An evidence-based socioecological framework to understand men’s use of anabolic androgenic steroids and inform interventions in this area

TLDR: In this article, a socio-ecological framework is presented based upon the international literature examining men's use of anabolic androgenic steroids (AAS), which is the result of the interaction of a range of factors at the individual, social network, institutional, community and societal levels.

Abstract: Research into men’s use of anabolic androgenic steroids (AAS) over the past three decades has identified many factors that contribute to decision making in this area However there are limited theoretical frameworks to synthesize this research and guide practice, such as interventions to prevent use or reduce health risks To address this gap a socioecological framework is presented based upon the international literature examining AAS use Socioecological models recognize that individuals and behaviors exist within complex physical and social systems and are useful tools for guiding interventions to ensure consideration is given to multiple influential factors This framework proposes that use of AAS is the result of the interaction of a range of factors at the individual, social network, institutional, community and societal levels that are likely to change over time and with experience Viewed through this framework it becomes clear that AAS use can be a complex behavior with many influential environments and relationships impacting on a diverse population in different ways and at different times The implications of findings for engaging with people who use AAS and delivering interventions are discussed, such as the identification of important transition times and influencing norms within social groups and communities

Full text

Bates, G, Tod, D, Leavey, C and McVeigh, J ORCID logoORCID:
https://orcid.org/0000-0001-5319-6885 (2018) An evidence-based socioeco-
logical framework to understand men’s use of anabolic androgenic steroids
and inform interventions in this area. Drugs: Education, Prevention, and
Policy, 29 (6). ISSN 0968-7637
Downloaded from:
https://e-space.mmu.ac.uk/624828/
Version: Accepted Version
Publisher: Taylor & Francis
DOI: https://doi.org/10.1080/09687637.2018.1488947
Please cite the published version
https://e-space.mmu.ac.uk

1
Title: An evidence-based socioecological framework to understand men’s use of anabolic
androgenic steroids and inform interventions in this area.
Geoff Bates
a*
, David Tod
b
, Conan Leavey
a
, Jim McVeigh
a
a
Public Health Institute, Liverpool John Moores University, Liverpool, UK
b
School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
*Corresponding author: Geoff Bates. Address: Public Health Institute, Faculty of Education,
Health and Community, Liverpool John Moores University, Henry Cotton Campus, 15-21
Webster Street, Liverpool L3 2ET, UK; email: g.bates@ljmu.ac.uk; tel: 44(0)151 231 4416.
Orcid ID https://orcid.org/0000-0001-6932-2372
Abbreviated title: A sociological framework to understand men's use of anabolic steroids

2
An evidence-based socioecological framework to understand men’s use of anabolic androgenic
steroids and inform interventions in this area.
Abstract
Research into men’s use of anabolic androgenic steroids (AAS) over the past three decades has
identified many factors that contribute to decision making in this area. However there are
limited theoretical frameworks to synthesize this research and guide practice, such as
interventions to prevent use or reduce health risks. To address this gap a socioecological
framework is presented based upon the international literature examining AAS use.
Socioecological models recognize that individuals and behaviors exist within complex physical
and social systems and are useful tools for guiding interventions to ensure consideration is
given to multiple influential factors. This framework proposes that use of AAS is the result of
the interaction of a range of factors at the individual, social network, institutional, community
and societal levels that are likely to change over time and with experience. Viewed through
this framework it becomes clear that AAS use can be a complex behavior with many influential
environments and relationships impacting on a diverse population in different ways and at
different times. The implications of findings for engaging with people who use AAS and
delivering interventions are discussed, such as the identification of important transition times
and influencing norms within social groups and communities.
Keywords: anabolic androgenic steroids; performing enhancing drugs; socioecological
framework; drug education and prevention; decision making
Word count: 4,691

3
An evidence-based socioecological framework to understand men’s use of anabolic androgenic
steroids and inform interventions in this area.
Introduction
Anabolic androgenic steroids
Anabolic androgenic steroids (AAS) are the most prominent of a range of substances used to
modify appearance and performance. Global prevalence has been estimated at 6.4% amongst
males (Sagoe, Molde, Andreassen, Torsheim, & Pallesen, 2014) with use increasingly common
outside of sporting environments (McVeigh & Begley, 2016; Pope, Kanayama, et al., 2014;
Sagoe, Molde, et al., 2014). Although AAS can be used without harmful consequences in
clinical settings, far greater doses are observed outside these environments (Pope, Kanayama,
et al., 2014) where the quality of substances purchased cannot be controlled. Evidence
increasingly suggests that this use is associated with a wide range of acute and chronic adverse
health consequences (Pope, Wood, et al., 2014) and consequently interventions are required to
reduce harmful use of AAS and improve health outcomes for those using them.
The socioecological model
In order to understand a behavior it is important to recognise that it does not exist in isolation,
but is part of a wider system of intra- and inter-personal beliefs, behaviors, contexts and
cultures (Michie, Atkins, & West, 2014). Like many other theories of behavior the
socioecological model recognizes the influence of personal characteristics and immediate
social influences, but also emphasizes the role of wider physical, social and cultural factors.
The socioecological model places individuals within complex physical and social systems and
suggests that health and behavior are a consequence of interactions between these individuals
and their immediate and distal environments and experiences (Bronfenbrenner, 1986; Stokols,

4
1992). This is important because to develop effective interventions researchers should consider
both individuals and the complex systems and environments in which they operate, and the
interactions that occur between them (Sniehotta et al., 2017). The socioecological framework
suggests interventions need to address multiple levels in order to achieve sustained behavior
change (Sallis & Owen, 2015). However, it appears that behavioral interventions have tended
to focus solely on individual and intrapersonal factors and rarely sought to influence
community, institutional and societal level factors (Golden & Earp, 2012) which has also been
identified with AAS interventions (Bates et al., 2017).
Aim and purpose
A body of evidence has been developed over the past three decades pointing towards a variety
of factors that influence choices relating to AAS use amongst different groups and in different
environments. Together these studies have highlighted the variability amongst people who use
AAS, but there are a lack of frameworks bringing this evidence together to stimulate and guide
interventions. This work attempts to address this by bringing together quantitative and
qualitative research examining experiences and beliefs about AAS to present AAS use through
a socioecological framework. Frameworks of this nature have been successfully applied to
understand and guide policy relating to a variety of behaviors such as violence (Smith Slep,
Foran, & Heyman, 2014), physical activity (Elder et al., 2007) and smoking (Corbett, 2001)
where, as with AAS, decisions may be effected by factors at different levels. Discussing the
different influences on AAS use and how these influences interact to effect decision making in
one framework will support the development and implementation of interventions, such as
those that aim to prevent or reduce use of AAS or to improve health outcomes and healthy
behaviors amongst users.

Frequently asked questions

Q1. What are the contributions in this paper?

However there are limited theoretical frameworks to synthesize this research and guide practice, such as interventions to prevent use or reduce health risks. To address this gap a socioecological framework is presented based upon the international literature examining AAS use. This framework proposes that use of AAS is the result of the interaction of a range of factors at the individual, social network, institutional, community and societal levels that are likely to change over time and with experience. Viewed through this framework it becomes clear that AAS use can be a complex behavior with many influential environments and relationships impacting on a diverse population in different ways and at different times. The implications of findings for engaging with people who use AAS and delivering interventions are discussed, such as the identification of important transition times and influencing norms within social groups and communities. 

Q2. What is the role of the community in influencing health behaviors?

The availability of appropriate healthcare services and the level of engagement between health professionals and the local population of AAS users will influence health seeking behaviors, information provision and treatment opportunities. 

Q3. What are examples of public policies that may influence AAS use and related behavior?

The commissioning and funding of services or materials designed to educate or to reduce harmassociated with AAS, such as clinics, needle and syringe programmes, or information websitesand hotlines are examples of public policies that may influence AAS use and related behavior. 

Q4. What is the importance of timing for interventions?

The timing forinterventions will be important and approaches delivered at important transition times, such as upon entering environments where AAS are normalized or following injury or an adverse health outcome associated with AAS use, may be more likely to have a preventative or habitbreaking impact. 

Q5. What is the common ban on AAS?

Most sporting organisations ban AAS alongside other performance enhancing drugs (PEDs) (WADA, 2017),with drug testing policies commonly implemented for elite sportspeople as part of efforts to reduce PED use. 

Q6. What are the main factors that have been associated with increased likelihood of AAS use?

Factors such as high drive for muscularity or muscle dysmorphia (Jampel, Murray, Griffiths, & Blashill, 2016; Zelli, Lucidi, & Mallia, 2010), holding masculine values (Keane, 2005),valuing traditional male roles (Kanayama, Barry, Hudson, & Pope, 2006) and low levels of self-esteem (Blank, Schobersberger, Leichtfried, & Duschek, 2016; Nicholls et al., 2014) have been associated with increased likelihood of AAS use. 

Q7. What are the implications of findings for engaging with people who use AAS?

The implications of findings for engaging with people who use AAS and delivering interventions are discussed, such as the identification of important transition timesand influencing norms within social groups and communities. 

Q8. What are examples of what types of environments that affect the prevalence of AAS?

Examples may include the increased prevalence of hard-corebodybuilding gyms or manual occupations in more deprived or working class areas. 

Q9. What role does the role of significant others play in promoting AAS?

Related to this, the role of significant others (for example peers, competitors or colleagues) asinformation providers, motivators and in reinforcing behavior and the desire to achieve recognition and social capital appears influential in a range of environments. 

Q10. What is the common age for initiation of AAS?

Use is more prominent amongst males, and while initiation occurs within a wide age range it is most likely before age30 (Sagoe, Andreassen, et al., 2014). 

Q11. Where use is common, what is the role of the environment in facilitating the use of A?

Where use is common, the acceptability (Boardley & Grix, 2014; Dennington et al., 2008) and normalization (Boardley & Grix, 2014; Dennington et al., 2008; Grogan et al., 2006; Hanley Santos &Coomber, 2017) of AAS in that environment appears to facilitate use in others and provides access to suppliers and information providers. 

Q12. What are the main factors that influence AAS decision making?

Frameworks of this nature have been successfully applied to understand and guide policy relating to a variety of behaviors such as violence (Smith Slep,Foran, & Heyman, 2014), physical activity (Elder et al., 2007) and smoking (Corbett, 2001) where, as with AAS, decisions may be effected by factors at different levels.