{"paper_id":"23339c2f-c8e4-47f5-95bc-66b3fa09abdf","body_text":"Effect of a Psychoeducation Intervention on Affiliate Stigma among Family Caregivers of Individuals with Mental Disorders in Western Ethiopia: A Pre-test Post-test Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Effect of a Psychoeducation Intervention on Affiliate Stigma among Family Caregivers of Individuals with Mental Disorders in Western Ethiopia: A Pre-test Post-test Study Adamu Kenea¹¸², Sudhakar N. Morankar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7372530/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Mental disorders are a major Public health concern globally, with profound consequences not only for individuals but also for their family care givers, particularly in low- and middle income countries (LMIC). One often-overlooked consequence is affiliate stigma, the internalization of public stigma by caregivers, which can negatively affect their psychological well-being and caregiving effectiveness. Objective: This study aimed to assess the effect of a structured psychoeducation intervention on reducing affiliate stigma among family caregivers of individuals with mental disorders in Western Ethiopia. Methods: A quasi-experiential, pre-post controlled study was conducted between March 2021 and February 2022. The intervention group (n = 277) received a six-session psychoeducation program and routine care at Mettu Karl Comprehensive Specialized Hospital, while the comparison group (n = 279) received routine care only at Nekemte Comprehensive Specialized Hospital. The Affiliate Stigma Scale was administered at baseline and post-intervention. Linear mixed-effects models and Difference-in-Differences (DID) analyses were employed to assess the intervention's effect, while adjusting for relevant covariates. Results: The intervention group showed a significant reduction in affiliate stigma scores from the baseline to post-intervention (mean difference = –7.71, 95% CI: –12.56 to –6.80), while the change in the comparison group was not statistically significant (mean difference = –1.85, 95% CI: –4.48 to 0.78). The DID analysis confirms a significant net reduction in affiliate stigma attributable to the intervention (DID = –5.68 ± 1.96, 95% CI: –9.49 to –2.23). The net intervention effect corresponded to a moderate-to-large reduction (d = −0.63), underscoring the substantial practical significance of the psychoeducation. The adjusted model (Model 3) further supported the intervention's effect (β = –8.84, 95% CI: –10.71 to –6.96, p < 0.001). Conclusion: Psychoeducation significantly reduced affiliate stigma among family caregivers of individuals with mental disorders. Incorporating structured psychoeducation into routine mental health services may enhance caregiver resilience and improve overall care outcomes. Health sciences/Diseases Health sciences/Health care Biological sciences/Psychology Social science/Psychology Affiliate Stigma Ethiopia Family Caregivers Mental Illness Psychoeducation Quasi-Experimental Study Figures Figure 1 Introduction Mental disorders are among the most common and disabling health conditions globally, affecting people across cultures, age groups, and income settings. Recent global burden analyses estimate that hundreds of millions of people are living with a diagnosable mental disorder at any given time, with the Global Burden of Disease (GBD) 2019 study reporting roughly 1 in 8 people affected worldwide. Depressive and anxiety disorders are consistently among the leading causes of years lived with disability (YLDs) worldwide [ 1 – 3 ]. The burden of mental disorders is particularly consequential in Low- and Middle-Income Countries (LMICs), including those in sub-Saharan Africa, where rapid demographic change, ongoing conflict and adversity exposures, and thin mental health systems converge to magnify unmet need. Treatment gaps remain wide, and mental health conditions frequently go unrecognized or untreated in general health settings [ 4 – 6 ]. Stigma is widely recognized as a critical barrier to mental health care. Public stigma shapes negative social attitudes toward people living with mental disorders, reduces social support, and undermines help-seeking. Importantly, the effects of stigma extend beyond service users to include family members who provide the bulk of day-to-day care in many LMIC contexts. Evidence from Ethiopia and other sub-Saharan African settings links stigma and discrimination to delays in service use, reduced adherence, and caregiver distress [ 7 ]. Affiliate stigma refers to the process by which a stigmatized individual internalizes negative societal reactions and attitudes. This internalization is defined as the process by which a stigmatized individual internalizes the negative reactions of others [ 8 ]. It manifests in three interrelated components: (i) a cognitive component endorsing or accepting negative societal beliefs about oneself as a caregiver; (ii) an affective component experiencing shame, guilt, embarrassment, or self-blame; and (iii) a behavioral component, such as social withdrawal, concealment, or distancing from the relative with mental illness. Affiliate stigma has further negative impacts on family caregivers’ physical and mental health, including elevated stress levels, symptoms of depression and anxiety, poorer quality of life, and increased perceived caregiving burden [ 9 ]. Psycho-education is an evidence-based intervention designed to enhance caregivers’ understanding of mental illness and equip them with coping strategies. By providing relevant information, communication skills, and problem-solving techniques, psycho-education can reduce caregiving burden and empower families to manage the challenges associated with mental illness effectively [ 10 , 11 ]. Psycho-education equips family caregivers with essential knowledge and practical skills to better understand and manage mental health conditions within the household. By enhancing caregivers’ awareness and their capacity for effective communication and problem-solving, psycho-education has the potential to alleviate caregiving-related stress and improve overall support for individuals with mental illness [ 12 , 13 ]. Ensuring the psychological well-being of caregivers is vital, as their mental resilience directly influences the quality of care they provide. Empowering caregivers through structured educational interventions fosters greater confidence in handling emotional challenges, promotes healthier coping strategies, and enhances their ability to maintain personal well-being. Given this context, the current study sought to assess the impact of a psycho-educational program on reducing affiliate stigma among family caregivers of individuals with mental disorders in Western Ethiopia. Methods Study Design and Setting A quasi-experimental, pre-post controlled design was employed to evaluate the effect of a structured psycho-educational intervention on affiliate stigma among family caregivers of individuals diagnosed with mental disorders. The study was implemented at two public referral Hospitals, Mettu Karl Comprehensive Specialized Hospital (MKCSH) and Nekemte Comprehensive Specialized Hospital (NCSH) located in Western Ethiopia. These facilities were selected based on their provision of outpatient psychiatric care and high caregiver flow. Caregivers attending MKCSH were assigned to the intervention group, while those at NCSH formed the comparison group receiving standard psychiatric services without additional intervention. Study Population and Eligibility Participants were primary family caregivers of individuals receiving outpatient psychiatric treatment, defined as adult relatives who regularly participated in care provision and decision-making. Inclusion criteria required caregivers to be aged between 18 and 65 years, reside with or maintain frequent contact with the person with a mental disorder, and have been involved in caregiving for a minimum of six months. Caregivers were excluded if they had cognitive impairments, severe physical illness, or encountered significant life disruptions (e.g., bereavement or hospitalization) during the study period. Only one caregiver per patient was eligible to ensure independent responses. Sample Size and Sampling Procedure Sample size determination was informed by prior psycho-education studies and aimed to detect a small-to-moderate effect in reducing affiliate stigma scores. Using G*Power with a statistical power of 80% and a 5% significance level, a total sample of 556 caregivers was targeted (277 in the intervention group and 279 in the comparison group), accounting for a 10% anticipated attrition. Caregivers were identified via psychiatric outpatient registries, and participants were systematically sampled using defined intervals based on daily caseloads. Allocation and Blinding Group allocation was based on hospital location, with MKCSH serving as the intervention site and NCSH as the control (Fig. 1 ). Due to the nature of the educational intervention, neither participants nor facilitators were blinded to group assignment. However, data collectors remained independent from intervention delivery to minimize measurement bias. To minimize performance bias, the intervention and comparison groups were recruited from two different hospitals (Mettu Karl Comprehensive Specialized Hospital for the intervention and Nekemte Comprehensive Specialized Hospital for the comparison). This physical and organizational separation prevented contact between participants from the two groups and eliminated the risk of intervention-related information being shared with the comparison group. In both hospitals, routine mental health services continued as usual for all participants. Intervention Description The six-monthly session psychoeducation program is designed to empower caregivers of individuals with mental disorders by enhancing their knowledge, practical skills, and emotional well-being. The first session introduces the structure and a goal of the intervention, identifies caregivers' informational needs, and provides an overview of mental disorders, including symptoms, causes, and the family’s role in relapse prevention. It also includes a testimonial from a clinically stable patient to humanize the experience of mental illness. The second session goes into more detail about psychotropic drugs, looking at their pros and cons and stressing how important it is for patients to stick to their treatment plans. It also talks about common fallacies and worries. In the third session, caregivers learn effective verbal and non-verbal communication strategies, along with techniques for expressing and managing intense emotions, all of which are crucial for supporting recovery and preventing relapse. The fourth session builds on this by teaching behavioral management tools including token economy and reinforcement concepts, as well as real-world ways to deal with symptoms like psychosis, agitation, or withdrawal. Session five turns the focus inward, helping caregivers recognize the impact of stress and offering tools such as relaxation techniques to support their mental health and resilience. The final session serves as a comprehensive review, reinforcing key lessons and encouraging participants to continue using relaxation strategies, while also providing a platform for reflection and feedback. Collectively, the program aims to strengthen the caregiver's role, reduce stress, and improve the overall quality of care provided to individuals with mental illness. Interactive teaching methods included discussions, role-plays, lived experience narratives, and culturally tailored handouts. Attendance was recorded for all sessions to track compliance. Intervention fidelity The intervention fidelity was evaluated using best practice recommendations developed by the National Institutes of Health (NIH) Behavioral Change Consortium[ 14 ]. The recommendations cover (i) study design: establishing procedures to monitor and reduce the potential for contamination between active treatments or treatment and control, as well as to measure dose and intensity; (ii) provider training: standardization of training to ensure that all providers are trained in the same manner; (iii) treatment delivery: behavioral checklists to ensure that providers adhered to the treatment protocol and (iv) treatment receipt: through supervisory visits to the study area and performance evaluation meetings with the Psychoeducation providers. Data Collection tools and procedures Data were collected using a pre-tested, structured, interviewer-administered questionnaire conducted by trained psychiatric nurses who were independent of the intervention team. This independence helped minimize potential interviewer bias and ensured objectivity throughout the data collection process. The questionnaire comprised several sections. The socio-demographic characteristics section captured participants’ age, gender, education, occupation, and relationship to the care recipient to describe the study population. The clinical characteristics section collected information about the care recipient’s diagnosis, duration of illness, and treatment status to provide context for caregiving. The affiliate stigma section assessed stigma using an adapted version of the Affiliate Stigma Scale for Caregivers of People with Mental Illness (CPMI) [ 15 ], supplemented with additional items from relevant literature [ 16 ] to ensure content validity and contextual appropriateness. All interviews were conducted face-to-face using a standardized protocol. This approach promoted uniformity in question delivery, minimized the risk of misinterpretation, and enhanced the reliability of responses. Data were gathered at two time points: prior to the intervention (baseline) and immediately after its completion (post-intervention). This design allowed for both within-group comparisons over time and between-group comparisons to evaluate the effect of the intervention relative to the control group. Outcome Measure The primary outcome measure was affiliate stigma, evaluated using a culturally adapted version of the Affiliate Stigma Scale for Caregivers of People with Mental Illness (CPMI) [ 15 ]. This validated instrument captures the extent of caregivers’ internalized stigma across three dimensions cognitive (negative beliefs and perceptions), emotional (feelings of shame, guilt, or distress), and behavioral (avoidance or withdrawal from social interactions). Responses are rated on a Likert scale, with higher scores reflecting greater levels of internalized stigma. For the current study, the adapted scale demonstrated good internal consistency, with a Cronbach’s alpha coefficient of 0.83, indicating favorable reliability for use in this population. Statistical Analysis Descriptive statistics, including measures such as means, standard deviations, frequencies, and percentages, were employed to summarize and characterize the socio-demographic and baseline clinical profiles of the study participants. A modified intent-to-treat (mITT) approach was employed for the primary analysis .To evaluate the impact of the intervention on affiliate stigma, a Linear Effects Model was used to compare post-intervention stigma scores between the intervention and control groups. The model was adjusted for potential confounders such as the caregivers’ age, educational status, employment status, family size, marital status and relationship with the patient. This model allowed for the inclusion of both fixed and random effects and was adjusted for baseline stigma scores to control for initial differences and improve the accuracy of the estimates. Within-group changes in affiliate stigma scores from pre- to post-intervention were assessed using paired t-tests, which tested whether the mean differences within each group were statistically significant. Furthermore, to quantify the net effect of the intervention while accounting for time trends and group differences, a Difference-in-Differences (DID) analysis was conducted. This approach compared the changes in outcomes over time between the intervention and control groups to isolate the effect attributable to the intervention itself. A p-value of less than 0.05 was considered statistically significant for all analyses, indicating a high level of confidence in the observed differences. Result Socio-demographic characteristics of caregivers The flow of the study participants through the intervention process is depicted in Fig. 1 . At baseline, the intervention and comparison groups were largely similar across all the socio-demographic characteristics, suggesting general comparability. No statistically significant differences were observed in age (p = 0.20), sex was (p = 0.106), residence (p = 0.664), marital status (p = 0.864), religion (p = 0.756), educational level (p = 0.166), employment status (p = 0.772), family size (p = 0.317), or patient diagnosis (p = 0.105). However, a notable difference was found in the patient (Table 1 ). Table 1 Baseline socio-demographic and Clinical Characteristics of Respondents by Group, MKCSH and NCSH, Western Ethiopia, 2021–2022 Characteristic Category Intervention (n = 277) Comparison (n = 279) p-value Age (years) Mean ± SD 31.91 ± 11.12 33.14 ± 11.50 0.200 Sex Male 137 (49.5) 119 (42.7) 0.106 Female 140 (50.5) 160 (57.3) Residence type Rural 168 (60.6) 164 (58.8) 0.664 Urban 109 (39.4) 115 (41.2) Marital status Single 154 (55.6) 147 (52.7) 0.864 Married 108 (39.0) 113 (40.5) Separated/Widowed 15 (5.4) 19 (6.8) Religion Christian 158 (57.0) 161 (57.7) 0.756 Muslim 116 (41.9) 113 (40.5) Wakefata 3 (1.1) 5 (1.8) Ethnic group Oromo 233 (84.1) 250 (89.6) 0.055 Amhara 38 (13.7) 21 (7.5) Other** 6 (2.2) 8 (2.9) Education level No formal education 136 (49.1) 139 (49.8) 0.166 Primary 34 (12.3) 51 (18.3) Secondary and above 107 (38.6) 89 (31.9) Employment status Unemployed 88 (31.8) 78 (28.0) 0.772 Self-employed 82 (29.6) 87 (31.2) Civil servant 74 (26.7) 84 (30.1) Student/Daily laborer 33 (11.9) 30 (10.8) Household size < 5 members 174 (62.4) 105 (37.6) 0.317 ≥ 5 members 185 (66.8) 92 (33.2) *Tigray, Gurage. Caregiver–Patient Relationship and Clinical Characteristics A statistically significant difference was observed in the patient (p = 0.032). Caregivers in the intervention group were more likely to be siblings (21.7%) or cousins (13.0%), whereas the comparison group had a higher proportion of siblings (31.2%) and spouses (13.0%) (Table 2 ). Table 2 Caregiver–Patient Relationship and Clinical Characteristics Characteristic Category Intervention (n = 277) Comparison (n = 279) p-value Relationship to patient Parent 108 (39.) 101 (36.2) 0.032 Sibling 60 (21.7) 87 (31.2) Uncle/Aunt 33 (11.9) 25 (9.0) Cousin 36 (13.0) 23 (8.2) Spouse 27 (9.7) 36 (13.0) Other* 13 (4.7) 7 (2.7) Primary patient diagnosis Mental disorders 63 (22.7) 71 (25.4) 0.105 Bipolar affective disorder 30 (10.8) 33 (11.8) Depression 66 (23.8) 80 (28.7) Substance use disorder 84 (30.3) 59 (21.1) Intellectual disability 21 (7.6) 15 (5.4) Partial seizures 3 (1.1) 9 (3.2) Other** 10 (3.6) 12 (4.3) *Grandparent, Step-parent ** Autism Spectrum Disorder, Personality Disorders Effect of the Psychoeducation intervention The findings from the table indicate a significant reduction in the outcome measure among participants in the intervention group compared to those in the comparison group over time. Specifically, the mean score in the intervention group decreased from 51.51 at baseline to 42.39 at end line, yielding a statistically significant mean difference of − 7.71 points (95% CI: −12.56 to − 6.80). In contrast, the comparison group showed a smaller, non-significant reduction from 52.88 to 51.03, with a mean difference of − 1.85 points (95% CI: −4.48 to 0.78). The Difference-in-Differences (DID) analysis further confirmed the effectiveness of the intervention, revealing a statistically significant net change of − 5.68 points (± 1.96), with a 95% confidence interval ranging from − 9.49 to − 2.23. This suggests that the observed improvements in the intervention group were attributable to the intervention itself, rather than external or temporal factors. Effect sizes indicated a large reduction in affiliate stigma within the intervention group (Cohen’s d = − 0.84) compared to a negligible change in the control group (d = − 0.17). The net intervention effect from the DID analysis corresponded to a moderate-to-large reduction (d = − 0.63), underscoring the substantial practical significance of the psychoeducation program (Table 3 ). Table 3 Stigma Scores at Baseline and End Line by Group Group BL Mean (± SD) 95% CI EL Mean (± SD) 95% CI Mean Difference (EL – BL) 95% CI Effect size Intervention Group 51.51 (11.75) 50.09–52.93 42.39 (9.95) 41.14–43.53 −7.71 (− 12.56,−6.80)**** −0.84 Comparison Group 52.88 (11.39) 51.49–54.26 51.03 (10.83) 49.71–52.36 −1.85(− 4.48,0.78) −0.17 Difference-in-Differences (DID) (± SE) – – – – −5.68 (± 1.96) (− 9.49,−2.23) *** −0.63 *p < 0.001) BL – Baseline EL – End line SD - Standard Deviation SE – Standard Error The final adjusted model (Model 3), which included the intercept, slope, and covariates, demonstrated significant effects of time, group assignment, and their interaction on the outcome measure. Specifically, caregivers in the intervention group had significantly lower burden scores compared to those in the comparison group (β = -8.84; 95% CI: -10.71, -6.96; p < 0.001). Moreover, the interaction between time and group was also significant, indicating a greater reduction in burden scores for the intervention group at end line compared to baseline (β = -7.32; 95% CI: -8.89, -5.75; p < 0.001). This suggests that the intervention effectively decreased caregiver affiliate stigma over time relative to the comparison group. Among the three models tested, Model 3 exhibited the best fit to the data, as reflected by the lowest AIC value (7856.19). This indicates that incorporating time, group assignment, their interaction, and relevant covariates provided the most comprehensive and accurate explanation for variations in caregiver affiliate stigma scores (Table 4 ). Table 4 Linear mixed-effects model predicting the Effect of Psychoeducation on Caregiver affiliate stigma Scores among Family Caregivers of People with Mental Disorders (n = 531,(268, C = 263) Fixed effect Model 1 Model 2 Model 3 Intercept 49.42 (48.71, 50.13)*** 51.03 (49.70, 52.36)*** 52.36 (44.36, 60.36)*** Intervention Effect Intervention group – -8.69 (- -10.56, -6.82)*** -8.84 (- -10.71, -6.96)*** Comparison group – – – Intervention and Group Interaction End line – –7.32 (–9.97, − 4.67))*** – 7.32 (–8.89, − 5.75)**** Baseline (Ref) Random effect AIC 8253.75 8117.44 7856.19 ICC 0.067 0.062 0.057 *** = p < 0.001 Note: Model 1. Intercept-only model Model 2:Slope‐only model Model 3. Intercept with slope model SE–Standard error CI–Confidence interval AIC – Akaike’s information criterion ICC—Intra-cluster correlation The model was adjusted for the caregivers’ age, educational status, employment status, family size, marital status and relationship with the patient Discussion This study aimed to assess the effect of psychoeducation on affiliate stigma among family caregivers of individuals with mental disorders. There was no significant difference in the mean affiliate stigma score between the intervention and comparison group at baseline. The findings showed that the mean affiliate stigma score significantly decreased after the intervention in the intervention group. The difference-in-differences analysis accounted for group differences and time trends, further confirming the intervention’s specific effect. Additionally, the linear mixed-effects model, which controlled for potential confounders, provided robust support for the observed outcomes. This result is consistent with an interventional study conducted in Iran, which also reported a significant reduction in affiliate stigma scores following psychoeducation [ 16 ]. Similarly, a related study demonstrated that the mean and standard deviation of affiliate stigma scores decreased significantly after training [ 17 ]. In line with these findings, research from a tertiary care hospital in India found that family psychoeducation significantly reduced affiliate stigma scores among caregivers of psychiatric patients compared to a control group [ 18 ]. Furthermore, a systematic review on interventions to reduce affiliate stigma related to mental illnesses in educational institutes reported that most anti-affiliate stigma interventions were successful in improving mental health literacy, as well as attitudes and beliefs toward mental illness[ 19 ]. This effect may be attributed to the increased knowledge and awareness [ 20 ] about mental illness provided through psychoeducation, which likely helped caregivers develop more positive attitudes toward both the patient and their caregiving role. By offering practical and relevant information about mental illness and its treatment, psychoeducation can reduce negative attitudes [ 20 ] and promote greater acceptance of the affected family member, ultimately improving caregivers' perceptions of both the patient and themselves. Additionally, the group-based format fosters social support by connecting caregivers with peers facing similar challenges, normalizing their experiences and alleviating feelings of isolation. Finally, the program enhances communication and problem-solving skills, enabling caregivers to manage difficult behaviors more effectively and interact with the patient in ways that reduce conflict and stress. Beyond its demonstrated effectiveness, the intervention’s design and delivery also support its potential for scalable and sustainable implementation in resource-limited settings. The strengths of this study include the use of a controlled quasi-experimental design, which enhances causal inference; the application of two complementary statistical approaches, difference-in-differences and linear mixed-effects modeling, that improve the robustness of the findings; and the use of validated measurement tools to ensure reliability and accuracy of the outcome assessment. However, the study is not without limitations. The quasi-experimental design, while pragmatic, limits random allocation and may introduce selection bias. Although baseline characteristics were largely comparable between groups, unmeasured confounders may still exist. Moreover, the lack of long-term follow-up prevents assessment of the durability of the intervention effect. Finally, the generalizability may be limited to similar public health settings within Ethiopia or comparable LMIC contexts. Implications for Practice and Policy: Integrating psychoeducational components into existing mental health services, especially within outpatient settings, could serve as a low-cost, scalable strategy to support caregiver mental health and reduce affiliate stigma at the household level. Health systems in LMICs should consider routine implementation of psychoeducation programs tailored to cultural and contextual realities. Abbreviations AOR Adjusted Odds Ratio BBZ Buno Bedele Zone CI Confidence Interval DHIS2 District Health Information Software, version 2 EFY Ethiopian Fiscal Year HIS Health Information System HMIS Health Management Information System HSTP Health Sector Transformation Plan IR Information Revolution (Ethiopia) LMIC Low–and Middle–Income Country ODK Open Data Kit PRISM Performance of Routine Information System Management RHIU Routine Health Information Utilization RHIS Routine Health Information System SD Standard Deviation UHC Universal Health Coverage VIF Variance Inflation Factor Declarations Ethics approval and consent to participate The study protocol was reviewed and approved by the Institutional Review Board (IRB) of Jimma University (IRB approval no.: IHRPGn/944/20) . Administrative permission letters were obtained from each participating hospital prior to data collection. All eligible caregivers were informed about the study’s purpose, procedures, potential benefits, and minimal risks; questions were encouraged. Because literacy levels varied, informed written consent was obtained in the participant’s preferred language after confirming comprehension. Participation was entirely voluntary, and caregivers were informed that refusal or withdrawal at any time would not affect the care they or their family member received. Confidentiality was protected by assigning unique study IDs, excluding personal identifiers from analytic datasets, and storing all data in password-protected files accessible only to the research team. A condensed psychoeducation session was offered to Comparison group caregivers after study completion as an ethical courtesy. This research adhered to the ethical principles outlined in the Declaration of Helsinki for research involving human subjects [21]. Consent for publication Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing Interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions AK conceptualized the study and initiated discussions with Sudhakar N. Morankar¹. The study was jointly designed by AK and SNM, who also supervised the project and contributed significantly to its implementation. AK led the manuscript writing, assumes responsibility for the content, and submitted the work for publication. All authors critically reviewed and approved the final version of the manuscript. Acknowledgements We would like to express our sincere gratitude to Jimma University, Mettu Karl Comprehensive Specialized Hospital (MKCSH), and Nekemte Comprehensive Specialized Hospital (NCSH) for their invaluable support in the implementation of this study. We also extend our heartfelt thanks to the data collectors, supervisors, study participants, and all others who contributed to the successful completion of this research. The views expressed in this publication are those of the authors and do not necessarily represent the official position of the sponsoring institution. Clinical trial number Not applicable. References Bhugra D, Watson C, Wijesuriya R. Culture and mental illnesses. Int Rev Psychiatry. 2021;33: 1–2. doi:10.1080/09540261.2020.1777748 WHO. Mental disorders. Retrieved from https://www.who.int/news-room/fact-sheets/detail/mental-disorders. 2022. Evaluation. I for HM and. Global Burden of Disease 2021. 2021. Mental GBD, Collaborators D. 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Ann Gen Psychiatry. 2018;17: 1–5. doi:10.1186/s12991-018-0218-y Gupta R, Soni S, Yadav R, Choudhary S, Verma R, Senwar S, et al. “ A Study to Assess the Effectiveness of Family Psycho-Education Programme on Stigma Related to Mental Disorder Among Caregivers of Psychiatric Patients at Selected Tertiary Care Hospital Bhopal .” Afr J Biomed Res. 2024;27: 7579–7586. Waqas A, Malik S, Fida A, Abbas N, Mian N. Interventions to Reduce Stigma Related to Mental Illnesses in Educational Institutes : a Systematic Review. 2020;91: 887–903. Roger K, Gregoire A, Desnavailles P, Misdrahi D, Luciano M. Family psychoeducation to improve outcome in caregivers and patients with schizophrenia : a randomized clinical trial. Front Psychiatry. 2023;14: :1171661. doi:10.3389/fpsyt.2023.1171661 World Health Organization. World Medical Association Declaration of Helsinki. Ethical principles for medical research involving human subjects.Bull World Health Organ. 2001;79: 373–4. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-7372530\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Article\",\"associatedPublications\":[],\"authors\":[{\"id\":506081552,\"identity\":\"c975df3a-287a-4939-a92f-aa872bf84b80\",\"order_by\":0,\"name\":\"Adamu Kenea¹¸²\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYFCCBCA+AGIwg0gJGVK0sIFYEjykaOExAJMENfC3Jz/dzHPGJo+f/cznVzdqLHgY2A8f3YBPi8SZZ2a3eW6kFUv25G6zzjkGdBhPWtoNvNbcSABq+XA4ccOB3G3GOWxALRI8Zni1yN9I/wbU8j9x//k3z4xz/hGhxeBGDshhBxI3SOQwP85tI0KL4Zk3ZTfnnElOnHHjmRlzbp8EDxshv8gdT992480xu8T+/uTHn3O+1cnxsx8+ht/7SIBNAkwSqxwEmD+QonoUjIJRMApGDgAAKNJQDJvKVPYAAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"Jimma University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Adamu\",\"middleName\":\"\",\"lastName\":\"Kenea¹¸²\",\"suffix\":\"\"},{\"id\":506081555,\"identity\":\"c7c50d7d-df84-4077-a116-14aa766efb59\",\"order_by\":1,\"name\":\"Sudhakar N. Morankar\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Jimma University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Sudhakar\",\"middleName\":\"N.\",\"lastName\":\"Morankar\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-08-14 10:15:43\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-7372530/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-7372530/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":90493037,\"identity\":\"45a8c309-ac4e-4e2e-9254-86468f097191\",\"added_by\":\"auto\",\"created_at\":\"2025-09-03 10:06:12\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":31162,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eFlow diagram\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7372530/v1/04729bdd76bdd05fd9a5321c.png\"},{\"id\":100563602,\"identity\":\"fdf7d763-c7e3-425d-868c-98addb8aa948\",\"added_by\":\"auto\",\"created_at\":\"2026-01-19 08:47:02\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1022519,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7372530/v1/d99d2613-f9a7-4af7-b058-193456f3dd06.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Effect of a Psychoeducation Intervention on Affiliate Stigma among Family Caregivers of Individuals with Mental Disorders in Western Ethiopia: A Pre-test Post-test Study\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eMental disorders are among the most common and disabling health conditions globally, affecting people across cultures, age groups, and income settings. Recent global burden analyses estimate that hundreds of millions of people are living with a diagnosable mental disorder at any given time, with the Global Burden of Disease (GBD) 2019 study reporting roughly 1 in 8 people affected worldwide. Depressive and anxiety disorders are consistently among the leading causes of years lived with disability (YLDs) worldwide [\\u003cspan additionalcitationids=\\\"CR2\\\" citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe burden of mental disorders is particularly consequential in Low- and Middle-Income Countries (LMICs), including those in sub-Saharan Africa, where rapid demographic change, ongoing conflict and adversity exposures, and thin mental health systems converge to magnify unmet need. Treatment gaps remain wide, and mental health conditions frequently go unrecognized or untreated in general health settings [\\u003cspan additionalcitationids=\\\"CR5\\\" citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eStigma is widely recognized as a critical barrier to mental health care. Public stigma shapes negative social attitudes toward people living with mental disorders, reduces social support, and undermines help-seeking. Importantly, the effects of stigma extend beyond service users to include family members who provide the bulk of day-to-day care in many LMIC contexts. Evidence from Ethiopia and other sub-Saharan African settings links stigma and discrimination to delays in service use, reduced adherence, and caregiver distress [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eAffiliate stigma refers to the process by which a stigmatized individual internalizes negative societal reactions and attitudes. This internalization is defined as the process by which a stigmatized individual internalizes the negative reactions of others [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. It manifests in three interrelated components: (i) a \\u003cem\\u003ecognitive\\u003c/em\\u003e component endorsing or accepting negative societal beliefs about oneself as a caregiver; (ii) an \\u003cem\\u003eaffective\\u003c/em\\u003e component experiencing shame, guilt, embarrassment, or self-blame; and (iii) a \\u003cem\\u003ebehavioral\\u003c/em\\u003e component, such as social withdrawal, concealment, or distancing from the relative with mental illness. Affiliate stigma has further negative impacts on family caregivers\\u0026rsquo; physical and mental health, including elevated stress levels, symptoms of depression and anxiety, poorer quality of life, and increased perceived caregiving burden [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003ePsycho-education is an evidence-based intervention designed to enhance caregivers\\u0026rsquo; understanding of mental illness and equip them with coping strategies. By providing relevant information, communication skills, and problem-solving techniques, psycho-education can reduce caregiving burden and empower families to manage the challenges associated with mental illness effectively [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003ePsycho-education equips family caregivers with essential knowledge and practical skills to better understand and manage mental health conditions within the household. By enhancing caregivers\\u0026rsquo; awareness and their capacity for effective communication and problem-solving, psycho-education has the potential to alleviate caregiving-related stress and improve overall support for individuals with mental illness [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. Ensuring the psychological well-being of caregivers is vital, as their mental resilience directly influences the quality of care they provide. Empowering caregivers through structured educational interventions fosters greater confidence in handling emotional challenges, promotes healthier coping strategies, and enhances their ability to maintain personal well-being. Given this context, the current study sought to assess the impact of a psycho-educational program on reducing affiliate stigma among family caregivers of individuals with mental disorders in Western Ethiopia.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eStudy Design and Setting\\u003c/h2\\u003e\\n \\u003cp\\u003eA quasi-experimental, pre-post controlled design was employed to evaluate the effect of a structured psycho-educational intervention on affiliate stigma among family caregivers of individuals diagnosed with mental disorders. The study was implemented at two public referral Hospitals, Mettu Karl Comprehensive Specialized Hospital (MKCSH) and Nekemte Comprehensive Specialized Hospital (NCSH) located in Western Ethiopia. These facilities were selected based on their provision of outpatient psychiatric care and high caregiver flow. Caregivers attending MKCSH were assigned to the intervention group, while those at NCSH formed the comparison group receiving standard psychiatric services without additional intervention.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003ch3\\u003eStudy Population and Eligibility\\u003c/h3\\u003e\\n\\u003cp\\u003eParticipants were primary family caregivers of individuals receiving outpatient psychiatric treatment, defined as adult relatives who regularly participated in care provision and decision-making. Inclusion criteria required caregivers to be aged between 18 and 65 years, reside with or maintain frequent contact with the person with a mental disorder, and have been involved in caregiving for a minimum of six months. Caregivers were excluded if they had cognitive impairments, severe physical illness, or encountered significant life disruptions (e.g., bereavement or hospitalization) during the study period. Only one caregiver per patient was eligible to ensure independent responses.\\u003c/p\\u003e\\n\\u003ch3\\u003eSample Size and Sampling Procedure\\u003c/h3\\u003e\\n\\u003cp\\u003eSample size determination was informed by prior psycho-education studies and aimed to detect a small-to-moderate effect in reducing affiliate stigma scores. Using G*Power with a statistical power of 80% and a 5% significance level, a total sample of 556 caregivers was targeted (277 in the intervention group and 279 in the comparison group), accounting for a 10% anticipated attrition. Caregivers were identified via psychiatric outpatient registries, and participants were systematically sampled using defined intervals based on daily caseloads.\\u003c/p\\u003e\\n\\u003ch3\\u003eAllocation and Blinding\\u003c/h3\\u003e\\n\\u003cp\\u003eGroup allocation was based on hospital location, with MKCSH serving as the intervention site and NCSH as the control (Fig.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Due to the nature of the educational intervention, neither participants nor facilitators were blinded to group assignment. However, data collectors remained independent from intervention delivery to minimize measurement bias. To minimize performance bias, the intervention and comparison groups were recruited from two different hospitals (Mettu Karl Comprehensive Specialized Hospital for the intervention and Nekemte Comprehensive Specialized Hospital for the comparison). This physical and organizational separation prevented contact between participants from the two groups and eliminated the risk of intervention-related information being shared with the comparison group. In both hospitals, routine mental health services continued as usual for all participants.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u003c/p\\u003e\\n\\u003ch3\\u003eIntervention Description\\u003c/h3\\u003e\\n\\u003cp\\u003eThe six-monthly session psychoeducation program is designed to empower caregivers of individuals with mental disorders by enhancing their knowledge, practical skills, and emotional well-being. The first session introduces the structure and a goal of the intervention, identifies caregivers\\u0026apos; informational needs, and provides an overview of mental disorders, including symptoms, causes, and the family\\u0026rsquo;s role in relapse prevention. It also includes a testimonial from a clinically stable patient to humanize the experience of mental illness. The second session goes into more detail about psychotropic drugs, looking at their pros and cons and stressing how important it is for patients to stick to their treatment plans. It also talks about common fallacies and worries. In the third session, caregivers learn effective verbal and non-verbal communication strategies, along with techniques for expressing and managing intense emotions, all of which are crucial for supporting recovery and preventing relapse. The fourth session builds on this by teaching behavioral management tools including token economy and reinforcement concepts, as well as real-world ways to deal with symptoms like psychosis, agitation, or withdrawal. Session five turns the focus inward, helping caregivers recognize the impact of stress and offering tools such as relaxation techniques to support their mental health and resilience. The final session serves as a comprehensive review, reinforcing key lessons and encouraging participants to continue using relaxation strategies, while also providing a platform for reflection and feedback. Collectively, the program aims to strengthen the caregiver\\u0026apos;s role, reduce stress, and improve the overall quality of care provided to individuals with mental illness. Interactive teaching methods included discussions, role-plays, lived experience narratives, and culturally tailored handouts. Attendance was recorded for all sessions to track compliance.\\u003c/p\\u003e\\n\\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eIntervention fidelity\\u003c/h2\\u003e\\n \\u003cp\\u003eThe intervention fidelity was evaluated using best practice recommendations developed by the National Institutes of Health (NIH) Behavioral Change Consortium[\\u003cspan class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. The recommendations cover (i) study design: establishing procedures to monitor and reduce the potential for contamination between active treatments or treatment and control, as well as to measure dose and intensity; (ii) provider training: standardization of training to ensure that all providers are trained in the same manner; (iii) treatment delivery: behavioral checklists to ensure that providers adhered to the treatment protocol and (iv) treatment receipt: through supervisory visits to the study area and performance evaluation meetings with the Psychoeducation providers.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003ch3\\u003eData Collection tools and procedures\\u003c/h3\\u003e\\n\\u003cp\\u003eData were collected using a pre-tested, structured, interviewer-administered questionnaire conducted by trained psychiatric nurses who were independent of the intervention team. This independence helped minimize potential interviewer bias and ensured objectivity throughout the data collection process.\\u003c/p\\u003e\\n\\u003cp\\u003eThe questionnaire comprised several sections. The socio-demographic characteristics section captured participants\\u0026rsquo; age, gender, education, occupation, and relationship to the care recipient to describe the study population. The clinical characteristics section collected information about the care recipient\\u0026rsquo;s diagnosis, duration of illness, and treatment status to provide context for caregiving. The affiliate stigma section assessed stigma using an adapted version of the Affiliate Stigma Scale for Caregivers of People with Mental Illness (CPMI) [\\u003cspan class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e], supplemented with additional items from relevant literature [\\u003cspan class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e] to ensure content validity and contextual appropriateness.\\u003c/p\\u003e\\n\\u003cp\\u003eAll interviews were conducted face-to-face using a standardized protocol. This approach promoted uniformity in question delivery, minimized the risk of misinterpretation, and enhanced the reliability of responses. Data were gathered at two time points: prior to the intervention (baseline) and immediately after its completion (post-intervention). This design allowed for both within-group comparisons over time and between-group comparisons to evaluate the effect of the intervention relative to the control group.\\u003c/p\\u003e\\n\\u003ch3\\u003eOutcome Measure\\u003c/h3\\u003e\\n\\u003cp\\u003eThe primary outcome measure was affiliate stigma, evaluated using a culturally adapted version of the \\u003cem\\u003eAffiliate Stigma Scale for Caregivers of People with Mental Illness (CPMI)\\u003c/em\\u003e [\\u003cspan class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. This validated instrument captures the extent of caregivers\\u0026rsquo; internalized stigma across three dimensions cognitive (negative beliefs and perceptions), emotional (feelings of shame, guilt, or distress), and behavioral (avoidance or withdrawal from social interactions). Responses are rated on a Likert scale, with higher scores reflecting greater levels of internalized stigma. For the current study, the adapted scale demonstrated good internal consistency, with a Cronbach\\u0026rsquo;s alpha coefficient of 0.83, indicating favorable reliability for use in this population.\\u003c/p\\u003e\\n\\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eStatistical Analysis\\u003c/h2\\u003e\\n \\u003cp\\u003eDescriptive statistics, including measures such as means, standard deviations, frequencies, and percentages, were employed to summarize and characterize the socio-demographic and baseline clinical profiles of the study participants. A modified intent-to-treat (mITT) approach was employed for the primary analysis .To evaluate the impact of the intervention on affiliate stigma, a Linear Effects Model was used to compare post-intervention stigma scores between the intervention and control groups. The model was adjusted for potential confounders such as the caregivers\\u0026rsquo; age, educational status, employment status, family size, marital status and relationship with the patient. This model allowed for the inclusion of both fixed and random effects and was adjusted for baseline stigma scores to control for initial differences and improve the accuracy of the estimates. Within-group changes in affiliate stigma scores from pre- to post-intervention were assessed using paired t-tests, which tested whether the mean differences within each group were statistically significant. Furthermore, to quantify the net effect of the intervention while accounting for time trends and group differences, a Difference-in-Differences (DID) analysis was conducted. This approach compared the changes in outcomes over time between the intervention and control groups to isolate the effect attributable to the intervention itself. A p-value of less than 0.05 was considered statistically significant for all analyses, indicating a high level of confidence in the observed differences.\\u003c/p\\u003e\\n\\u003c/div\\u003e\"},{\"header\":\"Result\",\"content\":\"\\u003ch2\\u003eSocio-demographic characteristics of caregivers\\u003c/h2\\u003e\\u003cp\\u003eThe flow of the study participants through the intervention process is depicted in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e. At baseline, the intervention and comparison groups were largely similar across all the socio-demographic characteristics, suggesting general comparability. No statistically significant differences were observed in age (p = 0.20), sex was (p = 0.106), residence (p = 0.664), marital status (p = 0.864), religion (p = 0.756), educational level (p = 0.166), employment status (p = 0.772), family size (p = 0.317), or patient diagnosis (p = 0.105). However, a notable difference was found in the patient (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eBaseline socio-demographic and Clinical Characteristics of Respondents by Group, MKCSH and NCSH, Western Ethiopia, 2021–2022\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"5\\\"\\u003e\\u003c/colgroup\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCharacteristic\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eCategory\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eIntervention (n = 277)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eComparison (n = 279)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003ep-value\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eAge (years)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eMean ± SD\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e31.91 ± 11.12\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e33.14 ± 11.50\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e0.200\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSex\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eMale\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e137 (49.5)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e119 (42.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u003cp\\u003e0.106\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eFemale\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e140 (50.5)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e160 (57.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eResidence type\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eRural\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e168 (60.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e164 (58.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u003cp\\u003e0.664\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eUrban\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e109 (39.4)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e115 (41.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eMarital status\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eSingle\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e154 (55.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e147 (52.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003e0.864\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eMarried\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e108 (39.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e113 (40.5)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eSeparated/Widowed\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e15 (5.4)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e19 (6.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eReligion\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eChristian\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e158 (57.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e161 (57.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003e0.756\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eMuslim\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e116 (41.9)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e113 (40.5)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eWakefata\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e3 (1.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e5 (1.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eEthnic group\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eOromo\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e233 (84.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e250 (89.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003e0.055\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eAmhara\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e38 (13.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e21 (7.5)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eOther**\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e6 (2.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e8 (2.9)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eEducation level\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eNo formal education\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e136 (49.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e139 (49.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u003cp\\u003e0.166\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePrimary\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e34 (12.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e51 (18.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eSecondary and above\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e107 (38.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e89 (31.9)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eEmployment status\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eUnemployed\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e88 (31.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e78 (28.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\" morerows=\\\"3\\\" rowspan=\\\"4\\\"\\u003e\\u003cp\\u003e0.772\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eSelf-employed\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e82 (29.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e87 (31.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eCivil servant\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e74 (26.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e84 (30.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eStudent/Daily laborer\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e33 (11.9)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e30 (10.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eHousehold size\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u0026lt; 5 members\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e174 (62.4)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e105 (37.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u003cp\\u003e0.317\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e≥ 5 members\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e185 (66.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e92 (33.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003cem\\u003e*Tigray, Gurage.\\u003c/em\\u003e\\u003c/p\\u003e\\u003ch2\\u003eCaregiver–Patient Relationship and Clinical Characteristics\\u003c/h2\\u003e\\u003cp\\u003eA statistically significant difference was observed in the patient (p = 0.032). Caregivers in the intervention group were more likely to be siblings (21.7%) or cousins (13.0%), whereas the comparison group had a higher proportion of siblings (31.2%) and spouses (13.0%) (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eCaregiver–Patient Relationship and Clinical Characteristics\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"5\\\"\\u003e\\u003c/colgroup\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCharacteristic\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eCategory\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eIntervention (n = 277)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eComparison (n = 279)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003ep-value\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eRelationship to patient\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eParent\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e108 (39.)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e101 (36.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\" morerows=\\\"5\\\" rowspan=\\\"6\\\"\\u003e\\u003cp\\u003e0.032\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eSibling\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e60 (21.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e87 (31.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eUncle/Aunt\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e33 (11.9)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e25 (9.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eCousin\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e36 (13.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e23 (8.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eSpouse\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e27 (9.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e36 (13.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eOther*\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e13 (4.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e7 (2.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePrimary patient diagnosis\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eMental disorders\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e63 (22.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e71 (25.4)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\" morerows=\\\"6\\\" rowspan=\\\"7\\\"\\u003e\\u003cp\\u003e0.105\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eBipolar affective disorder\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e30 (10.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e33 (11.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eDepression\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e66 (23.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e80 (28.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eSubstance use disorder\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e84 (30.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e59 (21.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eIntellectual disability\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e21 (7.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e15 (5.4)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePartial seizures\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e3 (1.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e9 (3.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eOther**\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e10 (3.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e12 (4.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003ch2\\u003e*Grandparent, Step-parent ** Autism Spectrum Disorder, Personality Disorders\\u003c/h2\\u003e\\u003ch2\\u003eEffect of the Psychoeducation intervention\\u003c/h2\\u003e\\u003cp\\u003eThe findings from the table indicate a significant reduction in the outcome measure among participants in the intervention group compared to those in the comparison group over time. Specifically, the mean score in the intervention group decreased from 51.51 at baseline to 42.39 at end line, yielding a statistically significant mean difference of − 7.71 points (95% CI: −12.56 to − 6.80). In contrast, the comparison group showed a smaller, non-significant reduction from 52.88 to 51.03, with a mean difference of − 1.85 points (95% CI: −4.48 to 0.78). The Difference-in-Differences (DID) analysis further confirmed the effectiveness of the intervention, revealing a statistically significant net change of − 5.68 points (± 1.96), with a 95% confidence interval ranging from − 9.49 to − 2.23. This suggests that the observed improvements in the intervention group were attributable to the intervention itself, rather than external or temporal factors. Effect sizes indicated a large reduction in affiliate stigma within the intervention group (Cohen’s d = − 0.84) compared to a negligible change in the control group (d = − 0.17). The net intervention effect from the DID analysis corresponded to a moderate-to-large reduction (d = − 0.63), underscoring the substantial practical significance of the psychoeducation program (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eStigma Scores at Baseline and End Line by Group\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"7\\\"\\u003e\\u003c/colgroup\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eGroup\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eBL\\u003c/p\\u003e\\u003cp\\u003eMean (± SD)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e95% CI\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eEL\\u003c/p\\u003e\\u003cp\\u003eMean (± SD)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e95% CI\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003eMean Difference (EL – BL)\\u003c/p\\u003e\\u003cp\\u003e95% CI\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003eEffect size\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eIntervention Group\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e51.51 (11.75)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e50.09–52.93\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e42.39 (9.95)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e41.14–43.53\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\"−\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e−7.71 (− 12.56,−6.80)****\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e−0.84\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eComparison Group\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e52.88 (11.39)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e51.49–54.26\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e51.03 (10.83)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e49.71–52.36\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\"−\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e−1.85(− 4.48,0.78)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e−0.17\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eDifference-in-Differences (DID) (± SE)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e–\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e–\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e–\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e–\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\"−\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e−5.68 (± 1.96) (− 9.49,−2.23) ***\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e−0.63\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003ctfoot\\u003e\\u003ctr\\u003e\\u003ctd colspan=\\\"7\\\"\\u003e\\u003cem\\u003e*p \\u0026lt; 0.001) BL – Baseline EL – End line SD - Standard Deviation SE – Standard Error\\u003c/em\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tfoot\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003cp\\u003eThe final adjusted model (Model 3), which included the intercept, slope, and covariates, demonstrated significant effects of time, group assignment, and their interaction on the outcome measure. Specifically, caregivers in the intervention group had significantly lower burden scores compared to those in the comparison group (β = -8.84; 95% CI: -10.71, -6.96; p \\u0026lt; 0.001). Moreover, the interaction between time and group was also significant, indicating a greater reduction in burden scores for the intervention group at end line compared to baseline (β = -7.32; 95% CI: -8.89, -5.75; p \\u0026lt; 0.001). This suggests that the intervention effectively decreased caregiver affiliate stigma over time relative to the comparison group. Among the three models tested, Model 3 exhibited the best fit to the data, as reflected by the lowest AIC value (7856.19). This indicates that incorporating time, group assignment, their interaction, and relevant covariates provided the most comprehensive and accurate explanation for variations in caregiver affiliate stigma scores (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eLinear mixed-effects model predicting the Effect of Psychoeducation on Caregiver affiliate stigma Scores among Family Caregivers of People with Mental Disorders (n = 531,(268, C = 263)\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"4\\\"\\u003e\\u003c/colgroup\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFixed effect\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eModel 1\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eModel 2\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eModel 3\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eIntercept\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e49.42 (48.71, 50.13)***\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e51.03 (49.70, 52.36)***\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e52.36 (44.36, 60.36)***\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eIntervention Effect\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eIntervention group\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e–\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-8.69 (- -10.56, -6.82)***\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e-8.84 (- -10.71, -6.96)***\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eComparison group\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e–\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e–\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e–\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eIntervention and Group Interaction\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eEnd line\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e–\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e–7.32 (–9.97, − 4.67))***\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e–\\u003c/b\\u003e7.32 (–8.89, − 5.75)****\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eBaseline (Ref)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eRandom effect\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eAIC\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e8253.75\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e8117.44\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e7856.19\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eICC\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0.067\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.062\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.057\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003ch2\\u003e*** = p \\u0026lt; 0.001\\u003c/h2\\u003e\\u003ch2\\u003eNote: Model 1. Intercept-only model Model 2:Slope‐only model Model 3. Intercept with slope model\\u003c/h2\\u003e\\u003ch2\\u003eSE–Standard error CI–Confidence interval\\u003c/h2\\u003e\\u003cp\\u003e\\u003cem\\u003eAIC – Akaike’s information criterion ICC—Intra-cluster correlation\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eThe model was adjusted for the caregivers’ age, educational status, employment status, family size, marital status and relationship with the patient\\u003c/em\\u003e\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study aimed to assess the effect of psychoeducation on affiliate stigma among family caregivers of individuals with mental disorders. There was no significant difference in the mean affiliate stigma score between the intervention and comparison group at baseline. The findings showed that the mean affiliate stigma score significantly decreased after the intervention in the intervention group. The difference-in-differences analysis accounted for group differences and time trends, further confirming the intervention\\u0026rsquo;s specific effect. Additionally, the linear mixed-effects model, which controlled for potential confounders, provided robust support for the observed outcomes.\\u003c/p\\u003e\\u003cp\\u003eThis result is consistent with an interventional study conducted in Iran, which also reported a significant reduction in affiliate stigma scores following psychoeducation [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e]. Similarly, a related study demonstrated that the mean and standard deviation of affiliate stigma scores decreased significantly after training [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]. In line with these findings, research from a tertiary care hospital in India found that family psychoeducation significantly reduced affiliate stigma scores among caregivers of psychiatric patients compared to a control group [\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]. Furthermore, a systematic review on interventions to reduce affiliate stigma related to mental illnesses in educational institutes reported that most anti-affiliate stigma interventions were successful in improving mental health literacy, as well as attitudes and beliefs toward mental illness[\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e]. This effect may be attributed to the increased knowledge and awareness [\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e] about mental illness provided through psychoeducation, which likely helped caregivers develop more positive attitudes toward both the patient and their caregiving role. By offering practical and relevant information about mental illness and its treatment, psychoeducation can reduce negative attitudes [\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e] and promote greater acceptance of the affected family member, ultimately improving caregivers' perceptions of both the patient and themselves. Additionally, the group-based format fosters social support by connecting caregivers with peers facing similar challenges, normalizing their experiences and alleviating feelings of isolation. Finally, the program enhances communication and problem-solving skills, enabling caregivers to manage difficult behaviors more effectively and interact with the patient in ways that reduce conflict and stress. Beyond its demonstrated effectiveness, the intervention\\u0026rsquo;s design and delivery also support its potential for scalable and sustainable implementation in resource-limited settings.\\u003c/p\\u003e\\u003cp\\u003eThe strengths of this study include the use of a controlled quasi-experimental design, which enhances causal inference; the application of two complementary statistical approaches, difference-in-differences and linear mixed-effects modeling, that improve the robustness of the findings; and the use of validated measurement tools to ensure reliability and accuracy of the outcome assessment. However, the study is not without limitations. The quasi-experimental design, while pragmatic, limits random allocation and may introduce selection bias. Although baseline characteristics were largely comparable between groups, unmeasured confounders may still exist. Moreover, the lack of long-term follow-up prevents assessment of the durability of the intervention effect. Finally, the generalizability may be limited to similar public health settings within Ethiopia or comparable LMIC contexts.\\u003c/p\\u003e\\u003cp\\u003eImplications for Practice and Policy: Integrating psychoeducational components into existing mental health services, especially within outpatient settings, could serve as a low-cost, scalable strategy to support caregiver mental health and reduce affiliate stigma at the household level. Health systems in LMICs should consider routine implementation of psychoeducation programs tailored to cultural and contextual realities.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eAOR\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eAdjusted Odds Ratio\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eBBZ\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eBuno Bedele Zone\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eCI\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eConfidence Interval\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eDHIS2\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eDistrict Health Information Software, version 2\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eEFY\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eEthiopian Fiscal Year\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eHIS\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eHealth Information System\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eHMIS\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eHealth Management Information System\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eHSTP\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eHealth Sector Transformation Plan\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eIR\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eInformation Revolution (Ethiopia)\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eLMIC\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eLow\\u0026ndash;and Middle\\u0026ndash;Income Country\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eODK\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eOpen Data Kit\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003ePRISM\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003ePerformance of Routine Information System Management\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eRHIU\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eRoutine Health Information Utilization\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eRHIS\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eRoutine Health Information System\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eSD\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eStandard Deviation\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eUHC\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eUniversal Health Coverage\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eVIF\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eVariance Inflation Factor\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe study protocol was reviewed and approved by the Institutional Review Board (IRB) of Jimma University (IRB approval no.: \\u003cem\\u003eIHRPGn/944/20)\\u003c/em\\u003e. Administrative permission letters were obtained from each participating hospital prior to data collection. All eligible caregivers were informed about the study’s purpose, procedures, potential benefits, and minimal risks; questions were encouraged. Because literacy levels varied, \\u003cstrong\\u003einformed written consent was obtained\\u003c/strong\\u003e in the participant’s preferred language after confirming comprehension. Participation was entirely voluntary, and caregivers were informed that refusal or withdrawal at any time would not affect the care they or their family member received. Confidentiality was protected by assigning unique study IDs, excluding personal identifiers from analytic datasets, and storing all data in password-protected files accessible only to the research team. A condensed psychoeducation session was offered to Comparison group caregivers after study completion as an ethical courtesy.\\u0026nbsp;This research adhered to the ethical principles outlined in the Declaration of Helsinki for research involving human subjects\\u0026nbsp;[21].\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting Interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors' contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAK conceptualized the study and initiated discussions with Sudhakar N. Morankar¹. The study was jointly designed by AK and SNM, who also supervised the project and contributed significantly to its implementation. AK led the manuscript writing, assumes responsibility for the content, and submitted the work for publication. All authors critically reviewed and approved the final version of the manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements\\u003c/strong\\u003e\\u003cbr\\u003e\\u0026nbsp;We would like to express our sincere gratitude to Jimma University, Mettu Karl Comprehensive Specialized Hospital (MKCSH), and Nekemte Comprehensive Specialized Hospital (NCSH) for their invaluable support in the implementation of this study. We also extend our heartfelt thanks to the data collectors, supervisors, study participants, and all others who contributed to the successful completion of this research. The views expressed in this publication are those of the authors and do not necessarily represent the official position of the sponsoring institution.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eClinical trial number\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eBhugra D, Watson C, Wijesuriya R. Culture and mental illnesses. Int Rev Psychiatry. 2021;33: 1\\u0026ndash;2. doi:10.1080/09540261.2020.1777748\\u003c/li\\u003e\\n\\u003cli\\u003eWHO. Mental disorders. Retrieved from https://www.who.int/news-room/fact-sheets/detail/mental-disorders. 2022. \\u003c/li\\u003e\\n\\u003cli\\u003eEvaluation. I for HM and. Global Burden of Disease 2021. 2021. \\u003c/li\\u003e\\n\\u003cli\\u003eMental GBD, Collaborators D. Global , regional , and national burden of 12 mental disorders in 204 countries and territories , 1990 \\u0026ndash; 2019 : a systematic analysis for the Global Burden of Disease Study 2019. The Lancet Psychiatry. 2022;9: 137\\u0026ndash;150. doi:10.1016/S2215-0366(21)00395-3\\u003c/li\\u003e\\n\\u003cli\\u003eStuart H. global mental health Reducing the stigma of mental illness. Glob Ment Heal. 2016;3: 1\\u0026ndash;14. doi:10.1017/gmh.2016.11\\u003c/li\\u003e\\n\\u003cli\\u003eAhmedani BK. Mental Health Stigma: Society, Individuals, and the Profession. J Soc Work Values Ethics. 2011;8: 1\\u0026ndash;14. \\u003c/li\\u003e\\n\\u003cli\\u003eChang C, Chen Y, Liu T, Hsiao RC, Chou W. A ffi liate Stigma and Related Factors in Family Caregivers of Children with Attention-Deficit / Hyperactivity Disorder. Int J Environ Res Public Health. 2020;17: 1\\u0026ndash;14. \\u003c/li\\u003e\\n\\u003cli\\u003eSaffari M, Lin C, Koenig HG, Amir H, Hom H, Kong H, et al. A Persian version of the Affiliate Stigma Scale in caregivers of people with dementia. Heal Promot Perspect. 2019;9: 31\\u0026ndash;39. doi:10.15171/hpp.2019.04\\u003c/li\\u003e\\n\\u003cli\\u003eMeichsner F, K\\u0026ouml;hler S WG. Moving through predeath grief: Psychological support for family caregivers of people with dementia. Dementia. 2017;18: 2474\\u0026ndash;2493. \\u003c/li\\u003e\\n\\u003cli\\u003eNurlaila Fitrian IS. A REVIEW STUDY ON ONLINE PSYCHO-EDUCATION FOR THE. Humanit Soc Sci Rev. 2019;6: 84\\u0026ndash;89. \\u003c/li\\u003e\\n\\u003cli\\u003eGirma E, M\\u0026ouml;ller-leimk\\u0026uuml;hler AM, Dehning S, Tesfaye M, Froeschl G, Girma E, et al. Self-stigma among caregivers of people with mental illness : toward caregivers \\u0026rsquo; empowerment. J Multidiscip Healthc. 2014;2390. doi:10.2147/JMDH.S57259\\u003c/li\\u003e\\n\\u003cli\\u003eFitriani, N., \\u0026amp; Suryadi I. A review study on online psychoeducation for the bipolar disorder patient and their caregivers. Humanit Soc Sci Rev. 2019;6: 84\\u0026ndash;89. \\u003c/li\\u003e\\n\\u003cli\\u003eGirma, E., Moller-Leimkuhler, A. M., Dehning, S., Mueller, N., Tesfaye, M., \\u0026amp; Froeschl G. Self-stigma among caregivers of people with mental illness: Toward caregivers\\u0026rsquo; empowerment. J Multidiscip Healthc. 2014;7: 37\\u0026ndash;43. \\u003c/li\\u003e\\n\\u003cli\\u003eBellg, A. J., Borrelli, B., Resnick, B., Hecht, J., Minicucci, D. S., Ory, M., Ogedegbe, G., Orwig, D., Ernst, D., Czajkowski S. Enhancing Treatment Fidelity in Health Behavior Change Studies: Best Practices and Recommendations From the NIH Behavior Change Consortium. Heal Psychol. 2004;23: 443\\u0026ndash;451. \\u003c/li\\u003e\\n\\u003cli\\u003eMak WW CR. Affiliate stigma among caregivers of people with intellectual disability or mental illness. J Appl Res Intellect Disabil. 2008;21: 532‑45. \\u003c/li\\u003e\\n\\u003cli\\u003eBahrami R. The Effect of Psycho-education on the Af fi liate Stigma in Family Caregivers of People with Bipolar Disorder. 2022;8: 1\\u0026ndash;7. doi:10.1177/23779608221132166\\u003c/li\\u003e\\n\\u003cli\\u003eHamsaei, FarshidFarshid Shamsaei FN and ES. The effect of training interventions of stigma associated with mental illness on family caregivers : a quasi ‑ experimental study. Ann Gen Psychiatry. 2018;17: 1\\u0026ndash;5. doi:10.1186/s12991-018-0218-y\\u003c/li\\u003e\\n\\u003cli\\u003eGupta R, Soni S, Yadav R, Choudhary S, Verma R, Senwar S, et al. \\u0026ldquo; A Study to Assess the Effectiveness of Family Psycho-Education Programme on Stigma Related to Mental Disorder Among Caregivers of Psychiatric Patients at Selected Tertiary Care Hospital Bhopal .\\u0026rdquo; Afr J Biomed Res. 2024;27: 7579\\u0026ndash;7586. \\u003c/li\\u003e\\n\\u003cli\\u003eWaqas A, Malik S, Fida A, Abbas N, Mian N. Interventions to Reduce Stigma Related to Mental Illnesses in Educational Institutes : a Systematic Review. 2020;91: 887\\u0026ndash;903. \\u003c/li\\u003e\\n\\u003cli\\u003eRoger K, Gregoire A, Desnavailles P, Misdrahi D, Luciano M. Family psychoeducation to improve outcome in caregivers and patients with schizophrenia : a randomized clinical trial. Front Psychiatry. 2023;14: :1171661. doi:10.3389/fpsyt.2023.1171661\\u003c/li\\u003e\\n\\u003cli\\u003eWorld Health Organization. World Medical Association Declaration of Helsinki. Ethical principles for medical research involving human subjects.Bull World Health Organ. 2001;79: 373\\u0026ndash;4. \\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Affiliate Stigma, Ethiopia, Family Caregivers, Mental Illness, Psychoeducation, Quasi-Experimental Study\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7372530/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7372530/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground:\\u003c/strong\\u003e Mental disorders are a major Public health concern globally, with profound consequences not only for individuals but also for their family care givers, particularly in low- and middle income countries (LMIC). One often-overlooked consequence is affiliate stigma, the internalization of public stigma by caregivers, which can negatively affect their psychological well-being and caregiving effectiveness.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eObjective:\\u003c/strong\\u003e This study aimed to assess the effect of a structured psychoeducation intervention on reducing affiliate stigma among family caregivers of individuals with mental disorders in Western Ethiopia.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods:\\u003c/strong\\u003e A quasi-experiential, pre-post controlled study was conducted between March 2021 and February 2022. The intervention group (n = 277) received a six-session psychoeducation program and routine care at Mettu Karl Comprehensive Specialized Hospital, while the comparison group (n = 279) received routine care only at Nekemte Comprehensive Specialized Hospital. The Affiliate Stigma Scale was administered at baseline and post-intervention. Linear mixed-effects models and Difference-in-Differences (DID) analyses were employed to assess the intervention's effect, while adjusting for relevant covariates.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults:\\u003c/strong\\u003e The intervention group showed a significant reduction in affiliate stigma scores from the baseline to post-intervention (mean difference = –7.71, 95% CI: –12.56 to –6.80), while the change in the comparison group was not statistically significant (mean difference = –1.85, 95% CI: –4.48 to 0.78). The DID analysis confirms a significant net reduction in affiliate stigma attributable to the intervention (DID = –5.68 ± 1.96, 95% CI: –9.49 to –2.23). The net intervention effect corresponded to a moderate-to-large reduction (d = −0.63), underscoring the substantial practical significance of the psychoeducation. The adjusted model (Model 3) further supported the intervention's effect (β = –8.84, 95% CI: –10.71 to –6.96, p \\u0026lt; 0.001).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion:\\u003c/strong\\u003e Psychoeducation significantly reduced affiliate stigma among family caregivers of individuals with mental disorders. Incorporating structured psychoeducation into routine mental health services may enhance caregiver resilience and improve overall care outcomes.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Effect of a Psychoeducation Intervention on Affiliate Stigma among Family Caregivers of Individuals with Mental Disorders in Western Ethiopia: A Pre-test Post-test Study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-09-03 10:06:08\",\"doi\":\"10.21203/rs.3.rs-7372530/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"9836ba05-aa51-404d-bcf9-36302aa6dc87\",\"owner\":[],\"postedDate\":\"September 3rd, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[{\"id\":53756014,\"name\":\"Health sciences/Diseases\"},{\"id\":53756015,\"name\":\"Health sciences/Health care\"},{\"id\":53756016,\"name\":\"Biological sciences/Psychology\"},{\"id\":53756017,\"name\":\"Social science/Psychology\"}],\"tags\":[],\"updatedAt\":\"2026-01-19T08:44:40+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-09-03 10:06:08\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7372530\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7372530\",\"identity\":\"rs-7372530\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}