The International Journal of Psychosocial Rehabilitation
 
User satisfaction and its associated factors among members
 of a Norwegian clubhouse for persons with mental illness


Victoria C. Ritter1, MSc student
Hege Nordli2, PhD, Vice Director
Orsolya R. Fekete3, MSc., PhD student
Tore Bonsaksen1, 4, MSc., Professor


 
1 Oslo and Akershus University College of Applied Sciences
 Faculty of Health Sciences, Department of Occupational Therapy, Prosthetics and Orthotics Oslo, Norway

2 Fontenehuset i Oslo, Oslo, Norway

3 Western Norway University of Applied Sciences, Faculty of Health and Social Sciences
 Department of Social Science and Social Education, Bergen, Norway

4 VID Specialized University, Faculty of Health Studies, Sandnes, Norway




Citation:
Ritter VC, Nordli H, Fekete OR & Bonsaksen T. (2017)   User satisfaction and its associated factors
 among members of a Norwegian clubhouse for persons with mental illness.
 International Journal of Psychosocial Rehabilitation. Vol 22 (1) 5-14


Abstract
For individuals experiencing mental illness, work may not be accessible such that alternatives to ordinary work are needed. Clubhouses provide work-oriented psychosocial rehabilitation for persons with mental illness, but little is known about the members’ satisfaction with the clubhouse they use. This study explored the members’ level of satisfaction with the clubhouse experience, and examined factors associated with their satisfaction. A cross-sectional design was used. The data, originating from a member survey, were analyzed with linear regression. Based on eighty-nine valid responses, the study found that women were more satisfied with “personal outcome” compared with men. Members with less work experience were more satisfied with “user involvement” compared with those with more work experience, and the scores on all satisfaction scales increased with more frequent use of the clubhouse. Given the value of diversity at the clubhouses, user satisfaction should be monitored and sustained for all members.

Keywords: clubhouse, mental health, user satisfaction vocational rehabilitation


Introduction:
Work has many positive effects on persons with serious mental illness, most notably income, but with it also the means to access desired goods and services. However, work may also contribute to time structure, a sense of meaning, improved self-esteem, better social functioning and positive social relationships with colleagues (Bull & Lystad, 2011; Ruesch, Graf, Meyer, Rössler, & Hell, 2004). Accordingly, work has been recommended in national and international policy documents as an important means to integrate people with mental health problems into communities (Department of Work and Inclusion & Department of Health, 2007-2012; World Health Organisation, 2000). People with mental illness have recently received more attention regarding the difficulties they may face when standing outside the normal arenas of society, especially vocation. For example, between 55% and 70% of people with severe mental illness have been reported as expressing a desire to work (Bond & Drake, 2014; Bull & Lystad, 2011; Mueser, Salyers, & Mueser, 2001), whereas their employment rates have been found to be less than 15% (Bond & Drake, 2014; Evensen et al., 2016; Helle & Gråwe, 2008; Melle, Friis, Hauff, & Vaglum, 2000). Approximately one third of the disability pensions in Norway are issued for mental health and behavioral disorders in general (Norwegian Labour and Welfare Administration [NAV], 2012).

For the individual experiencing the mental health problems, however, work may not always be accessible, possible or wanted, such that alternatives to ordinary work are needed.  The clubhouse model is a growing movement concerned with work-oriented psychosocial rehabilitation for persons with mental illness (Clubhouse International, 2015). In Norway, the number of clubhouses is increasing and their ideology and methods appear to fit well with current policies. These tend to emphasize engagement in meaningful occupations, independent living and social participation, rather than a narrow medical focus on remediation from illness and symptoms (Bjaarstad, Trane, Hatling, & Reinertsen, 2014; Department of Work and Inclusion & Department of Health, 2007-2012). As such, clubhouses are a workplace, a work community where members and staff support one another, and as a place for learning, development and training on their own premises (Stimo et al., 2015). In a social inclusion perspective, thus, work is considered an important route to social and community integration (Department of Work and Inclusion & Department of Health, 2007-2012). The clubhouses are theoretically based on health promotion and a salutogenic perspective (Fekete, Kinn, Larsen, & Langeland, 2017). The clubhouses are systematically understaffed such that the members are in fact needed to run the different activities that take place in them, and they aim at assisting its members getting prepared for real life work. The clubhouses incorporate assisting members to obtain competitive employment with standards related to voluntary membership, positive working relationships, and the work-ordered day at the clubhouse (Stimo et al., 2015).

Effect studies on acquiring and staying employed in ordinary work has concluded that participation in clubhouses can contribute to getting people with mental illness back to work (Battin, Bouvet, & Hatala, 2016; Schonebaum & Boyd, 2012; Schonebaum, Boyd, & Dudek, 2006). However, assisting members back to ordinary work is not the sole purpose of the clubhouse. For many members, being able to participate in meaningful activities, in their own pace and in cooperation with supportive and trusted people – employees as well as peer members – is a valued aspect of the clubhouse experience (McKay, Nugent, Johnsen, Eaton, & Lidz, 2016; Stimo et al., 2015). As members of a clubhouse showed significantly higher satisfaction scores than a control group participating in community outings (Jacobs, 1999), it appears that the clubhouses are successful in obtaining such desired qualities. To many, the clubhouse is a place where they are engaged in day-to-day tasks, but also in long-term relationships and projects. Without feeling a certain level of satisfaction and reward from using the clubhouse, such commitment to long-lasting relationships and projects would be difficult to achieve. Previous psychometric studies of the items used for measuring user satisfaction among clubhouse members in Norway have indicated that an overall satisfaction measure may be used (Thørrisen, Nordli, Fekete, & Bonsaksen, 2018; Uhrmann, Fekete, Nordli, & Bonsaksen, 2018). However, it is also possible to distinguish between two distinct aspects of user satisfaction: personal outcome and user involvement. To date, it appears that systematic, published studies of user satisfaction among clubhouse members are scarce. Moreover, studying factors associated with user satisfaction amongst clubhouse members may increase our understanding of their perception of the clubhouse.

Study aim
The aim of the study was to investigate factors associated with user satisfaction among members of one Norwegian clubhouse.

Methods
Design and data collection
The study had a cross-sectional design. All data were self-reported by the Clubhouse members, and Clubhouse staff collected the data during the winter of 2016.

Sample
All Clubhouse members were eligible participants in the study. There were no exclusion criteria. At the time of collecting the data, the clubhouse had 151 registered members, and 94 (62.3 %) of these opted to participate.

Measurement
The member survey asked the respondents to indicate their age group (21-30 years, 31-40 years, 41-50 years, 51-60 years, 61 years and above), gender (male, female, transperson), and highest completed education level – information about the latter was later dichotomized into a variable indicating high-school level or lower vs. BSc-level or higher. Moreover, the participants reported their work status (in paid work vs. not in paid work), work experience (later dichotomized into a variable indicating five years or less vs. six years or more) and use of the Clubhouse (4-5 days per week, 1-3 days per week, about every other week, and less frequent than every other week).

In addition, one section with six statements, all of which rated from 1 (totally disagree) to 5 (totally agree), constitute the revised User Satisfaction Survey. A Principal Components Analysis based on the 2016 member survey found that the statements “loaded” on two different factors, and they might therefore constitute two different scales, labeled “personal outcome” and “user involvement”, respectively (Uhrmann et al., 2018). There were no cross-loadings between the two scales, and Cronbach’s α was 0.84 (personal outcome) and 0.75 (user involvement). However, a subsequent Parallel Analysis revealed that a one-factor structure might be more appropriate, and Cronbach’s α was 0.84 for this scale consisting of the six items together. We have concluded that both factor structures may of use, depending on the purpose for which the measure is used. In this study, the main scale and the two subscales are both used as outcomes. The content of the revised Clubhouse User Satisfaction Survey is displayed in Table 1.


Table 1

The Clubhouse User Satisfaction Survey - Revised

To what extent do you agree with the following statements?

 

Personal outcome

1

I do meaningful work at the clubhouse

2

I can use my resources at the clubhouse

3

I feel useful at the clubhouse

 

User involvement

4

I feel that I have an influence on my workday at the clubhouse

5

At the clubhouse, I can participate in all meetings where important matters are discussed

6

I can take part in making decisions in matters that concern the clubhouse

Note. All statements are rated: 1 = totally disagree, 2 = partly disagree, 3 = not sure, 4 = partly agree, 5 = totally agree. The survey is used with a one-factor structure: User satisfaction = sum of all item scores, or with a two-factor structure: Personal outcome = sum score (items 1, 2, 3), and User involvement = sum score (items 4, 5, 6).



Data analysis
The initial descriptive analyses used frequencies and percentages for categorical variables and means and standard deviations for continuous variables (scale scores). Two persons reporting transperson to be their gender were removed from the dataset prior to the inferential analysis. A multivariate hierarchical linear regression analysis was conducted to investigate direct associations between the independent variables and the outcome scales derived from the User Satisfaction survey. Independent variables were included in three subsequent blocks, with block 1 representing member background (age group, gender, and education level), block 2 representing work factors (currently working/not working, and level of prior work experience) and block 3 representing one variable assessing the frequency with which the clubhouse was used. The SPSS software was used for all analyses (IBM Corporation, 2016). Effect sizes (ES) were reported as standardized beta weights, and ES > 0.30 were considered medium size. Statistical significance was set at p < 0.05.

Ethics

All members of the clubhouse was informed about the survey by the clubhouse staff. Participation was voluntary, the data were collected anonymously, and completing and returning the survey implied informed consent to participate. As the collected data was anonymous and not concerned with health and/or illness, formal approval from the Regional Ethics Committee for Healthcare Research or the Data Protection Official for research was not required.

Results
Sample characteristics
Ninety-four clubhouse members completed the survey. The age distribution showed that 61 participants (64.9 %) was at the age of 50 years or younger. The proportions of men and women were practically equal, and two participants indicated transperson to be their gender. Persons without completed higher education were in majority (n = 58, 62.4 %). Nineteen participants (20.2 %) reported that they currently had a paid job. Fifty-seven participants (60.6 %) indicated that their work experience exceeded five years, whereas 30 participants (31.9 %) indicated that their work experience was five years or less.

Based on 89 valid responses, 21 participants (22.3 %) stated that they used the clubhouse less frequently than every other week. Three participants (3.2 %) used the clubhouse about every other week, while a majority used it one to three days per week (n = 48, 51.1 %) or four to five times per week (n = 17, 18.1 %). The participants’ scores on personal outcome (M = 12.2, SD = 2.5, scale range = 3-15), user involvement (M = 12.6, SD = 2.7, scale range = 3-15), and user satisfaction (M = 24.8, SD = 4.6, scale range = 6-30) all implied satisfaction levels that exceeded 80 % of the highest possible score. The sociodemographic, work-related and clubhouse-related characteristics of the sample is displayed in Table 2.

Table 2

Sociodemographic characteristics of the participants

Age group (n = 94)

n

%

21-30 years

11

11.7

31-40 years

25

26.6

41-50 years

25

26.6

51-60 years

23

24.5

61 years and above

10

10.7

Gender (n = 94)

n

%

Men

45

47.9

Women

47

50.0

Transperson

2

2.1

Highest completed education (n = 93, 98.9 %)

n

%

Elementary school or high school

58

62.4

College or university (BSc level or higher)

35

37.2

Work (n = 94)

n

%

In paid work

19

20.2

Work experience (n = 87, 92.6 %)

n

%

Work experience > 5 years

57

60.6

Work experience ≤ 5 years

30

31.9

Use of the clubhouse (n = 89, 94.7 %)

n

%

4-5 days per week

17

18.1

1-3 days per week

48

51.1

About every other week

3

3.2

Less frequent than every other week

21

22.3

User satisfaction

M

SD

Personal outcome (n = 84, 89.4 %)

12.2

2.5

User involvement (n = 86, 91.5 %)

12.6

2.7

User satisfaction (n = 84, 89.4 %)

24.8

4.6

Note. On categorical variables with some missing responses (i.e., n < 94), the valid percent is reported.

 Factors associated with User Satisfaction scale scores

Female participants and participants who used the clubhouse more frequently were more satisfied with their personal outcome from being member of the clubhouse. Participants with less work experience and who used the clubhouse more frequently were more satisfied with user involvement. Finally, using the main User Satisfaction scale as outcome, those who used the clubhouse more frequently had higher scores on this scale. “Use of the clubhouse” contributed most to the explained data variance in all models, added explained variance ranging between 7.5 % (user involvement) and 13.4 % (personal outcome). The full models explained between 15.6 % (user involvement) and 21.0 % (personal outcome) of the total data variance. The results from the regression analyses are shown in Table 3.



Table 3

Hierarchical linear regression analysis showing direct associations with the User Satisfaction scales

Independent variables

Personal outcome

User involvement

User satisfaction

Age group

-0.01

-0.01

-0.01

Gender

0.24*

0.09

0.20

Education

0.04

0.12

0.09

Explained variance

6.4 %

2.8 %

4.3 %

Paid work

-0.01

0.06

0.02

Work experience

-0.03

-0.26*

-0.17

R2 change

1.2 %

5.3 %

3.2 %

Explained variance

7.6 %

8.1 %

7.5 %

Use of the clubhouse

0.38**

0.28*

0.37**

R2 change

13.4 %**

7.5 %*

12.9 %**

Explained variance

21.0 % **

15.6 %*

20.4 %**

Note. Table content is standardized β weights, indicating the strength of the relationship between the study variables. Variable coding: Higher “age group” is higher age, higher “gender” is female, higher “education” is higher education level, higher “paid work” is currently in paid work, higher “work experience” is more work experience, higher “use of the clubhouse” is more frequent use of the clubhouse.

*p < 0.05, **p < 0.01



Discussion
This is the first study to investigate user satisfaction and its associated factors amongst members of a Norwegian clubhouse. The results indicated that female participants were more satisfied with their personal outcome from being a member of the clubhouse than men (Table 3). Although a meta-analysis of 110 studies of patient satisfaction concluded that, there were no average differences in satisfaction with medical care between men and women when using standard instruments (Hall & Dornan, 1990), evidence for gender differences in satisfaction is mixed. Weisman and colleagues (2000) reported women to be more critical of health care than men, while other authors reported a preponderance of evidence that women were more satisfied with received healthcare than men (Weiss, 1988). Furthermore, compared to men, women use healthcare services more frequently (Statistics Norway, 2007) . Assuming a relationship between requesting a service and feeling satisfied when the service has been provided, it may be that female participants are more frequent users of the clubhouse, and that this adds to their perception of having a better personal outcome from that participation.
However, the context of the current study (work-oriented psychosocial rehabilitation) differs from that of the cited studies (medical care). It may be that the male participants were more eager to (re-)enter ordinary employment than the female participants were. Men may also have been more prone to associate being useful, doing meaningful work, and using personal resources (i.e., the content of the items on the personal outcome scale) to life in the community, and not as much to activities taking place in the clubhouse setting. In practical terms, men may perceive making a meal or writing minutes from a meeting to be relevant tasks, but may perceive them to be less meaningful when performed within the clubhouse context. If this were the case, it could contribute to explain why the female participants in general had higher scores on the personal outcome scale, compared to the male participants.

International research literature shows that the clubhouses propose an environment that provides to its members a sense of community and affiliation (Carolan, Onaga, Pernice-Duca, & Jimenez, 2011), where members can engage in tasks they deem meaningful (Norman, 2006). One important source of meaning can be found in the possibility to influence one’s environment through one’s own actions. In this study, members with less work experience reported higher satisfaction with user involvement than those with more work experience (Table 3). We wondered whether a difference in level of education amongst the members with more and less work experience could explain their differing perceptions of what constitutes meaningful involvement in the organization of the clubhouse. However, this appears not to be the case, as education level was not significantly related to the participants’ scores on the user involvement scale (Table 3). On the other hand, members with less work experience may feel that the clubhouses’ daily tasks better coincides with their capacity, compared to members with more work experience. This could play a part in explaining why those with less work experience reported a greater sense of user involvement. Alternatively, those with more work experience may have felt that user involvement strategies at the clubhouse fall short of the strategies used in real-life employment. Thus, in comparison to their experiences from regular jobs, they may have been relatively disappointed with the clubhouse in this respect.

Furthermore, members who utilized the clubhouse more scored higher, both on the dimension-specific scales (personal outcome and user involvement) and on the overall user satisfaction scale, indicating that more frequent use of the clubhouse was associated with higher satisfaction with it (Table 3). In line with these findings, Chang and colleagues (2014) found that higher frequency of clubhouse use predicted lower levels of social isolation. In combination, this could indicate that individual clubhouse members may receive greater benefit from the clubhouse – in a range of areas – if they use it relatively often. Each visit to the clubhouse may include the opportunity to do something worthwhile, but daily routines and a sense of affiliation to and companionship with other members can hardly be expected from a few or infrequent visits. Group relationships develop based on frequent interactions over time (Forsyth, 2006). Similarly, regular use of the clubhouse would likely be needed to be able to impact on its development (user involvement) and to be able to experience some kind of personal reward from being a member (personal outcome). Thus, it is likely that the relatively frequent users of the clubhouse are able to benefit more from them. For the regular users of the clubhouse, the variation of the members’ backgrounds represents a diversity that may contribute to creating an inclusive environment where people feel appreciated. The differences between the members could contribute to them becoming resources for each other, such that the individual can both provide and receive support (Bomann & Iversen, 2015; Hancock, Bundy, Honey, Helich, & Tamsett, 2013; Norman, 2006), much in line with the clubhouse ideology (Clubhouse International, 2016).

Study limitations
The study was based on a relatively small sample, all members of one particular clubhouse in Norway. Thus, generalizations based on the study results should be performed with caution. We used a cross-sectional study design, using data from one point in time only. As a result, causal inferences should not be made. In particular, the detected associations between the outcome scale scores (user satisfaction) and frequency of use of the clubhouse might be reciprocal rather than unidirectional: More frequent use may lead to more satisfaction, perhaps owing to stronger feelings of commitment and engagement in the clubhouse routines and activities. On the other hand, stronger feelings of commitment and engagement may logically lead to using the clubhouse more frequently. Thus, there may be a self-strengthening cycle between these variables.

Conclusion
Compared to men, women were more satisfied with their personal outcome from being members of the clubhouse. Compared to participants with more work experience, participants with less work experience were more satisfied with user involvement at the clubhouse, and more frequent use of the clubhouse was associated with higher satisfaction. Overall, this study suggests that members of the clubhouse have a high level of overall satisfaction with the clubhouse. However, the systematic associations with user satisfaction may indicate a special need to monitor the way men, those with more work experience, and infrequent clubhouse visitors perceive the clubhouse environment. Given that diversity is considered an asset for the clubhouse and its members, one should make an effort to keep satisfaction at a high level for all groups of participants.

Funding -None

Conflict of interest: None.


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