Development and Validation of a Chinese Standardized Client Satisfaction Scale

Abstract

Purpose: The purpose of this study is to develop and validate a standardized client satisfaction scale for social work programs in China. Method: We generated items through a thorough literature review, confirmed by experts, and indigenized and revised by scholars, practitioners, and clients. The sample was from 15 government-sponsored social work programs’ clients in Jiangsu Province, China. We conducted exploratory factor analyses to test reliability (N = 299) and confirmatory factor analyses to examine validity (N = 699). Predictive validity was also tested. Results: The client satisfaction scale, consisting of 4 dimensions with 15 items, demonstrates good internal consistency, satisfactory factorial validity, and positive correlation with clients’ service participation frequency. Discussion: The 4-dimension client satisfaction scale is a reliable and valid instrument. It taps into client perceptions and feedback based on their service experiences. This study offers a feasible way to promote the standardization of social work programs in China.

Keywords

China client satisfaction standardization scale development validation

In recent decades, Chinese governments, from central to local, have encouraged the development of various social work programs to tackle a wide range of social issues, including aging, poverty, domestic violence, juvenile delinquency, drug addiction, and so forth (e.g., Ban, 2014; Fei, 2017; Teng & Xiang, 2019). Subsidies for social work programs provided by the Ministry of Civil Affairs have increased from 1181.1 billion yuan in 2008 to 1704.2 billion yuan in 2020, with an average increase of 40.24 billion yuan per year (Ministry of Civil Affairs, 2009; 2021). To monitor and assess the quality and effectiveness of these programs, the Chinese government introduced third-party evaluation in 2012. Third-party evaluators often use various assessment instruments, among which client satisfaction is one of the most common (Liu, Wu, & Fraser, 2013; Liu, 2016).

Client satisfaction is an important outcome variable for social work programs and services. Client satisfaction is also important when implementing social work programs, because it can be used to rate the quality of social work services and is also vital for continuous monitoring, quality improvement, and promotion of standardization in service delivery systems. Scholars such as Greenfield and Attkisson (1989), Larsen, Attkisson, Hargreaves, and Nguyen (1979), and Marshall and Hays (1994) have measured client satisfaction in different fields, such as inpatient services, community-based services, and substance abuse prevention. In the Western context, there are two common approaches to measure client satisfaction for received services: direct and indirect (Attkisson & Greenfield, 2004; Marshall, Hays, Sherbourne, & Wells, 1993). The indirect approach asks for opinions about services in general, whereas the direct approach asks about clients’ own specific and general experiences with multiple dimensions of satisfaction (Marshall et al., 1993; Wilkin, Hallam, & Doggett,1992).

In China, there are two similar ways to measure client satisfaction. One is a general question, and the other is multidimensional. The general question is indirect and oversimplified: “What do you think about the services you received?” This question is often measured by a point Likert scale (i.e., 1 = not at all satisfied, 5 = very satisfied). The general question is often based on evaluators’ clinical experience and has not been given rigorous statistical reliability and validity testing. Stakeholders, such as social work program sponsors, evaluation researchers, and even clients themselves, doubt whether this simple measurement can be meaningful for social work programs because it offers limited insight into the quality and effectiveness of programs (Liu et al., 2013). While some evaluators and scholars have adopted multidimensional scales to measure client satisfaction, including criteria such as management skills, organization capacity, service delivery skills (Yang & Zheng, 2018), service ethics, and direct practice skills (Han & Zheng, 2018), the scales are primarily theory-based and/or experience-based without rigorous statistical reliability and validity testing (Qu, 2017; Han & Zheng, 2018; Yang & Zheng, 2018).

Therefore, there is a need for satisfaction scales that can be used as an effective instrument for process monitoring, quality improvement, and standardization promotion in social work delivery systems. They should be adapted to the Chinese context and include suitable psychometric properties in terms of reliability, validity, and sensitivity to changes.

Statement of Purpose

Scholars from Western countries have widely accepted client satisfaction scales as one of the most effective evaluation tools for social and health services. A client satisfaction scale usually measures the following areas: (a) perceived service outcomes (Larsen et al., 1979); (b) relationship with staff, staff skills, and staff competence (Hansson & Höglund, 1995; Priebe & Gruyters, 1995); (c) continuity of service, accessibility of service, information received by clients (Ruggeri, Dall’Agnola, Bisoff, & Greenfield, 1996); and (d) physical environment (Hansson & Höglund, 1995; Ruggeri et al., 1996). Given various sociocultural contexts, many client satisfaction scales have been developed and validated to monitor and assess the effectiveness of human services in different countries, such as the United States (Greenfield & Attkisson, 1989; Larsen et al., 1979; Marshall & Hays, 1994), the United Kingdom (Barker et al., 1996; Evans et al., 2012), Italy (Ruggeri et al., 1996), and Sweden (Schröder, Larsson, & Ahlström, 2007). These scales have been widely used to evaluate various social and health services, including inpatient services (Marshall & Hays, 1994; Evans et al., 2012), outpatient and community services (Barker et al., 1996), and various human services offered across different settings (e.g., Greenfield & Attkisson, 1989; Larsen et al., 1979; Reid & Gundlach, 1983).

Compared with Western countries, social work programs in China are still in their nascent stage. Client satisfaction scales developed in the West may not be compatible with the Chinese social work context as clients, stakeholders, and practitioners in China have different understandings and goals when designing and implementing programs. These different perceptions of client satisfaction may also yield distinct characteristics. Although several Chinese scholars (e.g., Liu et al., 2013) have translated frequently used client satisfaction scales from English into Chinese (e.g., Pain Treatment Satisfaction Scale [PTSS]; Service Satisfaction Scale [SSS]), they have seldom tested the reliability and validity of translated scales in the Chinese context. Research on developing and validating client satisfaction scales for China’s social work programs is still nascent. The lack of validated client satisfaction instruments has challenged the reliability and validity of social work program evaluation, which likely further impedes the development of social work in China.

Currently, in order to cover a wide range of dimensions across different types of services (e.g., rehabilitation, adolescent delinquency reduction), satisfaction scales in social work programs in China tend to mix a variety of subscales. This approach also meets the requirement from governments on the central and local levels—the major sponsors of social work programs in China—to cover as many dimensions of the programs and/or services as possible. As such, the need for developing a client satisfaction scale that can systematically and rigorously evaluate diverse dimensions of social work programs in China has become urgent. Thus, the purpose of this study is to develop a multidimensional client satisfaction scale for social work programs in China and to test the reliability and validity of this multidimensional scale in the Chinese context.

Literature Review

Definitions and Functions of Client Satisfaction

Client satisfaction refers to clients’ preferences and feelings toward social work programs, understood from cognitive or emotional perspectives (Cardozo, 1965; Copeland, Koeske, & Greeno, 2004; Liu et al., 2013). It signals the success of behavioral health and social work programs (Cardozo, 1965). From the cognitive perspective, satisfaction suggests clients’ perceptions of whether the activities, deliveries, and effects of services they receive are in accordance with their expectations (Vukovic et al., 2012); clients subjectively compare between their expectations and perceptions of service performance (Almeida et al., 2015; Fournier & Mick, 1999). From the emotional perspective, client satisfaction shows clients’ emotional reactions to the services they receive, which indicates their feelings and preferences about services (Miglietta, Belessiotis-Richards, Ruggeri, & Priebe, 2018; Ruggeri, 1994), that is, whether they like or dislike the service after experiencing it (Kitapci, Akdogan, & Dortyol, 2014; Woodside, Frey, & Daly, 1989).

Client satisfaction is an important indicator of the quality of the services that clients actually receive (Cleary & McNeil, 1988; Edlund et al., 2003; Miglietta, Young, Kung, Sherbourne, & Wells, 2018; Shipley et al., 2000). A wide range of factors at both individual and program levels can influence client satisfaction, including clients’ expectation of programs, their actual perception of program services, client-practitioner relationships, types of treatment received, organizational atmosphere, service accessibility, and service delivery (Henderson et al., 2003; Woodward, Berry, & Bucci, 2017). Thus, client satisfaction is highly sensitive to various aspects and different levels of quality of services, and as such, can motivate providers’ commitment to improving services (Almeida, Bourliataux-Lajoinie, & Martins, 2015; Attkisson & Greenfield, 1996; 2004; Larsen et al., 1979; Nguyen, Attkisson, & Stegner, 1983; Scascighini, Angst, Uebelhart, & Aeschlimann, 2008).

Client satisfaction, indicating clients’ feelings and preferences about services, can further suggest clients’ perspectives to help reduce the evaluator’s biases during service evaluations (Greenfield & Attkisson, 1989; Woodward et al., 2017). Integrating client satisfaction with evaluations of programs and specific services, evaluators can know better about detailed service processes, resource input, and outcomes, resulting in a fair evaluation from clients’ perspective.

Evaluating client satisfaction can benefit clients themselves as well. High satisfaction suggests success in meeting clients’ needs. The more satisfied they are with received services, the more clients are inclined to stay involved in programs and services, in contrast to their dissatisfied counterparts, who are more likely to withdraw (Attkisson & Zwick, 1982; Lebow, 1983; Woodward et al., 2017).

Client Satisfaction Scale: A Multidimensional Measurement

While unidimensional scales provide a general impression of a social work program, multidimensional scales can detail specific features as well as illustrate the service process, thus capturing a holistic understanding of the entire program and process from clients’ perspectives. Researchers have adopted multidimensional measurement to determine the content of client satisfaction to describe their specific experiences of seeking and receiving services, including service accessibility, service information, service delivery, and client–practitioner relationships (Attkisson & Greenfield, 2004; Hansson & Höglund, 1995; Ruggeri et al., 1996; Wilkin et al., 1992).

We reviewed 28 English client satisfaction scales with high reliability and validity, and chose four scales that most frequently appear in the existing evaluation studies: CSQ-8 (internal consistency = 0.93) (Larsen et al., 1979), Client Assessment of Treatment (internal consistency = 0.90) (CAT; Priebe & Gruyters, 1995), Self-rating Patient Satisfaction Questionnaire (internal consistency = 0.87) (SPRI; Hansson & Höglund, 1995), and Verona Service Satisfaction Scale-European Version (internal consistency = 0.96) (VSSS-EU; Ruggeri et al., 1996). Of these four scales, CSQ-8 and CAT are unidimensional.

In contrast, SPRI and VSSS-EU are multidimensional client satisfaction scales. SPRI is primarily used to assess psychiatric care from patients’ perspectives. It includes seven dimensions: ward environment, staff–patient relationships, information and influence, treatment design, treatment program, restriction, and compulsory care (Hansson & Höglund, 1995). VSSS-EU is commonly used to measure patients’ satisfaction with mental health services. It includes seven dimensions: overall satisfaction, professional skills and behavior, information, access, efficacy, types of intervention, and relatives’ involvement. It has been used in outpatient, community, and inpatient settings (Ruggeri et al., 2000).

We also reviewed a multidimensional scale specifically targeted for social work services, the Reid-Gundlach Social Service Satisfaction Scale (internal consistency = 0.95) (R-GSSSS; Reid & Gundlach, 1983). This scale has three dimensions, including 34 items in total: relevance (fit between problems and services provided), impact (effects of services on the problem), and gratification (effects of services on clients’ sense of self-efficacy). Similar to client satisfaction scales in the health care field, R-GSSSS focuses on the service provision process and the effectiveness of services. Unlike scales in health and mental health fields, this scale particularly emphasizes assessing direct practice skills of social workers, such as listening, empathy, respect, and confidentiality (Liu et al., 2013). Taken together, these five client satisfaction scales inform the multidimensional nature of client satisfaction in the social and human services field.

Table 1.

Dimensions Covered by Most Frequently Used Client Satisfaction Scales.

Contents of Logic Model	Dimensions of Scales	Scales
Inputs	Physical environment	SPRI; VSSS-EU
Inputs	Rules and procedures	SPRI; VSSS-EU
Process	Accessibility of service	SPRI; VSSS-EU
	Information received	SPRI; VSSS-EU
	Continuity of service	VSSS-EU
	Involvement	SPRI
	Medication	SPRI; VSSS-EU
	Practical support	SPRI; VSSS-EU; R-GSSSS
	Recreational opportunity	SPRI; VSSS-EU
	Relationship with staff	SPRI; VSSS-EU; R-GSSSS
	Relatives’ involvement	VSSS-EU
	Rights and dignity	SPRI; VSSS-EU; R-GSSSS
	Staff skills and competence	SPRI; VSSS-EU; R-GSSSS
Outcomes	Overall satisfaction	SPRI; VSSS-EU
	Perceived service outcomes	VSSS-EU
	Perception of tailored care	SPRI; VSSS-EU
	Views on services and treatment received	SPRI; VSSS-EU

Note. SPRI = Self-Rating Patient Satisfaction Questionnaire; VSSS-EU = Verona Service Satisfaction Scale-European Version; R-GSSSS = Reid-Gundlach Social Service Satisfaction Scale.

Theoretical Framework

We employed the logic model to determine and organize the dimensions and content of the Chinese client satisfaction scale. This model can facilitate effective program planning, implementation, and evaluation (Greene, 2013; Hansen, Alkin, & Wallace, 2013). “Logic models are narrative or graphical depictions of processes in real life that communicate the underlying assumptions upon which an activity is expected to lead to a specific result…[illustrating] a sequence of cause and effect relationships” (Unrau et al., 2007, p. 74).

Although the components of the logic model vary among different evaluators or stakeholders, there is a consensus on the four components: inputs, process, outputs, and outcomes. Informed by the logic model, social work programs begin with inputs and work their way through the process to finish with the desired results, whether output or outcome (Cooksy, Gill, Kelly, & Morell, 2001; Millar et al., 2001). The logic model can be used as a program-based, scale-developing theory framework. Liu (2018) studied 128 social work programs for people with disabilities with the logic model as the theoretical framework, and constructed an effect-oriented program management indicator system, which includes three dimensions with 11 items.

In the logic model, inputs include different kinds of resources and raw materials, such as financial, human, physical, and other resources required to support the program. Process involves all actions or interventions necessary to produce outputs (Julian, 1997; McLaughlin & Jordan, 1999). Outputs are the products (or numbers) of program activities. Outcomes are changes in clients’ behaviors, knowledge, skills, status, and so forth.

Based on our review of the five commonly used client satisfaction scales worldwide, we determined eight dimensions. Following the logic model, we assigned these subscales to inputs, process, and outcomes. (We explain how the subscales were chosen and formed in the Methods section.) Two dimensions were allocated to inputs, four dimensions were allotted to process, and two dimensions were allotted to outcomes. In doing so, we formed a theoretical framework for the client satisfaction scale (see Figure 1). Table 1 compares the dimensions of frequently used client satisfaction scales in terms of the logic model.

Figure 1.

Theoretical framework of client satisfaction scale.

Method

Study Procedure

In this study, we developed and validated a Chinese client satisfaction scale based on 15 government-sponsored social work programs in Jiangsu Province in China. We first conducted a thorough review of the five client satisfaction scales and generated 37 items to form an item pool. Second, we translated these items into Chinese. A total of five academic and direct practice experts assessed the cultural competence and content validity of the 37 items. Then we invited 20 frontline social workers, who had provided direct practice and services for at least two years, to determine the wording and length of the questionnaire; we finalized the questionnaire based on their feedback and suggestions. Finally, we invited 15 third-party evaluators to disseminate the questionnaire to 15 government-sponsored social work programs in Jiangsu Province, China. We provided professional survey training for these evaluators before data collection.

Next, we conducted a two-phase survey to validate this general client satisfaction scale. At Phase 1 (June 2019), we administered the survey during the mid-term of the 15 programs (N = 299). At Phase 2 (November 2019), we administered the survey again at the end of these programs (N = 609).

Scale Construction

Based on our theoretical framework, we formed the item pool (see Table 2). Through two researchers’ back-to-back checking, we determined eight dimensions, with a total of 37 items: (a) physical environment (PE) with 5 items, (b) staff skills and competence (S & C) with 5 items, (c) service accessibility (SA) with 4 items, (d) information accessibility (IA) with 5 items, (e) service involvement (SI) with 4 items, (f) rights and dignity (R & D) with 5 items, (g) service suitability (SS) with 4 items, and (h) perceived service outcomes (PSO) with 5 items. Then we turned these items into 5-point Likert scale. Answers ranged from 1 (not satisfied at all) to 5 (very satisfied).

Table 2.

Item Pool of Client Satisfaction Questionnaire for Social Work Service in China.

37 Items (Initial Scale)	25 Items after Content Checking
Physical environment (PE)	Physical environment (PE)
Good physical environment	——
Activity room is large enough to accommodate clients	——
Activity room is clean and tidy	——
Activity room is well equipped	——
Activity room is able to adapt or be adapted to many different functions or activities	——
Staff skills and competence (SC)	Staff skills and competence (SC)
Social workers are competent and knowledgeable	Social workers are competent and knowledgeable
Social workers are able to deliver easy-to-understand services	Social workers are able to deliver easy-to-understand services
Social workers are able to listen to and understand my problems	Social workers are able to listen to and understand my problems
Social workers are able to provide targeted services	Social workers are able to provide targeted services
Social workers are able to connect clients with resources from residents’ committees	——
Service accessibility (SA)	Service accessibility (SA)
Accessible services	Accessible services
Efficient service procedure	Efficient service procedure
Easy-to-access service site	Easy-to-access service site
Fits my schedule	Fits my schedule
Information accessibility (IA)	Information accessibility (IA)
Sufficient service information	Sufficient service information
Detailed explanation of service process	Detailed explanation of service process
Formally publicizing service information	Formally publicizing service information
Service information publishing via electronic media (e.g., WeChat)	——
Publicizing service information via community members (e.g., volunteers)	——
Service involvement (SI)	Service involvement (SI)
Clientts are able to give suggestions on service preparation	Clients are able to give suggestions on service preparation
Clientts are able to participate in service design	Clients are able to participate in service design
Clientts are able to participate in organizing and scheduling during the service process	Clients are able to participate in organizing and scheduling during the service process
Clientts are able to express (positive/negative) opinions during the service process	Clients are able to express (positive/negative) opinions during the service process
Rights and dignity (R & D)	Rights and dignity (R & D)
Social workers take good care of my special needs	Social workers take good care of my special needs
I can trust the social workers	I can trust the social workers
Social workers are nice to me	Social workers are nice to me
Social workers protect my confidentiality	Social workers protect my confidentiality
Social workers respect me	Social workers respect me
Service suitability (SS)	Service suitability (SS)
Services meet my needs	Services meet my needs
A variety of service items are available to meet my needs	A variety of service items are available to meet my needs
Services enrich my daily life	Services enrich my daily life
I prefer this organization even if others are competitive	I prefer this organization even if others are competitive
Perceived service outcomes (PSO)	Perceived service outcomes (PSO)
Services effectively meet my needs and solve my problems	——
Services enhance my interpersonal relationships	Services enhance my interpersonal relationships
Services establish relationships beyond family kinship	——
Services encourage my engagement in the community	——
Services promote my interactions with neighbors	——

First, we conducted the two-way translation. Two researchers with doctoral degrees in social work translated the 37 items into Chinese. We then invited an associate professor in the Department of English Literature at JL’s university to translate these items back to English. This iterative checking method reduced the discrepancies between original English meaning and Chinese translation. Second, five experts independently assessed the content validity and cultural appropriateness. Each expert met at least two of the following criteria: (a) graduated from MSW program; (b) at least 5 years’ direct practice service experience or social work teaching experience in a university; (c) published in top-tier, peer-reviewed journals in Chinese or English; and (d) knowledgeable of social work programs and practices in China. We disseminated a brief questionnaire to these experts to assess the quality of the initial scale, including overall coherence, cultural appropriateness, and Chinese contextual specificity. All five experts independently answered the questionnaire based on their own knowledge and experiences of social work.

Simultaneously, we invited laypersons to assess the preliminary scale. We invited 10 clients from the targeted 15 programs to complete the scale to determine the time it took to complete and their understanding of the questionnaire to avoid any potential jargon. These 10 clients included three children, four middle-aged people, and three older adults. After they completed the questionnaire, we conducted a focus group with each age group to collect opinions about the cultural and generational appropriateness of the items. Based on the assessments of both the experts and the clients, we deleted 12 items. Two of them belonged to information accessibility (IA). One of them belonged to staff skills and competence (SC). Four of them belonged to perceived service outcomes (PSO). The remaining five belonged to physical environment (PE); thus, we removed the PE dimension from this scale completely. Finally, we formed a scale containing seven dimensions with 25 items.

Sampling

After receiving ethical approval from the university with which JL is affiliated and the research ethics committee of the study funder, we contacted the Social Work Association of Jiangsu Province to obtain its ethical approval. We emphasized voluntary participation and confidentiality for each participant and each program. We received written informed consent from each participant.

Participants in this study came from the 15 programs that were sponsored by the Civil Affairs Department of Jiangsu Province. These 15 social work programs covered a wide range of services, including aging, healthcare, mental health, corrections diversion programs, children, and rural youth. The programs are located across the southern, central, and northern regions of Jiangsu Province, reflecting the variation of socio-economic status of different regions in the Jiangsu Province. The Provincial government assigned a third-party evaluation agency to monitor and assess the quality and effectiveness of these 15 programs.

Data Collection

We collected data as follows. First, we gathered the rosters from the 15 programs, with a total of 1125 participants, which we entered into an Excel spreadsheet as the sampling frame; we randomly selected our research sample from this. The trained third-party evaluator disseminated and collected the client satisfaction scale from these randomly selected program participants. To ensure that participants answered all the questions, each survey was completed face-to-face during the evaluators’ field visits.

At Phase 1, we randomly selected 300 program participants to explore the structure and content of the client satisfaction scale and received 299 valid questionnaires, a response rate of 99.67%. The goal of Phase 2 was to verify the structure and content of the client satisfaction scale that was revised by exploratory factor analysis (EFA) in Phase 1 and thus amplify the sample size. At Phase 2, we randomly selected 650 program participants and received 609 valid questionnaires, a response rate of 93.69%. We performed t-tests to make sure there were no significant statistical differences between these two samples, indicated as p values and 95% CI of differences below.

Age (p = 0.986, CI [0.010, 0.190]); gender (p = 0.961, CI [−0.351, 6.533]); 23-item scale score (p = 0.051, CI [−2.815, 0.067]); dimension scores: SA (p = 0.073, CI [−1.010, 0.006]), SC (p = 0.070, CI [−1.006, 1.112]), SI (p = 0.386, CI [−0.424, 0.315]), NF (p = 0.177, CI [−0.606, 2.148]).

Data analysis

We used Stata 15 to analyze the data, including exploratory factor analysis (EFA), to conduct the confirmatory factor analysis (CFA), and to evaluate the internal reliability. Very few missing data existed because the third-party evaluators monitored survey completion throughout the two-phase process. The very few missing data had little effect on the statistical analysis so we did not perform interpolation. We also examined univariate and multivariate skewness and kurtosis (Kline, 2005).

Results

Phase 1

Sociodemographic characteristics of clients

In Phase 1, there were 141 men (48.45%) and 150 women (51.54%; 8 missing data). The mean age was 35.15. The hukou (i.e., household status) was distributed as follows: local urban areas (148; 51.75%), local rural areas (54; 18.88%), other urban areas in the same province (20; 6.99%), rural areas in the same province (8; 2.79%), urban areas in other province (28; 9.79%), rural areas in other province (28; 9.79%; 13 missing data). A majority of the clients (150; 52.63%) were frequent program participants, 119 (41.75%) were occasional participants, and 16 (5.61%) rarely participated (14 missing data).

EFA (N = 299)

Given the high number of indicators (25), the good subject-to-question ratio (12:1), the number of factors (7), and the high level of commonalities (KMO = 0.908), an adequate sample size for factor analysis would be at least 150 clients; thus, 299 clients in Phase 1 was adequate.

In Phase 1, we conducted principal components analysis (PCA) to identify the factor structure of the client satisfaction scale. We calculated Kaiser-Meyer-Olkin (KMO) and Bartlett’s test before factor analysis. The results indicated that the dataset was adequate for conducting PCA (KMO = 0.908, p < 0.001). The following criteria determined factors and their items: (a) eigenvalue is greater than 1 for one factor, (b) factor loading is greater than 0.4 for an item, (c) a factor with at least three items, (d) the factor and its items are interpretable in a theoretical or practical way.

Along with these criteria, we identified four factors, which were very different from those in the initial scale in Table 2. Among these four factors, factor 1 contained all items of staff competence (SC) and three items of rights and dignity (R & D). Factor 2 merged from dimensions of service accessibility (SA) and information accessibility (IA). Factor 4 contained all items of service suitability (SS) and one item of rights and dignity (R & D). Factor 3 remained the same as it was in the initial scale. Given the cross-loading, we deleted two items: “I can trust the social workers” (0.550 on factor 1 and 0.585 on factor 4), and “services were able to meet my needs” (0.508 on factor 3 and 0.493 on factor 4). We renamed these four factors as staff competence (SC; factor 1), service accessibility (SA; factor 2), service involvement (SI; factor 3), and needs fulfillment (NF; factor 4). This resulted in four dimensions with 23 items, which explained 67.08% of the total variance (see Table 3). The cumulative explanations were: SA (20.47%), SC (38.52%), SI (54.15%), and NF (67.08%).

Table 3.

Pattern Matrix of Four Dimensions.

	New SC	New SA	New SI	New NF
Accessible services	0.126	0.738	0.256	0.161
Efficient service procedure	0.240	0.551	0.313	0.188
Easy-to-access service site	0.169	0.708	0.322	0.021
Fits my schedule	0.140	0.551	0.385	0.007
Sufficient service information	0.355	0.697	0.042	0.247
Detailed explanation of service process	0.261	0.704	0.104	0.336
Service information formally publicized	0.292	0.680	0.171	0.219
Clients are able to give suggestions on service preparation	0.204	0.199	0.739	0.219
Clients are able to participate in service design	0.234	0.131	0.736	0.285
Clients are able to participate in organizing and scheduling during the service process	0.287	0.117	0.665	0.297
Clients are able to express (positive/negative) opinions during the service process	0.378	0.287	0.621	0.294
A variety of service items are available to meet my needs	0.156	0.202	0.339	0.754
Services enrich my daily life	0.327	0.337	0.365	0.527
I prefer this organization even if others are competitive	0.256	0.301	0.303	0.541
Social workers take good care of my special needs	0.279	0.163	0.161	0.742
Social workers are nice to me	0.701	0.086	0.077	0.342
Social workers protect my confidentiality	0.603	0.393	0.164	0.260
Social workers respect me	0.771	0.216	0.256	0.165
Social workers are competent and knowledgeable	0.643	0.414	0.169	0.201
Social workers are able to deliver easy-to-understand services	0.758	0.289	0.279	0.088
Social workers are able to listen to and understand my problems	0.728	0.017	0.228	0.208
Social workers are able to provide targeted services	0.688	0.280	0.210	0.194
Services enhance my interpersonal relationships	0.556	0.404	0.408	0.205

Reliability

Internal consistency

Table 4 shows that the internal consistency for the whole scale was 0.949. The internal consistency for each dimension (factor) was also excellent. Cronbach’s α ranged from 0.848 to 0.915.

Table 4.

Internal Consistency of the Four Dimensions in Phase 1.

Effect Size	All Items	SC	SA	SI	NF
Cronbach’s α	0.949	0.915	0.885	0.853	0.848
Number of items	23	8	7	4	4

Note. N = 299. SA = service accessibility; SC = staff competence; SI = service involvement; NF = needs fulfillment.

Retest reliability (N = 54)

After two months, we randomly selected 60 clients to complete the same questionnaire with 23 items. A total of 54 clients responded (response rate = 90%). The two-month test–retest reliability, as Pearson’s r, was 0.75. By a Pearson’s r, the reliability of four dimensions between 0.42 and 0.59 (SC = 0.45, SA = 0.52, SI = 0.42, NF = 0.59). We also conducted a paired t-test to analyze the difference in the scores on the 23-item scale in the test and retest. The result (t = −0.901, p = 0.223, confidence interval [−0.17, 0.06]) indicated there was no difference in the test and retest.

Phase 2

Sociodemographic characteristics of clients

In Phase 2, there were 316 men (53.38%) and 276 women (46.62%; 17 missing data). The mean age was 32.06; the age range was 6–90 (8 missing data). The hukou of these clients was distributed as follows: urban areas (286; 48.31%), rural areas (165; 27.87%), other urban areas in the same province (27; 4.56%), other rural areas in the same province (39; 6.59%), urban areas in other province (35; 5.91%), rural areas in other province (40; 6.76%; 17 missing data). More than half of the sample were frequent participants (N = 349; 58.75%), 218 (36.70%) were occasional participants, and 27 (4.54%) rarely participated (15 missing data).

CFA (N = 609)

We conducted CFA in Phase 2. We adopted the maximum likelihood estimation method and fixed the first loading of each factor to 1. The results showed that the factor loading of all 23 items was more than 0.55. The model fit is satisfactory when χ²/df is less than 2, the comparative fit index (CFI) and Tucker-Lewis ρ are equal to or above 0.9, the root mean square error of approximation (RMSEA) is less than 0.05, and the standardized root mean square residual (SRMR) is less than 0.05. Model 1 produced very bad fitness: χ²/df = 6.419, RMSEA = 0.096, RSMR = 0.065, CFI = 0.854, TLI = 0.835. To correct this, we calculated large modification indices. At the same time, we deleted 8 items and added 16 pairs of error covariance. Then we fitted model 2. In model 2, χ²/df = 1.863, RMSEA = 0.056, RSMR = 0.028, CFI=0.974, TLI = 0.961. Table 5 presents the goodness-of-fit indices of model 1 and model 2. Model 2 was more desirable than model 1. In model 2, loadings of items were all significant (p < 0.001) and greater than 0.611 (see Table 6), which means good convergent validity of the four-factor model, where any of the correlations of two of the four factors are less than 0.8, ranging from 0.542 to 0.708 (see Table 7). These correlations indicate acceptable discriminant validity.

Table 5.

Goodness-of-Fit Indices of Model 1 and Model 2.

Model	Description	χ²/df	RMSEA	RSMR	CFI	TLI
1	Four-factor model without modification	6.419	0.096	0.065	0.854	0.835
2	Four-factor model with modification	1.863	0.056	0.028	0.974	0.961
Pair 1: Accessible services ∼ Social workers are nice to me.
Pair 2: Efficient service procedure ∼ Social workers are able to deliver easy-to-understand services.
Pair 3: Efficient service procedure ∼ Clients are able to participate in service design.
Pair 4: Efficient service procedure ∼ Clients are able to give suggestions on service preparation.
Pair 5: Easy-to-access service site ∼ Sufficient service information.
Pair 6: Easy-to-access service site ∼ Clients are able to participate in service design.
Pair 7: Social workers are competent and knowledgeable ∼ Social workers are able to deliver easy-to-understand services.
Pair 8: Social workers are competent and knowledgeable ∼ A variety of service items are available to meet my needs.
Pair 9: Social workers deliver easy-to-understand services ∼ Social workers are able to listen to and understand my problems.
Pair 10: Social workers are able to listen to and understand my problems ∼ Services enrich my daily life.
Pair 11: Clients are able to give suggestions on service preparation ∼ A variety of service items are available to meet my needs.
Pair 12: Clients are able to participate in organizing and scheduling during the service process ∼ A variety of service items are available to meet my needs.
Pair 13: Sufficient service information ∼ Services enrich my daily life.
Pair 14: Services enrich my daily life ∼ Social workers are able to deliver easy-to-understand services.
Pair 15: Clients are able to give suggestions on service preparation ∼ Clients are able to participate in organizing and scheduling during the service process.
Pair 16: Clients are able to participate in service design ∼ Clients are able to participate in organizing and scheduling during the service process.

Table 6.

Unstandardized and Standardized Values for the 15 Items.

15 Items	F Factors	URW	SE	SRW	p	SMC
Social workers are nice to me	NEW SC	1.000		0.611	***	0.373
Social workers are competent and knowledgeable		1.321	0.104	0.706	***	0.498
Social workers are able to deliver easy-to-understand services		1.317	0.095	0.744	***	0.554
Social workers are able to listen to and understand my problems		1.348	0.103	0.726	***	0.527
Accessible services	NEW SA	1.000		0.801	***	0.642
Efficient service procedure		0.877	0.049	0.685	***	0.469
Easy-to-access service site		0.908	0.052	0.706	***	0.498
Fits my schedule		1.118	0.055	0.777	***	0.604
Sufficient service information		0.989	0.047	0.815	***	0.664
Clients are able to give suggestions on service preparation	NEW SI	1.000		0.854	***	0.729
Clients are able to participate in service design		1.009	0.053	0.785	***	0.616
Clients are able to participate in organizing and scheduling during the service process		0.926	0.052	0.783	***	0.613
Social workers take good care of my special needs	NEW NF	1.000		0.768	***	0.589
A variety of service items are available to meet my needs		1.048	0.058	0.741	***	0.549
Services enrich my daily life		0.754	0.044	0.693	***	0.480

Note. N = 609. SC = staff competence; SA = service accessibility; SI = service involvement; NF = needs fulfillment. ***p < 0.001.

Table 7.

Correlations Among Four Dimensions.

Four Factors	SC	SA	SI	NF
SC	—
SA	0.624***	—
SI	0.556***	0.542***	—
NF	0.674***	0.708***	0.705	—

Note. N = 299. SC = staff competence; SA = service accessibility; SI = service involvement; NF = needs fulfillment. ***p < 0.001.

Criterion validity

We conducted a linear regression model to test criterion validity (see Table 8). In this model, we calculated the total score of the whole scale and treated it as dependent variable. The independent variable was the program participation frequency. The response options were “rarely,” “sometimes,” and “often.” Gender, age, political status, and hukou status were control variables. Linear regression model results showed that, compared to rarely participating, sometimes participating and very often participating were positively related to satisfaction (Beta = 0.827, p = 0.026; Beta = 0.870, p = 0.000); F = 6.35 (p = 0.000), Adj R-squared = 12.53%, mean VIF = 2.65. The results indicated the four-factor scale had good criterion validity.

Table 8.

OLS Analysis of Participation Frequency on Clients’ Satisfaction.

	Beta
Control variable	Controlled
Participation frequency (rarely participating)
Sometimes participating	0.827*
Very often participating	0.870***
F	6.35
p	0.000
Adj R-squared	12.53%
VIF	2.65

Discussion and Applications to Practice

This study developed and validated a standardized client satisfaction scale for social work programs in China (see Table 9 for the Chinese version). We conducted a preliminary test of validity of the client satisfaction scale and followed by a confirmatory analysis. The results of EFA met the theoretical requirement for identifying reliability factors: the number of indicators per factor (>2 indicators), the factor loading of indicators (>0.4), the level of commonalities of all indicators (>0.5), and the number of factors (Gagné & Hancock, 2006). The results of the CFA met the theoretical requirements of parameters; model fit is satisfactory when (χ²/df) is less than 2; root mean square error of approximation (RMSEA) is less than 0.05 (or 0.06); standardized root mean squared residual (SRMR) is less than 0.08; and Tucker-Lewis ρ (TLI ρ²) and comparative fit index (CFI) are above 0.9 (Brown, 2006; Hu & Bentler, 1999; Wang & Chui, 2017). The results of EFA and CFA suggest that client satisfaction consists of four dimensions with 15 items in the Chinese sociocultural context: staff competence (SC), service accessibility (SA), service involvement (SI), and needs fulfillment (NF). As such, this client satisfaction scale constitutes a standardized psychometric instrument to evaluate clients’ experiences and service delivery of social work programs in China.

Table 9.

The Chinese version of the four-dimension client satisfaction questionnaire.

题目	打分
社会工作者胜任能力
社会工作者对我非常友好	1	2	3	4	5
社会工作者能力强且有丰富的专业知识	1	2	3	4	5
社会工作者能够提供容易理解的服务	1	2	3	4	5
社会工作者善于倾听和同理	1	2	3	4	5
服务获得
可以无障碍地获取服务	1	2	3	4	5
具有高效的服务流程	1	2	3	4	5
服务站点易于访问	1	2	3	4	5
服务安排与工作和生活时间契合	1	2	3	4	5
服务信息丰富充足	1	2	3	4	5
服务参与
可以在服务筹备期间提供建议	1	2	3	4	5
可以参与服务方案设计	1	2	3	4	5
可以在服务过程中参与服务组织和调度工作	1	2	3	4	5
需求满足
特殊性需求能够得到社会工作者的回应	1	2	3	4	5
一般性需求可以通过多种多样的服务得到满足	1	2	3	4	5
日常生活因多样性的服务而变得丰富	1	2	3	4	5

社会工作服务满意度量表, 请您根据参与社会工作项目的经历, 对如下题目进行打分。其中, 1=非常不满意、2=比较不满意、3=一般、4=比较满意、5=非常满意

However, the findings of this study are not consistent with findings in the Western context (e.g., Hansson & Höglund, 1995; Shipley, Hilborn, Hansell, Tyrer, & Tyrer, 2000; Reid & Gundlach, 1983; Ruggeri et al., 1996). For example, physical environment (PE) seemed not to be crucial and we removed it from the scale. We merged staff competency and rights and dignity (R & D) into one subscale. These changes in items and subscales reflect the fact that clients’ understanding and perception of social work programs in China may differ from those in Western contexts, possibly because clients in China are concerned more about the competence of social workers, service accessibility, and whether the service can meet their needs than about the physical environment of service programs. Also, existing social work research shows that R & D is considered an important dimension of competence rather than an independent dimension of social work services in China (Lei & Huang, 2017; Li, Liang, & Tang, 2020).

The logic model provided a theoretical lens to construct the client satisfaction scale by following the procedure of a general social work program. As the logic model hypothesizes a linear relationship among inputs, processes, and outcomes, we conceptualized the four dimensions as inputs (SC), processes (SA and SI), and outcomes (NF). The relationships among SC, SA and SI, and NF in this study suggest a mechanism to understand client satisfaction. As such, the client satisfaction scale we developed mapped out the sequence of program procedures, connecting the need for the planned program with the program’s intended results (Unrau et al., 2007).

In terms of the implications, this four-dimension client satisfaction scale has several advantages. First, it can help clients to appraise their holistic experiences of social work services. Following the logic model, this scale can be a practical guide to carry out social work programs, paying attention to input, output, and outcomes, which captures clients’ experience in its entirety. As such, this scale can be applied to a wide range of social work programs, like its Western counterparts, such as community practice, mental health, child protection, and so forth.

Second, it can contribute to improving the quality of care of social work programs in China. The findings suggest that clients’ satisfaction correlated to their program participation frequency, which means this scale can help analyze the antecedents of client satisfaction. As a validated, rigorous evaluation instrument, the scale can generate critical feedbacks to advance social work practice and social work program design.

Third, it can offer a feasible way to standardize social work programs in China. The scale can inform social work programs to focus on staff competence (SC), service accessibility (SA), service involvement (SI), and needs fulfillment (NF), in order to enhance clients’ service experience and increase their participation frequency.

Relevantly, this scale can be a stepping stone for strengthening social worker competence in China. Taking clients’ satisfaction into consideration, training for social workers should further emphasize clients’ experience during and after social work programs and/or services. Clients’ perspectives should be incorporated in designing, implementing, and evaluating social work programs and services.

Still, we should be cautious when applying this scale. Given the reality that most social work programs in urban China rely on experts’ or the third-party evaluation (Liu et al., 2013; Qu, 2017), our scale, admittedly, may not be the main evaluation tool but rather a supplement to understand these social work programs from clients’ perspectives. Also, clients may not have adequate knowledge of a certain social work program. So they may not be able to clearly distinguish the four dimensions. This may lead to difficulties in widely applying this scale.

Social workers and various stakeholders also need specific training when applying this scale, including: (a) strengthening the competence of social workers, such as practical skills, statistical analysis, and program design (Lei & Huang, 2017); (b) expanding the availability of services; and (c) promoting in-depth client participation and involvement. It is also essential for social workers to administrate this scale in a pre-test and post-test design and through a face-to-face, structured interview with each client, which requires them to be familiar with survey research. In practice, it can be difficult for social workers to utilize this satisfaction scale in a research manner, such as pre-test and post-test. This may bring additional pressure for social workers to carry out clients’ satisfaction evaluation.

This study has several limitations. First, the generalizability of the scale in this study is limited. We developed the scale based on 15 social work programs in the Jiangsu Province, which is on the east coast of China. Our findings cannot represent the country as a whole. More evidence is needed from social work programs nationwide Also, we only conducted a two-phase, cross-sectional study on 15 social work programs. Further studies need longitudinal data from a wide range of social work programs. Second, the content and/or dimensions of the scale needs updates. Although the content of the scale in this study was examined by different stakeholders (e.g., experts, practitioners, and clients), different understandings of satisfaction among stakeholders may influence the content of the scale. Future studies need to increase the heterogeneity of stakeholders to exhaust the potential content of the client satisfaction scale. Third, this scale may not be able to directly test the effectiveness of social work programs and/or services. This scale measures the clients’ perception and experience of receiving programs and/or services, which can reflect the quality of service but may not capture the effectiveness.

This study is among the first to develop and validate a culturally competent client satisfaction scale in the Chinese context, using rigorous procedures. We also tested the reliability and validity of the scale. Our results suggest that the four-dimension client satisfaction scale is a psychometrically robust instrument, drawing on clients’ perceptions of their program participation. The four dimensions (SC, SA, SI, NF) represent the inputs, processes, and outcomes of a social work program. This multidimensional client satisfaction scale provides a way to evaluate and compare client satisfaction across various types and forms of social work programs. Moreover, the scale can contribute to our understanding of clients’ decisions to participate in the social work programs, as well as their experiences and impressions. Increased understanding of client satisfaction is essential for the development of social work in China.

Footnotes

Author Contributions

Jiang Liu planned the study, analyzed data, and wrote the paper. Lin Chen strengthened the organization of manuscript and revised the manuscript. Both authors contributed equally to the final version of the paper before submission.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: “Social Work Professional and Institutional System in China,” Major Fund, National Social Science Foundation of China. Grant Number: 19ADZ144.

ORCID iD

Lin Chen

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