Introduction

Schizophrenia is one of the chronic mental disorder characterized by significant alterations in thought, perception, mood, and social conduct1. People with schizophrenia frequently find it difficult to go about their everyday lives normally, which has an impact on their employment and social contacts2. Family members or other close relatives who provide unpaid financial, social, psychological, and physical support to patients are known as primary caregivers3. Family members are important partners in the rehabilitation process and assume a major role as primary caregivers for individuals with schizophrenia4,5.

Expressed emotion (EE) refers to the level of emotion expressed by primary caregivers toward other people, typically assessed in terms of criticism, hostility, or emotional overinvolvement3. Expressed emotion (EE) comprises two major components, namely Emotional overinvolvement (EOI) and critical comments (CC). Emotional overinvolvement (EOI) refers to the attitudes or feelings of self-sacrifice and overprotection that family members display toward a patient, while critical comments (CC) indicate the negative assessment of a patient’s behavior; and hostility which involves uncontrollably high levels of anger and irritation that follow CC3.

When one or more of these components are present in at least one member of the family, the family’s EE is referred to be high. Warmth and positive regard lead to positive interpersonal dynamics and strengthen ties with others; hostility, EOI, and CC tend to have a negative evaluation and can strain relationships6,7. The hostility and CC components are shown to overlap considerably. As such, the EE-based primary caregiver classification system mainly depends on determining the EOI and CC levels of each caregiver8.

High rates of relapse in people with schizophrenia are linked to high levels of expressed emotion in families, particularly in those who have been the primary caregiver for at least 6 months. Long-term caregiving, especially when it involves constant close contact, can exacerbate these emotions and potentially hinder recovery, highlighting the importance of supportive and balanced family environments for those living with schizophrenia3.

Emotional expression is thought to have a relationship with a several clinical and social aspects of how people with mental illness and the primary caregivers in their families function. These variables include the number of family members living with people who are struggling with mental health issues, work status, cognitive capacities, frequency of hospitalizations, length of illness, and duration of untreated psychosis9.

Recent studies have shown that the prevalence of highly expressed emotion among primary caregivers of people with schizophrenia ranges from 21% to 63%. This variation highlights the significant emotional burden that caregivers often experience12,13.

Approximately half of patients living with either a spouse or parents experienced readmission following discharge, whereas 30% of those living independently experienced readmission3. Reactions from high expressed emotion (HEE) family caregivers may create a negative emotional atmosphere, potentially increasing stress for persons with schizophrenia and precipitating a relapse14,15,16. Returning to family environments characterized by high expressed emotion (HEE), including criticism, excessive emotional involvement, or hostility, is associated with an elevated risk of recurrence compared with individuals returning to families characterized by low expressed emotion17,18,19,20.

However, despite progress in understanding EE and its components, further research is essential to gather data from diverse cultural backgrounds for comparative analysis and to deepen comprehension of this phenomenon. Therefore, examining EE dimensions across various cultural contexts is imperative, as EE is strongly influenced by social and cultural factors21,22. Studying Expressed Emotion (EE) among caregivers of individuals with schizophrenia in Eastern Ethiopia is crucial because the expression and impact of EE are deeply influenced different factors, which vary significantly across regions. These factors may shape how caregivers express emotion and how such expression affects patient outcomes. Without region-specific data, interventions may not be culturally appropriate or effective. Therefore, understanding EE in this context is essential for developing tailored mental health strategies, supporting caregivers, and improving recovery outcomes for individuals with schizophrenia.

Therefore, this study aims to assess the EE of primary caregivers and its associated factors with the addition of new variables such as depression, anxiety, and medication payment modality among primary caregivers of patients with schizophrenia receiving follow-up treatment at public hospitals in Harari Regional State and the Dire Dawa city administration.

Methods and materials

Study area and period

The study was conducted among public hospitals found in Harari Regional State and Dire Dawa Administrative City. There are two public hospitals in the Harari Regional State that provide psychiatric treatment and one referral hospital that provides psychiatric treatment in Dire Dawa city. Accordingly, Hiwot Fana Comprehensive Specialized Hospital (HFUSH), Jogol General Hospital (JGH), and Dill Chora Referral Hospital (DCRH) were selected because they are the only hospitals that serve as psychiatry treatment units in the study area. The study was conducted from June 1 to 30, 2024.

Study design

A hospital-based cross-sectional study design was used.

Population

Source of population

All primary caregivers of people living with schizophrenia on follow-up at HFCSUH, JGH, and DCRH.

Study population

All primary caregivers of people living with schizophrenia in HFCSUH, JGH, and DCRH who are available during the data collection period from June 1 to June 30, 2024.

Inclusion and exclusion criteria

Inclusion criteria

Primary caregivers who are \(\:\ge\:\)18 years of age and who have stayed with patients for at least six months23.

Exclusion criteria

Primary caregivers who are not competent in providing information due to difficulty in communication.

Sample size determination

The sample size required for this study was determined via a single population proportion formula by considering an estimated prevalence of highly expressed emotion of 50.5%24, a 5% margin of error, a 95% confidence interval, and a 10% nonresponse rate.

$${\text{n}} = \frac{{{{\left( {{\text{Z}}\alpha /2} \right)}^2} \times {\text{p}}(1 - {\text{p}})}}{{{{\text{d}}^{\text{2}}}}}$$

where n is the sample size, P is the expected prevalence (proportion) of expressed emotion, d is the margin of error and Z is the standard score, which corresponds to 1.96.

Therefore, the total sample size is determined by using the above formula P = 50.5%24.

Z = 1.96 at 95% CI d = 5% (0.05) n = 384 + 38 = 422.

After adding 10% (384 × 0.10 = 38) nonrespondents, the total sample size for this study was 384 + 38 =  422.

The maximum sample size that was used for the study of expressed emotion among primary caregivers of people with schizophrenia was 422.

Sampling procedure and technique

The samples were proportionally allocated to each hospital on the basis of primary caregivers who accompany people with schizophrenia and who were on follow-up at each hospital. The sampling interval was calculated by dividing the total number of primary caregivers in the selected hospitals by the required sample size (K = N/n). The participants were then selected via systematic sampling with every Kth interval.

According to the Health Management Information System (HMIS) of Hiwot-Fana Comprehensive Specialized Hospital, Jogol General Hospital, and Dill Chora Referral Hospital, the psychiatry treatment unit provides treatment to an average of 400, 150, and 300 people living with schizophrenia, respectively, who visit with their primary caregiver each month. Thus, the total number of primary caregivers of people living with schizophrenia per month in the three hospitals was 850. Therefore, the sampling interval (K) was determined by dividing the expected number of primary caregivers of people living with schizophrenia per month by 850 divided by the sample size “422” to obtain a sampling interval (K) of “2”. The data were subsequently collected from each study participant with an interval of “2” until the desired sample size was reached. However, the first participant (random start) was chosen via the lottery method. If the patient had two or more caregivers, one primary caregiver was selected via the lottery method.

Data collection methods

Data collection tools

Sociodemographic characteristics: Interviewer-administered structured and semi-structured questionnaire were used to investigate the characteristics of primary caregivers (10items) and the patients(4items). The characteristics of the primary caregivers include age, sex, religion, marital status, educational status, residence, occupation, kinship, and average monthly income. The characteristics of the patients include age, sex, educational level, and marital status.

Clinical characteristics: Interviewer-administered structured and semi-structured questionnaires were used to investigate the clinical characteristics. It includes Caregiver Depression, Caregiver Anxiety, Illness severity of patients, number of admissions, History of mental illness primary caregiver in life, another family history of mental illness and known medical diagnosis.

Family Questioner (FQ): Expressed emotions of primary caregivers among people living with schizophrenia was assessed by using FQ. it contains 20 items, divided into two domains—CC (10 items—2, 4, 6, 8, 10, 12, 14, 16, 18, 20) and EOI (10 items—1, 3, 5, 7, 9, 11, 13, 15, 17, 19) with each maximum value 40 points. The items in the two domains reflect different situations that the family members use to cope with their daily problems. To complete the questionnaire, the family members had to indicate how frequently they deal with the schizophrenia patients in determined situations. Possible responses are never or very rarely, rarely, frequently, and very frequently, ranging from one to four, for each item. Respondents should provide only one response for each item. The higher the score, the greater the number of critical comments, and the greater the emotional overinvolvement of the family members. The cutoff values on the FQ determined by the author of the original version of the instrument High Expressed Emotion: If respondents score above 23 in critical comments or above 27 in emotional overinvolvement or both on family questioner and Low Expressed Emotion: If respondent score 23 and below in critical comments or score 27 and below 27 in emotional overinvolvement or in both on family questionnaire25,26,27,28. For the current study, the internal consistency of EOI was found cronbach’s alpha, α = 0.935 for CC, α = 0.872. For overall items the internal consistency in this study was Cronbach’s α = 0.869.

PHQ-9: To screen depression, the Patient Health Questionnaire (PHQ-9) was used. It is a 9-point item questionnaire and every item incorporate a 4-point Likert scale that ranges from 0 (“not at all”) to 3 (“nearly every day”), generating a complete score starting from 0 to 27. Moreover, PHQ-9 has been validated in Ethiopian healthcare context with specificity and sensitivity of 67 and 86%, respectively. A cutoff point of 10 and above has was used to screen depression among study participants29the internal consistency of PHQ9 was found cronbach’s alpha, α = 0.756.

GAD-7: To screen anxiety, the Generalized Anxiety Disorder (GAD-7) was used. It is a 7- point item questionnaire and every item incorporates a 4-point Likert scale that ranges from 0 (“not at all”) to 3 (“nearly every day”), generating primary a complete score starting from 0 to 21. A cutoff point at a score of 10 and above on the GAD-7 scale had been defined as anxiety with a sensitivity and specificity of 89% and 82%, respectively30. The internal consistency of GAD-7 in the current study was found to be cronbach’s alpha, α = 0.732.

Oslo social support scale: The OSSS-3 is a self-reported social support scale. It consists of 3 items with a total score ranging from 3 to 14. Scores from 3 to 8 are considered to indicate poor support, scores from 9 to 11 indicate intermediate support, and a score between 12 and 14 is considered to indicate strong social support31. The internal consistency of OSS in the current study was found to be cronbach’s alpha, α = 0.823.

Zarit burden interview (ZBI-12): A questionnaire was used to assess the perceived burden among study participants. This scale has 12 items and they are defined subjectively. Each item is graded on a 4-point scale, from never to almost always present. Total ratings range from 0 (low load) to 48 (high burden). The cutoff points for ZBI-12 are 0 for no burden, 1–10 for mild burden, 10–20 for moderate burden, and greater than 20 for severe burden32. The internal consistency of ZBI-12 in the current study was found to be cronbach’s alpha, α = 0.823.

The family interview schedule: A questionnaire was used to assess perceived stigma among primary caregivers. The FIS includes 14 questions about the family‘s experience of stigma in the community. Each stigma item was rated on a four-point scale, not at all (0), sometimes1, often2, and a lot3 concerning stigma. To assess the distribution of stigma responses between groups, a stigma sum score was computed by summarizing all positive responses ≥ 1 for each of the 14 items. Those study participants who score below the mean score was considered as having “low sigma”, and those who score above the mean score was considered as having “high stigma”33. The internal consistency in this study was Cronbach’s α = 0.813.

Clinical global impression (CGI): A standard questionnaire used to assess the Perceived severity of the illness has three sections; symptom severity for the last four weeks, degree of change in symptom since starting treatment, degree of change in experiencing care34.

Every substance: is the use of a substance during a lifetime.

Current substance: is the use of a substance in the last 3 months35.

Data collectors and supervisors

To enhance the efficiency of the data collection process, two BSc psychiatric professionals at HFSUH, One BSc psychiatric professionals at JGH and two BSc psychiatric professionals at DCRH currently operate within the study area were recruited. In addition, two MSc mental health professional specialists was assigned as supervisors.To assure data quality, the team was trained and oriented for one day regarding the tools, objectives, methods of data collection, and other related ethical issues.

Data collection procedures

A semistructured and structured questionnaire was prepared to gather information from the study participants. The data were collected from each participant by interviewing them via an interviewer-administered questionnaire.

Data quality control

The questionnaire was prepared first in English and then translated into the local languages Afan Oromo, Amharic, and Somali. Then, it was returned to English to ensure the consistency of the tools. A pretest study was conducted on 5% of the sample population one week before actual data collection at Haramaya General Hospital one week before actual data collection to check tool consistency. The results of the pretest study show that the tools have good internal consistency, as indicated by Cronbach’s α = 0.813. The data collectors and supervisors were trained for one day. Throughout the data collection, supervision was provided by the supervisor and principal investigator to maintain the quality of the data.

Methods of data processing and analysis

The collected data were checked, coded, and entered into Epi-data version 4.6, and then the data were exported to STATA version 14 statistical software for cleaning and analysis. Descriptive statistics such as frequencies and percentages for categorical data and medians and interquartile ranges for continuous data were calculated. Bivariable logistic regression was computed to select variables with a p value < 0.25 as candidate variables for multivariable logistic regression analysis. Finally, variables with p values < 0.05 were considered statistically significant with AORs with 95% CIs to determine the strength of the associations between associated factors and outcome variables. Model fitness was checked via the Hosmer–Lemeshow test, and the assumption was fulfilled (the p value was 0.69). Multicollinearity was checked for the overall model by the variance inflation factor (VIF), and the VIF was < 5 for all independent variables (Fig. 1).

Fig. 1
figure 1

Schematic representation of the sampling method used to assess expressed emotion and its associated factors among primary caregivers of people with schizophrenia at public hospitals in the Harari regional state and Dire Dawa City Administrative, Eastern Ethiopia, 2024

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Ethical considerations

Ethical clearance was obtained from the Institutional Health Research Ethics Review Committee (C/AC/R/D/01/6384/1) College of Health and Medical Science of Haramaya University. A formal permission letter was then sent to HU-HFCSH, JGH, and DCRH before data collection. Before the questionnaires were interviewed, the objectives and advantages of the study were clearly explained to the participants, who were informed, voluntarily written, and signed consent was obtained from both hospital heads and participants. Every participant has the right to refuse or discontinue participation at any time they want. For the issue of confidentiality, the participant’s name was not asked, and all other personal information was kept secret. The data collectors provided their signatures because they obtained written consent (fingerprint those unable to read and write) for the interviews with the respondents.

Results

Sociodemographic and economic characteristics of the study participants

Out of 422 individuals, a total of 414 primary caregivers of people living with schizophrenia were included in the final analysis, yielding a response rate of 98.1%. Eight samples were found to be insufficient because of incomplete responses and were discarded. The median age of primary caregivers was 35 years, with an IQR of 16. Out of the 414 primary caregivers of people living with schizophrenia, 132 (31.88%) were in the age group of 28–37 years, and in this study, more than half of the 214 (51.69%) of them were female. Additionally, 281 (67.87%) were married, 201 (48.55%) were Oromo by ethnicity, and 211 (51.97%) were Muslim religious followers. With respect to education, 147 (35.51%) of the respondents had attended primary school. In terms of occupation, 113 (27.29%) were housewives. More than half of the respondents, 215 (51.93%), were rural residents, 124 (29.95%) lived 8 km from the hospital, and 269 (64.98%) earned a monthly income of less than 3224 ETB, placing them below the poverty line. Among their kin, 110 (26.57%) were siblings (Table 1).

Table 1 Sociodemographic and economic characteristics of primary caregivers of people with schizophrenia receiving treatment at referral hospitals in Eastern Ethiopia, 2024 (n = 414).
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Sociodemographic and economic characteristics of people living with schizophrenia

The median age of the patients was 31 years (IQR 13). Among the total study participants, 173 (41.79%) were aged between 26 and 35 years. More than half of the patients (232 [56.04%]) were male. Half of the patients, 208 (50.24%), were married, and 128 patients (30.92%) had received secondary education (Table 2).

Table 2 Sociodemographic characteristics of people living with schizophrenia receiving treatment at referral hospitals in Eastern Ethiopia, 2024 (n = 414).
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Clinical and psychosocial characteristics of primary caregivers of people living with schizophrenia

Among the respondents, 13 (3.14%) caregivers had a history of mental illness during their life, and 98 (23.67%) caregivers reported having other family members with a history of mental illness. Furthermore, 184 (44.44%) caregivers had a family size of 5–6 members. With respect to comorbid medical illness, 37 (8.94%) caregivers reported having comorbid medical illnesses. The median caregiver duration score was 4.5 years, with an IQR of 4. The median score of caregivers’ average daily caregiving hours was 6 h, with an IQR of 5. Regarding illness severity, 172 (41.55%) participants were classified as having severe illness on the basis of the CGI score. A total of 189 (45.65%) participants experienced moderate burdens, 174 (42.03%) participants experienced high levels of stigma, and 200 (48.31%) experienced poor social support. Additionally, 45- (10.87%) and 38 (9.18%) patients had caregiver histories of depression and anxiety respectively. A total of 237 (57.25%) patients had no admission history (Table 3).

Table 3 Clinical and psychosocial characteristics of primary caregivers of people living with schizophrenia.
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Substance use characteristics of the study participants

Among the 414 primary caregivers of people living with schizophrenia, approximately 219 (52.90%) and 173 (41.79%) had lifetime and current substance users, respectively (Fig. 2).

Fig. 2
figure 2

Type of psychoactive substance use used by primary caregivers of people living with Schizophrenia Harari Regional State and Dire Dawa Administrative City Public Hospitals, Ethiopia, 2024 (N, 414).

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Prevalence of expressed emotions among primary caregivers of people living with schizophrenia

Among the 414 participants, n=200 (48.31%; 95% CI 43.51–53.14%) highly expressed emotion. Among the study participants, 102 (24.64%) reported highly critical comments (CCs), and 132 (31.88%) reported high emotional over-involvement (EOI) (Table 4).

Table 4 Components of expressed emotion of primary caregivers of people with schizophrenia at Harari regional state and dire Dawa administrative City public Hospitals, Ethiopia, 2024 (N = 414).
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Factors associated with expressed emotions among primary caregivers of people living with schizophrenia

The results of the final model revealed that duration of caregiving for > 8 years, severity of illness, severe burden among caregivers, perceived high stigma and poor social support were significantly associated with highly expressed emotions, with p values < 0.05.

In this study, the odds of having high emotional expression were 2.74 higher among those who had been providing care for > 8 years (AOR 2.74; 95% CI 1.02, 7.33) than among those with up to 2 years of caregiving. This study also revealed that the odds of highly expressed emotions in those who had severe illness were 3.45 (AOR 3.45; 95% CI 1.89, 6.28) higher than those in those who had mild illness.

With respect to burden among caregivers, the odds of having highly expressed emotion was 4.34 times greater (AOR 4.34; 95% Cl 2.03, 9.28) among participants with severe burden than among those with mild burden. The odds of having high emotional expression were 2.59 times greater (AOR 2.59; 95% CI 1.53, 4.41) in those who perceived high stigma than in those who perceived low stigma. This study revealed that the odds of having high emotional expression were 3.54 times greater (AOR 3.54; 95% CI 1.74, 7.19) among poor social support than among strong social support (Table 5).

Table 5 Bivariate and multivariate logistic regression analyses of factors associated with expressed emotions among primary caregivers of people with schizophrenia in the Harari regional state and dire Dawa administrative City public Hospitals, Ethiopia, 2024 (n = 414.
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Discussion

This study aimed to assess the magnitude and associated factors of highly expressed emotion among primary caregivers of people living with schizophrenia receiving treatment at public hospitals in Harari Regional State and Dire Dawa City Administration, Eastern Ethiopia.

The proportion of highly expressed emotions identified in this study was 48.31% (95% CI 43.51–53.14%). These findings are in line with those of studies conducted in Brazil26, Ethiopia at Jimma36, and Dilla24, which reported values of 52%, 43.6% and 50.5%, respectively.

This finding is lower than those of studies conducted in Pakistan37, which revealed a prevalence of 75%, and Lagos, Nigeria38, which reported a prevalence of 63%. The difference could be the use of different assessment tools and sociocultural variability among the two populations.

This finding is greater than that of a study conducted in India39, which reported a 21% difference, possibly because of the use of different assessment tools, such as the Family Attitude Scale (FAS), and the cultural differences between the two populations. The study was conducted in India and excluded family members suffering from mental illness.

It is evident from this study that the duration of caregiving is significantly associated with greater EE. This agrees with the findings of studies conducted in Egypt at Cairo and in Ethiopia at Jimma and Dilla. The possible explanation for this association is that providing care for people with schizophrenia may affect the care giver’s daily routines, as it needs time adjustment to fulfill the needs of patients25, and after so many attempts, care givers may believe that they cannot handle the symptoms and develop a negative view of treatment impact on the patient, which may increase the possibility of higher EE40.

Suffering from severe schizophrenia was significantly associated with increased emotional expression. This is supported by the findings of studies conducted in Italy. This might be related to the fact that people with severe schizophrenia may not be able to independently carry out daily activities and turn back to depend more on their caregivers40. As a result, care givers may experience the feeling of being “interrupted” in their life41, and later, such belief toward inability to handle severe symptoms may result in persistent stress42, which in turn leads to greater expressed emotion43.

In this study, stigma was significantly associated with higher levels of expressed emotion. This may be related to the effect of stigma on people with schizophrenia, as they may isolate themselves from nonfamily individuals and be more dependent on family care givers44, which may lead care givers to experience negative emotions45,46. The burden of caregiving eventually increases expressed emotion40,47.

Poor social support was significantly associated with increased emotional expression. This may be attributable to the fact that caregivers may experience emotional distress and greater caregiving burdens because of poor social support since social support can serve as a buffer against those negative effects, which can lead to greater expressed emotion48,49.

Limitations of the study

In our study, we used a cross-sectional design to assess levels of expressed emotion (EE) among caregivers of individuals with schizophrenia. While this design is useful for identifying associations between variables at a single point in time, it has an important limitation: it does not allow for conclusions about causality or the direction of relationships .The study might have been devoted to selection bias, as a patient may come with more than one caregiver. Caregivers might hesitate to provide complete answers due to social desirability and recall bias, potentially leading them to overreport or underreport information. However, the lottery method has been used to ensure fair participation, and extensive training has been given to data collectors to enhance the genuine engagement of study participants, which may contribute to obtaining reliable information. While our study focused on lifetime versus current use, we did not specifically address the severity, frequency .

Conclusions and recommendation

This study revealed that the prevalence of expressed emotion is significantly high. The duration of caregiving, perceived stigma, burden, severity of illness and social support of study participants were significantly associated with expressed emotion.

Mental health professionals should assess expressed emotions among caregivers of people living with schizophrenia Therefore, they can conduct psychotherapy to promote the ability of family caregivers to reappraise their situations and experiences so that they can more effectively manage the stress of the caregiving situations of their family members people living with schizophrenia. It should provide continuous training and support to primary caregivers of people living with schizophrenia. This training should focus on enhancing caregivers’ skills and confidence in managing the illness. Health professionals can help reduce feelings of frustration, inadequacy, and the emotional burden associated with caregiving.

Public awareness campaigns should be implemented to reduce the stigma associated people living with schizophrenia and organize community outreach programs, workshops, and seminars that educate the public about schizophrenia, emphasizing that it is a medical condition similar to any other, not a cause for shame or fear.

There is need for family interventions that provide proper information and psychological support to help relatives improve their understanding of the disorder. There is also a need for social support.

Qualitative research will be taken into consideration for the next study since patients’ perceptions of conveyed emotion and its constituent parts are influenced by culture.