Assessing the mediating role of self-disclosure between mental health literacy and psychological distress: a cross-sectional study among HIV-positive young and middle-aged men who have sex with men in China

Study design and participants

A cross-sectional study was conducted at a tertiary hospital in Nanjing, China, between November 2023 and January 2024. The STrengthening the Reporting of OBservational Studies in Epidemiology guidelines informed the study’s design and reporting.23 Participants were recruited through convenience sampling from the outpatient clinic of the Department of Infection. Inclusion criteria for patients included the following: (1) aged 18–50 years old; (2) previously diagnosed as HIV-positive; (3) self-reported HIV route of infection as MSM; (4) able to express themselves verbally fluently and (5) informed consent and voluntary participation in the study. Exclusion criteria for patients included the following: (1) the presence of impaired cognitive function (assessed using Montreal Cognitive Assessment) or other psychiatric disorders (assessed using the Patient Health Questionnaire-9 and medical records) and (2) combination of severe impairment of heart, brain, kidney and other vital organ functions (determined through oral inquiries and review of medical records). Patients included in this study were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

Patient and public involvement

Patients or the public were not involved in the development of the research question, study design or data interpretation in this study.

Instruments

In this study, we collected information on demographic and clinical characteristics, MHL, psychological distress and self-disclosure from the participants. The general questionnaire was developed based on the study objectives and relevant literature, then refined through team discussions and expert consultations.24–26 The general information questionnaire included general demographic characteristics (age, ethnicity, religious beliefs, education, marital status, work status, income), disease-related characteristics (length of time to diagnosis of HIV infection, complications) and health-related (past participation in psychological services, overall health status).

Multicomponent MHL was developed by Jung et al.27 In this study, we used the Chinese version revised by Ming et al.28 This scale consists of 22 items, which can be divided into 3 dimensions: mental health knowledge (10 items), beliefs (8 items) and resources (4 items). In the knowledge and beliefs dimensions, items are rated on a 5-point Likert scale with an additional ‘don’t know’ option. For the knowledge dimension, items are scored positively, with responses of ‘agree’ or ‘strongly agree’ earning 1 point, while all other options receive 0 points. The scoring range for this dimension is 0–10 points. Conversely, in the beliefs dimension, items are scored negatively, awarding 1 point for responses of ‘disagree’ or ‘strongly disagree’, with all other options scoring 0 points. The scoring range for this dimension is 0–8 points. The resources dimension consists of yes/no items where ‘yes’ scores 1 point and ‘no’ scores 0 points, with a possible score range of 0–4 points. The total score ranged from 0 to 22, with higher scores indicating higher levels of individual MHL. Based on previous research, an average MHL score of 11 was used as the cut-off point to distinguish between high and low levels of MHL in this study.29 30 The Chinese version has been validated, with an overall Cronbach’s alpha coefficient of 0.80, indicating good internal consistency. The Cronbach’s alpha coefficient of the scale in this study was 0.833.

The Kessler Psychological Distress Scale (K-10) was developed by Kessler et al.31 This study used the Chinese version of K-10 translated by Zhou et al.32 It includes 10 items, and each item is measured on a 5-point Likert scale from 1 (none of the time) to 5 (all of the time). The total score ranges from 10 to 50, with higher scores indicating higher psychological distress. Scores ranging from 10 to 19 are considered minimal or no distress, 20 to 24 are considered moderate distress, 25 to 29 are considered relatively severe distress and 30 to 50 are considered very severe distress. The Chinese version has demonstrated good internal consistency, with the Cronbach’s alpha coefficient of 0.801.32 The Cronbach’s alpha coefficient in our study was 0.877.

Distress Disclosure Index (DDI) was compiled by Kahn et al.33 We used the Chinese version of DDI developed by Li.34 The scale contains 12 items, and each item is rated on a scale from 1 to 5, yielding a total score range of 12–60. Scale scores ranging from 12 to 29 points are considered low level, 30 to 44 are considered medium level and 45 to 60 are considered high level. The Cronbach’s alpha coefficient for this scale was 0.866 and the retest reliability was 0.780.34 The Cronbach’s alpha coefficient in our study was 0.849.

Procedure

Potential participants were identified through recommendations from outpatient department administrators and direct contact in the waiting areas. Trained researchers explained the purpose and content of the study to the participants using uniform instructions. They obtained informed consent from the participants and further assessed whether each individual met the inclusion and exclusion criteria. Eligible participants were invited to join this study, receiving comprehensive information regarding potential risks and benefits. Following the provision of written informed consent, they were officially enrolled. Participants subsequently completed a detailed self-report questionnaire in quiet and private environment, ensuring immediate submission on completion. Emphasis was placed on the strict confidentiality and anonymisation of all data to minimise social desirability bias.

The online application named Monte Carlo Power Analysis for indirect effects was used to calculate sample size of mediation models in this study.35 Specifically, based on findings from prior studies and data from our preliminary pilot study, we set the standardised path coefficients as follows: 0.20 for the a path, −0.42 for the b path and −0.18 for the c’ path.18 Simultaneously ensuring 80% statistical power and a 95% confidence level, the sample size was estimated to be 200.

Statistical analysis

SPSS V.26.0 statistical software was used to analyse the data. Descriptive statistics was used to analyse the characteristics of the patients. Pearson correlation analysis was used to determine the relationship between MHL, self-disclosure and psychological distress. Model 4 in Process V.4.2 was used to analyse the mediating effect of self-disclosure between MHL and psychological distress. The Bootstrap method was used to test the mediating effect via a resampling of 5000 samples to calculate 95% CIs. If the 95% CI does not exceed 0, the indirect effect is significant. The significance level was set at 0.05.

The common method bias test was conducted using the Harman single-factor test method, and the results showed that there were 12 factors with eigenvalues>1, and the variance explained by the first factor was 19.13% (<40%), suggesting that the data in this study did not have serious common method bias problems.

Participant characteristics

A total of 236 eligible individuals were invited to participate, of whom 220 consented to participate in the study (response rate=93.2%). Among those who consented, 11 did not complete the questionnaire due to temporary interruptions such as unscheduled medical examinations or a loss of interest. Consequently, the final sample comprised 209 participants who completed the questionnaire. The participants’ ages ranged from 18 to 49 years, and the mean age was 34.72 years (SD=6.72). In this study, 19.6% of the participants had previously participated in psychological services. Other demographic information is shown in table 1.

Status and correlation of MHL, self-disclosure and psychological distress

The mean MHL score of HIV-positive young and middle-aged MSM was 11.90 (SD=5.09). The average score of self-disclosure of HIV-positive young and middle-aged MSM was 31.97 (SD=6.87) and the mean score of psychological distress was 25.43 (SD=8.16). Table 2 shows the detailed scores of HIV-positive young and middle-aged MSM on MHL, self-disclosure and psychological distress.

The results of correlation analysis showed that self-disclosure was positively correlated with MHL (r=0.264, p<0.001), self-disclosure was negatively correlated with psychological distress (r=−0.496, p<0.001) and MHL was negatively correlated with psychological distress (r=−0.308, p<0.001), which are shown in table 3.

Analysis of the mediating effect of self-disclosure

A mediation effect model was established with psychological distress as the dependent variable, MHL as the independent variable and self-disclosure as the mediating variable. (figure 1). After standardising the variables, model 4 in Process V.4.2 was used to test the mediating effect of self-disclosure on MHL and psychological distress among HIV-positive young and middle-aged MSM. The results showed that MHL was positively associated with self-disclosure (β=0.263, p<0.001); self-disclosure was negatively associated with psychological distress (β=−0.446, p<0.001); and MHL was negatively associated with psychological distress (β=−0.190, p<0.01). After including the mediating variable self-disclosure, MHL still was negatively associated with psychological distress (β=−0.118, p<0.001). The findings are illustrated in figure 1 andtable 4. The 95% CI was calculated using Bootstrap test with 5000 random samples, which showed that self-disclosure mediated the effects of MHL on psychological distress, accounting for 38.31% of the total effect, as shown in table 5.

Current status of MHL, self-disclosure and psychological distress among HIV-positive young and middle-aged MSM

The results of this study showed that the MHL score of HIV-positive young and middle-aged MSM was 11.90 (SD=5.09), which was slightly above the mean value of 11. This suggests that participants had a moderate level of MHL, consistent with the findings by Li et al.30 The possible reason is that the study population is a young and middle-aged group, and their education level is high school and above, which makes it easier for them to get in touch with and understand mental health-related knowledge. However, they are also more likely to be bound by traditional thinking about gender, and such behaviours as revealing one’s emotions and asking for help are often defined as a sign of vulnerability and incompetence, which is not in line with the image of strong and independent men demanded by the society.36 Consequently, this group tends to neglect their own mental health and is unable to accurately assess the severity of psychological problems.37 The self-disclosure score of the subjects was 31.97 (SD=6.87), which was at a medium level. This can be attributed to the multiple pressures faced by this group related to illness, sexual orientation, marriage and reproduction, making it difficult for them to rationally and comfortably disclose their inner thoughts and emotions, often choosing to bear the pressure alone.38 This study also found that the psychological distress score of this group was 25.43 (SD=8.16), indicating that HIV-positive young and middle-aged MSM had relatively severe psychological distress. This could be linked to the influence of Confucianism in China and other East Asian countries, which emphasises collectivism and family harmony.39 Individuals are expected to conform to social norms and family expectations, which may suppress the expression of their unique personalities and qualities. As a result, for this group with special identities and circumstances, they often need to cover up their true situation in order to conform more to social norms.40 This masking is considered a source of distress.41 By masking their identity, feelings and thoughts, and isolating their true selves from others and society, they are more likely to develop a sense of loneliness and alienation, which in turn increases their own psychological distress.

Correlates of MHL, self-disclosure and psychological distress

The results revealed a negative correlation between MHL and psychological distress among HIV-positive young and middle-aged MSM, suggesting that higher MHL is associated with lower psychological distress. When individuals have a high level of MHL, their own reserves of mental health-related knowledge and skills can help them cope with challenges more positively.42 Meanwhile, people with high levels of MHL are more inclined to adopt mental health services, which is associated with managing psychological distress.17 Therefore, individuals with higher levels of MHL experience less psychological distress. In addition, our study showed that self-disclosure was negatively associated with psychological distress. For this group, initial disclosures are often made to family members, close friends or intimate partners.43 However, out of fear of anticipated stigma, fear of losing social support and unpreparedness for disclosure, this group often choose to conceal their illness and aptitudes. They tend to process their negative emotions alone and present an optimistic picture.44 In fact, suffering more negative experiences alone further aggravates their psychological distress.

The mediation effect of distress disclosure

Self-disclosure is an individual’s willingness to confide and express their inner thoughts to others rather than keeping them to themselves .45 The results found that self-disclosure exerted a partial mediating effect on MHL and psychological distress among HIV-positive young and middle-aged MSM. Specifically, MHL not only directly affected psychological distress but also indirectly predicted psychological distress through self-disclosure. To some extent, this result clarifies how MHL impacts psychological distress in young and middle-aged HIV-positive MSM. According to our knowledge, this study is the first to examine the relationship between MHL and self-disclosure in HIV-positive young and middle-aged MSM. Self-disclosure has been found to be associated with a number of positive outcomes, such as enhanced well-being, reduced isolation and increased social support, which in turn promotes adherence to ART.46 47 Lower levels of MHL can limit individuals’ perception of self-disclosure, diminishing their concern for mental health. This makes them less likely to take the initiative to learn about mental health, and seek help from others or professional counselling through self-disclosure, which can further exacerbate their psychological distress.48 49

This finding suggests that understanding the mediating role of self-disclosure can significantly inform the design and implementation of interventions to reduce psychological distress. Specifically, at the governmental level, there should be active promotion of MHL campaigns that include elements focused on self-disclosure. Given the frequent use of social media by this demographic, platforms such as Blued and Weibo can serve as effective channels for disseminating educational content and providing ongoing support.50 Moreover, policy-makers should consider enhancing laws that address stigma surrounding HIV and sexual minorities, thereby reducing public prejudice against HIV-positive MSM.46 Creating a non-discriminatory environment facilitates more open self-disclosure and supports better mental health outcomes. At the community level, peer navigators, who are trained individuals with similar backgrounds or experiences, provide personalised guidance and support to HIV-positive individuals within these communities.51 Community organizations can consider developing MHL-based training programmes for peer navigators, transforming them into effective disseminators of mental health information. Trained peer navigators leverage their close connections and shared experiences to significantly influence the MHL and self-disclosure of HIV-positive individuals, thereby improving personal welfare and reducing psychological distress.52 At the medical level, the disclosure process model (DPM) assists HIV-positive individuals in understanding when and why they should disclose their status, clarifying the decision-making process and potential outcomes of self-disclosure.53 Previous research has shown that DPM-based interventions effectively improve self-disclosure practices and reduce psychological distress among HIV-positive individuals.54 55 Therefore, healthcare providers should regularly assess patients’ psychological status and integrate disclosure skills training into routine mental health education. This approach can prevent or alleviate psychological distress and enhance overall mental well-being for HIV-positive young and middle-aged MSM.

To the best of our knowledge, this study first investigated the mediating role of self-disclosure in the relationship between MHL and psychological distress among HIV-positive young and middle-aged MSM, providing valuable directions for developing targeted interventions. Alleviating psychological distress is often a complex and ongoing process that requires sustained effort.56 In contrast, MHL and self-disclosure can be improved through systematic education and support over a relatively short period. Therefore, understanding how MHL can reduce psychological distress by promoting effective self-disclosure not only enriches the theoretical framework of this field but also offers practical implications for policymakers, social organizations and healthcare providers.

Limitations

This study also has some limitations that need to be noted. First, the study population was recruited from a single tertiary hospital in Nanjing, limiting the generalisability of our findings. Further research is needed to expand the representative sample from various areas and hospital levels. Second, convenience sampling was chosen because it enabled us to efficiently collect preliminary data from this hard-to-reach population within resource constraints. However, this method, along with the relatively small sample size, introduces selection bias and limits external validity. Therefore, future research should consider adopting multicentre studies with larger samples, using stratified random sampling techniques to enhance representativeness and reduce potential biases. Third, the cross-sectional design allows us to explore associations but not causal relationships between variables. Longitudinal studies are necessary to further investigate the causal pathways between MHL, self-disclosure and psychological distress. Fourth, the data were collected through self-report questionnaires, which may introduce recall and social desirability bias. The repeat measurements could be performed in a proportion of patients to test the reliability of the results. Fifth, due to ethical considerations and the challenges associated with obtaining dual informed consent from minors and their guardians, this study did not include HIV-positive MSM under 18 years of age. Future research should focus on this critical subgroup, addressing both ethical concerns and privacy protection to ensure the legitimacy and integrity of such studies. Finally, unmeasured confounding factors, such as negative life events and lifestyle habits, may have influenced the results. Future research should explore these factors in more depth.

Patient consent for publication

Not applicable.

Ethics approval

This study involves human participants and was approved by the Ethics Committee of the Affiliated Hospital of Nanjing University of Chinese Medicine (No.2023-SL-kt029). Participants gave informed consent to participate in the study before taking part.