The Pre-Exposure Prophylaxis (PrEP) Personal Obstacle Scale (PPOS): measurement Properties in English, German, and French

1 © The Author(s) 2025. Published by Oxford University Press on behalf of Faculty of Public Health. This is an Open Access article distributed under the terms of the Creative Commons Attribution NonCommercial-NoDerivs licence (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact [email protected] Alexander Ort, Senior Lecturer and Researcher Tess L. C. Bardy, Health Economist & Project Leader Journal of Public Health | pp. 1–11 | https://doi.org/10.1093/pubmed/fdaf013 The pre-exposure prophylaxis personal obstacle scale: measurement properties in English, German, and French Alexander Ort1,* and Tess L. C. Bardy2 1Faculty of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, CH-6002 Lucerne, Switzerland 2Groupe Mutuel Insurance, Rue des Cèdres 5, CH-1920, Martigny, Switzerland *Corresponding author. Faculty of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, CH-6002 Lucerne, Switzerland. E-mail: [email protected] ABSTRACT Background: This study aimed to validate the Pre-Exposure Prophylaxis Personal Obstacle Scale (PPOS) across English, German, and French (PPOS-EN/DE/FR) for men who have sex with men (MSM). The PPOS measures perceived barriers related to knowledge and uncertainty surrounding PrEP use, which are particularly important factors in the early stages of the PrEP Care Continuum (PCC). Methods: The original PPOS was adapted and translated into German and French. Data were collected through an online survey in four European countries (N = 1124). Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) assessed the factor structure, while multigroup CFA (MGCFA) tested measurement invariance across language groups and adoption statuses. Results: EFA revealed a two-factor structure: (i) “Impact of PrEP on personal health” and (ii) “Knowledge about PrEP.” CFA confirmed this structure, and measurement invariance was established across languages and adoption statuses with high reliability (α = 0·82, ω = 0·82). Conclusions: The PPOS-EN/DE/FR is a valid and reliable tool for assessing personal obstacles to PrEP uptake among MSM across different languages. It supports public health efforts by identifying specific challenges to PrEP adoption, facilitating culturally sensitive interventionsto improve uptake and reduce HIV transmission. Keywords :cross-cultural measurement; HIV prevention; men who have sex with men; personal barriers; pre-exposure prophylaxis; scale validation Introduction The global HIV pandemic continues to pose a significant public health challenge, with millions of new cases reported each year.1,2 Despite the availability of evidence-based HIV prevention strategies, the rate of new infections remains concerningly high, especially among men who have sex with men (MSM), who often face significant social and structural obstacles to accessing prevention measures.3–5 Among the recent biomedical advancements, pre-exposure prophylaxis (PrEP) has shown immense potential in combating HIV. PrEP, an oral antiretroviral medication taken according to a prescribed regimen, can reduce the risk of HIV infection by up to 92% when adhered to consistently, making it one of the most effective tools in HIV prevention.6 However, despite its efficacy, adoption rates for PrEP remain comparatively low, especially considering the number of individuals who could benefit from it. Studies investigating PrEP access, adoption and (dis)continuation conclude, that PrEP delivery is a complex process that depends on the successful interaction between multiple stakeholders and the interplay of various delivery factors.7 The PrEP Care Continuum (PCC) has been proven suitable to systematize and investigate these factors by outlining five steps, from individuals not considering themselves at risk to achieving effective PrEP adherence. The PCC also recognizes that individuals may experience multiple risk episodes, where discontinuation may lead them to start the process again.8,9 Within and beyond this framework, a range of structural, social, and personal barriers have already been identified and studied in relation to PrEP uptake, adherence, and (dis)continuation. Structural barriers that (depending on the regional or country-context) continue to hinder widespread use include inadequate PrEP eligibility guidelines, lack of access to PrEP provider/programs, medication shortages, and costs associated with the drug and required quarterly testing. Furthermore, affordability issues are exacerbated Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdaf013/8006050 by guest on 10 February 2025 2Ort and Bardy by varied health insurance coverage, making the medication less accessible to many.8,10–12 From a social perspective, previous research has also explored ingroup stigmatization, societal stigma, and perceived racism as a barrier to PrEP uptake;13–17. Lastly, given that PrEP requires individuals to make an informed and deliberate decision, i.e., the cost-risk calculus to adopt, adhere, or dis(continue) PrEP use, plays a crucial role, too. While structural and social factors mainly impact this calculus at later stages in the PCC, the personal recognition of being at risk and the willingness to use PrEP are at the very beginning of this process and, thus, can be seen as the gatekeepers or foundation for the PrEP appropriation process. In this “PrEP contemplation” step, lack of awareness, knowledge, willingness, and self-perception have been identified as crucial barriers.8 Given their central role in early stages of the PCC, they may significantly limit the uptake, impact use, and explain discontinuation, consequently contributing to controlling HIV infection rates. Understanding these personal barriers is essential for early intervention, as they are often the first hurdles in the decision-making process. Addressing these factors early on can significantly improve the chances of PrEP adoption and adherence, ultimately aiding in reducing HIV transmission rates. Given the pivotal role that personal factors (i.e. knowledge, awareness, and willingness) play in early stages of the PCC, systematically assessing them is crucial. To empower researchers and practitioners in public health to better understand these factors, this study aims to validate the Pre-Exposure Prophylaxis Personal Obstacle Scale (PPOS), originally proposed by Washington and Klein13, in English, German, and French. The instrument specifically measures MSM’s perceived lack of knowledge about and uncertainty surrounding PrEP use. By providing a validated, crosscultural tool to assess these obstacles, this research seeks to offer public health professionals a more nuanced understanding of the challenges hindering PrEP uptake in early stages of the PCC. The insights gained can ultimately inform the development of tailored interventions to enhance PrEP adoption and adherence. Methods Development of the PrEP personal obstacle scale in English, German, and French (PPOS-EN/DE/FR) The PrEP Personal Obstacle Scale (PPOS) was originally introduced by Washington and Klein.13 The scale was introduced with both a 20-item version and a shortened 8-item version. The scale was developed for and tested with a MSM sample of prospective PrEP users. Each item evaluates anticipated obstacles towards PrEP adoption and use. Each item can be answered on a five-point Likert scale, 1 being “Totally disagree” and 5 “Totally agree.” A total score can be derived as the average score of all answers to the scale. A higher score indicates greater anticipated or experienced obstacles, and therefore, greater barriers to taking PrEP. As this study aims to broaden the utility and scope of use of the 8-item version of the scale to suit various target groups beyond prospective PrEP users, each item of the survey instrument was adapted to enable the evaluation of self-reported anticipated (PrEP non-adopters) or experienced (previous or current PrEP users) obstacles among MSM, reflecting MSMs’ barriers to PrEP adoptions. This necessitated minor adaptations to fit the wording of the scale for these populations. To extend its applicability beyond Englishspeaking contexts, the modified items were then translated from English (US/GB) to French (FR) and German (DE) following the guidelines from Epstein and colleagues14 to create the PPOS-EN/FR/DE. Translations were carried out for each language by native speakers, compared, and refined to create the final version of the instrument in each of the two additional languages. For an overview, see Table A1. Data collection and participants Following the adaptation and translation, the PPOS-EN/DE/ FR was integrated into an online survey conducted in four European countries: the United Kingdom, France, Switzerland, and Germany, between December 2020 and April 2021. The survey was available in English, German, and French. Participation was voluntary, and individuals had to give explicit, informed consent before joining. The survey covered a range of demographic factors and assessed participants’ knowledge, experience, and (previous) use of PrEP. The final dataset included 1124 responses, which were used for analysis. The study complied with ethical standards for research involving human subjects, with ethical waiver granted by the institutional review board. Participants, specifically MSM, were recruited through multiple channels. The primary method was snowball sampling, utilizing mailing lists from AIDS and MSM-focused organizations. Counseling and testing centers across the four countries also supported recruitment by distributing posters and flyers. Additionally, the study was promoted on social media platforms, such as Facebook and Instagram, through LGBTIAQ+ and HIV/AIDS advocates. A key distinction within the selected MSM sample is their PrEP adoption status, which was considered crucial in shaping their perceptions of barriers to PrEP access and use. Specifically, the sample differentiates between PrEP adopters and nonadopters. This distinction is vital, as PrEP adopters encounter “experienced” obstacles, while nonadopters face “anticipated” obstacles. Consequently, barriers to PrEP adoption may vary across these groups. The sample can Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdaf013/8006050 by guest on 10 February 2025 The PrEP personal obstacle scale (PPOS) 3 be further divided: among the PrEP adopters are (1) MSM currently taking PrEP and (2) former PrEP users, while among the nonadopters are those who (3) intend to take PrEP, (4) are undecided, or (5) do not intend to take it. Statistical procedure To assess the overall validity and reliability of the PPOSEN/DE/FR, an Exploratory Factor Analysis (EFA) with promax rotation was conducted on a randomly selected half of the sample, balanced by language group (n = 563). The number of factors was determined through scree plot analysis (see Fig. A1), parallel analysis, and the conceptual clarity of the rotated factors. Factor loadings of .3 or higher were considered strong associations.15 A confirmatory factor analysis (CFA) was then performed on the other half (n = 561) to confirm the factor structure. Model adequacy was assessed using several fit indices, including the Root Mean Squared Error of Approximation (RMSEA), Tucker-Lewis Index (TLI), Comparative Fit Index (CFI), and Standardized Root Mean Squared Residual (SRMR), with good fit indicated by thresholds of RMSEA ≤0·05, CFI > 0·9, TLI > 0·9, and SRMR ≤0·05.18,19 Given the nested structure of the data (language groups and MSM groups), we analyzed the validity and reliability of the PPOS-EN/DE/FR separately for adopters and nonadopters. Since the factor structure was the same for both groups, we chose to conduct the EFA and CFA by language group. Next, a multigroup CFA (MGCFA) on the full sample (N = 1124) was used to test whether the instrument measured the same construct across different languages and PrEP adoption statuses, focusing on configural (model 1), metric (model 2), and scalar invariance (model 3). Model 1 assessed the stability of the factor structure across groups, model 2 tested for equal factor loadings, and model 3 added constraints on item intercepts. Due to smaller sample sizes in the English, German, and French groups, the thresholds for RMSEA and SRMR were relaxed to RMSEA ≤ 0·08 and SRMR ≤ 0·08.20 Invariance was judged based on changes in fit indices, with CFI ≥ −0·005, RMSEA ≤ 0·010, or SRMR ≤0·025 indicating invariance.21 The reliability of the validated structure across all languages was evaluated using standardized Cronbach’s alpha and McDonald’s omega, with α and ω > 0·70 considered acceptable.22 Results Sample description and PPOS-EN/DE/FR scale Table 1 presents the sample characteristics. The final sample includes 1124 MSM, aged 18 to 70 (M =38·79, SD =1·68). More than half of the participants are currently taking PrEP, and the majority have a high level of education. Most MSM reported either being in an open relationship (38%) or sexually active (40%). These patterns are consistent across countries. The average PPOS score across the sample is 2·07 (SD =0·83), reflecting a moderate level of perceived PrEP obstacles. The French-speaking sample reports the lowest average score of 2·00 (SD =0·87), while the Germanspeaking sample has the highest, though still moderate, score of 2·12 (SD =0·81). Additional details regarding the scale and item distributions, such as skewness, kurtosis, floor, and ceiling effects, can be found in Table A2. Validity KMO and Bartlett’s tests for sphericity measures indicate that the data are suitable for factor analysis (KMO = 0·875, χ2 = 2349·822, df = 28, p < 0·001).23 The Scree plot of eigenvalues suggests a two-factor solution (see Fig. A1). Table 2 presents the results from the EFA. After oblique rotation, all items loaded onto a two-factor solution, labeled: (i) “Impact of PrEP on personal health” and (ii) “Knowledge about PrEP.” All items showed factor loadings above 0·3, except for item 6, which was dropped after the EFA. The factor structure was further confirmed through CFA, with fit indices of CFI = 0·986, TLI = 0·978, RMSEA = 0·067, and SRMR = 0·030. These results indicate that the PPOSEN/DE/FR scale is a reliable tool for assessing obstacles to PrEP use within the MSM population. Measurement invariance Table 3 presents the outcomes of the MGCFA analysis (N = 1124). First, three independent baseline models were computed in English, German, and French. Subsequently, to investigate invariance across language groups, a sequence of three nested models was conducted: the configural invariance model (model 1), the metric invariance model (model 2), and the scalar invariance model (model 3). Model 1 shows a reasonable fit, confirming configural invariance (CFI = 0·95, RMSEA = 0·09, SRMR = 0·06). When constraining factor loadings to be equal across groups in Model 2, the fit remains reasonable (CFI = 0·96, RMSEA = 0·08, SRMR = 0·07) and changes in fit indices indicate metric invariance (CFI = 0·006, RMSEA =−0·027, SRMR = 0·012). When restricting intercepts to be equal in Model 3, the fit remained reasonable (CFI = 0·84, RSMEA = 0·075, SRMR = 0·079), and changes in model fit indicated scalar invariance (CFI =−0·118, RMSEA = Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdaf013/8006050 by guest on 10 February 2025 4Ort and Bardy Table 1 Sample characteristics overall and per language group. Total English German French Group sizes 1124 235 (20.9%) 657 (58.5%) 232 (20.6%) Variables p Agea38.50 (1.52) 38.37 (1.93) 37.95 (1.17) 4.22 (1.93) .016 Formal level of education Low 103 (9.2%) 5 (2.1%) 84 (12.8%) 14 (6.0%) <.001 Mid 282 (25.1%) 57 (24.3%) 182 (27.7%) 43 (18.5%) High 739 (65.7%) 173 (73.6%) 391 (59.5%) 175 (75.4%) Residential area .066 Countryside 177 (15.7%) 26 (11.1%) 109 (16.6%) 42 (18.1%) Urban area 947 (84.3%) 209 (88.9%) 548 (83.4%) 190 (81.9%) Relationship status .445 Single, no sexual contact 115 (1.2%) 26 (11.1%) 68 (1.4%) 21 (9.1%) Single, sexually active 439 (39.1%) 85 (36.2%) 258 (39.3%) 96 (41.4%) Exclusive relationship 138 (12.3%) 35 (14.9%) 83 (12.6%) 20 (8.6%) Open relationship 432 (38.4%) 89 (37.9%) 248 (37.7%) 95 (4.9%) Sexual orientation .480 Homosexual 1074 (95.6%) 222 (94.5%) 631 (96.0%) 221 (95.3%) Bisexual 39 (3.5%) 10 (4.3%) 22 (3.3%) 7 (3.0%) Pansexual 11 (1.0%) 3 (1.3%) 4 (0.6%) 4 (1.7%) MSM group .038 Yes, I take PrEP 667 (59.3%) 149 (63.4%) 357 (54.3%) 161 (69.4%) No, but I took it before 87 (7.7%) 20 (8.5%) 57 (8.7%) 10 (4.3%) No, but I intend to 96 (8.5%) 30 (12.8%) 53 (8.1%) 13 (5.6%) No, and I do not intend to 161 (14.3%) 21 (8.9%) 111 (16.9%) 29 (12.5%) No, but I am undecided 113 (1.1%) 15 (6.4%) 79 (12.0%) 19 (8.2%) Country of residence <.001 Switzerland 267 (23.8%) 20 (8.3%) 200 (28.2%) 70 (28.8%) Germany 456 (4.6%) 8 (3.3%) 480 (67.7%) 3 (1.2%) France 150 (13.4%) 2 (0.8%) 0 (0.0%) 151 (62.1%) PPOS-EN/DE/FR scorea2·07 (0.83) 2·02 (0.86) 2·12 (0.81) 2·00 (0.87) 0·02 High education includes short-cycle tertiary education (e.g. HNC/HND in the UK), bachelor’s or equivalent level, master’s or equivalent level, and doctoral degree or equivalent level. p-column: Tests for significant differences between countries using Fishers’ exact test for categorical variables and Kruskal– Wallis test for continuous variables. aContinuous variable, mean and standard deviation (in parentheses) are reported. −0·050, SRMR = 0·007). Therefore, the PPOS-EN/DE/ FR Scale is a suitable tool to measure experienced stigma across the three languages. Reliability Standardized Cronbach’s alpha and McDonald’s omega were calculated for the overall scale and the two subscales. Regarding the Cronbach’s alpha values, the overall reliability is α =0·82. For the subscale, Factor 1’s reliability is α =0·69 and Factor 2’s reliability equals α =0·74. For McDonald’s omega, the overall reliability is ω=0·82. The detailed reliability results for each subsample are available in Table A3. Discussion Main finding of this study This study successfully validated the PPOS in English, German, and French (PPOS-EN/DE/FR) among MSM, establishing it as a reliable tool for assessing perceived barriers to PrEP use across different linguistic and cultural contexts. The scale’s two-factor structure, consisting of “Impact of PrEP on personal health” and “Knowledge about PrEP,” was supported by both EFA and confirmatory factor analysis (CFA). Furthermore, measurement invariance was confirmed across language groups and PrEP adoption statuses, demonstrating the robustness of the instrument in capturing Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdaf013/8006050 by guest on 10 February 2025 The PrEP personal obstacle scale (PPOS) 5 Table 2 Retained factor structure of the PPOS-EN/DE/FR scale after EFA and correlation matrix among the retained factors. Factors Item MSD 1 2 Uniqueness Factor 1: Impact of PrEP on personal health 2. Uncertainty about long-term consequences of PrEP 2.46 1.24 0.488 0.587 3. Incompatibility of PrEP with other medication(s) 1.91 1.26 0.614 0.605 4. Uncertainty about consequences of discontinuing PrEP 2.17 1.30 0.388 0.556 5. Disliking of taking a drug despite being healthy 2.23 1.36 0.568 0.544 Factor 2: Knowledge about PrEP and access 1. Not feeling sufficiently informed about PrEP 1.91 1.23 0.484 0.639 7. Too little is known about PrEP 1.96 1.17 0.614 0.422 8. Not knowing how to get PrEP 2.07 1.31 0.558 0.707 M = mean, SD = standard deviation. For the analysis, the sample was randomly split into two groups, balanced by language group. Sample 1 (n = 563) was used for the EFA, while sample 2 (n = 561) was used to test the two-factor solutions in the CFA. Spearman rho correlation between factors: 0·93, p < .001 Table 3 Measurement invariance of the PPOS-EN/DE/FR scale across the three languages. Fit indices χ2df pCFI RMSEA SRMR Baseline 4686.00 21 <.001 0.986 0.067 0.030 English 1512.25 21 <.001 0.979 0.101 0.044 German 1336.10 21 <.001 0.986 0.078 0.039 French 2312.24 21 <.001 0.984 0.067 0.035 Model comparisons Model 1202.03 78 <.001 0.950 0.093 0.060 CFI RMSEA SRMR Model 2211.38 103 <.001 0.957 0.075 0.071 1vs2 0.006 0.027 0.012 Model 3601.38 198 <.001 0.838 0.105 0.079 2vs3 −0.118 −0.050 0.007 N = 1194. Scaled coefficients reported. χ2 = chi-squared; df = degrees of freedom, p = p-value; CFI = comparative fixed index; RMSEA = root mean square error of approximation; SRMR = standardized root mean square residuals. represents the change in fit indices. Model details: model 1 = configural invariance, model 2 = metric invariance, model 3 = scalar invariance. obstacles related to both knowledge and uncertainty regarding PrEP. What is already known on this topic Existing research has consistently identified numerous barriers to PrEP uptake, particularly within MSM populations, where HIV risk remains disproportionately high despite the availability of effective biomedical prevention strategies. These barriers can be categorized into structural, social, and personal factors. Structural barriers include limited access to PrEP-related healthcare services, costs of the medication and associated testing, and varying healthcare coverage, all of which contribute to uneven PrEP adoption across regions and countries.10–12 Social barriers, such as stigma, discrimination, and mistrust in the healthcare system, further complicate PrEP uptake, particularly for MSM who may already face intersectional forms of marginalization.24–26 Personal barriers, however, are particularly relevant in the early stages of the PCC, where individuals assess their own risk and make initial decisions about whether to adopt PrEP. Previous studies have highlighted key personal obstacles to PrEP initiation, such as lack of knowledge about PrEP’s efficacy, uncertainty regarding its long-term effects, and concerns about taking medication when otherwise healthy.5,8 Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdaf013/8006050 by guest on 10 February 2025 6Ort and Bardy These personal barriers are crucial because they influence the individual’s willingness to consider PrEP as a viable prevention method. For example, the perceived difficulty in obtaining reliable information and uncertainty about PrEP’s longterm health impacts have been shown to delay or prevent individuals from starting PrEP.6 Although many studies have examined these personal barriers, most of the existing research has been context-specific, focusing either on a single population or a single language, without providing a validated tool for systematically assessing these obstacles across different cultures and languages. Therefore, the added value of this study lies in its development and cross-cultural validation of a standardized instrument (PPOSEN/DE/FR) to capture these personal obstacles comprehensively. What this study adds This study introduces the first cross-culturally validated instrument—the PPOS-EN/DE/FR—aimed at systematically assessing personal obstacles to PrEP uptake among MSM. While previous research has often centered on structural and social determinants of PrEP adoption, the present findings underscore the importance of personal, perception-based factors in the early phases of the PrEP Care Continuum (PCC). By elucidating a two-factor structure— encompassing health-related concerns (e.g. uncertainty about long-term effects or compatibility with other medications) and knowledge-based barriers (e.g. perceived difficulty accessing reliable information)—this study provides a more nuanced understanding of the personal challenges that influence MSM’s initial considerations regarding PrEP initiation, ongoing use, and potential re-engagement after discontinuation. A key contribution of this work lies in the cross-cultural validation of the PPOS across English, German, and French. This linguistic and cultural adaptability enables researchers and practitioners to capture the heterogeneity of personal obstacles experienced by MSM in diverse European settings. As a result, the instrument can be reliably employed in multicultural contexts to gauge the prominence and nature of these barriers, regardless of a given population’s language background or stage in the PCC. This versatility is of particular relevance to regions where MSM populations vary widely in terms of healthcare access, sociocultural attitudes, and historical uptake of HIV prevention measures.7 Beyond its theoretical value, the PPOS holds considerable potential for practical application. In public health programs, the scale may be integrated into baseline community assessments or periodic monitoring activities. Such integration would allow public health professionals to identify the most salient obstacles—be they concerns about longterm health implications of PrEP or difficulties in navigating the healthcare system to obtain it—and subsequently tailor interventions that directly address these issues. For instance, if a population frequently endorses knowledge-related barriers, focused educational campaigns, culturally sensitive online decision aids, and provider-led informational sessions could be implemented to demystify how PrEP works, how to access it, and what to expect regarding safety and efficacy. Similarly, suppose fear of long-term consequences emerges as a prevalent concern. In that case, targeted messaging can emphasize current scientific evidence on the safety profiles of PrEP medications, engage trusted healthcare providers in community outreach, and make side-effect management strategies more transparent. In clinical settings, the PPOS can be used as a proactive, patient-centered tool. By incorporating it into routine intake procedures or annual screenings, clinicians and other healthcare providers can identify individual-level barriers early in the patient journey. For example, a patient scoring high on the “Impact of PrEP on personal health” dimension might benefit from a more in-depth consultation addressing questions about long-term safety data or drug–drug interactions, while another patient indicating lower levels of knowledge about PrEP might receive straightforward, step-by-step guidance on how to access prescriptions or confirm eligibility. Such targeted counseling can support a more personalized approach to risk communication and decision-making, potentially improving adherence, retention, and satisfaction with prevention services. Moreover, because the PPOS is applicable to a range of PrEP statuses—including current users, former users, and those who have never initiated PrEP—its utility extends throughout the PCC. This comprehensive reach allows healthcare providers and policymakers to monitor evolving barriers as individuals progress through different stages of PrEP engagement.8 In turn, policy measures, insurance guidelines, and healthcare provider trainings can be informed by the evolving patterns of these personal obstacles, enabling adaptation of services over time. In summary, the PPOS-EN/DE/FR offers a validated, reliable, and context-sensitive tool for identifying and understanding the personal barriers that shape early and ongoing decisions regarding PrEP use. By linking these insights to practical applications—ranging from targeted educational campaigns and patient-tailored clinical counseling to broader policy and training interventions—this research provides a foundation for more responsive, effective, and Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdaf013/8006050 by guest on 10 February 2025 The PrEP personal obstacle scale (PPOS) 7 culturally attuned HIV prevention strategies. As such, the PPOS-EN/DE/FR stands to play a meaningful role in informing efforts to enhance PrEP uptake, adherence, and impact among MSM across diverse linguistic, cultural, and healthcare landscapes.27,28 Limitations of this study While this study provides valuable insights, there are some limitations to consider. First, the sample was recruited primarily through snowball sampling and leaned toward MSM who are already familiar with or currently using PrEP. This could limit the generalizability of the findings to MSM who are less engaged with healthcare systems or unaware of PrEP. Additionally, the sample was drawn mainly from high-income European countries, which may not reflect the experiences of MSM in lowand middle-income countries with different healthcare infrastructures and access issues. Future research should explore the applicability of the PPOS in more diverse geographic and economic contexts. Another limitation is the timing of data collection, which occurred during the COVID-19 pandemic. The pandemic’s impact on healthcare access and sexual behavior may have influenced participants’ perceptions of PrEP, especially since many MSM reduced sexual activity during this period.28 Although theprimary aimof thisstudywastovalidatea tool for assessing personal obstacles, the pandemic context might have introduced additional variables affecting PrEP perceptions and behavior that were not fully accounted for. Finally, while the PPOS demonstrated strong reliability and validity, further work is needed to investigate whether anticipated obstacles (reported by nonusers) are fully comparable to the experienced obstacles of current and former PrEP users. Similar challenges have been noted in other areas of research, such as studies on stigma in problematic gambling, where anticipated and experienced obstacles differ substantially.29 Supplementary data Supplementary data areavailableatthe Journal of Public Health online. Conflict of interest The authors declare that there is no conflict of interest. Funding The authors declare that no financial support was received for the research, authorship, and publication of this article. This research did not receive any funding. Data availability All data underlying the analysis is available upon reasonable request after sending an email to the corresponding author. Appendix Figure A1 Screeplot and parallel analysis. Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdaf013/8006050 by guest on 10 February 2025 8Ort and Bardy Table A1 PPOS-EN/DE/FR instrument. Item Group Question 1 1 EN: It is difficult to get enough reliable information to help me make a decision for or against PrEP. DE: Es ist schwierig ausreichend verlässliche Informationen zu bekommen, die mir bei meiner Entscheidung für oder gegen PrEP behilflich sind. FR: Il est difficile d’obtenir suffisamment d’informations fiables pour m’aider à prendre une décision pour ou contre la PrEP. 2EN: It is difficult to get enough reliable information to help make a decision for or against PrEP. DE: Es ist schwierig ausreichend verlässliche Informationen zu bekommen, die bei der Entscheidung für order gegen PrEP behilflich sind. FR: Il est difficile d’obtenir suffisamment d’informations fiables pour aider à prendre une décision pour ou contre la PrEP. 3EN: I have the feeling that I was not sufficiently informed about PrEP. DE: Ich hatte das Gefühl, dass ich nicht ausreichend genug über PrEP informiert war. FR: J’ai le sentiment que je n’étais pas suffisamment informé(e) au sujet de la PrEP. 4EN: I have the feeling that I am not sufficiently informed about PrEP. DE: Ich habe das Gefühl, nicht ausreichend genug über PrEP informiert zu sein. FR: J’ai le sentiment de ne pas être suffisamment informé(e) au sujet de la PrEP. 2 1 EN: PrEP is so new that no one really knows what long-term effects it can have. DE: PrEP ist so neu, dass niemand wirklich weiss, welche Langzeiteffekte die Einnahme haben kann. FR: La PrEP est si nouvelle que personne ne sait vraiment quels effets elle peut avoir à long terme. 2EN: PrEP is so new that no one really knows what long-term effects it can have. DE: PrEP ist so neu, dass niemand wirklich weiss, welche Langzeiteffekte die Einnahme haben kann. FR: La PrEP est si nouvelle que personne ne sait vraiment quels effets elle peut avoir à long terme. 3EN: PrEP is so new that no one really knows what long-term effects it can have. DE: PrEP ist so neu, dass niemand wirklich weiss, welche Langzeiteffekte die Einnahme haben kann. FR: La PrEP est si nouvelle que personne ne sait vraiment quels effets elle peut avoir à long terme 4EN: PrEP is so new that no one really knows what long-term effects it can have. DE: PrEP ist so neu, dass niemand wirklich weiss, welche Langzeiteffekte die Einnahme haben kann. FR: La PrEP est si nouvelle que personne ne sait vraiment quels effets elle peut avoir à long terme. 3 1 EN: PrEP might not be compatible with other medications that I am taking. DE: PrEP könnte sich mit anderen Medikamenten, die ich nehme, nicht vertragen. FR: La PrEP pourrait ne pas être compatible avec les autres médicaments que je prends. 2EN: PrEP might not be compatible with other medications one is already taking. DE: PrEP könnte sich mit anderen Medikamenten, die man bereits einnimmt, nicht vertragen. FR: La PrEP pourrait ne pas être compatible avec d’autres médicaments qu’une personne prend déjà. 3EN: PrEP is not compatible with other medications I am/was taking. DE: PrEP hat sich mit anderen Medikamenten, die ich einnehme/eingenommen habe, nicht vertragen. FR: La PrEP n’est pas compatible avec les autres médicaments que je prends/prenais. 4EN: PrEP is not compatible with other medications that I am taking. DE: PrEP verträgt sich nicht mit anderen Medikamenten, die ich einnehme. FR: La PrEP n’est pas compatible avec les autres médicaments que je prends. 4 1 EN: I do not know what effects interrupting PrEP could have on my health. DE: Ich weiss nicht, welche Auswirkungen das Absetzen von PrEP auf meine Gesundheit haben könnte. FR: Je ne sais pas quels effets interrompre la PrEP pourrait avoir sur ma santé. 2EN: It is not clear what effects interrupting PrEP could have on health. DE: Es ist nicht klar, welche Auswirkungen das Absetzen von PrEP auf die Gesundheit haben könnte. FR: Il n’est pas clair quels effets l’arrêt de la PrEP pourrait avoir sur la santé. 3EN: I do not know what effects interrupting PrEP will have on my health. DE: Ich weiss nicht, welche Auswirkungen das Absetzen von PrEP auf meine Gesundheit hat. FR: Je ne sais pas quels effets interrompre la PrEP aura sur ma santé. 4EN: I do not know what effects interrupting PrEP could have on my health. DE: Ich weiss nicht, welche Auswirkungen das Absetzen von PrEP auf meine Gesundheit haben könnte. FR: Je ne sais pas quels effets interrompre la PrEP pourrait avoir sur ma santé. (Continued) Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdaf013/8006050 by guest on 10 February 2025 The PrEP personal obstacle scale (PPOS) 9 Table A1 PPOS-EN/DE/FR instrument. Item Group Question 5 1 EN: I do not like the idea of taking a medication like PrEP, being otherwise healthy from a medical point of view. DE: Ich mag die Vorstellung nicht ein Medikament wie PrEP einzunehmen, obwohl ich aus medizinischer Sicht sonst eigentlich gesund bin. FR: Je n’aime pas l’idée de prendre un médicament comme la PrEP, étant sinon en bonne santé d’un point de vue médical. 2EN: I do not like the idea that one takes a medication like PrEP, being otherwise healthy from a medical point of view. DE: Ich mag die Vorstellung nicht, dass man ein Medikament wie PrEP einnimmt, obwohl man aus medizinischer Sicht sonst eigentlich gesund ist. FR: Je n’aime pas l’idée que l’on prenne un médicament comme la PrEP, étant sinon en bonne santé d’un point de vue médical. 3EN: I did not like the idea of taking a medication like PrEP, being otherwise healthy from a medical point of view. DE: Ich mochte die Vorstellung nicht ein Medikament wie PrEP einzunehmen, obwohl ich aus medizinischer Sicht sonst eigentlich gesund bin. FR: Je n’aimais pas l’idée de prendre un médicament comme la PrEP, étant sinon en bonne santé d’un point de vue médical. 4EN: I do not like the idea of taking a medication like PrEP, being otherwise healthy from a medical point of view. DE: Ich mag die Vorstellung nicht ein Medikament wie PrEP einzunehmen, obwohl ich aus medizinischer Sicht sonst eigentlich gesund bin. FR: Je n’aime pas l’idée de prendre un médicament comme la PrEP, étant sinon en bonne santé d’un point de vue médical. 6 1 EN: I think that I would be concerned about having to remember to take a pill every single day. DE: Ich glaube, es würde mir schwer fallen, jeden Tag an die Einnahme zu denken. FR: Je crois qu’il serait difficile pour moi de devoir me souvenir de prendre un comprimé tous les jours. 2 EN: I think that it is difficult to have to remember to take a pill. DE: Ich glaube es fällt schwer, an die Einnahme zu denken. FR: Je crois qu’il est difficile de devoir se souvenir de prendre un comprimé. 3 EN: I find it difficult having to remember to take a pill every single day. DE: Es fiel mir schwer, jeden Tah an die Einnahme zu denken. FR: Je trouvais difficile de devoir me souvenir de prendre un comprimé tous les jours. 4 EN: I find it difficult having to remember to take a pill every single day. DE: Es fällt mir schwer, jeden Tag an die Einnahme zu denken. FR: Je trouve difficile de me souvenir de prendre un comprimé tous les jours. 7 1 EN: I know too little about how PrEP works and its effects. DE: Ich weiss zu wenig über die Wirkungsweise von PrEP und was es genau tut. FR: J’en sais trop peu sur le fonctionnement de la PrEP et ses effets. 2EN: Too little is known about how PrEP works and what it exactly does. DE: Es ist zu wenig über die Wirkungsweise von PrEP und was es genau tut bekannt. FR: On en sait trop peu sur le fonctionnement de la PrEP et de ses effets. 3EN: I knew too little about how PrEP works and its effects. DE: Ich wusste zu wenig über die Wirkungsweise von PrEP und was es genau tut. FR: J’en savais trop peu sur le fonctionnement de la PrEP et ses effets. 4EN: I know too little about how PrEP works and its effects. DE: Ich weiss zu wenig über die Wirkungsweise von PrEP und was es genau tut. FR: J’en sais trop peu sur le fonctionnement de la PrEP et sur ses effets. 8 1 EN: I do not know how easy it would be for me to get PrEP. DE: Ich weiss nicht, wie einfach es für mich wäre mir PrEP zu besorgen. FR: Je ne sais pas à quel point il serait facile pour moi d’obtenir la PrEP. 2EN: I do not know how easy it is to get PrEP. DE: Ich weiss nicht, wie einfach es ist sich PrEP zu besorgen. FR: Je ne sais pas à quel point il est facile d’obtenir la PrEP. 3EN: It was not easy for me to get PrEP. DE: Es war nicht einfach für mich, mir PrEP zu besorgen. FR: Il n’était pas facile pour moi d’obtenir la PrEP. 4EN: It is not easy for me to get PrEP. DE: Es ist nicht einfach für mich, mir PrEP zu besorgen. FR: Il n’est pas facile pour moi d’obtenir la PrEP. Group 1 = Interested in taking PrEP, Group 2 = Undecided/Not interested, Group 3 = Former user, Group 4 = User. Language version: EN = English, DE = German, FR = French. Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdaf013/8006050 by guest on 10 February 2025