Schizophrenia, one of the most prevalent functional psychotic disorders, is characterized by illusions, hallucinations, thought disturbances, and affective and volitional behavior disturbances. These symptoms affect both the patients and their caregivers, imposing substantial emotional strain and creating practical challenges for family members. Several studies have examined the caregiving role of family members in the lives of patients with schizophrenia and recognized that caring for these patients requires continuous vigor, relevant knowledge and skills, empathy, and financial capacity, as well as seriously affect their daily lives (1–3). Furthermore, early onset and chronic schizophrenia affects the lives of patients who could manifest social and relational disabilities and require years of caregiving. In China, most patients with schizophrenia choose to return to their families after receiving treatment during the acute phase, and their family members, as the main caregivers, provide continuous rehabilitation exercises and home care. Family caregivers play a vital role in meeting all aspects of patients’ care demands, including their physiological, cognitive, and emotional needs, and face challenges, such as care ability and psychology (4, 5). However, family caregivers, especially those assuming the caregiver role for the first time, are typically uncertain about the patient’s disease, have inadequate knowledge of psychotic disorders, and perceive an inability to discharge their caregiving function (6). Although caregivers feature in the course of treatment and recovery, those who do not receive appropriate support services and lack care knowledge and skills often feel unprepared to perform their role and experience a greater burden (7, 8). Prior studies on caregiver preparedness have focused on patients with cancer or dementia (9–11). This study focuses on extending this stream of research to the context of schizophrenia.

Caregivers’ preparedness is a multidimensional and dynamic construct, defined as “how ready caregivers believe they are for the tasks and stresses of caregiving” (12). Researchers have described the beneficial effects of caregivers’ preparedness (13–15). Greater preparation leads to better patient-reported outcomes and quality of life for caregivers. However, insufficient preparation has a negative impact on family dynamics and structure, thus affecting the capacity of family members to cope with caregiving-related demands effectively. A considerable body of research focuses on demographic comparisons of caregiver preparedness in the current healthcare context (13, 16, 17). For example, being less prepared is more common among men (18), the less educated (19), and those in inadequate financial situations (20). These findings underscore the need to develop a better understanding of the determinants of caregivers’ preparedness, thereby enabling targeted interventions in high-risk populations. Nevertheless, research specifically examining caregivers’ preparedness for patients with schizophrenia and the influencing factors has not yet been reported.

Caregiving is burdensome, with most caregivers experiencing sustained high levels of psychological distress (21). Furthermore, psychological factors are increasingly being recognized as critical determinants of caregiver preparedness. Among these factors, anxiety and hope are two contrasting yet interconnected emotional and cognitive constructs that may play pivotal roles in shaping caregivers’ preparedness.

Anxiety is a prominent negative emotional response to caregiving stressors and is highly prevalent among caregivers of patients with schizophrenia, with reported rates ranging from 29 to 41.4% (22–24). Studies have shown that anxiety not only negatively affects caregivers’ social function, economic status, physical health, and quality of life but also correlates with poorer patient-reported outcomes (21, 22, 25). Dionne-Odom et al. (26) found an association between low caregivers’ preparedness and greater anxiety among patients with cancer, suggesting that anxiety may erode caregivers’ sense of preparedness by consuming cognitive resources, increasing perceived burden, and impairing problem-solving abilities, all of which are critical for effective caregivers’ preparedness. However, research on the relationship between anxiety and caregivers’ preparedness specifically among patients with schizophrenia remains limited.

Hope, as a positive source of support for addressing caregiving stressors, has recently garnered increasing attention (27, 28). Hope is recognized as an intentional, highly personalized, and multidimensional dynamic process central to human life and oriented towards the future (29). Several studies have revealed relationships between hope and various factors, such as happiness, quality of life, problem-solving coping strategies, and management of loss, sadness, pain, and loneliness (30, 31). For caregivers, hope may enhance preparedness by fostering a sense of control, providing motivation to acquire caregiving skills, buffering the negative impact of stressors, and ultimately transforming how families navigate the challenges of caring for a loved one with a chronic illness (28, 32). Emerging research has highlighted the beneficial effects of hope in terms of disease management among primary caregivers of patients with schizophrenia (33, 34). However, its specific role in shaping caregivers’ preparedness remains understudied.

The rationale for examining anxiety and hope simultaneously lies in their conceptual and empirical interconnections, as well as their complementary roles in influencing caregiver outcomes. Previous studies have consistently demonstrated an inverse association between anxiety and hope. Higher anxiety corresponds to diminished hope, reflecting a potential dynamic in which negative emotional states may deplete positive cognitive resources, and conversely, positive cognitive orientations may mitigate psychological distress (18, 35). This interplay is particularly significant within the framework of caregivers’ preparedness. Anxiety may erode preparedness through its deleterious impact on cognitive functioning and emotional regulation, whereas hope can counteract such effects by fostering resilience and facilitating goal-directed behavior (36, 37). Furthermore, preliminary evidence has indicated that hope may mediate the relationship between stress-related factors and caregiver outcomes. For example, Liu et al. (38) demonstrated that hope can partially mediate the association between disease uncertainty and caregivers’ preparedness among family members of patients with heart failure, suggesting that positive cognitive resources, such as hope, may explain how negative experiences translate into variations in preparedness. Considering these research gaps and interconnections, we hypothesized that hope mediates the relationship between anxiety and caregivers’ preparedness of patients with schizophrenia. To date, no study has validated this association in this population.

Building upon the hypothesized mediating role of hope between anxiety and caregivers’ preparedness, this study aims to systematically investigate these dynamics in the context of schizophrenia caregiving. The primary objective was to investigate the level of caregivers’ preparedness. Subsequently, the study examines the interrelationships between anxiety, hope, and caregivers’ preparedness. Ultimately, it aims to test the specific mediating pathway of hope in the relationship between anxiety and caregivers’ preparedness.

This study addresses two critical gaps in schizophrenia caregiving research: the under-researched area of caregivers’ preparedness and the unexamined mediating role of hope between anxiety and caregivers’ preparedness. To the best of our knowledge, it is the first study to investigate these relationships. The results showed that the mean caregivers’ preparedness score was below the medium level. Furthermore, anxiety significantly and negatively predicted both hope and caregivers’ preparedness, while hope itself was positively correlated with caregivers’ preparedness. Crucially, mediation analysis confirmed that hope partially mediates the relationship between anxiety and caregivers’ preparedness.

Caring for a family member is a highly stressful and demanding role. Caregivers’ preparedness, benefit-finding, and caregiving ability are key outcome indicators that have long been the focus of research in the caregiving field (50–52). In this study, the mean caregivers’ preparedness score was (20.79 ± 5.25), which is significantly lower than that reported for caregivers of patients without chronic psychiatric illnesses, indicating substantial room for improvement among caregivers of patients with schizophrenia (51–55). However, this score was higher than that reported for caregivers of patients with eating disorders (56). One possible explanation is that national attention to mental health, especially common mental illnesses, is increasing, thereby gradually enhancing mental health literacy among the general public (57, 58). Our study found significant associations between caregiver preparedness and years of education, financial status, caregiving experience, mental health knowledge, and number of hospitalizations, which is consistent with prior research (9–11, 51–55). Research shows that caregivers with higher education, better financial status, more mental health knowledge, more hospitalizations, and richer caregiving experience tend to show greater ability to actively seek medical information, handle crises, and adapt to their role, all of which are factors that may enhance caregivers’ preparedness. Furthermore, this study identified a negative correlation between perceived disease severity and caregivers’ preparedness. A plausible explanation is that the diagnosis and treatment of schizophrenia, as a major stressor, imposes a substantial psychosomatic burden on caregivers. Higher perceived disease severity correlates with heightened stress, necessitating more time and effort for coping, thereby increasing caregiving burden and impairing preparedness (59). However, this study had several limitations. First, key variables-including financial status, knowledge of mental health, and disease severity, were measured based on caregivers’ subjective reports. Although such measures capture meaningful lived experiences, they are susceptible to bias from factors such as mood or caregiving burden. For instance, financial status was categorized broadly, which lacks the precision of objective indicators like household income or socioeconomic indices. Similarly, knowledge of mental health was based on self-assessment rather than objective mental health literacy tests. Theoretical frameworks posit that insufficient knowledge may contribute to anxiety, the inverse relationship, whereby anxiety symptoms bias self-perceptions of knowledge, warrants equal consideration (60). Therefore, relying solely on self-reported measures may confound these constructs. The severity of disease reflects the extent to which caregivers believe the disease has affected the patient’s life. However, reliance on caregiver-reported severity may introduce bias owing to factors such as anxiety or unmeasured confounders. Future studies should incorporate objective measures, such as income brackets, standardized mental health literacy tests, and clinician-rated symptom scales (e.g., PANSS), to enhance validity and comparability. Second, the number of hospitalizations was used as a proxy for illness progression. While this metric reflects significant care-related stressors, it does not distinguish between clinical staging (e.g., prodromal vs. acute phases) or symptom severity at admission. While frequent hospitalizations may suggest disease recurrence or worsening, they do not fully capture individual symptom profiles or precise illness progression. Future studies should incorporate clinician-rated symptom scales (e.g., PANSS) to better delineate disease course and improve classification accuracy. Third, our measurement of caregiving experience was a dichotomized (yes/no) classification. While this may not capture variations in caregiving duration intensity, or daily caregiving hours, it provides a preliminary assessment of caregiver status. Future studies should incorporate detailed temporal and behavioral metrics (e.g., daily hours, total months) to better quantify caregiving burden.

Consistent with prior studies (10, 19, 61), we confirmed a significant negative association between anxiety and caregivers’ preparedness. Specifically, anxiety, which independently explained 12.9% of the variance in caregivers’ preparedness, can manifest as debilitating symptoms (e.g., diminished interest, impaired concentration, appetite loss, restlessness, despair, and suicidal ideation) (21–24, 62, 63) that directly erode functional capacities. This symptom burden compromises communication with healthcare providers and impedes the acquisition of disease knowledge (61), leading to a synergistic decline in caregiving ability, confidence, and engagement, ultimately resulting in markedly low preparedness. These findings suggest practical methods for improving caregivers’ preparedness. First, early screening for anxiety (e.g., using GAD-7) can facilitate timely mental health support. Second, psychoeducational programs incorporating coping strategies (e.g., mindfulness) and peer support groups may help alleviate anxiety symptoms and foster shared problem-solving. Integrating these strategies into tailored interventions could effectively reduce anxiety and thereby improve preparedness, ultimately benefiting both caregivers and patients.

Aligned with international caregiver studies (56, 64), we found a strong positive correlation between hope and caregivers’ preparedness. Hope serves as a pivotal psychological resource for caregivers facing chronic conditions like schizophrenia (34). The caregiving context, characterized by unpredictable challenges, relational losses, and life disruptions, often erodes hope (28). Conversely, hope helps caregivers construct and sustain meaning amid adversity. Empirically, caregivers with higher hope report lower psychosomatic stress, greater well-being, and a stronger sense of competence (65). They also exhibit more enthusiasm, motivation, and positive self-identity when confronting caregiving demands, which directly enhances caregivers’ preparedness (18, 65). Based on our findings, intervention designs should strategically integrate hope-enhancing components to target both the direct and indirect pathways identified in this study. Specifically, structured hope-focused programs could employ a multimodal approach. Cognitive-behavioral techniques could support caregivers in reframing negative appraisals of caregiving challenges (66, 67), while narrative therapy exercises could facilitate the reconstruction of personal resilience (68). These exercises emphasize past successes in overcoming caregiving obstacles to reinforce goal-directed thinking. Furthermore, psychoeducational modules focused on schizophrenia prognosis and caregiving skills can alleviate the critical hope-depleting factor of uncertainty by enhancing caregivers’ understanding of disease trajectories and equipping them with practical problem-solving tools (69, 70).

The most notable finding of this study was the mediating effect of hope on the relationship between anxiety and caregivers’ preparedness of patients with schizophrenia. This finding suggests that anxiety not only directly influenced caregiver preparedness but also indirectly influenced it via hope. Life-threatening situations, losses, and changes throughout life can affect a person’s level of hope. Motaghi et al. (27) found that one member’s disease affects the lives of everyone in the family, especially primary caregivers, thereby increasing anxiety and decreasing hope. Simultaneously, anxiety can reduce caregivers’ expectations of disease prognosis and medical decision-making, leading to lower levels of hope (71). Hope is related to factors such as well-being, quality of life, survival, problem-solving ability, and dealing with loss, tragedies, suffering, and loneliness (72). Individuals with more hope are inclined to adopt positive attitudes and coping strategies when faced with practical care problems. This mediating effect (24.8% of the total effect) highlights a critical intervention target: mitigating anxiety through hope-focused strategies rather than solely relying on anxiety-reducing techniques. For example, mindfulness programs could incorporate hope-building elements, such as reflecting on “small wins” in caregiving to counter anxiety-induced hopelessness (73, 74). Peer support interventions in which experienced caregivers share their journeys of maintaining hope amid anxiety may also foster vicarious learning and reduce feelings of isolation, both of which strengthen hope (75).

This study utilized a convenience sample from a single psychiatric hospital, which limits sample representativeness and potentially restricts generalizability to broader populations. Future research should use multicenter sampling across diverse regions to enhance population diversity and improve the representativeness of the findings. Second, our conclusions were based on cross-sectional data, which resulted in a one-time measurement of the variables. Third, social support and depression have been shown to significantly influence caregivers’ preparedness; however, we did not address this issue in our study. Therefore, future research should examine the associations between social support, depression, and caregiver preparedness. Finally, although this study clarified the importance of hope for caregiver preparedness, follow-up studies are needed to determine the effects of hope-based educational interventions on caregivers’ preparedness.

The preparedness of caregivers of patients with schizophrenia shows room for improvement. This study found that caregivers’ preparedness was negatively related to anxiety but positively related to hope. This study also showed that hope could mediate the relationship between anxiety and caregivers’ preparedness. These findings call for healthcare professionals to take various measures to weaken anxiety and promote hope, both of which are beneficial for caregivers’ preparedness.

From a policy and practice perspective, these findings highlight the need to systematically integrate hope-focused support into caregiving services while offering practical guidance for clinical and community interventions. Healthcare systems and mental health organizations should train providers (e.g., psychiatrists, social workers, and nurses) to assess hope and anxiety among caregivers using validated tools to enable personalized interventions for high-risk groups (e.g., those with high anxiety or new caregivers) and implement hope-building programs tailored to caregivers of patients with schizophrenia, including psychoeducation on realistic care goals, peer success stories, and skill development, alongside anxiety-reducing strategies such as mindfulness, counseling, and support groups. Policymakers could fund community-based programs offering psychoeducation, peer mentorship, and counseling to sustain hope throughout caregiving, as hope’s far-reaching benefits-enhancing well-being, problem solving, and coping–may reduce burnout, improve care quality, and lessen healthcare burdens. Future research could strengthen the current evidence by using longitudinal designs to examine how anxiety, hope, and caregiver preparedness interact over time and whether sustained hope fosters long-term resilience, supporting the scalability of such programs. Finally, randomized controlled trials comparing hope-focused interventions (e.g., cognitive-behavioral versus peer support) are needed to refine evidence-based strategies to improve outcomes for caregivers and patients.