Heterosexual .06 .81 .00 0.08 .94 2.00 .10 .10 2.01 .05� 1.12 .50 .12 2.24 .03�

Racial/ethnic minority .36 .50 .04 0.73 .47 �.10 .61 �.01 �0.16 .87 .12 .31 .02 0.39 .70 Subjective social status .17 .14 .06 1.23 .22 �.72 .17 �.21 �4.19 .00�� �.11 .09 �.07 �1.27 .20

Adjusted R2 .03�� .08�� .03��

F for Step 1 3.74�� 9.53�� 3.90��

Step 2 Age .43 .11 .20 3.89 .00�� �.54 .13 �.21 �4.22 .00�� �.17 .07 �.13 �2.54 .01�

Heterosexual �.11 .84 �.01 �0.13 .90 1.57 .99 .08 1.59 .11 .88 .51 .09 1.75 .08†

Racial/ethnic minority .22 .52 .02 0.43 .67 �.42 .61 �.03 �0.69 .49 �.02 .31 .00 �0.08 .94 Subjective social status .22 .14 .08 1.51 .13 �.66 .17 �.19 �3.91 .00�� �.06 .09 �.03 �0.65 .51 Power over Women .13 .12 .07 1.06 .29 �.34 .14 �.14 �2.45 .02� �.02 .07 �.02 �0.31 .75 Violence �.10 .07 �.08 �1.32 .19 .06 .09 .04 0.74 .46 .01 .04 .01 0.14 .89 Emotional Control .00 .07 .00 0.04 .97 �.14 .08 �.10 �1.87 .06† �.08 .04 �.12 �2.15 .03�

Winning .08 .07 .07 1.14 .25 .21 .09 .13 2.41 .02� .12 .04 .16 2.69 .01�

Heterosexual Self-presentation .00 .07 .00 0.07 .95 .19 .08 .15 2.45 .02� .05 .04 .09 1.38 .17 Primacy of Work .08 .10 .04 0.78 .44 .14 .12 .06 1.17 .24 .10 .06 .08 1.59 .11 Risk-taking .01 .09 .00 0.07 .94 �.05 .10 �.03 �0.53 .59 .09 .05 .09 1.65 .10 Self-reliance .03 .09 .02 0.36 .72 �.29 .10 �.15 �2.84 .01� �.01 .05 �.02 �0.28 .78 Playboy �.06 .09 �.04 �0.65 .51 �.13 .10 �.07 �1.28 .20 �.02 .05 �.02 �0.30 .76

Adjusted R2 change .02 .09�� .07��

Adjusted R2 full model .02 .16 .08 F for full model 1.61† 6.33�� 3.41��

† p � .10. � p � .05. �� p � .01.

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272 SALGADO, KNOWLTON, AND JOHNSON

ethnicity, sexual orientation, and subjective social status). The study focused on men between the ages of 18 and 25 to understand early patterns that could be addressed and incorporated into health programming and interventions to improve health outcomes later on. Additional research would also benefit from examining the function of masculine norms in a more diverse age range of men because research suggests gender norms may vary throughout development (Twenge, 1997). Levant and Wimer (2014) sug- gested some differences in the prediction of men’s behaviors might be due to sample characteristics across their two studies.

Previous studies on men’s health behavior include additional variables (e.g., multiple measures of masculine norms, longer measures, and perceptions of men’s normative health behaviors) to predict a higher proportion of the variance in men’s engagement in health-risk and protective behaviors. In the current study, the first set of regressions with CMNI-46 total scores accounted for only between 4% and 11% across the HBI-20-total score and the five health-risk and protective factors, which increased to between 7% and 9% when all nine masculine norms were included.

Although the CMNI has been influential at understanding the attitudes and behaviors of men (Parent & Moradi, 2011; Parent & Smiler, 2013), additional research on the psychometrics of the HBI-20 is warranted given low internal consistency estimates for some of the subscales (Levant & Wimer, 2014). Results from the Preventive Self-Care subscale of the HBI-20 should be interpreted cautiously given its low � coefficient (�.70) but were included in the current study, given its purpose was to compare and contrast findings from two previously published articles (Levant & Wimer, 2014; Levant et al., 2011).

Conclusion

Harrison (1978) stated masculinity is dangerous for your health. In support, results from the current study suggest that conformity to masculine norms (CMNI-46) predicted lower engagement in health behaviors. However, more complex representations of the associations between masculinity and health is needed, especially when considering the effects of specific masculine norms compos- ing most multidimensional measures of masculinity. Gough (2013) suggested that masculinity can function to both constrain and facilitate health behaviors among men. In the current study, some masculine norms were found to uniquely predict either health- protective (i.e., Emotional Control, Winning) or risk behaviors (i.e., Playboy, Risk-taking); others (i.e., Power over Women, Self- reliance) might be characterized as particularly detrimental to men’s health and well-being because they predict less engagement in health-protective behaviors and more engagement in health-risk behaviors; and a few (i.e., Primacy of Work, Violence) were not associated with health-protective or risk behaviors in the current study. In their recent study, Gerdes and Levant (2018) urged future researchers to present findings on the predictive nature of specific masculine norms on men’s health behaviors in general and health- risk and protective behaviors in particular. The current study offers one example of how future researchers might approach to under- standing these associations and clarifying specific norms associ- ated with masculinity that might be detrimental or beneficial to men’s health and well-being.

Implications

The current study suggests health-related interventions with boys and men that focus on men’s emotional expressiveness, winning at all costs, or being one’s best could be important topics for inclusion. For example, tapping into masculine norms associ- ated with winning and success might encourage men to engage in the Proper Use of Health Care Resources as a way to succeed in being healthy. However, the findings also suggest interventions and programs for boys and men need to address what Brooks and Silverstein (1995) called the “darker side of masculinity,” namely, heterosexist and sexist attitudes associated with masculinity, so health and well-being are not predicated on the marginalization and domination of other men and women.

Leone, Rovito, Mullin, Mohammed, and Lee (2017) suggest men’s prevention, promotion, and intervention programs may ben- efit from gender-specific programming informed by masculine norms. Within this context, some health-enhancing masculine norms may act as a core programmatic feature (e.g., Winning) while other commonly endorsed norms associated with lower engagement in health behaviors are reframed (e.g., Self-reliance), and norms associated with harmful attitudes towards others are addressed (e.g., Playboy, Violence). At the same time, researchers are pointing to the need for more understanding on how to recruit men into participating in health-related interventions (Farrimond, 2012; Houle et al., 2017; Mansfield et al., 2003), capture those features most relevant to men (Calasanti, Pietilä, Ojala, & King, 2013; Neukrug, Britton, & Crews, 2013; Parent & Bradstreet, 2017; Robertson & Baker, 2017), and how to best respond to barriers men report having (Boman & Walker, 2010; Mahalik et al., 2007). In summary, health care providers and clinicians would benefit from accounting for aspects of masculinity when develop- ing prevention and intervention efforts targeting boys and men.

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Received November 1, 2017 Revision received February 8, 2019

Accepted February 26, 2019 �

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275MASCULINITY, NORMS, AND HEALTH BEHAVIORS