Yimam et al.

Annals of General Psychiatry 2022, 21(1):27

https://doi.org/10.1186/s12991-022-00404-3 Annals of General Psychiatry

PRIMARY RESEARCH Open Access

Expressed emotion of caregivers

among schizophrenic patients visiting Jimma
University Medical Center Psychiatry Outpatient
Unit, Southwest Ethiopia
Bethlehem Yimam1* , Matiwos Soboka2, Yemiamrew Getachew1*, Bezaye Alemu2, Gutema Ahmed2,
Elias Tesfaye2 and Mogesie Necho1

Abstract
Background: Expressed emotion (EE) measures the emotion among caregivers of schizophrenic patients and is pre-
dictive of symptom levels in a range of medical and psychiatric conditions. It is worth assessing expressed emotion
and associated factors among caregivers of patients with schizophrenia in Ethiopia since there is limited data on this
issue in this part of the world.
Objective: To assess the status of expressed emotions and selected patients’ clinical factors among caregivers of
patients with schizophrenia attending Psychiatry Outpatient Unit of Jimma University Medical Center, Southwest
Ethiopia, 2019.
Method: A cross-sectional study was conducted on 422 caregivers of schizophrenic patients using a consecutive
sampling technique. Data were collected using a structured interviewer administrated questionnaires (Family Ques-
tionnairre) which assessed the level of expressed emotion. Data were entered into Epidata 4.4 and analyzed by Statis-
tical package for social science (SPSS) version 25. Descriptive statistics was which used to summarize data, bivariate
logistic regression was done to identify candidate variables for multivariable logistic regressions and the association
between expressed emotion and predictor variables was identified by using multiple logistic regression models.
Results: High expressed emotion was observed in 43.6% of respondents while caring for schizophrenic patients for
about 6–8 years, having 3–4 episodes of the illness which was significantly associated with high expressed emotion.
Conclusions: This study revealed that there is a high level of expressed emotion among caregivers. It also showed
that increment in the episode of the illnesses had a significant association with high caregivers’ expressed emotion.
Hence, health care systems which provide interventions for patients with schizophrenia need to design proper strate-
gies to address caregivers’ needs as well.
Keywords: Ethiopia, Expressed emotion, Care givers, Schizophrenia

Introduction
Expressed emotion measures the emotion of caregivers
and is predictive of symptom levels in a range of medical
*Correspondence: [email protected]; [email protected]
and psychiatric conditions [1]. Expressed emotion (EE) is
1
Department of Psychiatry, College of Medicine and Health Science, Wollo
an attitude, feeling, or behavior of the family caregiver in
University, Dessie, Ethiopia
Full list of author information is available at the end of the article

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Yimam et al. Annals of General Psychiatry 2022, 21(1):27 Page 2 of 10

response to and reaction towards the person with schizo- illness was 58.12 which indicated high expressed emo-
phrenia [2]. tions among caregivers, all the demographic factor
The classification of expressed emotion in caregivers results the calculated value is less than the tabulated
is based mainly on two variables; (1) ‘criticism’ (critical value, so there is no association found between selected
comments), and (2) emotional over-involvement, a third demographic variables and EE of the caregivers [11].
variable, ‘hostility’, is normally associated with high lev- In the study conducted at outpatient clinics in
els of critical comments. Hence, caregivers who showed Abbasia and Banha Hospitals for Mental Health, it
high criticism or over-involvement are rated as ‘high EE’ was found that statistically significant relationships
[3–5]. existed between patients’ genders and parent EE; it
Schizophrenia is one of the most common serious was reported that parents of females made more criti-
mental disorders that result in changes of perception, cal comments than parents of males. More than half of
emotion, cognition, thinking, and behavior. Both patients Patients with adolescent-onset had parents rated high
and family members often suffer from poor care and criticism [4].
social isolation because of widespread ignorance of the The educational status of the demographic characteris-
disorder. In families with high levels of expressed emo- tic of patients and relatives was also significantly associ-
tion, the relapse rate for schizophrenia is high [6]. ated with high EE [5].
Approximately 50% of patients living with a spouse or A hospital-based cross-sectional study conducted in
their parents had at least one instance of readmission fol- India among 125 patients revealed that younger patients
lowing discharge, compared to only 30% of those living experienced more EE and patients who were single expe-
alone [7]. rienced significantly more EE than married patients,
Additional caregiving role to already existing family which was similar to the study done in Pakistan [12].
roles becomes stressful psychologically as well as eco- A study done in Nigeria showed that female caregivers
nomically [7]. Unemployment of both patients and fami- were associated with high expressed emotion. It has been
lies is a major indirect cost, resulting in more than half found that younger age, female sex, higher educational
(61%) of the total economic burden of schizophrenia, level, and part-time occupation result in higher levels of
these experiences lead family caregivers to have high psychological distress and distressed caregivers have high
expressed emotion (HEE), which in turn increases the expressed emotion [13].
risk of relapse in persons they are caring for [2]. The British studies indicated that, among patients liv-
A prospective study done in Brazil showed that 31% ing in “high-EE” homes, the risk of relapse more than
of patients presented relapses and, among the relatives, doubled for patients who were in face-to-face contact
68% presented elevated levels of expressed emotion. The with relatives having high EE 35 h per week or more
proportions of family members with high levels of criti- (69% relapse rate) compared with those (28%) fewer than
cal comments and emotional over-involvement were 49% 35 weekly contact hours [14].
and 52%, respectively [8].
A study conducted in Nigeria showed the prevalence
of high expressed emotion to be 50.0%. Relapse rates of Methods and materials
people in differing living arrangements after an episode Study area and period
of mental disorder is as follows: 17% for patients living An institutional based cross-sectional study was con-
alone or with siblings, 32% for those living with parents ducted from April to June 2019 at Jimma University
and 50% for those living with a spouse [9]. Medical Center (JUMC), which is found in Jimma. Jimma
Schizophrenic patients living with relatives having a town is found 352 km from southwest of Addis Ababa,
high expressed emotion (EE) level at hospital admission the capital city of Ethiopia, providing specialized clini-
are more likely to relapse within 9 months after discharge cal services to about 15 million people in the catchment.
than those patients who are living with relatives showing Currently, on average 518 schizophrenic patients are hav-
a low EE level [3]. ing follow-up at the Psychiatry Outpatient Department
In a cross-sectional study conducted in Delhi, India (OPD) monthly. At Jimma University Medical Center, a
schizophrenic patients having families with a high level psychiatric clinic was established in 1988 and has been
of critical comments had a threefold greater risk of serving more than 10,000 psychiatry patients annually.
relapse within 9 months after recovery, and patients with Currently, the clinic has 26 beds for in-patient service
high criticism had a higher chance of early relapse [10]. and 04 outpatients department with 2 psychiatrists, 10
In the psychiatric in-patient department of the gov- psychiatric nurses, 2 clinical psychologists, and 9 M.Sc.,
ernment medical College and hospital Nagpur the total 1 Ph.D., and 1 Ph.D. fellow mental health professionals
mean score among caregivers of patients with mental serving about 15 million people in Southwest Ethiopia.
Yimam et al. Annals of General Psychiatry 2022, 21(1):27 Page 3 of 10

Participants Study variables

Source population: all caregivers of patients with schizo- The dependent variable of the study was Expressed
phrenia, visiting the Psychiatry Outpatient Department Emotion (EE) of caregivers (Yes/No).
at Jimma University Medical Center. Independent variables included caregivers socio-
The sample size was determined using the single pop- demographic factors (age, gender, ethnicity, occupation,
ulation proportion formula by taking the result done in marital status, educational status, family size, relation-
Nigeria; the result of high expressed emotions of car- ship with the patient), distance from hospital in km,
egiver was 50.0%. To get the possible sample at 95% CI and average household monthly income,
that is Z–the value of 1.96 and marginal error of 5% is Socio-demographic factors of patients: age, gender,
calculated as follows: marital status, educational status, employment status,
n = (Z α/2)2 p (1−p)/d2, where n = number of sample the impact of illness on occupation.
size. Z = desired 95% confidence, Z = 1.96. p = population Clinical variables: duration of illness, duration of tak-
proportion. q = 1− p = 1− 0.5 = 0.5, d = is the margin of ing care of the patient, time spent with the patient per
sampling error tolerated (5%). day, number of the episode, number of previous hospi-
talizations, number of a family member with psychiat-
(1.96)2 (0.5)(1 − 0.5) ric illnesses, and co-morbid disorder of the patients.
n= , n initial = 384.
(0.05)2

By considering 10% (10/100*384 = 38) non-response

Operational definitions
rate, the final sample size was 422.
High expressed emotion: high EE relatives are with
Study participants were recruited by consecutive sam-
cutoff point of > 23 for critical comments and > 27 for
pling techniques.
emotional over-involvement (22,9,33,19,34).
Caregivers who were ≥ 18 years of age and were taking
Low expressed emotion: low EE relatives are with
care of patients with schizophrenia were included.
cutoff point of ≤ 23 of critical comments and ≤ 27 for
emotional over-involvement (22,9,33,19,34).
Data collection tool and procedures
A structured questionnaire was developed after review-
Data processing, analysis, and interpretation
ing related literature. It was used to collect data about
The data were checked for consistency and complete-
caregivers and patient socio-demographic variables. The
ness throughout the time of data collection. Data coded
last psychiatric diagnosis was taken from medical records
and entered twice into double EPI-DATA version 4.41
of patients. The caregivers Expressed Emotion status was
and then exported to SPSS version 25 for analysis.
measured by Family Questionnaire (FQ) which is devel-
Before performing binary regression the scores were
oped by Wiedemann, Rayki, Feinstein, and Hahlweg in
checked for assumption and whether the model fits or
2002, with 20—items which included two domains—
not via Hosmer–Lemeshow. Bivariate regression was
Critical Comments CC (10 items—2, 4, 6, 8, 10, 12, 14,
computed for each independent variables separately
16, 18, 20), and Emotional Over Involvement [EOI] (10
from the dependent variables. Finally, those variables
items—1, 3, 5, 7, 9, 11, 13, 15, 17, 19), with maximum
having a p < 0.25 were taken to multiple logistic regres-
value of 40 and the cut-off point for high EE relatives
sions model once, and those with a p < 0.05 were con-
being > 23 for critical comments and > 27 for emotional
sidered as having statistically significant association
over-involvement [4, 15].
with the dependent variable.
Low EE relatives are those with cutoff point of ≤ 23 for
critical comments and ≤ 27 for emotional over-involve-
ment. Possible responses of participants is never or very
Ethical consideration
rarely, rarely, frequently, and very frequently, with values
Ethical clearance was obtained from the Institutional
ranging from one to four for each response, respectively.
Review Board of JU after approval of the proposal. Offi-
The FQ had better agreement with the gold standard
cial permission was collected from Jimma University
questioners of CFI (Camberwell Family Interview) on
Medical Center’s psychiatry clinic. The purpose of the
CC and EOI than did other short EE questionnaires,
study was communicated with study participants and
because both have sensitivity 80%, specificity 70%. Criti-
data were collected after written consent is obtained.
cism (α = 0.86, n = 257) and emotional over-involvement
Caregivers with HEE were consulted with mental health
(α = 0.80, n = 256) subscales showed strong internal con-
professionals and psychologists working in the unit.
sistency (22,9, (18) 33,19,34).
Yimam et al. Annals of General Psychiatry 2022, 21(1):27 Page 4 of 10

Results 259 (61.4) of patients had no history of admission (see

Socio‑demographic characteristics of study participants Table 4).
A total of 422 caregivers of patients with schizophre-
nia have participated in this study. Among study par- Status of expressed emotions among caregivers of patients
ticipants, 281 (66.6%) were males, 263 (62.3%) were with schizophrenia
married, the majority, 313 (74.2%) of respondents were Of the total study participants, 101 (23.9%) reported
Oromo by ethnicity and 313 (74.2%) were Muslims by high critical comments (CC) and 148 (35.1%) reported
religion. The mean age of participants was 40.24 years high emotional over-involvement (EOI). Overall, the sta-
(SD ± 15.3) and 166 (39.3%) were parents. Nearly one- tus of expressed emotion among caregivers as measured
third (30.6%) of respondents attended primary educa- by considering either high CC or high EOI, 184 [43.6%
tion. Regarding the occupation of the respondents, 146 (38.5–48.6)] had higher expressed emotion (see Table 5).
(34.6%) were farmers. More than half of the respond-
ents, 228 (54%) live in urban areas, 110 (26.1%) live in a Factors associated with expressed emotions
distance of 9–23 km from the Hospital and the median among caregivers of patients with schizophrenia
income was 1000 ETB (see Table 1). Bivariate analysis of factors associated with expressed
emotion
Those who gave care for about 6–8 years were found to
Caregivers perceived difficulties during caregiving
be 2.4 [COR = 2.373, 95% CI (1.335, 4.218)] Participants
Of the total respondents, 164 (38.9%) were more than
who were from a household with monthly income > 2000
seven family sizes. Three hundred seventy-one (87.9%)
ETB were nearly 2 [COR = 1.711, 95% CI (0.976,
had only one family member with mental illness. The
2.999)]. Patients who had 3–4 episode were 2.3 times
mean duration of caregiving was 5.7 (SD ± 4.18) years
[COR = 2.382, 95% CI (1.339, 4.236)] (see in Table 6).
and the mean length of stay with the patient per 24 h
was 7.49 (SD ± 6.24) h. More than half of respondents,
Independent predictors of expressed emotions
260 (61.8%) had reported no objective burden and 173
among caregivers of patients with schizophrenia at JUMC
(41%) had reported severe subjective burden. Nearly
Duration of giving care for about 6–8 years was
all respondents had reported low perceived stigma 410
[AOR = 2.439, 95% CI (1.308, 4.549)] caregivers report
(97.2%). Out of the total respondents, 185 (43.8%) had
of no diagnosis of chronic medical/physical illness were
low social support. Nearly all of the participants 97.9%
[AOR = 2.274, 95% CI (1.174, 4.406)] and patients who
(n = 413) reported not having a mental illness and
had 3–4 episode were 2.3times [AOR = 2.281, 95% CI
86.7% (n = 366) did not have chronic medical/physical
(1.253, 4.150)] were demonstrated to have a statistically
illness which is reported by participants as diagnosed
significant association with caregivers high expressed
by a health professional (see Table 2).
emotion.
The odds of having high expressed emotion among
Socio‑demographic characteristics of the patients those who gave care for the patient for about 6–8 years
The median age of the patient was 30 years and nearly were 2.4 times higher than those who gave care for
one-third, 131 (31%) of the patient’s age was 25 and about < 2 years.
below. More than half, 310 (73.5%) were males. Most The odds of having high expressed emotion were 2.2
of the patients 271 (64.2%) were single and almost one- times higher in those who had no chronic medical/physi-
fourth, 109 (25.8%) were married. One hundred eighty cal illness than those who had chronic medical/physical
(42.7%) of patients attended primary education and 157 illness.
(37.2%) were unemployed. About 176 (41.7%) patients Finally, the odds of having high expressed emotion
had stopped their jobs due to the illness (see Table 3). among those caregivers who had patients with 3–4 epi-
sodes of illness were 2.3 times higher than those who had
1–2episode of illness (see Table 7).
Clinical characteristics of the patient
Out of the total patients, 70 (16.6%) had a co-morbid Discussion
neuropsychiatric and medical disorder in summa- A total of 422 caregivers of patients with schizophre-
tion. Of this, 33 (7.8%) had substance use disorder as nia were included in this study. The proportion of high
reviewed from their medical record. The mean duration expressed emotion (EE) was 43.6% which is consistent
of illness was 6.13 (SD ± 5.18) years and the mean age with similar studies conducted in Nigeria (41.4%) [16].
of the first onset of illness was 26.28 (SD ± 13.2) years. The discrepancy may be due to use of a different assess-
On the other hand, 295 (69.9%) had 1–2 episodes and ment tools and sample size.
Yimam et al. Annals of General Psychiatry 2022, 21(1):27 Page 5 of 10

Table 1 Socio-demographic characteristics of caregiver of patient with schizophrenia at Jimma University Medical Center Psychiatry
Clinic, Southwest Ethiopia 2019 (n = 422)
Variable Category Frequency (n) Percent

Age 18–27 117 27.7

28–38 97 23.0
39–52 105 24.9
52–79 103 24.4
Sex Male 281 66.6
Female 141 33.4
Marital status Single 111 26.3
Divorced 19 4.5
Married 263 62.3
Widowed 29 6.9
Religion Muslim 313 74.2
Orthodox 76 18.00
Protestant 33 7.8
Ethnicity Amhara 48 11.4
Oromo 313 74.2
Tigre yem, gurage, kefa 30 7.1
Siltea and Dawuro 31 7.3
Educational status Not able to write and read 87 20.6
Only able to write and read 28 6.6
Primary education 129 30.6
Secondary education 91 21.6
Higher education and above 87 20.6
Occupation Farmer 146 34.6
House wife 43 10.2
Merchant 56 13.7
Gov’t employee 57 13.5
Private employee 42 10.00
Student 33 7.8
Retired and unemployed 30 7.1
Others* 13 3.1
Average household monthly Income in ETB < 200 114 27.0
201–1000 162 38.4
1001–2000 58 13.7
> 2000 88 20.9
Place of residence Rural 194 46
Urban 228 54
Relation to the patient Parents 166 39.3
Child 44 10.4
Siblings 151 35.8
Aunt/uncle 22 5.2
Spouse 24 5.7
Others** 15 3.6
*
Others (occupation)—daily laborer
**
Others (relation)—half brothers/sisters, neighborhood, grandchildren

Regarding the duration of patient care, those who showed that caregivers do not practice any activities
give care for about 6–8 years 82 (19.4%) were 2.4 times and hobbies; this might be due to the caregivers alloca-
more likely to have high expressed emotion than those tion of their lots of time with the patient to provide care
who give care for about ≤ 2 years. A study done in Cairo and hence the majority of caregivers were spending more
Yimam et al. Annals of General Psychiatry 2022, 21(1):27 Page 6 of 10

Table 2 Perceived difficulties during care giving and health Table 3 Socio-demographic characteristics of patient with
status among caregiver of patient with schizophrenia at Jimma schizophrenia at Jimma University Medical Center Psychiatry
University Medical Center Psychiatry Clinic, Southwest Ethiopia Clinic Southwest Ethiopia 2019 (n = 422)
2019 (n = 422)
Variable Frequency (n) Percent
Variable Frequency (n) Percent
Age
Family size 13–25 years 131 31.0
  ≤4 family 130 30.8 26–30 years 102 24.2
5–6 family 128 30.3 31–40 years 96 22.7
  > 7 family 164 38.9 40–96 years 93 22.0
Family size with MI Sex
1 family with MI 371 87.9 Male 310 73.5
  > 2 family with MI 51 12.1 Female 112 26.5
Duration of take care of patient Marital status
  < 2 years 121 28.7 Single 271 64.2
3–5 years 118 28.0 Divorced 30 7.1
6–8 years 82 19.4 Married 109 25.8
  > 8 years 101 23.9 Widowed 12 2.8
Relative’s hours per day spent in contact with the patient Educational status
<3 h 129 30.6 Unable to read and wright, only read and 89 21.1
4–6 h 126 29.9 wright
7–12 h 117 27.7 Primary education 180 42.7
  > 12 h 50 11.8 Secondary education 108 25.6
Distance from hospital in km Higher education and above 45 10.7
  < 8 km 106 25.1 Occupation
9–23 km 110 26.1 Farmer 101 23.9
24–50 km 107 25.4 Housewife 47 11.1
  > 50 km 99 23.5 Merchant 18 4.3
Report of medical/physical illness Gov’t and private employee 44 10.4
Yes 55 13.0 Student 38 9.0
No 367 87.0 Unemployed 157 37.2
Report of mental disorder Others* 17 4
Yes 8 1.9 Impact of the illness on occupational status
No 414 98.1 Unemployed due to illness 50 11.8
Working full time 77 18.2
Working part time 114 27.0
Retired and stop working 181 42.9
than 12 care hours per day and this leads them to have *
Others, daily laborers
HEE [4]. The possible explanation for this might be that
patients with schizophrenia may not be able to carry out
their daily activities on their own and hence depends likely to have high expressed emotion than who had not.
more on their caregivers. Consequently, family caregiv- This might be due to the fact caregivers with medical/
ers are likely to evaluate their life as being filled with physical illness being responsible for having follow-up
interruptions. program for the patients, and helping with the day to day
This belief of the caregivers about their own inability activities of the schizophrenic patient since these patients
to manage severe symptoms might make them encoun- have difficulties in self-helping behavior. In relation to
ter repetitious long-term stress, causing them to have the this caregivers might get exhausted and show HEE than
reactions or behaviors found in the HEE. Similarly, the caregivers who does not have a history of medical/physi-
study in northern India showed that caregivers who had cal illness.
sustained distress were likely to show high EE and also Another explanation might be because those caregivers
had a longer care giving history [3]. who have medical/physical illness might not take respon-
A participant who had history of medical/physical ill- sibility to take care of the schizophrenic patient or spend
ness diagnosis by health professionals was 2.2 times more more time with them since the caregivers themselves
Yimam et al. Annals of General Psychiatry 2022, 21(1):27 Page 7 of 10

Table 4 Clinical characteristics of patient with schizophrenia at have their own illness. This leads them to have a short
Jimma University Medical Center Psychiatry Clinic, Southwest time contacting the patient, therefore they become less
Ethiopia 2019 (n = 422) likely to have HEE.
Variable Frequency (n) Percent Those caregivers of patients who had 3–4 episodes of
illness were 2.3 times more likely to have high expressed
First onset of illness emotion than those who had 1–2 episode of illness. Con-
  ≤ 18 years 110 26.1 sistently with the current study a meta-analysis identi-
19–23 years 115 27.3 fied 27 articles reporting EE and psychiatric relapses in
24–30 years 97 23.0 schizophrenia patients and confirmed that EE is a good
  > 30 100 23.7 predictor of schizophrenia relapses, especially in patients
Number of episode in the most chronic phase of the disease, current study
1–2 episodes 295 69.9 result found no significant association between relapse
3–4 episodes 58 13.7 and HEE [17].
  > 4episodes 69 16.4
Hospital admission
Yes 163 38.6 Conclusions
No 259 61.4 In our study, nearly half of caregivers (43.6%) had high
Number of admission expressed emotion. Having 3–4 episodes of illness, Dura-
None 259 61.4 tion of giving care for 6–8 years, caregiver’s report of no
1 admission 102 24.2 diagnosis of medical illness had demonstrated a statisti-
2 admission 25 5.9 cally significant association with caregivers expressed
3 admission 19 4.5 emotion. This study highlights the presence of high
4 admission 17 4 expressed motion among caregivers of patients with
Duration of illness schizophrenia in our setup. Such findings can be used
  < 2 years 145 34.4 as a guideline for screening vulnerable family caregivers
3–5 years 79 18.7 who have more influential factors of expressed emotion,
6–10 years 133 31.5 Therefore, the Ethiopia policy direction can address not
  > 10 years 65 15.4 only the patient’s mental health, but also the caregiver-
Patient’s co-morbid diagnosis expressed emotion.
Yes 70 16.6 Mental health professionals are supposed to assess
No 352 83.4 expressed emotion among caregivers of a schizophrenic
patient. Therefore, they can conduct psychotherapy to
promote the capability of family caregivers to reappraise
their situations and experiences, so that they can more
effectively manage the stress of caregiving situations of
Table 5 The Family Questionnaire (FQ) sub-scale among their family members with schizophrenia.
caregiver of patient with schizophrenia at Jimma University It also helps the caregivers in lowering their expressed
Medical Center Psychiatry Clinic, Southwest Ethiopia 2019 emotions and enhancement in their coping strategy. The
(n = 422) findings of the present study can be eventually utilized
Family Questionnaire (FQ) components Frequency (n) Percent to bring a reduction in a negative atmosphere in car-
for assessment of expressed emotion egivers where there is a patient with schizophrenia, like
Critical comments expressed emotion.
Low critical comment 321 76.1 As the research design was cross-sectional, the inter-
High critical comment 101 23.9 pretation of causal relationships must be done with
422 100.0 caution and preferably, a longitudinal study should be
Emotional over-involvement undertaken to verify the credibility of the study find-
Low emotional over-involvement 274 64.9 ings. Qualitative study since expressed emotion culturally
High emotional over-involvement 148 35.1 influenced, patient perception of expressed emotion and
422 100.0 components of expressed emotion, is going to be consid-
Expressed emotion status ered for next study.
Low expressed emotion 238 56.4
High expressed emotion 184 43.6
Total 422 100.0
Yimam et al. Annals of General Psychiatry 2022, 21(1):27 Page 8 of 10

Table 6 Bivariate analysis of factor associated and Status of expressed emotion among caregiver of patient with schizophrenia at
Jimma University Medical Center Psychiatry Clinic, Southwest Ethiopia 2019 (n = 422)
Variable Category Frequency (%) Expressed emotion status P value COR (95% CI)
High EE (n = 184) Low EE (n = 238)

Care giver age 18–27 117 (27.7) 52 (28.3%) 65 (27.3%) 0.323 1.313 (0.765, 2.253)
28–38 97 (23.0) 44 (23.9%) 53 (22.3%) 0.283 1.362 (0.775, 2.395)
39–52 105 (24.9) 49 (26.6%) 56 (23.5%) 0.200* 1.436 (0.826, 2.496)
52–79 103 (24.4) 39 (21.2%) 64 (26.9%) 1
Caregiver occupation Farmer 146 (34.6) 54 (29.3%) 92 (38.7%) 1
House wife 43 (10.2) 21 (11.4%) 22 (9.2%) 0.165* 1.626 (0.819, 3.229)
Merchant 56 (13.7) 27 (14.7%) 31 (13.0%) 0.209* 1.484 (0.802, 2.747)
Gov’t employee 57 (13.5) 28 (15.2%) 29 (12.2%) 0.115* 1.645 (0.886, 3.053)
Private employee 42 (10.00) 20 (10.9%) 22 (9.2%) 0.216* 1.549 (0.775, 3.096)
Student 33 (7.8) 13 (7.1%) 20 (8.4%) 0.796 1.107 (0.510, 2.403)
Retired and unemployed 30 (7.1) 16 (8.7%) 14 (5.9%) 0.099* 1.947 (0.882, 4.299)
Others 13 (3.1) 5 (2.7%) 8 (3.4%) 0.916 1.065 (0.332, 3.420)
Average monthly income < 200 114 (27.0) 47 (25.5%) 67 (28.2%) 1
in ETB 201–1000 162 (38.4) 69 (37.5%) 93 (39.1%) 0.821 1.058 (0.651, 1.719)
1001–2000 58 (13.7) 20 (10.9%) 38 (16.0%) 0.392 .750 (0.389, 1.448)
> 2000 88 (20.9) 48 (26.1%) 40 (16.8%) 0.061* 1.711 (0.976, 2.999)
Place of residence Rural 194 (46) 78 (42.4%) 116 (48.7%)
Urban 228 (54) 106 (57.6%) 122 (51.3%) 0.195* 1.292 (0.877, 1.904)
Relation to the patient Parents 166 (39.3) 68 (37.0%) 98 (41.2%) 1
Child 44 (10.4) 15 (8.2%) 29 (12.2%) 0.408 0.745 (0.372, 1.495)
Siblings 151 (35.8) 76 (41.3%) 75 (31.5%) 0.095* 1.460 (0.936, 2.277)
Aunt/uncle 22 (5.2) 8 (4.3%) 14 (5.9%) 0.680 0.824 (0.328, 2.071)
Spouse 24 (5.7) 9 (4.9%) 15 (6.3%) 0.747 0.865 (0.358, 2.090)
Others 15 (3.6) 8 (4.3%) 7 (2.9%) 0.356 1.647 (0.570, 4.756)
Family size <4 130 (30.8) 62 (33.7%) 68 (28.6%) 0.442
5–6 128 (30.3) 56 (30.4%) 72 (30.3%) 0.525 0.853 (0.522, 1.393.)
>7 164 (38.9) 66 (35.9%) 98 (41.2%) 0.201* 0.739 (0.464, 1.175)
Family size with mental 1 371 (87.9) 168 (91.3%) 203 (85.3%) 1
illness >2 51 (12.1) 16 (8.7%) 35 (14.7%) 0.063* 0.552 (0.295, 1.033)
Duration of take care of pt < 2 years 121 (28.7) 41 (22.3%) 80 (33.6%) 1
3–5 years 118 (28.0) 51 (27.7%) 51 (28.2%) 0.139* 1.485 (0.880, 2.508)
6–8 years 82 (19.4) 45 (24.5%) 45 (15.5%) 0.003* 2.373 (1.335, 4.218)
> 8 years 101 (23.9) 47 (25.5%) 47 (22.7%) 0.056* 1.698 (.987, 2.922)
Caregiver chronic physical/ Yes 55 (13.0) 19 (10.3%) 36 (15.1%) 1
medical illness No 367 (87.0) 165 (89.7%) 202 (84.9%) 0.149* 1.548 (.856,2.799)
Patients age 13–25 years 131 (31.0) 54 (29.3%) 77 (32.4%) 0.706 1.110 (.645, 1.912)
26–30 years 102 (24.2) 47 (25.5%) 55 (23.1%) 0.299 1.353 (.765, 2.394)
31–40 years 96 (22.7) 479 (25.5%) 49 (20.6%) 0.157* 1.519 (.852, 2.707)
40–96 years 93 (22.0) 36 (19.6%) 57 (23.9%) 1
Patients occupation Farmer 101 (23.9) 36 (19.6%) 65 (27.3%) 1
House wife 47 (11.1) 21 (11.4%) 26 (10.9%) 0.294 1.458 (0.721, 2.950)
Merchant 18 (4.3) 8 (4.3%) 10 (4.2%) 0.478 1.444 (0.523, 3.986)
Gov’t and private employee 44 (10.4) 27 (14.7%) 17 (7.1%) 0.005⃰ 2.868 (1.381, 5.955)
Student 38 (9.0) 16 (8.7%) 22 (9.2%) 0.483 1.313 (0.613, 2.813)
Unemployed 157 (37.2) 70 (38.0%) 87 (36.6%) 0.155* 1.453 (0.868, 2.430)
Others 17 (4) 6 (3.3%) 11 (4.6%) 0.978 0.985 (0.336, 2.885)
Yimam et al. Annals of General Psychiatry 2022, 21(1):27 Page 9 of 10

Table 6 (continued)
Variable Category Frequency (%) Expressed emotion status P value COR (95% CI)
High EE (n = 184) Low EE (n = 238)

Co morbid diagnosis of Yes 70 (16.6) 36 (19.6%) 34 (14.3%) 1

patients
No 352 (83.4) 148 (80.4%) 204 (85.7%) 0.150* 0.685 (0.410, 1.146)
Number of episode 1–2 295 (69.9) 115 (62.5%) 180 (75.6%) 1
3–4 58 (13.7) 35 (19.0%) 23 (9.7%) 0.003* 2.382 (1.339, 4.236)
>4 69 (16.4) 34 (18.5%) 35 (14.7%) 0.119* 1.520 (0.898, 2.575)
Number of admission None 259 (61.4) 117 (63.6%) 142 (59.7%) 1
1 admission 102 (24.2) 34 (18.5%) 68 (28.6%) 0.041* 0.607 (0.376, .980)
2 admission 25 (5.9) 13 (7.1%) 12 (5.0%) 0.514 1.315 (0.578, 2.991)
3 admission 19 (4.5) 12 (6.5%) 7 (2.9%) 0.136* 2.081 (0.794, 5.45)
4 admission 17 (4) 8 (4.3%) 9 (3.8%) 0.880 1.079 (0.404, 2.884)
Duration of illness ≤ 2 years 145 (34.4) 52 (28.3%) 93 (39.1%) 1
3–5 years 79 (18.7) 34 (18.5%) 45 (18.9%) 0.292 1.351 (0.772, 2.366)
6–10 years 133 (31.5) 66 (35.9%) 67 (28.2%) 0.021* 1.762 (1.090, 2.848)
> 10 years 65 (15.4) 32 (17.4%) 33 (13.9%) 0.069* 1.734 (0.958, 3.138)
NB *P < 0.25

Table 7 Multivariable logistic regression analysis of factors associated with high expressed emotions among caregivers of patient with
schizophrenia at Jimma University Medical Center Psychiatry Clinic, Southwest Ethiopia 2019 (n = 422)
Variables Category Frequency (%) Expressed emotion status Multivariable P-value
result AOR (95%
High expressed Low expressed CI)
emotion (n = 184) emotion
(n = 238)

Duration of taking care of the pt < 2 years 121 (28.7) 41 (22.3%) 80 (33.6%) 1
3–5 years 118 (28.0) 51 (27.7%) 51 (28.2%) 1.529 (0.890,2.626) 0.124
6–8 years 82 (19.4) 45 (24.5%) 45 (15.5%) 2.313 (1.261,4.242) 0.007*
> 8 years 101 (23.9) 47 (25.5%) 47 (22.7%) 1.467 (0.797,2.701) 0.218
Caregivers report of chronic Yes 55 (13.0) 19 (10.3%) 36 (15.1%) 1
medical/physical illness No 367 (87.0) 165 (89.7%) 202 (84.9%) 2.135 (1.143,3.987) 0.017*
Number of episode 1–2 295 (69.9) 115 (62.5%) 180 (75.6%) 1
3–4 58 (13.7) 35 (19.0%) 23 (9.7%) 0.007* 2.281 (1.253, 4.150)
>4 69 (16.4) 34 (18.5%) 35 (14.7%) 0.183 1.504 (0.825, 2.741)
1 = reference value
NB *P < 0.05 statistically significant

Abbreviations colleagues (Workwa, Bennyam), the nurses, and all other members of staff
CC: Critical comments; CFI: Camberwell Family Interview; DALYs: Disability- of the Department of Psychiatry of Jimma University. I am grateful to all the
adjusted life years; EE: Expressed emotion; EOI: Emotional over-involvement; caregivers of patients with schizophrenia who gave me the information which
FBIS: Family Burden Interview Schedule; FQ: Family Questionnaire; H: Hostility; would help in this study and data collectors.
HEE: High expressed emotion; LEE: Low expressed emotion; MMAS: Morisky
Medication Adherence Scale; PDD: Perceived devaluation and discrimination; Author contributions
YLD: Years lived with disability. BY conceived the study; played a leading role in the analyses of the research
and prepared the first draft of the manuscript. MS, YG, BA, GA, ET, MN reviewed
Acknowledgements and approved the final manuscript. All authors read and approved the final
My sincere gratitude goes to Jimma University and Wollo University for giv- manuscript.
ing me a conducive environment during my study. My advisors Mr. Matiws
Soboka, Dr. Bezaye Alemu, Mr. Gutema Ahmed, and Dr. Elias Tesfaye should Funding
also get my thanks. Besides, I value you as my teacher (Mr. Yemiamrew) Jimma University has funded the research work but played no role in the
and mentor in the art of research (Mr. Mamo). You all guided me through manuscript preparation.
this study with patience and understanding. My gratitude also goes to my
Yimam et al. Annals of General Psychiatry 2022, 21(1):27 Page 10 of 10

Availability of data and materials 14. King S, Dixon MJ. Expressed emotion and relapse in young schizophrenia
The data elements utilized in this research work are accessible from the cor- outpatients. British J psychiatry. 1999;25(2):377–86.
responding authors on a rational request. 15. Mitsonis C, Vousoura E. Factors associated with caregiver psychologi-
cal distress in chronic schizophrenia Factors associated with caregiver
psychological distress in chronic schizophrenia. 2010;(December)
Declarations 16. Ogunwale A, Hospital N, Babalola EO, Hospital N. CO. www.​elsev​ier.​com.
2017.
Ethics approval and consent to participate 17. Butzlaff RL, Hooley JM. Expressed emotion and psychiatric relapse. Meta-
Ethical clearance was obtained from the Institutional Review Board of JU Analysis. 1998;55(June):547–52.
after approval of the proposal. Official permission was received from Jimma 18. Aguilera A, Lo SR, Breitborde NJK, Kopelowicz A, Zarate R. Expressed
University Medical Center’s psychiatry clinic. The purpose of the study was emotion and sociocultural moderation in the course of schizophrenia. J
communicated with study participants and data were collected after written Abnorm Psychol. 2010;119(4):875–85.
consent is obtained. Caregivers with HEE were consulted with mental health 19. Mitsonis C, Vousoura E. Factors associated with caregiver psychological
professionals and psychologists working in the unit. distress in chronic schizophrenia. Soc Psychiatry Psychiatr Epidemiol.
2010. https://​doi.​org/​10.​1007/​s00127-​010-​0325-9.
Consent for publication 20. Hooley JM, Parker HA. Measuring expressed emotion : an evaluation of
Not applicable. the shortcuts. J Family Psychol. 2006. https://​doi.​org/​10.​1037/​0893-​3200.​
20.3.​386.
Competing interests 21. Bailey RC. The relationship between expressed emotion and wellbeing
No competing interests for the present research work. for families and carers of a relative with borderline personality disorder.
Personal Ment Health. 2015;9:21–32.
Author details 22. The influence of burden of care and perceived stigma on expressed
1
Department of Psychiatry, College of Medicine and Health Science, Wollo emotions of relatives of stable person settings. Master’s Dissertation in
University, Dessie, Ethiopia. 2 Department of Psychiatry, College of Medicine International Mental Health supervisors. 2013.
and Health Science, Jimma University, Jimma, Ethiopia. 23. Ikram A, Suhail K, Jafery SZ, Singh S. Rates of expressed emotions in
Pakistani relatives of patients with schizophrenia. Isr J Psychiatry Relat Sci.
Received: 12 March 2021 Accepted: 6 July 2022 2011;48(2):74–81.
Published: 18 July 2022 24. Gogo K. Assessment of emotion in family members of a patient with
schizophrenia in a selected Medical College Hospital Assam. Open J
psychiatry allied Sci. 2016;8(1):62–70.

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