Health Literacy,Knowledge of HIV/AIDS,and Public Stigma Among General Citizens of Japan: An Online Cross-Sectional Survey

Abstract

Background

This study aimed to examine how health literacy, knowledge of HIV/AIDS, and public stigma are associated with social distance toward people living with HIV/AIDS (PLWH), as a behavioral manifestation of stigma, among the general Japanese population.

Methods

We conducted an online cross-sectional survey targeting adults (age range: 20-60 s) from among the 2.2 million registrants in Rakuten Insight from September 20 to 25, 2019. Stratified randomized sampling was performed according to the region, sex, and age. The study participants were 2268 eligible for analysis (effective response rate: 90.7%).

Results

Models were examined using hierarchical multiple regression analysis. The results indicated that low-level knowledge of HIV/AIDS affected social distance to PLWH (B = 3.77, (95% CI, 1.30 to 6.24)). ‘Access,’ ‘understand,’ ‘appraise’ and ‘use’ of European health literacy survey questionnaire affected social distance to PLWH (B = .03, (-.07 to .13); - B = .15, (−.27 to −.04); B = .06, (−.04 to .17); B = −.07, (−.19 to .05)). Public stigma of HIV/AIDS affected social distance to PLWH (B = .97, (.92 to 1.01)).

Conclusions

These findings indicate that health literacy not only maintains and promotes individual health but also has the potential to reduce social distance toward PLWH.

Plain Language Summary Title

How knowing about HIV/AIDS and having health literacy can reduce negative attitudes and social distance toward people living with HIV in Japan

This study looked at how knowledge about HIV/AIDS and health literacy affect people's attitudes toward those living with HIV in Japan. HIV is a virus that can affect the immune system, and people living with HIV (PLWH) often face stigma, which means negative judgments or unfair treatment from others. Reducing stigma is important for the health and well-being of PLWH and for public health. We conducted an online survey with 2,268 adults aged 20 to 60 years using a panel provided by Rakuten Insight, a Japanese online survey company. Participants were selected to represent different regions, ages, and sexes in Japan. They answered questions about their knowledge of HIV/AIDS, their health literacy, and their attitudes toward PLWH. Health literacy refers to the ability to find, understand, evaluate, and use health information to make decisions about one's health. The results showed that people with less knowledge about HIV/AIDS tended to keep a greater social distance from PLWH, meaning they were more likely to avoid contact or have negative feelings toward them. People with higher health literacy were more likely to have closer, more positive attitudes. Public stigma was also strongly related to social distance. These findings suggest that improving health literacy and knowledge about HIV/AIDS in the general population may not only help people take better care of their own health but also reduce stigma toward PLWH. By learning accurate information about HIV and understanding how to use health information, people may become more accepting and supportive, which can improve the lives of PLWH and contribute to a healthier society.

Keywords

HIV/AIDS people living with HIV/AIDS (PLWH)social stigma social discrimination health literacy social distance to PLWH

Introduction

Since the start of surveillance in 1985, the number of newly reported HIV infections and AIDS cases in Japan continued to increase, exceeding 1500 in 2007. However, since 2013, the number of new reports has decreased, reaching 1057 by 2021.¹ Sexual contact is the main route of HIV transmission in Japan,¹ and a survey by the Japanese government reported that 85.3% of Japanese citizens were aware that HIV is primarily transmitted through sexual contact.²

Stigma toward people with HIV has been reported globally. Goffman defined stigma as “an attribute that is significantly discrediting”,³ while Link and Phelan described it as involving labeling, stereotyping, separation, status loss, and discrimination occurring together.⁴ In the HIV/AIDS research, stigma encompasses social and personal dimensions^5,6 with the personal dimension differentiating between stigmatizers and stigmatized individuals.⁷

Drawing from mental health stigma research, stigma at the individual level comprises public and self-stigma. Public stigma is defined as a “negative belief about a group, agreement with belief and/or negative emotional reaction, and behavioral response to prejudice”.⁸ Self-stigma represents the internalized negative beliefs and emotional responses of stigmatized individuals.⁸ Within the Health Stigma and Discrimination Framework,⁹ public stigma—encompassing negative beliefs, emotional reactions, and behavioral responses toward a stigmatized group—corresponds to ‘stigma practices’ manifested by the general population.

Extensive research on people living with HIV/AIDS (PLWH) self-stigma, including “internalized stigma” and “perceived stigma,” has demonstrated significant burdens on physical and mental health.⁷ UNAIDS's “Zero discrimination” vision for 2020¹⁰ reflects evidence that stigma hinders HIV testing and healthcare access. In Japan, most PLWH perceive disclosure as dangerous and actively conceal their HIV status,¹¹ underscoring stigma's continued significance.

While extensive research has examined self-stigma among PLWH, fewer studies have investigated public stigma—the stigmatizing attitudes held by the general population—particularly in Japan. Understanding public stigma is crucial because it directly contributes to discrimination and social exclusion of PLWH. Prior research has identified demographic factors (male gender, older age, less education, lower income),^12–14 homophobia and social conformity,¹⁴ and attributions of shame and self-responsibility¹⁵ as correlates of HIV/AIDS public stigma. The common-sense model of stigma, derived from mental illness research,¹⁶ identifies key evaluative dimensions including disease controllability, timeline, severity, and coherence.¹⁶

In recent years, increasing attention has been paid to the fact that individual mental health literacy (MHL) is a factor that can reduce public stigma toward people living with mental illness. Jorm conceptualized MHL as encompassing “(a) knowledge of how to prevent mental disorders, (b) recognition of when a disorder is developing, (c) knowledge of help-seeking options and treatments available, (d) knowledge of effective self-help strategies for milder problems, and (e) first aid skills to support others who are developing a mental disorder or are in a mental health crisis”.^17,18 Although there are various measures of MHL, many intervention studies have been conducted to reduce public stigma by improving MHL. Interventions to improve mental health literacy have demonstrated effectiveness in reducing mental illness stigma across various populations, including adolescents, workplace settings, and educational institutions.

Given the established relationship between MHL and reduced stigma toward mental illness, we hypothesized that general health literacy might similarly influence stigma toward PLWH. However, MHL and health literacy evolved separately.¹⁸ In the 2000s, health literacy was reconceptualized as an empowerment-oriented asset, defined as “people's knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and make decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course”.¹⁹ This definition informed the European Health Literacy Survey (HLS-EU),²⁰ subsequently adopted as a health policy outcome across Europe.²¹

Therefore, while MHL focuses on disease-specific factual knowledge and recognition skills, health literacy as conceptualized in the HLS-EU framework represents a broader construct associated with comprehensive empowerment. Although the HLS-EU definition includes the term “knowledge,” this refers to functional and procedural knowledge about navigating health information systems rather than factual content knowledge about specific diseases. The HLS-EU specifically measures self-perceived competencies across four information management domains (access, understand, appraise, apply) without assessing disease-specific factual knowledge. This distinction is crucial: an individual may possess extensive factual knowledge about HIV transmission and treatment while having limited competence in evaluating conflicting health information sources, and vice versa. These represent conceptually distinct pathways through which stigma reduction may occur. Health literacy as measured by HLS-EU may influence stigma through mechanisms distinct from disease-specific knowledge. However, this relationship between general health literacy and HIV-related stigma has not been fully investigated particularly in comparison with HIV-specific knowledge.

We examined social distance toward PLWH as the primary outcome. Social distance is a sociological concept proposed in the early twentieth century that describes the degree of empathetic understanding between individuals, between individuals and groups, and between groups.²² Later, in studies of stigma against people with mental illness,²³ social distance was used to assess stigmatizers’ behavioral intentions toward stigmatized individuals. We examined social distance as an indicator of discriminatory behavioral intentions toward PLWH, representing a manifestation of stigma practices within the Health Stigma and Discrimination Framework,⁹ which directly impacts their social integration and quality of life.

Given this background, the present study aimed to examine the independent and combined contributions of HIV-specific knowledge, general health literacy (HLS-EU-Q16), and public stigma toward HIV/AIDS in predicting social distance toward PLWH, targeting the general Japanese population.

Methods

Sampling

An online cross-sectional survey was conducted from September 20 to 25, 2019, targeting adults aged 20 to 69 years from the Rakuten Insight panel (2.2 million registrants). We employed stratified random sampling with three-way stratification: 11 geographic regions (Hokkaido, Tohoku, Kanto, Hokuriku, Tozan, Tokai, Kinki, Chugoku, Shikoku, North Kyushu, and South Kyushu), 2 sex categories, and 5 age groups (20-29, 30-39, 40-49, 50-59, 60-69 years), creating 110 strata. Sample allocation was proportional to the Japanese population distribution across strata.

To avoid response bias, we included the following screening items at the beginning of the survey: ‘Do you have an acquaintance living with HIV?’, “Are you currently living with HIV?” and “Which of the following are your sexual orientations?”. The study participants were 2500 heterosexual HIV-negative adults with no acquaintances, who were PLWH. Among these participants, 232 who provided incomplete responses were excluded from the analysis. The final analytical sample comprised 2268 participants (effective response rate: 90.7%). Sample size was determined using G*Power 3.1.²¹ For hierarchical multiple regression analysis with a medium effect size (f² = 0.15), α = 0.05, power = 0.85, and 24 total predictors, the required sample size was calculated to be 64.²⁴

Variables

Public Stigma

We used the 21-item 6-point scale developed by Mak et al.¹⁶ This scale measures the degree of public stigma perceptions and attitudes. It consists of two subscales. The Public Stigma (PS) subscale consists of 12 items, such as “People with HIV/AIDS are a burden to society” and “People with HIV/AIDS often cause troubles to others”. The Personal Advocacy (PA) subscale consists of nine items, such as “If I were an employer, I would provide job opportunities to people with HIV/AIDS,” and “I am willing to participate in volunteer services for people with HIV/AIDS.” The α coefficients for the Japanese version were 0.93 for 21 items. The items were scored on a 4-point Likert scale ranging from 1 (acceptable) to 4 (unacceptable). The reliability and validity of this scale have already been examined.²⁵ For the analysis, we used the total score across all 21 items, ranging from 0 to 100, with higher scores indicating greater public stigma.　

Social Distance to PLWH

In stigma research, social distance has been used to assess stigmatizers’ discriminatory behavioral intentions toward stigmatized individuals,²³ specifically, their willingness to engage in various forms of social contact. In this study, social distance represents participants’ behavioral intentions toward PLWH (ie, psychological willingness for social interaction), not physical proximity. This study was based on the questionnaire^26,27 created in “The Stigma in Global Context Mental Health Study” and translated into Japanese by Yamazaki et al. After reading the vignette (Mr A's case), in this study, there were nine items, including “Mr A will live in the neighborhood,” “Mr A will be a colleague at work,” and “Mr A will marry your relative.” The items were scored on a 4-point Likert scale ranging from 1 (acceptable) to 4 (unacceptable). The total social distance score was calculated by summing responses across all nine items (range: 9-36). The α coefficient is 0.93.

In addition, when applied to PLWH, the vignette content (see appendix) was revised based on the opinions of experts in PLWH research.

Health Literacy

The present study focused on the comprehensive health literacy of the general public in Japan. We used the Japanese version²⁸ of the HLS-EU short version (16-item version; HLS-EU-Q16)²⁹ created by the Consortium Health Literacy Project European,¹⁹ which was examined from this perspective. The reliability and validity of the Japanese short version have also been demonstrated.³⁰ The HLS-EU-Q16 comprises four subscales: access (four items), understanding (six items), appraise (three items), and apply/use (three items). It was measured on a 4-point Likert scale from “very easy” to “very difficult”.²⁹ As in previous studies,²⁸ a “don't know/not applicable” response option was provided, and this response was coded as a missing value. Based on previous studies, the score was converted to a range of 0–50 points and analyzed accordingly. For the analysis, we used the four domain scores separately (Access, Understand, Appraise, and Use) rather than a total health literacy score, as each domain may have distinct relationships with stigma-related outcomes.

Knowledge of HIV/AIDS

We provided the participants with eight statements to gauge their basic scientific knowledge about HIV, including “HIV is the name of a virus (human immunodeficiency virus) and AIDS is the name of a disease (acquired immunodeficiency syndrome)”, “If you are infected with HIV, but receive treatment, it is extremely difficult to develop AIDS”, and “If the level of HIV in the blood remains undetectable for more than 6 months as a result of treatment, HIV cannot be transmitted through sexual intercourse”. The responses were given on a 3-point scale: 0, “I just learned about it for the first time; 1, “I have heard of it; “and 2, “I know it well”. The content was set after consultation with experts on HIV/AIDS. The α coefficient is 0.86. The total knowledge score (range: 0-16) was categorized into three groups based on quartiles: low knowledge (below the 25th percentile), middle knowledge (25th to 75th percentile), and high knowledge (above the 75th percentile).

Attribute Variables

Gender, age, marital status, education, and job were used as attribute variables.

Statistical Methods

First, we confirmed the psychometric properties of the multiitem scale. We then examined associations between sociodemographic characteristics (sex, age, marital status, education, and occupation) and social distance to PLWH using multiple regression analysis. Subsequently, we conducted a hierarchical regression analysis with social distance to PLWH as the dependent variable. All models included sociodemographic characteristics as covariates. Variables were entered in three sequential steps to examine how associations change when additional predictors are included. Model 1 examined the association between HIV/AIDS knowledge and social distance, controlling for demographic covariates. Model 2 added the four HLS-EU-Q16 domains (Access, Understand, Appraise, Use) to examine whether the knowledge-social distance association is attenuated when information management competencies are included, which would suggest overlapping mechanisms or shared variance. Model 3 added public stigma (total score) to examine whether associations with knowledge and health literacy are attenuated when societal-level stigmatizing attitudes are included, which would indicate confounding or mediation by normative factors.

Missing values were handled using restricted maximum likelihood estimation. The statistical packages IBM SPSS 29 (Chicago, IL) were used for the analysis. The reporting of this cross-sectional study conforms to the STROBE statement³¹ (Supplementary File).

Results

The mean age of participants was 44.8 [13.6] years. Table 1 presents the sociodemographic characteristics and socioeconomic status of the sample. Table 2 shows the descriptive statistics and psychometric properties of the multi-item scales used in this study.

Table 1.

Socio-Demographic Attributions and Socioeconomic Status (N = 2268).

		n	(%)
Gender
	Male	1093	(48.2)
	Female	1175	(51.8)
Age group
	20–29	443	(19.5)
	30–39	452	(19.9)
	40–49	448	(19.8)
	50–59	469	(20.7)
	60–69	456	(20.1)
Marital status
	Married	1446	(63.8)
	Unmarried	655	(28.9)
	Divorced/ bereaved	167	(7.4)
Education
	12years or less	614	(27.1)
	13∼15 years	618	(27.2)
	16 years or more	1036	(45.7)
Job
	Health Care profession	134	(5.9)
	Welfare profession	87	(3.8)
	Other profession	248	(10.9)
	Manager/Self-employed	204	(9.0)
	Sales/Office	621	(27.4)
	Field worker	197	(8.7)
	Other jobs	190	(8.4)
	House keeping	344	(15.2)
	Other	243	(10.7)

Table 2.

Psychometric Properties of Each Multi-Item Scale (N = 2268).

Subscale Name		Number of Items	Range	Mean	(SD)	Cronbach's Alpha
HLS-EU-16
	Obtain/Access information relevant to health (n = 2027)	4	0–50	23.58	(10.30)	0.74
	Understand Information relevant to health (n = 2056)	6	0–50	31.88	(9.68)	0.83
	Evaluate/Appraise information relevant to health (n = 1872)	3	0–50	24.23	(10.70)	0.68
	Apply/use information relevant to health (n = 1.931)	3	0–50	27.91	(10.00)	0.67
Knowledge of HIV/AIDS		8	0–16	5.29	(3.79)	0.86
Public Stigma		21	0–100	41.91	(15.56)	0.93
Social Distance Scale		9	9–36	18.23	(5.95)	0.93

HLS-EU-Q16: European health literacy survey questionnaire 16.

Note: n indicates the number of participants with non-missing data for each variable.

Table 3 shows the association between sociodemographic attributes, socioeconomic status and social distance to PLWH. Social distance was significantly greater among men than among women (B = 6.82; 95% CI, 4.65-8.99), and was greatest in those in their 60 s compared to younger groups. Regarding education, participants with 12 years or less of education showed greater social distance than those with 16 years or more (B = 4.32; 95% CI, 2.05-6.59). By occupation, those in Sales/Office positions (B = 4.81; 95% CI, 0.71-8.90) and homemakers (B = 6.58; 95% CI, 2.07-11.10) showed significantly greater social distance compared to medical professionals.

Table 3.

A Linear Regression Model of Attribute Variables on Social Distance to PLWH.

		B	95%CI [lower upper]	P
Intercept		28.35	[23.30 to 33.39]	<.001
Gender
	Male	6.82	[4.65 to 8.99]	<.001
	Female	ref
Age group
	20–29	-5.20	[-8.32 to -2.07]	0.001
	30–39	-5.92	[-8.91 to -2.93]	<.001
	40–49	-4.62	[-7.58 to -1.65]	0.002
	50–59	-4.07	[-6.96 to -1.17]	0.006
	60–69	ref
Marital status
	Married	ref
	Unmarried	1.68	[-0.56 to 3.93]	0.141
	Divorced/ bereaved	-0.40	[-4.26 to 3.47]	0.841
Education
	12years or less	4.32	[2.05 to 6.59]	<.001
	13∼15 years	1.22	[-1.07 to 3.51]	0.297
	16 years or more	ref
Job
	Health Care profession	ref
	Welfare profession	0.25	[-5.64 to 6.14]	0.934
	Other profession	4.11	[-0.54 to 8.75]	0.084
	Manager/Self-employed	2.44	[-2.43 to 7.31]	0.327
	Sales/Office	4.81	[0.71 to 8.90]	0.021
	Field worker	4.68	[-0.24 to 9.60]	0.062
	Other jobs	3.65	[-1.22 to 8.52]	0.142
	Homemaker	6.58	[2.07 to 11.10]	0.004
	Other	2.41	[-2.36 to 7.18]	0.323
AIC		20325.76

PLWH: people living with HIV

AIC: Akaike Information Criterion

The dependent variable is social distance to PLWH

Table 4 presents the results of hierarchical multiple regression analyses examining the association between knowledge of HIV/AIDS, health literacy domains (HLS-EU-Q16), public stigma, and social distance to PLWH, adjusting for sociodemographic attributes and socioeconomic status. In Model 1, participants with low knowledge of HIV/AIDS showed significantly greater social distance from PLWH compared to those with high knowledge (B = 12.15; 95% CI, 9.04-15.27). When the four HLS-EU-Q16 domains were added in Model 2, the knowledge effect remained significant but was somewhat attenuated (B = 9.85; 95% CI, 6.33-13.37). Among the health literacy domains, “Understanding information” was negatively associated with social distance (B = -0.45; 95% CI, −0.61 to −0.29), while “Appraising information” showed a positive association (B = 0.24; 95% CI, 0.09-0.38).

Table 4.

Effects of Knowledge of HIV/AIDS, Health Literacy, and Public Stigma of HIV/AIDS on Social Distance Towards PLWH.

		Model1				Model2				Model3
			95%CI				95%CI				95%CI
		B	[lower upper]	β	P	B	[lower upper]	β	P	B	[lower upper]	β	P
	Intercept	26.68	[22.35 to 31.01]			42.69	[36.66 to 48.73]			−2.14	[−6.83 to 2.54]
Knowledge of HIV/AIDS
	Low	12.15	[9.04 to 15.27]	0.21	<.001	9.85	[6.33 to 13.37]	0.17	<.001	3.77	[1.30 to 6.24]	0.06	0.003
	Middle	3.78	[1.31 to 6.24]	0.08	0.003	2.87	[0.30 to 5.44]	0.06	0.029	0.40	[−1.40 to 2.20]	0.01	0.660
	High	ref				ref				ref
HLS-EU-Q16
	Access information					−0.02	[−0.16 to 0.13]	−0.01	0.837	0.03	[−0.07 to 0.13]	0.01	0.534
	Understand information					−0.45	[−0.61 to −0.29]	−0.20	<.001	−0.15	[−0.27 to −0.04]	−0.07	0.008
	Appraise information					0.24	[0.09 to 0.38]	0.11	0.002	0.06	[−0.04 to 0.17]	0.03	0.226
	Use information					−0.18	[−0.35 to 0.00]	−0.08	0.048	−0.07	[−0.19 to 0.05]	−0.03	0.260
Public stigma of HIV/AIDS										0.97	[0.92 to 1.01]	0.68	<.001
AIC			20257.36				15678.47				14426.65

PLWH: people living with HIV.

AIC: Akaike information criterion.

Adjusted for gender, age, marital status, education and job.

Dependent variables were social distance to PLWH.

In the final model (Model 3), which included public stigma, the low HIV/AIDS knowledge significantly associated with greater social distance (B = 3.77; 95% CI, 1.30-6.24). Among the health literacy domains, only “Understand information” retained its negative association (B = -0.15; 95% CI, −0.27 to −0.04), while the effect of “Appraising information” became non-significant (B = 0.06; 95% CI, −0.04 to 0.17). Public stigma of HIV/AIDS showed a significant positive association with social distance (B = 0.97; 95% CI, 0.92-1.01).

Discussion

This study examined social distance toward PLWH as an indicator of discriminatory behavioral intentions and a manifestation of public stigma. We first confirmed associations between demographic factors and social distance to PLWH. Consistent with prior research on HIV-related stigma,^12–14 male gender, older age and lower educational attainment were significantly associated with greater social distance to PLWH. These finding underscore the importance of adjusting for these demographic variables when examining the effects of health literacy and HIV knowledge.

Regarding occupation, social distance was the shortest among health professionals and the greatest among homemakers and white-collar workers. While stigma and discrimination among healthcare providers toward PLWH have been well-documented,¹¹ our findings suggest that discriminatory behavioral intentions may be even greater among certain non-healthcare occupations. This warrants further investigation and tailored intervention approaches.

The hierarchical regression analysis demonstrated both independent and combined contributions of health literacy domains and public stigma to social distance toward PLWH. Among the HLS-EU-Q16 domains, “Understanding information” showed a negative association with social distance that was attenuated but retained when public stigma was added to the model, while “Use information” showed a negative association that was substantially attenuated with the addition of public stigma. Public stigma itself demonstrated a strong positive association with social distance. These patterns suggest that different health literacy domains operate through distinct pathways in relation to social distance. The substantial attenuation of the “use information” association indicates that information utilization capacity primarily contributes to social distance through the formation of stigma-related perceptions and attitudes toward PLWH. In contrast, the retained association of “understanding information” suggests that basic comprehension of health information may contribute to social distance beyond its role in stigma formation, possibly through reducing uncertainty and diffuse fears regarding infection risks.

Public stigma itself showed a strong positive association with social distance. This finding is consistent with previous studies on stigma toward people with mental illness,^16,32 which has conceptualized social distance as a behavioral manifestation of public stigma.²³

However, an unexpected finding emerged for “appraise information.” In the model without public stigma adjustment, higher ability to evaluate health information was associated with greater social distance to PLWH. This counterintuitive association disappeared when public stigma was controlled, suggesting it was largely confounded by public stigma. The mechanism underlying this unexpected association remains unclear. One possibility is that individuals with higher appraisal skills may focus more on risks and negative aspects when critically evaluating information about PLWH, which could paradoxically contribute to greater social distance. However, this interpretation is speculative and requires further investigation through replication studies.

These findings have implications for public health interventions to reduce stigma toward PLWH. Knowledge campaigns such as the “U = U (undetectable = untransmittable)” initiative^33,34 provide important accurate information about HIV transmission. However, our findings suggest that improving the ability to understand and use health information—not just providing knowledge—may also contribute to reducing discriminatory behavioral intentions. Future stigma reduction efforts may benefit from integrating health literacy enhancement with HIV-specific education.

These findings also have important implications for developing targeted interventions for high-stigma groups. Given that health literacy—particularly the ability to understand health information—and HIV knowledge were associated with reduced social distance in this study, stigma-reduction interventions might be enhanced by addressing both dimensions. For instance, interventions targeting homemakers could leverage community-based settings where peer learning facilitates health literacy development. Programs for older adults may require age-appropriate materials and delivery methods that account for potential differences in health information processing. For men, who showed greater social distance in this study, workplace-based or male-targeted outreach programs integrating health literacy skills with HIV education may be particularly relevant. These demographic-specific approaches warrant empirical evaluation in future intervention research.

To the best of our knowledge, this study is one of the few to attempt to clarify the relationship between health literacy and public stigma toward PLWH, and the results are of theoretical and practical significance. However, the following limitations of this study should be noted.

First, this was an online survey and the sample was drawn from a panel administered by a survey agency. Although the panel used in this study is one of the largest in Japan, the reproducibility of other sampling methods, such as the Basic Resident Register, needs to be examined. Additionally, this study excluded participants who were HIV-positive or knew someone with HIV to focus on stigma among the general population without direct contact experience. Future research should examine whether these findings are replicated among populations with greater exposure to PLWH, such as healthcare workers or individuals in communities with higher HIV prevalence.

Second, as this was a cross-sectional study, no causal relationships could be established. Longitudinal or experimental studies are needed to examine causal pathways and temporal relationships between health literacy, HIV knowledge, public stigma, and discriminatory behavioral intentions.

Third, this study relied on self-reported behavioral intentions, which may differ from actual behaviors and may be subject to social desirability bias. Future research could incorporate behavioral experiments or implicit measures of attitudes to more directly assess discriminatory behaviors toward PLWH.

Fourth, this study examined stigma only at the individual level and did not address how structural, institutional, or community-level factors shape stigma toward PLWH. Future research should adopt multilevel approaches that examine interactions between individual attitudes and broader social contexts, including healthcare systems, workplace policies, and media representations of HIV/AIDS.

Conclusions

This study examined the independent and combined contributions of HIV/AIDS knowledge, health literacy domains, and public stigma to social distance toward PLWH among the general Japanese population. Different HLS-EU-Q16 domains demonstrated distinct patterns: “Understanding information” retained its negative association even after controlling for public stigma (cognitions and attitudes), while “Use information” showed substantial attenuation, indicating different pathways. Public stigma demonstrated the strongest association with social distance. These findings highlight the importance of addressing both health literacy and stigma in interventions aimed at reducing social distance. Given that health literacy—particularly understanding information—and HIV knowledge were associated with reduced social distance, targeted interventions for high-stigma groups (eg, homemakers, older adults, men) should integrate health literacy enhancement with stigma reduction, using demographic-specific approaches such as community-based peer learning or workplace-based programs. These approaches warrant empirical evaluation in future intervention research.

Supplemental Material

sj-docx-1-jia-10.1177_23259582251414562 - Supplemental material for Health Literacy, Knowledge of HIV/AIDS, and Public Stigma Among General Citizens of Japan: An Online Cross-Sectional Survey

Supplemental material, sj-docx-1-jia-10.1177_23259582251414562 for Health Literacy, Knowledge of HIV/AIDS, and Public Stigma Among General Citizens of Japan: An Online Cross-Sectional Survey by Taisuke Togari, PhD, RN, Yoji Inoue, PhD, RN, and Sakurako Abe, PhD, RN in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Footnotes

Acknowledgements

We would like to thank all the people who cooperated in conducting this survey.

ORCID iD

Taisuke Togari

Ethical Considerations

The authors declare that all methods were carried out in accordance with relevant guidelines and regulations. They also declare that all procedures contributing to this work have been performed in accordance with the ethical standards of the relevant national and institutional committees on human experimentation and the Helsinki Declaration of 1975, as revised in 2008. Ethical approval was obtained from the Open University of Japan Institutional Review Board committee (2019-30).

Consent to Participate

All study subjects participated in the survey with electronic informed consent.

Authors’ Contributions

TT and YI conceptualized the project; TT provided guidance in the analyses; TT and SA conducted the data analyses; TT drafted the manuscript; all authors participated in writing the manuscript and approved the final version for submission.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Japan Society for the Promotion of Science, (grant number 19H03928).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability

The datasets generated and/or analyzed in this study are not publicly available to protect the privacy of the participants but are available from the corresponding author on reasonable request.

Supplemental material

Supplemental material for this article is available online.

Appendix Vignette Contents for the Social Distance Toward PLWH Scale

Mr A (35 years old, male, single), who works for a major trading company, was found to be HIV-positive and is receiving treatment at a hospital. Mr A told his coworkers that he was HIV-positive, and with their understanding, he achieved a lot of results. However, Mr A's current job makes it difficult for him to take time off and he is overworked, so he decided to change to a less burdensome job. His doctor thought the same.

Mr A contacted several companies on the condition that they understood he was a PLWH and would hire him, but none did. Mr A currently has to take oral medicine every day. He has to take time off from his job once every few months for medical examinations and tests at a specialized hospital. In the past, he was hospitalized for several weeks because of side effects when switching from oral medication to a new type.

However, Mr A currently has no symptoms and can commute to work every day without any problems. In addition, Mr A has an honest personality. He can perform his work just like any other person. Mr A suspected that he would not be able to change jobs because he was a PLWH, and he felt deep regret.

References

JapanNationalInstituteofInfectiousDisease. The topic of HIV/AIDS in Japan. Infectious Agent Surveillance Report (IASR). 2022;43(10):221-230.

Office

. Overview of the Public Opinion Survey on HIV/AIDS. https://survey.gov-online.go.jp/hutai/h29/h29-hiv.pdf Accessed 07/18, 2023.

Goffman

. Stigma: Notes on the Management of Spoiled Identity. Prentice Hall; 1963.

Link

Phelan

. Conceptualizing stigma. Annu Rev Sociol. 2001;27(1):363-385. doi:10.1146/annurev.soc.27.1.363

Cook

Purdie-Vaughns

Meyer

Busch

JTA

. Intervening within and across levels: A multilevel approach to stigma and public health. Soc Sci Med. 2014;103:101-109. doi:10.1016/j.socscimed.2013.09.023

Deacon

. Towards a sustainable theory of health-related stigma: Lessons from the HIV/AIDS literature. J Community Appl Soc Psychol. 2006;16(6):418-425. doi:10.1002/casp.900

Earnshaw

Chaudoir

. From conceptualizing to measuring HIV stigma: A review of HIV stigma mechanism measures. AIDS Behav. 2009;13(6):1160-1177. doi:10.1007/s10461-009-9593-3

Corrigan

Watson

. Understanding the impact of stigma on people with mental illness. World Psychiatry. 2002;1(1):16-20.

Stangl

Earnshaw

Logie

, et al. The Health Stigma and Discrimination Framework: A global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Med. 2019;17:31. doi:10.1186/s12916-019-1271-3

10.

UNAIDS. 2020 Global AIDS Update: Seizing the moment: Tackling entrenched inequalities to end epidemics. https://www.unaids.org/en/resources/documents/2020/global-aids-report Accessed Aug, 2023.

11.

team HFJp. The summary of HIV Futures Japan 3rd research https://survey.futures-japan.jp/result/3rd/.

12.

Stringer

Turan

McCormick

, et al. HIV-Related Stigma among healthcare providers in the deep south. AIDS Behav. 2016;20(1):115-125. doi:10.1007/s10461-015-1256-y

13.

Wong

. Prevalence and factors associated with HIV/AIDS-related stigma and discriminatory attitudes: A cross-sectional nationwide study. Prev Med. 2013;57(Suppl):S60-S63. doi:10.1016/j.ypmed.2013.03.013

14.

Yeo

TED

Chu

. Social-cultural factors of HIV-related stigma among the Chinese general population in Hong Kong. AIDS Care. 2017;29(10):1255-1259. doi:10.1080/09540121.2017.1282601

15.

Mak

Cheung

Woo

Cheung

Lee

. Comparative stigma of HIV/AIDS, SARS, and tuberculosis in Hong Kong. Soc Sci Med. 2006;63(7):1912-1922. doi:10.1016/j.socscimed.2006.04.016

16.

Mak

Chong

Wong

. Beyond attributions: Understanding public stigma of mental illness with the common sense model. Am J Orthopsychiatry. 2014;84(2):173-181. doi:10.1037/h0099373

17.

Jorm

. Mental health literacy: Empowering the community to take action for better mental health. Am Psychol. 2012;67(3):231-243. doi:10.1037/a0025957

18.

Jorm

. The concept of mental health literacy. In: Okan

Bauer

Levin-Zamir

Pinheiro

Sørensen

, eds. International Handbook of Health Literacy: Research, Practice and Policy Across the Life-Span. Policy Press; 2019:53-66.

19.

Sørensen

Van den Broucke

Fullam

, et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health. 2012;12:80. doi:10.1186/1471-2458-12-80

20.

Sørensen

Van den Broucke

Pelikan

, et al. Measuring health literacy in populations: Illuminating the design and development process of the European health literacy survey questionnaire (HLS-EU-Q). BMC Public Health. 2013;13:948. doi:10.1186/1471-2458-13-948

21.

van der Heide

Heijmans

Rademakers

. Health literacy policies: European perspectives. In: Okan

Bauer

Levin-Zamir

Pinheiro

Sørensen

, eds. International handbook of health literacy: research, practice and policy across the lifespan. Policy Press; 2019:403‐418.

22.

Bogardus

. Measurement of personal-group relations. Sociometry. 1947;10(4):306-311. doi:10.2307/2785570

23.

Link

Phelan

Bresnahan

Stueve

Pescosolido

. Public conceptions of mental illness: Labels, causes, dangerousness, and social distance. Am J Public Health. 1999;89(9):1328-1333. doi:10.2105/ajph.89.9.1328

24.

Faul

Erdfelder

Buchner

Lang

A-G

. Statistical power analyses using G*power 3.1: Tests for correlation and regression analyses. Behav Res Methods. 2009;41(4):1149-1160. doi:10.3758/BRM.41.4.1149

25.

Togari

Inoue

Abe

. Development of a Japanese version of the public stigma scale and the applicability of the stigma model to HIV/AIDS field. The Journal of AIDS Research. 2025;27(3):154-165.

26.

Yamazaki

Matoba

Kikuzawa

Sakano

. Eyes and stigma towards mental illness: national survey research. Akashi Shoten; 2012.

27.

Kikuzawa

Pescosolido

Kasahara-Kiritani

Matoba

Yamaki

Sugiyama

. Mental health care and the cultural toolboxes of the present-day Japanese population: Examining suggested patterns of care and their correlates. Soc Sci Med. 2019;228:252-261. doi:10.1016/j.socscimed.2019.03.004

28.

Nakayama

Osaka

Togari

, et al. Comprehensive health literacy in Japan is lower than in Europe: A validated Japanese-language assessment of health literacy. BMC Public Health. 2015;15:505. doi:10.1186/s12889-015-1835-x

29.

Pelikan

Röthlin

Ganahl

. Measuring comprehensive health literacy in general populations: validation of instrument, indices and scales of the HLS-EU study: 6th Annual Health Literacy Research Conference November 3-4, 2014 Bethesda, Maryland, Hyatt Regency Bethesda https://www.bumc.bu.edu/healthliteracyconference/files/2014/06/Pelikan-et-al-HARC-2014-fin.pdf Accessed 07/17, 2023.

30.

Maie

Kanekuni

Yonekura

Nakayama

Sakai

. Evaluating short versions of the European health literacy survey questionnaire (HLS-EU-Q47) for health checkups. 総合健診. 2021;48(4):351-358. doi:10.7143/jhep.2020-28

31.

von Elm

Altman

Egger

Pocock

Gøtzsche

Vandenbroucke

. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies. Lancet. 2007;370(9596):1453-1457. doi:10.1016/S0140-6736(07)61602-X

32.

Lem

Kawata

KHDS

Kobayashi

Oyama

. Public stigma related to people with mental health conditions among Japanese company employees. J Clin Med Res. 2023;15(3):139-147. doi:10.14740/jocmr4868

33.

The Lancet H. U=U taking off in 2017. Lancet HIV. 2017;4(11):e475. doi:10.1016/S2352-3018(17)30183-2

34.

Calabrese

Kalwicz

Zaheer

, et al. The potential role of undetectable=untransmittable (U=U) in reducing HIV stigma among sexual minority men in the US. AIDS Behav. 2024;28(2):741-757. doi:10.1007/s10461-023-04263-1

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