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

Abstract

Objective
To investigate the associations between mental health literacy (MHL), self-disclosure and psychological distress among HIV-positive young and middle-aged men who have sex with men (MSM). We hypothesised that self-disclosure would mediate the relationship between MHL and psychological distress.

Design
A cross-sectional study.

Setting
Participants were recruited from the outpatient clinic of the Department of Infection at a tertiary hospital in Nanjing, Jiangsu province, China.

Participants
A total of 209 HIV-positive young and middle-aged MSM.

Outcome measures
Using convenient sampling method, the study selected 209 HIV-positive young and middle-aged MSM from a tertiary hospital in Nanjing, China, from November 2023 to January 2024. The data were collected using a general information questionnaire, the Multicomponent Mental Health Literacy, the Kessler Psychological Distress Scale and the Distress Disclosure Index. Descriptive statistics, Pearson correlation analysis and mediation analysis were conducted in the study.

Results
The mean MHL score among HIV-positive young and middle-aged MSM was 11.90 (SD=5.09). Their mean score for self-disclosure was 31.97 (SD=6.87) and for psychological distress was 25.43 (SD=8.16). The bivariate correlation analysis showed that self-disclosure was positively correlated with MHL (r=0.264, p<0.001) and 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). Self-disclosure partially mediated the relationship between MHL and psychological distress among HIV-positive young and middle-aged MSM, and the mediating effect accounted for 38.31% of the total effect.

Conclusion
Self-disclosure mediated the relationship between MHL and psychological distress. To improve psychological distress among HIV-positive young and middle-aged MSM, targeted intervention measures aimed at enhancing MHL and self-disclosure should be conducted.

Full text

1
YouX, etal. BMJ Open 2025;15:e095735. doi:10.1136/bmjopen-2024-095735
Open access
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
Xinyi You,1 Qi Wen,1 Jiayi Gu,2 Wenwen Yang,1 Yuhan Wu,1 Liman Zhang,3
Yan Song 4
To cite: YouX, WenQ, GuJ,
etal. 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. BMJ Open
2025;15:e095735. doi:10.1136/
bmjopen-2024-095735
►Prepublication history for
this paper is available online.
To view these les, please visit
the journal online (https://doi.
org/10.1136/bmjopen-2024-
095735).
Received 28 October 2024
Accepted 27 January 2025
For numbered afliations see
end of article.
Correspondence to
Yan Song;
njyy037@ njucm. edu. cn
Original research
© Author(s) (or their
employer(s)) 2025. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ Group.
ABSTRACT
Objective To investigate the associations between mental
health literacy (MHL), self- disclosure and psychological
distress among HIV- positive young and middle- aged men
who have sex with men (MSM). We hypothesised that self-
disclosure would mediate the relationship between MHL
and psychological distress.
Design A cross- sectional study.
Setting Participants were recruited from the outpatient
clinic of the Department of Infection at a tertiary hospital in
Nanjing, Jiangsu province, China.
Participants A total of 209 HIV- positive young and
middle- aged MSM.
Outcome measures Using convenient sampling method,
the study selected 209 HIV- positive young and middle-
aged MSM from a tertiary hospital in Nanjing, China,
from November 2023 to January 2024. The data were
collected using a general information questionnaire,
the Multicomponent Mental Health Literacy, the Kessler
Psychological Distress Scale and the Distress Disclosure
Index. Descriptive statistics, Pearson correlation analysis
and mediation analysis were conducted in the study.
Results The mean MHL score among HIV- positive young
and middle- aged MSM was 11.90 (SD=5.09). Their
mean score for self- disclosure was 31.97 (SD=6.87)
and for psychological distress was 25.43 (SD=8.16). The
bivariate correlation analysis showed that self- disclosure
was positively correlated with MHL (r=0.264, p<0.001)
and 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). Self-
disclosure partially mediated the relationship between
MHL and psychological distress among HIV- positive
young and middle- aged MSM, and the mediating effect
accounted for 38.31% of the total effect.
Conclusion Self- disclosure mediated the relationship
between MHL and psychological distress. To improve
psychological distress among HIV- positive young and
middle- aged MSM, targeted intervention measures
aimed at enhancing MHL and self- disclosure should be
conducted.
INTRODUCTION
The global burden of HIV infection among
men who have sex with men (MSM) is dispro-
portionately elevated.1 Between 2010 and
2022, new HIV infections among MSM in Asia
and the Pacific rose by 32%.2 In China, the
proportion of new HIV infections attributed
to MSM surged from 2.5% in 2006 to 25.7%
in 2023, making this group one of the most
severely affected populations by HIV.3 4 While
the widespread use of antiretroviral therapy
(ART) has effectively reduced morbidity and
mortality among HIV- positive individuals, the
growing number of long- term survivors now
faces significant and complex mental health
challenges.5 6
HIV/AIDS- related psychological distress is
a multidimensional experience of suffering
STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒Mediation analysis was used to quantify the contri-
bution of self- disclosure to the association between
mental health literacy and psychological distress.
⇒Compared with traditional methods such as the
Sobel test and the causal steps approach, the
Bootstrap method demonstrates greater statistical
power and provides more accurate CI estimates
when conducting mediation analysis.
⇒The study population was selected from only one
tertiary hospital, which was not representative of a
pan- global population.
⇒The study used a cross- sectional design, limiting its
ability to explore the causal relationship between
mental health literacy, self- disclosure and psycho-
logical distress.
⇒Self- reported data may be subject to recall bias and
social desirability effects, potentially impacting the
validity and accuracy of the measurements.

2YouX, etal. BMJ Open 2025;15:e095735. doi:10.1136/bmjopen-2024-095735
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influenced by physiological, psychological, social and spir-
itual factors, creating a continuous, enduring and often
hidden psychological burden in managing the disease.7
Previous studies have shown that HIV- positive individ-
uals experience higher levels of psychological distress
compared with the general population.8 This phenom-
enon is notably more pronounced among HIV- positive
young and middle- aged MSM.9 They are at critical life
stages involving education, employment, marriage and
parenthood, thus shouldering multiple social responsi-
bilities.10 11 Due to the dual stigma associated with their
sexual orientation and health condition, HIV- positive
young and middle- aged MSM bear heavy physical and
psychological burdens.6 Under the alternating influ-
ence of internal and external pressures, HIV- positive
young and middle- aged MSM are particularly vulnerable
to psychological issues such as anxiety, depression and
suicidal thoughts.12 Several studies have demonstrated
that psychological distress can lead to adverse health
outcomes, including poor adherence to medication,
increased risk of HIV transmission and higher rates of
suicide.13 14 Therefore, it is essential to investigate the
mechanisms that contribute to psychological distress in
HIV- positive young and middle- aged MSM, which will
facilitate the development of effective interventions to
address this issue within the group.
Mental health literacy (MHL) refers to the knowledge
and beliefs that help individuals identify, manage and
prevent mental illness.15 In 2019, China launched the
‘Healthy China Action (2019–2030)’ which includes the
special initiative ‘Promotion of Mental Health’.16 This
initiative explicitly states that enhancing MHL is one of the
most economical, fundamental and effective measures to
improve individual mental health levels, underscoring the
importance of MHL in maintaining psychological well-
being. A latent class analysis found that HIV- positive MSM
in the low MHL group have difficulty acquiring mental
health- related knowledge, which hinders their ability to
recognise the importance of seeking psychological help
and negatively impacts their mental health.17 Addition-
ally, several studies have found that MHL is associated
with psychological distress, suggesting that individuals
with higher levels of MHL experience less psychological
distress.18 19 Therefore, it is reasonable to hypothesise that
improving MHL plays a crucial role in alleviating psycho-
logical distress among HIV- positive young and middle-
aged MSM.
Self- disclosure is the process that individuals reveal
information about their emotions, opinions, experi-
ences and feelings to others.20 Disclosing stigmatised
information can help HIV- positive individuals gain
social support at both material and psychological levels,
thereby reducing perceived stigma and improving
psychological well- being.21 A randomised controlled
study showed that self- disclosure interventions can effec-
tively improve HIV- positive individuals’ self- disclosure
levels and reduce their psychological distress.22 There-
fore, increasing the level of self- disclosure is also
considered to be an effective strategy for improving indi-
vidual psychological distress.
In summary, the relationships between MHL, self-
disclosure and psychological distress were tested sepa-
rately and found to be significant. However, there are
some limitations of previous studies. First, the relationship
between self- disclosure and MHL among HIV- positive
young and middle- aged MSM has not been confirmed.
In addition, it is unclear whether self- disclosure mediates
the relationship between MHL and psychological distress.
Therefore, the purpose of this study was to examine the
relationship between MHL, self- disclosure and psycho-
logical distress among HIV- positive young and middle-
aged MSM. Additionally, the study aimed to test whether
self- disclosure mediates the relationship between MHL
and psychological distress among this population. The
hypotheses of this study are as follows: (a) MHL is posi-
tively related to self- disclosure and (b) self- disclosure
mediates the relationship between MHL and psycholog-
ical distress.
METHODS
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. Inclu-
sion 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. Exclu-
sion 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 Question-
naire- 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 develop-
ment of the research question, study design or data inter-
pretation 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 objec-
tives and relevant literature, then refined through team

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discussions and expert consultations.24–26 The general
information questionnaire included general demo-
graphic 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 knowl-
edge 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 coef-
ficient 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 coef-
ficient 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 recommen-
dations 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 environ-
ment, 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 coef-
ficients 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 charac-
teristics 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 signif-
icant. 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.
RESULTS
Participant characteristics
A total of 236 eligible individuals were invited to partici-
pate, 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 examina-
tions or a loss of interest. Consequently, the final sample
comprised 209 participants who completed the question-
naire. The participants’ ages ranged from 18 to 49 years,

4YouX, etal. BMJ Open 2025;15:e095735. doi:10.1136/bmjopen-2024-095735
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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 psycho-
logical distress as the dependent variable, MHL as the
independent variable and self- disclosure as the medi-
ating variable. (figure 1). After standardising the vari-
ables, model 4 in Process V.4.2 was used to test the
mediating effect of self- disclosure on MHL and psycho-
logical 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
Table 1 Demographic characteristics of participants
(N=209)
Characteristics N (%)
Age (years)
18–34 143 (68.4)
35–49 66 (31.6)
Ethnicity
Han Chinese 200 (95.7)
Other 9 (4.3)
Religious beliefs
Yes 13 (6.2)
No 196 (93.8)
Education
Junior high school and below 9 (4.3)
High school or college 79 (37.8)
Undergraduate and above 121 (57.9)
Marital status
Married 41 (19.6)
Unmarried, divorced or widowed 168 (80.4)
Working status
On- the- job 179 (85.6)
Unemployed/sick leave 2 (1.0)
Other 28 (13.4)
Monthly per capita household income (yuan)
＜3000 16 (7.7)
3000–6000 52 (24.9)
＞6000 141 (67.5)
Length of time to diagnosis of HIV infection
(years)
＜138 (18.2)
1–3 53 (25.4)
＞3–10 95 (45.5)
＞10 23 (11.0)
Past participation in psychological services
Yes 41 (19.6)
No 168 (80.4)
Presence of HIV- related complications
Yes 23 (11.0)
No 186 (89.0)
Overall health status
Good 125 (59.8)
Fair 77 (36.8)
Poor 7 (3.3)
Table 2 MHL, self- disclosure and psychological distress
scores in participants
Item
Item score
(Mean±SD)
MHL 22 11.90±5.09
Mental health knowledge 10 5.61±2.60
Mental health beliefs 8 4.40±2.31
Mental health resources 4 1.89±1.42
Self- disclosure 12 31.97±6.87
Psychological distress 10 25.43±8.16
MHL, mental health literacy.
Table 3 Pearson correlation analysis of MHL, self-
disclosure and psychological distress among participants
(N=209)
123
1.MHL 1
2.Self- disclosure 0.264*** 1
3.Psychological distress −0.308*** −0.496*** 1
***p<0.001.
MHL, mental health literacy.

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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.
DISCUSSION
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 tradi-
tional 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 inde-
pendent 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 psycholog-
ical 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 ratio-
nally 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 circum-
stances, 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 iden-
tity, 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 associ-
ated 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 psycho-
logical distress.17 Therefore, individuals with higher levels
Figure 1 A graphical example of the mediating effect of the
dimensions of self- disclosure. **p<0.01, ***p<0.001.
Table 4 Regression analysis of the mediating role model of self- disclosure (standardised)
Regression model Goodness- of- t indices Regression coefcient and signicance
Outcome variable Predictor variable R R2Fβt
Self- disclosure 0.264 0.070 15.489***
MHL 0.263 3.936***
Psychological distress 0.529 0.280 40.011***
MHL −0.190 −3.102**
Self- disclosure −0.446 −7.275***
***p<0.01, **p<0.001
MHL, mental health literacy.

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of MHL experience less psychological distress. In addi-
tion, 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 psycho-
logical 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 effec-
tive 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 navi-
gators, who are trained individuals with similar back-
grounds 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 dissem-
inators 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 inte-
grate disclosure skills training into routine mental health
education. This approach can prevent or alleviate psycho-
logical distress and enhance overall mental well- being for
HIV- positive young and middle- aged MSM.
To the best of our knowledge, this study first investi-
gated the mediating role of self- disclosure in the rela-
tionship between MHL and psychological distress among
HIV- positive young and middle- aged MSM, providing
valuable directions for developing targeted interven-
tions. 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 rela-
tively short period. Therefore, understanding how MHL
can reduce psychological distress by promoting effective
self- disclosure not only enriches the theoretical frame-
work of this field but also offers practical implications
for policymakers, social organizations and healthcare
providers.
Table 5 Mediating effects of self- disclosure
Pathway Effect SE Bootstrapped 95% CI Proportion of total effect%
Direct effect −0.190 0.061 (−0.311 to –0.069) 61.69
MHL→Psychological distress
Indirect effect −0.118 0.041 (−0.203 to –0.045) 38.31
MHL→Self- disclosure→Psychological distress
Total effect −0.308 0.066 (−0.438 to –0.177) —
MHL, mental health literacy.

7
YouX, etal. BMJ Open 2025;15:e095735. doi:10.1136/bmjopen-2024-095735
Open access
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 general-
isability 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 prelim-
inary 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 asso-
ciations 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 measure-
ments 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 integ-
rity 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.
CONCLUSION
This study preliminarily validated the partial mediating
role of self- disclosure between MHL and psychological
distress in HIV- positive young and middle- aged MSM.
It is suggested that in the future, targeted intervention
measures should be designed under multidisciplinary
collaboration. These interventions should aim to enhance
MHL and promote self- disclosure, thereby reducing the
psychological distress of this group.
Author afliations
1School of Nursing, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
2The Afliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, Jiangsu,
China
3Department of Infectious Disease, The Second Hospital of Nanjing, Afliated to
Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
4Department of Nursing, The Second Hospital of Nanjing, Afliated to Nanjing
University of Chinese Medicine, Nanjing, Jiangsu, China
Acknowledgements We would like to extend our gratitude to all the participants,
as well as the outpatient department staff who assisted with participant
recruitment. Special thanks are also due to Wenhui Wang for providing valuable
feedback during the revision of the manuscript.
Contributors XY conceptualised and designed the research and drafted the initial
manuscript. QW and JG collected the data, conducted the statistical analysis. WY,
YW and LZ prepared the manuscript, gures and tables. All the authors (XY, QW,
JG, WY, YW, LZ and YS) participated in editing and revising the manuscript and
approved the nal manuscript as submitted. YS was responsible for the overall
content as guarantor.
Funding This study was supported by the Jiangsu Province Postgraduate
PracticeInnovation Program in 2024, grant number SJCX24_0853; Health Science
andTechnology Development Special Fund of Nanjing, grant number YKK19111;
NanjingSecond Hospital Talent Support Project Funding Program, grant number
RCMS23014.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not applicable.
Ethics approval This study involves human participants and was approved by
the Ethics Committee of the Afliated Hospital of Nanjing University of Chinese
Medicine (No.2023- SL- kt029). Participants gave informed consent to participate in
the study before taking part.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available on reasonable request. Data are
available on reasonable request. The data used to support the ndings of this study
are available from the corresponding author on request.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non- commercial. See:http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iD
YanSong http://orcid.org/0009-0000-6643-0087
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