Beyond Expressed Emotion: Development and validation of a contextual measure of family communication and involvement in the context of psychosis in Ethiopia

Abstract Background and Aim: Family caregiving environments significantly influence psychosis outcomes, yet existing measures like Expressed Emotion lack cultural relevance in non-Western settings. This study aimed to develop and validate a socioculturally appropriate Family Communication and Involvement (FCI) scale in Ethiopia. Methods An initial FCI scale (version 0) was generated by integrating items from existing measures of aspects of family communication with findings from an ethnographic study with Ethiopian families caring for a relative with psychosis. To ensure content validity and clarity, items underwent translation, back-translation, expert consensus review, and cognitive interviews (n=20). The resulting FCI v1.0 (37 items) was piloted with 201 people with psychosis in rural Ethiopia. Exploratory factor analysis, item-item/item-total correlations, and test-retest reliability (n=50) informed stakeholder discussions to reduce items, leading to a 24-item, two-factor structure. The final 24-item scale (FCI v2) was validated with a separate sample of 401 people with psychosis in Addis Ababa. Confirmatory factor analysis (CFA) assessed structural validity. Convergent validity was evaluated against the WHO Disability Assessment Schedule and the Brief Psychiatric Rating Scale Expanded version. Results The scale demonstrated robust psychometric performance: excellent internal consistency (Cronbach α = 0.92) and acceptable convergent validity, correlating with disability (WHODAS, r = -0.45) and symptom severity (BPRS-E, r = -0.48). Confirmatory factor analysis supported the 24-item bi-factor with acceptable model fit. Conclusion The FCI scale is a culturally grounded, psychometrically sound tool for assessing family communication and involvement in Ethiopia. It holds promise for use in similar non-Western settings where family support and sociocultural influences shape mental health care.