Satisfaction in Mental Health Care: Examining Psychometric Properties of Experience of Service Questionnaire in a Turkish Population

Satisfaction in Mental Health Care: Examining Psychometric Properties of Experience of Service Questionnaire in a Turkish Population | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Satisfaction in Mental Health Care: Examining Psychometric Properties of Experience of Service Questionnaire in a Turkish Population Pelinsu Bulut Ozer, Sibel Halfon This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3859764/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: Measuring satisfcation with psychological health services is important in clinical settings in order to evaluate the benefits of treatment. Past research has shown that relationship with clinician is at the core of satisfaction reports. However, measurement tools focusing on patients’ psyhcological health care experiences are rather scarce. The objective of this study is to adapt the Experience of Service Questionnaire (ESQ) Parent form and examine its psychometric properties in a Turkish population. Method: ESQ Parent form was translated into Turkish and was presented to parents (N = 242) of children who have completed their treatment in a university’s psychological counseling center. Child Behavior Checklist (CBCL) was also gathered from parents pre- and post-treatment in order to measure symptomatic gains and investigate their associations with satisfaction with treatment. Results: Factor analysis revealed a two-factor solution (‘Care’ and ‘Environment’) similar to questionnaire’s original structure. In addition, discriminant validity results showed that participants showing higher therapeutic gains (as measured by CBCL) show significantly higher satisfaction in ESQ. Conclusions: This study is the first to measure satisfaction in psychological health care settings in Turkey, and therefore aims to contribute to a gap in the field. Results indicate a significant association between treatment outcome and satisfaction levels. Also, adapted measurement tool demonstrates adquate reliability and validity scores supporting it’s use in clinical settings. Patient satisfaction Treatment outcome Child Psychotherapy Measurement of health care experience Figures Figure 1 Introduction Health services are services offered to meet health-related needs, focusing on the physical and mental well-being of the person (Aslantekin et al., 2007 ). Experiences of health services reported by the patient are considered to be a crucial aspect of quality of care; therefore measurement of these experiences became increasingly vital in ameliorating the quality of the health services. Experience of health services may also become useful for evaluating new treatments and practices when public health policies are concerned. Another benefit of measuring experiences of health services is its reflections on treatment outcomes; such that positive experinces with health services are generally associated with more gains and more positive outcomes (Crow et al., 2002 ). Health services may comprise a variety of different factors including the relationship between the patient and the service provider (doctor, therapist etc.), patient's expectations, and also the readiness to provide the service (competence of the staff, environmental factors etc.). Within the framework of psychological health services, it has been determined that the relationship between the patient and the therapist is at the core of perceived service quality. The care received from the therapist is an important component of the mental health service experience (Parasuraman et al., 1985 ). When patients are satisfied with the mental health service that they receive, they tend to show more compliance and cooperation within the treatment (Anderson et al., 1998) and show more treatment gains (Crow et al., 2002 ). One qualitative study investigated what ‘satisfaction with service’ means to adolescent patients and showed that a good mental health service was described as a secure place where adolescent patients could freely express themselves and felt that they were treated humanely (Biering & Jensen, 2011 ). Deriving from these descriptions, it is clear that adolescents put much focus on the therapy relationship when they evaluate their satisfaction with mental health care. In addition to care received from the therapist, other elements of the treatment were also shown to contribute positively to the perceived mental health service. These included certain aspects of the environment such as accessibility, transportation, facility, and staff (Attride-Stirling, 2002 ). Mental Health Service, Patient Caharcteristics and Therapeutic Gains There is a growing area of study that investigate the relationship between patient satisfaction with mental health services and therapeutic gains. Shapiro et al. ( 1997 ) in their psychometric study, measured for convergent validity through parents’ reports of problem behaviors and found that satisfaction was significantly related with parents’ outcome reports as well as therapists’ ratings of therapeutic progress. Day et al. ( 2011 ) also showed that with children/youth aged 8–18, satisfaction with treatment was significantly associated with clinical outcomes as rated by parents. In addition some studies also suggest a bidirectional relationship between patient’s experience/satisfaction and treatment outcome: as patients showed advancements in therapy, they also became more satisfied with the service they received (Kennedy, 2010 ). Similarly, many of the patients who evaluated their experience negatively show this dissatisfaction during their treatment process: Stallard ( 1995 ) showed that parents’ of adolescents who were more dissatisfied with therapy attended fewer sessions, dropped out of treatment, or were reluctant to fill out the survey. The literature on factors affecting the experience of the patient on mental health services are quite scarce. Crow et al. ( 2002 ) lay out two distinct factors: firstly, factors that are related to patient rather than the actual quality of the provided mental health service (e.g., patient characteristics, health status and expectations) and secondly factors that are actually related to health service delivery (e.g. staff number, qualifications, facility arrangements etc.). However when patients’ satisfaction is being measured, the objective health service care delivery arrangements are rather irrelevant, and patient-related factors are more prominent in shaping their perception of satisfaction and experience (Crow et al., 2002 ). When factors about patients’ characteristics are examined, literature conveys mixed results on sociodemographic properties such as age and sex in relation to satisfaction with the service experience (Turchik et al., 2010 ; Copeland et al., 2004 ; Stuntzer-Gibson et al., 1995). Turchik et al. ( 2010 ) showed that satisfaction (reported both by the parent and the child) differentiated in relation to the age of the child: ages 14–16 showed less satisfaction than ages 16–18. On the contrary, Stuntzer-Gibson et al. (1995) showed that younger youth were more satisfied with mental health services that they have received. Copeland et al. ( 2004 ) conducted a study with both children’s own treatment satisfaction ratings and parents’ satisfaction ratings of their children’s treatment, and demonstrated that children’s ratings may depend on their age and sex. Other studies also demonstrated that adolescent males were more satisfied with mental health services than their female peers (Shapiro et al. 1997 ; Stuntzer-Gibsonet al. 1995). In a recent study by Barber et al ( 2006 ), results conveyed no significance in the relationship between satisfaction and sociodemographic variables. Similarly Garland et al. ( 2007 ) did not find any significance between satisfaction and age-gender however a small significance was found between satisfaction and race: being Caucasian associated with higher satisfaction levels. Reasons for referral and distress levels are other factors that are researched in satisfaction of health services studies. Studies show that child/adolescent patients presenting with severe behavioral disorders report significantly lower satisfaction in mental health services than patients with other symptoms (Barber et al., 2006 ; Garland et al., 2000 ; Godley et al., 1998 ). Godley et al. ( 1998 ), Garland et al. ( 2000 ) and Barber et al. ( 2006 ) found that youth problem severity level as reported by themselves was associated with their satisfaction level. Turchik et al. ( 2010 ) showed that adolescents with a disruptive disorder diagnosis reported lower satisfaction scores than adolescents with other diagnoses (mood disorders, depression, adjustment disorders, anxiety disorders). On the other hand, Stuntzer-Gibson et al. (1995) found that severity of referral problems showed no significant relationship with children’s experience of mental health service. As outlined above, the literature on patient characteristics is rather mixed and therefore require more research when the experience of mental health services is considered. Measurement of Mental Health Service Experience Self-report methods that include patient feedback and satisfaction are the most common methods of measurement to assess perceived health service. Even though there are various scales that aim to measure the experience of received mental health care with adults, however scales that aim to measure child/adolescent mental health services are scarce (Brown et al., 2014 ). Garland et al. ( 2000 ) developed the Multidimensional Adolescent Satisfaction Scale that focused on adolescents’ satisfaction of mental health services. Data gathered from adolescents (ages 13–18) yield a four-factor structure (clinician characteristics, meeting needs, effectiveness, conflict with the clinician). The scale showed good reliability and validity was supported with reasons for terminating treatment. Similarly, Shapiro et al. ( 1997 ) also developed The Youth Client Satisfaction Questionnaire; a tool consisting of 17 items that can be administered to adolescent samples (ages 11–17). Results of this study conveyed a two-factor structure: (1) relationship with the clinician and (2) benefits of the treatment. This study also demonstrated significant relationships of convergent validity between parental satisfaction and and therapeutic gains as reported by the parents. Other psychometric studies account for both parents’ and children/adolescents’ reports of their mental health treatment experience. Day et al. ( 2011 ) developed the Child and Adolescent Service Experience (ChASE) applied on 132 children/adolescents and their parents. Resuls indicated a three-factor structure (relationship, confidentiality and session activities). Another youth scale was developed by Stuntzner-Gibson et al. (Youth Satisfaction Questionnaire; 1995) which consisted of five global questions about mental health treatment. Evaluating 165 youth responses, scale was unidimensional and showed adequate reliability. Brannan et al. ( 1996 ) developed the Satisfaction Scales (parent and adolescent forms) and found a four-factor structure for both versions: (1) access and convenience, (2) child’s treatment process and relationship with the therapist, (3) parent and family services, (4) global satisfaction. In all of these psychometric studies, relationship with the clinician seems to be a common factor for the experience of mental health services. Experience of Service Questionnaire (ESQ; Attride-Stirling, 2002 ; Brown et al., 2014 ) also aims to measure the service satisfaction of children/young people and their families. ESQ includes self-report forms for both parents and children (two separate forms for ages 9–11 and 11–18). The two separate child forms aim to take into account the developmental level of the child. All forms are parallel to each other, the questions are asked in the same order, with only minor adjustments to suit the age of the child. In the psychometric study of ESQ, a two-factor solution was found. The first factor was named ' Care '; this factor consisted of items focusing on the relationship between the patient and the therapist. The second factor, ' Environment ', consisted of items related to the environmental factors of treatment. Aims of the Current Study The literature on mental health care satisfaction is very limited. One of the two studies in Turkey on mental health care services was conducted by Erciş et al. (2020) where they focused on adult psychiatric patients’ experiences upon their discharge. In this study, User’s Satisfaction in Psychiatric Services Questionnaire by Nilsen and Johanneseen ( 2012 ) was translated into Turkish and was administered to the psychiatric patients upon discharge. Main results showed that satisfaction levels were associated with the duration of time spent with the patient, and staff unavailability was correlated with dissatisfaction. This result may also point to the importance of clinician-patient relationship and the care received. In another interview-based qualitative study that was conducted by World Health Organization and Ministry of Health on Syrian refugees receiving mental health care and psychosocial support, the results showed that the satisfaction level and ‘having needs met’ were high among participants (Kahiloğulları et al., 2020 ). To our knowledge, there were no other studies that focused on measuring experiences with mental health services in Turkey. In addition, the measurement tools to investigate satisfaction with mental health care for child/adolescent treatment settings are also lacking. Due to the gap in this area, the development of tools for measuring the satisfaction of mental health care gain importance. They may provide insight to patients’ experiences, and help improve the quality of services. Therefore, the purpose of this study is to adapt the Experience of Service Questionnaire (ESQ) Parent form and examine its psychometric properties. With this current study, we aim to present a tool for measuring the perceived satisfaction of mental health care in Turkey and aim to contribute to the usage of this tool in child/adolescent clinical health care settings. Deriving from the literature findings outlined above, we hypothesize that; The factor strucutre of ESQ parent form will resemble its original study and reveal a two-factor structure. Satisfaction with mental health services will be significantly related to clinical outcomes; higher treatment gains will be associated with higher satisfaction levels. Satisfaction with mental health services will be lower for patients showing more severe symptoms at the start of treatment; parents of children showing comorbid symptoms will report lower satisfaction. Due to the mixed literature on sociodemographic characteristics, the direction of hypotheses is not indicated for the relationship between satisfaction with mental health services and the sociodemographic characteristics (age, gender) of the child. Method Participants The sample of this study consists of the parents who received psychotherapy services for their children at Istanbul Bilgi University Psychological Counseling Center where different types of psychotherapeutic support are provided for children/adolescents and families. Before starting treatment, families are screened to exclude patients (both children and parents) with psychosis, substance abuse, eating disorders and serious risk of harm to self or others. All parents who agreed to participate filled out a consent form informing them about the purposes of the study. In total the sample of the study consisted of 242 parents whose children underwent a psychotherapy treatment. The average age of this parent sample was 39.59 ( sd = 6.37), and 88% of the questionnaires were filled out by mothers. As for the socioeconomic level, 70% of the parents reported that their family belonged to low to middle income bracket. Parental education level showed that 37% of parents who have participated in this study were elementary, 50% were high school, and 13% were university graduates. Demographic information for children who have received treatment will also be presented since parent participants reported their satisfaction with their child’s treatment process. Children’s age range varied from 5 to 17 ( M = 8.31, sd = 2.92), with 64% being boys. Referral reasons for children were determined using the pretreatment Child Behavior Checklist (CBCL) scores. Parallel to CBCL subscales, referral reason categories included internalizing (showing clinical symptoms of anxiety, depression, somatic problems), externalizing (showing clinical symptoms of aggressiveness, rule-breaking behavior, adjustment and attention problems) and comorbid problems (showing clinical symptoms of both internalizing and externalizing symptoms). Children’s reasons for referral rates were as follows; 53% internalizing, 24% externalizing and 23% comorbid problems. In addition, families were offered different types of treatment from the university’ counseling center depending on the availability of these treatments and therapists. The types of treatment that families participated can be listed as follows: 64% child-adolescent therapy, 4% family therapy, and 32% group therapy services. Demographics for both parent participants and children who have received the therapy are presented in Table 1 . Table 1 Demographic Characteristics of the Parent Sample and Children in Treatment (N = 242) N % M (sd) Parent Age 39.59 (6.37) Parent Sex Female 213 (88) Male 29 (12) SES Low 83 (34) Middle 87 (36) High 72 (30) Education Level Elementary 89 (37) High School 121 (50) Undergraduate/Graduate 32 (13) Child Age 8.31 (2.92) Child Sex Female 87 (36) Male 155 (64) Reason of Referral Internalizing 128 (53) Externalizing 58 (24) Comorbid 56 (23) Treatment Type Received Child-Adolescent Therapy 155 (64) Family Therapy 10 (4) Group Therapy 77 (32) Instruments Sociodemographic Form Sociodemographic form was utilized to collect demographic information of families applying to university’s Psychological Counseling Center. The form includes questions about child's age, sex, referral reason, as well as the education and income level of the family and the age of the parents. Experience of Service Questionnaire (ESQ) Parent Form The original scale was first developed by Attride-Stirling ( 2002 ) to measure the psychological support service provided within the framework of the Child and Adolescent Mental Health Service (CAMHS) in England. Later the sample size was expanded by Brown et al. ( 2014 ) to examine its psychometric properties. ESQ Parent form is a 3-point Likert type scales (0 = not true , 1 = partially true , 2 = absolutely true ) consisting of 12 questions measuring the perceived satisfaction level of the patient receiving mental health services. The original study of ESQ showed that the measurement tool conveyed good reliability for Care factor ( α = .75) and acceptable reliability for Environment factor ( α = .60). In order to adapt the original scale to Turkish, two clinicians who are experts in the field of clinical psychology translated and then back translated the scale items. The final version of the translation was presented to the evaluation of four clinical psychology faculty members with different theoretical backgrounds and at least 15 years of experience. The scale took its final form as a result of the adjustments made in line with the suggestions of the evaluators. Child Behavioral Checklist The Child Behavioral Checklist (CBCL) was initially developed to include the ages from 6 through 18, however later adapted to younger ages too CBCL/1.5-5 (Achenbach, 1991 b; Achenbach & Rescorla, 2000). Items refer to emotional and behavioral problems that yield 3 subscales: ‘Internalizing Problems’ (e.g., depression or anxiety problems), ‘Externalizing Problems’ (e.g., aggression or rule-breaking behavior) and ‘Total Problems’. Caregiver rates the child on items between 0 ( not at all ), 1 ( sometimes ) and 2 ( most of the time ). Item ratings are then summed up to a raw score on subscales mentioned above. Minor adaptations of CBCL/1.5-5 occur because of the age factor. Original scale showed good internal consistency for both forms ( α = .97) and test-retest reliability (for CBCL 1.5-5 r = .90, for CBCL 6–18 r = .94) (Achenbach & Rescorla, 2000). CBCL 6–18 and 1.5-5 were adapted to Turkish (Erol et al. 1995; Erol & Şimşek, 2001). The reliability and validity of CBCL revealed adequate results: test-retest reliability coefficient of Total Problems was .94 and internal consistency coefficient was .93. Procedure Sociodemographic forms and Child Behavior Checklist (CBCL) were filled out by the parents at the start of treatment. In all treatment types, children were at the focus of the treatment process however regular parent meetings were also conducted. At the end of the treatment, CBCL was again collected from the parents to capture the symptomatic change of their children. ESQ was also presented to the parents at that time to measure their satisfaction and experience with treatment process. Data Analytic Strategy An Exploratory Factor Analysis (EFA) followed by a Confirmatory Factor Analysis (CFA) were conducted to measure the construct validity of the ESQ. While conducting factor analysis, the sample was divided into two and EFA and CFA were applied to different data sets. Cronbach's Alpha coefficient was calculated for the internal consistency analysis of the scale. As for the discriminant validity, a multivariate analysis of variance (MANOVA) was conducted between the ESQ factors and the treatment characteristics. In line with our hypotheses, treatment characteristics involved referral reason categories (internalizing problems, externalizing problems, and comorbid problems), and treatment outcome levels (significant clinical change and no significant clinical change). Treatment outcome was measured via calculating Reliable Change Index (RCI; Jacobson and Truax, 1991 ) of CBCL Total Problems scores. RCI measures the change between pretreatment and post treatment scores while accounting for the measurement error. For each patient a RCI score was calculated using the formula below: (adjusted pretreatment scores – post treatment scores) / standard error of measurement These scores reflected the clinical change for each patient. As RCI proposes, scores falling under 1.96 represent ‘no clinical change’ whereas scores that are over 1.96 represent ‘significant clinical change’ (Jacobson & Truax, 1991 ). Using these RCI scores, participants were categorized into two groups: ones with significant clinical change and others with no significant clinical change. These two categories were used as independent variables to analyze whether satisfaction with mental health services differed depending on therapeutic outcome. SPSS 21 and AMOS 26 programs were used for analysis. Results Exploratory Factor Analysis EFA was conducted using the Principal Component Analysis with direct oblimin roataion on the 12 items of the scale. The items' suitability for factor analysis was evaluated by examining their Kaiser Meyer Olkin (KMO) value and Bartlett Sphericity value. It was found that the KMO value of the items was .87 and the Bartlett Sphericity value was statistically significant ( χ2 (66) = 626.84, p < .001). Moreover, all items had communality scores above .30 and were suitable for factor analysis. As a result of EFA, a two-factor solution with an eigenvalue greater than 1 explained 65% of the variance. Similar to the psychometric properties of the original scale, the first factor which explains the 55% of the variance, was named ' Care ', The second factor, which explains 10% of the variance and was name ' Environment '. The first factor consists of 9 items in total (1, 2, 3, 4, 5, 6, 7, 11, 12) and examines the patient's experience with the therapist (e.g., ‘ It was easy to talk to the people who have seen my child’ or ' My views and worries were taken seriously '). The second factor consists of 3 items (8, 9, 10) and focuses on environmental factors of the treatment (' The facilities here are comfortable - e.g. the waiting area .' or ' It was quite easy to get to the place where the appointments are ’). The results showing the factor structure are presented in Table 1 . Table 1 Exploratory Factor Analysis for Experience of Service Questionnaire Descriptives Factor Loadings Commmunalities M sd F1 F2 Factor 1: Care; 9 items. Eigenvalue: 6.55, Variance: 54.6% 1. I feel that the people who have seen my child listened to me 1.81 .42 .83 .75 2. It was easy to talk to the people who have seen my child 1.79 .44 .81 .73 3. I was treated well by the people who have seen my child 1.84 .45 .79 .74 4. My views and worries were taken seriously 1.77 .51 .86 .79 5. I feel the people here know how to help with the problem I came for 1.57 .58 .71 .64 6. I have been given enough explanation about the help available here 1.64 .57 .81 .68 7. I feel that the people who have seen my child are working together to help with the problem(s) 1.61 .56 .72 .66 11. If a friend needed similar help, I would recommend that he or she come here 1.75 .48 .75 .62 12. Overall, the help I have received here is good 1.66 .56 .88 .77 Factor 2: Environment; 3 items. Eigenvalue: 1.26, Variance: 10.5% 8. The facilities here are comfortable (e.g. waiting area) 1.45 .60 .60 .37 9. The appointments are usually at a convenient time (e.g. don’t interfere with work, school) 1.71 .59 .69 .41 10. It is quite easy to get to the place where the appointments are. 1.46 .67 .51 .34 Confimatory Factor Analysis CFA was conducted with the robust maximum likelihood method (MLR) to examine the statistical fit of the two-factor structure obtained by EFA. In this analysis, the ratio of Chi square to the Degrees of Freedom ( χ2/df < 5), Root Mean Square Error (sRMR .90), Tucker-Lewis Index (TLI > .90) and Root Mean Square Errors of Approximation (RMSEA < .08) values were used for comparison. The first analysis showed marginally acceptable results. The model suggested adding covariances of the error values between Item 4 (' My views and worries were taken seriously' ) and Item 6 (' I have been given enough explanation about the help available here ’). When the analysis was repeated with this modification, the model achieved acceptable values. The model fit values were as follows; χ2/df : 1.78, sRMR: .066, CFI: .90, TLI: .87 and RMSEA: .080. All items loaded significantly on their factors. The path diagram showing the standardized factor loadings is presented in Fig. 1. Reliability Cronbach Alpha internal consistency coefficients of the two factors were examined to analyze the reliability level. Item-total correlations for the Care factor ranged between .617 and .818, and the internal consistency coefficient was found to be α = .92. For the Environment factor, item-total correlations ranged between .410-.470 and the internal consistency coefficient was determined as α = .65. In addition, the results of the correlation analysis between the subscales showed that the Care and Environment factors were positively and significantly related to each other ( r = .47, p < .01). Discriminant Validity The results of the MANOVA was evaluated with respect to a significance level of 0.01 derived from Bonferroni correction. Results showed that the referral reason did not have a discriminatory effect on ESQ results ( p = .087). Exploratory analyses on child’s gender ( p = .09) and age ( p = .97) also did not reveal any significance. As for treatment outcome, patients’ calculated RCI scores ( M = 2.53; sd = 2.76) show that 57% of these patients showed significant clinical change. The results of the MANOVA demonstrate that patients showing higher therapeutic gains (as measured by parent-rated CBCL Total Problems RCI), show significantly higher satisfaction in ESQ as reported by the parents (F(2,239) = 4.71; p = .01; Wilk’s Λ = .95; η2 = .05). When different ESQ factors are investigated, participants with significant clinical change showed higher scores on ESQ Care factor (F(1,242) = 8.88; p = .003; η2 = .05). The comparison between ESQ Care factor means shows that the group with significant clinical change has reported a higher levels of satisfaction ( M = 16.33, sd = 2.76) than the group who has not showed a clinical change ( M = 14.93, sd = 3.39). As for the ESQ Environment factor, the MANOVA results approach to a significance level (F(1,242) = 3.04; p = .02, η2 = .03). Again, the comparison between the means of ESQ Environment factor shows that that the group with significant clinical change has reported a higher levels of satisfaction on this factor ( M = 4.88, sd = 1.25) than the group who has not showed a clinical change ( M = 3.98, sd = 1.32). Discussion This study is the first to examine the psychometric properties of ESQ in a clinical sample in Turkey. The findings of the study convey that the instrument shows good reliability and validity results. The scale showed a two-factor structure similar to the original study of the scale. The first factor was named Care because it consisted of items involving the relationship with the therapist, and the second factor was named Environment because it consisted of items focusing on environmental conditions of the treatment setting. The internal consistency of the first factor, Care , shows a good relability score. This is not surprising since the literature is very consistent on the importance of the relationship between the therapist and the patient when experience of health services are concerned (Crow et al., 2002 ; Parasuraman et al., 1985 ). However the internal consistency of the Environment factor in the original scale was also only at an acceptable level ( α = .60). It has been argued by the authors of the original scale that the reliability is low due to the small number of items loading on this factor (Brown et al., 2014 ). Other studies should repeat this factor analysis with larger and different samples in order to further investigate the effects of environmental factors on mental health care experiences. The first-run confirmatory factor analysis results suggested modification indices to correlate the error terms between the items indicated below: Item 4: ‘ My views and worries were taken seriously ’ and Item 6: ‘ I have been given enough explanation about the help available here ’ These items were found to be conceptually similar and probably rated in a similar fashion. These modifications had a positive effect on the fit of the model. In addition, all items loaded significantly on relevant factors which could be interpreted as support for construct validity. Parallel to our hypothesis, discriminant validity results convey that satisfaction level was significantly associated with the level of therapeutic gains. The group that had made more gains showed higher satisfaction especially for Care factor. This result is in accordance with findings from previous studies that highlight the relationship between treatment outcomes and satisfaction with mental health care (Garland et al., 2000 ; Shapiro et al., 1997 ). These two variables may have a bidirectional relationship where satisfaction increasing treatment retention and improvement as well as gains in treatment increasing the satisfaction experienced in the therapy. Other studies focusing on this relationship also demonstrated that there were no significant relationship between satisfaction and treatment outcome (Lambert et al. 1998; Shapiro et al., 1997 ). On a closer look, in these studies the treatment outcome measures were gathered from the youth rather than the parent. Lambert et al. (1998) found that only parent ratings (but not the youth) were significantly related to perceived clinical improvement. Similar results were reported by Shapiro et al. ( 1997 ) study where multiple informants were included. This might be an important distinction in terms of differentiating the perspectives of both therapy gains and satisfaction levels. Different studies have outlined that the relationship between parent and children ratings of satisfaction of mental health service were only reaching a moderate level, but generally low and inconsistent (Copeland et al., 2004 ; Turchik et al., 2010 ). Some of the previous studies on this issue suggest that children's service experience satisfaction is lower than that of parents (Barber et al., 2006 ; Brown et al., 2014 ). This may be one of the causes of why parents’ satisfaction ratings were more discriminant of treatment outcome. Copeland et al. ( 2004 ) underline in their study that children’s ratings of satisfaction are more complex and that they shouldn’t be inferred from the ratings of the parents. In addition, Turhcik et al. (2011) also discuss that the difference in ratings may be due to children’s own motivation in starting treatment rather than being brought to treatment. Analyzing the differences between children and parents may also shed light on to how each group sees mental health care services. Thus further research should be focused on investigating different perspectives of families and children in mental health settings. In addition, the Environment factor in ESQ despite failing to reach the significance level, showed a trend towards becoming significant. This result may indicate that there needs to be an increase in the sample size in order to further give evidence for the effect of treatment outcome on satisfaction with Environment factor. This factor also showed relatively low internal consistency in both the original study and in our study sample due to small number of items. The factor structure not being too strong may result in a lower discriminant validity too. The result may also indicate that the Care factor, in other words the care received from the therapist may be more prominent in treatment outcome. Literature generally highlights issues regarding cooperation, compliance to treatment, treatment retention and alliance in relation to satisfaction with care (Day et al., 2011 ; Hawley & Weisz, 2005 ; Shapiro et al., 1997 ). Further research may focus on how environmental factors are related to treatment satisfaction. Contrary to what was hypothesized, the relationship between satisfaction with mental health service and referral reason was not significant in discriminant validity analyses. We predicted that comorbid pre-treatment problems would indicate severe and mixed symptoms, thus negatively affecting the satisfaction level. These comorbid problems were assumed to create difficulties in forming the therapeutic alliance and hinder the care received from the therapist. The results did not show such a relationship. There are other studies that also found no significant relationship between these two constructs. Stuntzer-Gibson et al. (1995) for instance, show no relationship between satisfaction and severity too. However studies that found a significant relationship between pretreatment symptoms and satisfaction, focus on behavioral/disruptive symptomatology or specific diagnoses rather than comorbidity (Turchik et al., 2010 ; Hasler et al., 2004 ). Conduct disorder in youth for example was found to be a reliable pretreatment symptomatology that negatively affects treatment satisfaction (Barber et al., 2006 ). Unfortunately our study did not draw distinctions between types of internalizing, externalizing and comorbid problems. For instance, the externalizing group in our study included patients other than severe behavioral disturbances (e.g., hyperactivity and attention disorder symptoms). Another limitation on this issue is that there is a screening procedure for patients who are admitted to the university’s counseling center. The exclusion criteria for the patients include psychosis, risks of harming self or other, severe conduct disorder behaviors. This exclusion criteria may have caused an elimination of patients who show the most severe behavioral/emotional disturbances before the treatment process starts. We believe that these factors may have affected the results of the relationship between referral reason and satisfaction levels in our study. Rather than grouping symptoms, future studies could focus on different diagnoses and how each of them is represented in terms of mental health care satisfaction. Also, repeating the validity of this scale in other clinical settings such as hospitals and psychiatric facilities could give more insight into how satisfaction levels of treatment with high-risk children and adolescents function. The relationship between mental health care satisfaction and other treatment characteristics has been rarely investigated (Brown et al., 2014 ; Garland et al., 2000 ). This study put forth a significant relationship between the level of therapy gains and satisfaction of mental health services. However there is still a need to explore the function of this scale with different constructs such as; treatment retention, treatment duration, therapeutic alliance, patient treatment expectations and motivation. Limitations and Directions for Future Research One important limitation of the study, and the one that is being discussed in most self-rated satisfaction measures, is that there may be a sample selection bias in measuring satisfaction in health services (Crow et al., 2002 ). The difficulty in delivering service experience questionnaires to participants who drop out of treatment (and therefore may have low satisfaction with mental health services) may lead to this selection bias (Garland et al., 2000 ). One other study again shows that patients who were non-respondents of satisfaction scales were the patients who dropped out of treatment and the ones who had fewer sessions (Stallard, 1995 ). The fact that these patients were reluctant to fill out these surveys is one important indicator that patients with a strong level of dissatisfaction with mental health services may be out of reach and therefore may be left out of these psychometric studies. Other studies focusing on this area again report and discuss ‘inflated satisfaction scores’ (Brannan et al., 1996 ; Brown et al., 2014 ). Brown et al. ( 2014 ) argue that these scores in satisfaction scales may be attributable to social desirability issues on self-reports as well as biased sampling where only the most satisfied patients report their experiences. In order to prevent this, future studies should measure service experience satisfaction not only at the end of treatment but also at different stages of treatment, which will enable a more diverse sample. In addition, patient/treatment characteristics of participants who refuse to fill out satisfaction scales should also be examined more closely in order to make a comparison. Self-reports can also be problematic in terms of exaggeration or social desirability (Eysenck, 2002 ). Especially some patients might have though that their therapists could access their answers and may have reported their satisfaction in a more positive fashion too. These may have resulted in a high level of satisfaction ratings among participants. This study also only incorporated one parent’s ratings. Considering the discrepancy between the parent and child ratings, future research can also focus on gathering reports from other members of the family (e.g., the other parent) who have been a part of the treatment process. Other family members may have different views on treatment and therefore have different satisfaction levels. This may be crucial in terms of explaining cross-informant discrepencies. Another limitation is the overall sample size. The current study was conducted with a relatively small sample size and with low diversity. Different age groups, races/ethnicities and different diagnoses should be included in prospective studies. In the current study, older ages that correspond to adolescence were not very well represented in the patient sample. The gender variability was also not very sufficient. These issues in the sample may have negatively affected the relationship between sociodemographic factors and satisfaction. Larger sample sizes with more variability would shed more light on how different age groups and different genders function in terms of reporting mental health care satisfaction. Lastly, therapist characteristics were not included in this study. Garland et al. ( 2007 ) have underlined the importance of therapist characteristics as much as treatment characteristics. The study shows therapists’ experience level being in a significant relationship with satisfaction level; however this was also outlined as the first study to investigate this relationship (Garland et al., 2007 ). More research should focus on how therapists’ orientation, demographic characteristics, expectations, interpersonal skills and how these relate to patients’ satisfaction levels. Measurement tools for the evaluation of psychological health services for children are very limited in the literature (Barber et al., 2006 ). Instruments on satisfaction and experiences about mental health services is especially scarce. In light of this current study, the psychometric properties of the ESQ scale have been shown to be at an acceptable level. There is still a need to continue testing the psychometric properties of this scale in different studies with different populations in order to examine its use in Turkey. Satisfaction with mental health care is an indicator of quality of service, however it is bounded by variables that are not directly related to the quality of the service received. Patient factors, or other factors surrounding the treatment should be investigated in order to better understand the phenomenon of health care satisfaction. This study aims to contribute to a gap that exists in the literature about evaluating health services and act as a pioneer to help the measurement of experiences in mental health services in Turkey. Declarations This study was partially supported by the Scientific and Research Council of Turkey: Project No: 121K733. The authors have no relevant conflicts of interest to disclose. Ethical approval was obtained ftom the ethics committee of Istanbul Bilgi University (No: 2021-40024-48; Dat: 6.10.2021). Informed consent was obtained from all participants included in the study. The data that support the findings is a clinical data that is confidential, therefore it is not publicly available. Author Contribution Both authors contributed to the conception and the design of the study. Material preparation, data collection and analysis were performed by Pelinsu Bulut Ozer. The first draft of the manuscript was written by Pelinsu Bulut Ozer and subsequents comments and revisions were provided by Sibel Halfon. All authors approve the final manuscript. References Achenbach TM (1991) Manual for the Child Behavior Checklist/4–18 and 1991 Profile. University of Vermont, Department of Psychiatry, Burlington, VT Anderson KH, Ford S, Robson D, Cassis J, Rodrigues C, Gray R (2010) An exploratory, randomized controlled trial of adherence therapy for people with schizophrenia. Int J Ment Health Nurs 19(5):340–349. https://doi.org/10.1111/j.1447-0349.2010.00681.x Aslantekin F, Göktaş B, Uluşen M, Erdem R (2007) Sağlık hizmetlerinde kalite deneyimi: Dr. Ekrem Hayri Üstündağ kadın hastalıkları ve doğum hastanesi örneği. Fırat Sağlık Hizmetleri Dergisi 2(6):55–71. https://www.researchgate.net/profile/BayramGoektas/publication/ 237342840_Saglik_Hizmetlerinde_Kalite_Deneyimi_Dr_Ekrem_Hayri_Ustundag_Kadin_Hastaliklari_ve_Dogum_Hastanesi_Ornegi/links/54d4b8480cf2464758063838/ Saglik-Hizmetlerinde-Kalite-Deneyimi-Dr-Ekrem-Hayri-Uestuendag-Kadin-Hastaliklari-ve-Dogum-Hastanesi-Oernegi.pdf Attride-Stirling J (2002) Development of methods to capture users’ views of CAMHS in clinical governance reviews . https://www.corc.uk.net/media/1215/chi_projectevaluationreport.pdf (Accessed November, 2023) Barber AJ, Tischler VA, Healy E (2006) Consumer satisfaction and child behaviour problems in child and adolescent mental health services. J Child Health Care 10(1):9–21. 10.1177/1367493506060200 Biering P, Jensen VH (2011) The concept of patient satisfaction in adolescent psychiatric care: a qualitative study. J child Adolesc psychiatric Nurs 24(1):3–10. https://doi.org/10.1111/j.1744-6171.2010.00261.x Blenkiron P, Hammill CA (2003) What determines patients’ satisfaction with their mental health care and quality of life? Postgrad Med J 79(932):337–340. https://doi.org/10.1136/pmj.79.932.337 Brannan AM, Sonnichsen SE, Heflinger CA (1996) Measuring satisfaction with children's mental health services: Validity and reliability of the satisfaction scales. Eval Program Plan 19(2):131–141. https://doi.org/10.1016/0149-7189(96)00004-3 Brown A, Ford T, Deighton J, Wolpert M (2014) Satisfaction in Child and Adolescent Mental Health Services: Translating Users’ Feedback into Measurement. Adm Policy Mental Health Mental Health Serv Res 41(4):434–446. https://doi.org/10.1007/s10488-012-0433-9 Copeland VC, Koeske G, Greeno CG (2004) Child and mother client satisfaction questionnaire scores regarding mental health services: Race, age, and gender correlates. Res Social Work Pract 14(6):434–442. https://doi.org/10.1177/1049731504265839 Crow H, Gage H, Hampson S, Hart J, Kimber A, Storey L, Thomas H (2002) Measurement of satisfaction with health care: Implications for practice from a systematic review of the literature. Health Technol Assess 6(32):1–244. https://uhra.herts.ac.uk/bitstream/handle/2299/1073/102382.pdf Day C, Michelson D, Hassan I (2011) Child and adolescent service experience (ChASE): Measuring service quality and therapeutic process. Br J Clin Psychol 50(4):452–464. https://doi.org/10.1111/j.2044-8260.2011.02008.x Eklund E, Hansson L (2001) Determinants of satisfaction with community-based psychiatric services: a cross-sectional study among schizophrenia outpatients. Nord J Psychiatry 55:413–418. https://doi.org/10.1080/08039480152693318 Erciş M, Seçkin M, Ayık B, Üçok A (2021) Correlates of Patient Satisfaction in Psychiatric Inpatient Care: A Survey Study from a Tertiary Hospital in Turkey. J PsychoSoc Nurs Ment Health Serv 59(4):38–47. 10.3928/02793695-20201203-04 Eysenck MW (2002) Simply Psychology. Psychology Press, Hove Garcia JA, Weisz JR (2002) When youth mental health care stops: Therapeutic relationship problems and other reasons for ending youth outpatient treatment. J Consult Clin Psychol 70:439–443. 10.1037//0022-006X.70.2.439 Garland AF, Saltzman MD, Aarons GA (2000) Adolescent satisfaction with mental health services: Development of a multidimensional scale. Evaluation and Program Planning , 23 (2), 165–175. DOI: 1522-3434/00/0900-0127$18.00/0 Garland AF, Haine RA, Boxmeyer CL (2007) Determinates of youth and parent satisfaction in usual care psychotherapy. Eval Program Plan 30(1):45–54. https://doi.org/10.1016%2Fj.evalprogplan.2006.10.003 Godley SH, Fiedler EM, Funk RR (1998) Consumer satisfaction of parents and their children with child/adolescent mental health services. Eval Program Plan 21(1):31–45. https://doi.org/10.1016/S0149-7189(97)00043-8 Hasler G, Moergeli H, Bachmann R, Lambreva E, Buddeberg C, Schnyder U (2004) Patient satisfaction with outpatient psychiatric treatment: The role of diagnosis, pharmacotherapy, and perceived therapeutic change. Can J Psychiatry 49:315–321. https://doi.org/10.1177/070674370404900507 Hawley KM, Weisz JR (2005) Youth versus parent working alliance in usual clinical care: Distinctive associations with retention, satisfaction, and treatment outcome. J Clin Child Adolesc Psychol 34(1):117–128. https://doi.org/10.1207/s15374424jccp3401_11 Jacobson NS, Truax P (1991) Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol 59:12–19. https://psycnet.apa.org/doi/10.1037/10109-042 Kahiloğulları K, Alataş A, Ertuğrul F, Malaj A (2020) Responding to mental health needs of Syrian refugees in Turkey: mhGAP training impact assessment. Int J Mental Health Syst 14:1–9. https://doi.org/10.1186/s13033-020-00416-0 Kennedy I (2010) Getting it right for children and young people: Overcoming cultural barriers in the NHS so as to meet their needs. London: Department of Health. DH_119445. (Accessed November, 2023) Nilsen J-E, Johanneseen JO (2012) User’s satisfaction in psychiatric services: A system of continuous monitoring [Conference session]. 3rd Schizophrenia International Research Society Conference , Florence, Italy Parasuraman A, Zeithaml VA, Berry LL (1985) A conceptual model of service quality and its implications for future research. J Mark 49(4):41–50. https://doi.org/10.1177/002224298504900403 Shapiro JP, Welker CJ, Jacobson BJ (1997) The youth client satisfaction questionnaire: Development, construct validation, and factor structure. J Clin Child Psychol 26(1):87–98. https://doi.org/10.1207/s15374424jccp2601_9 Stallard P (1995) Parental satisfaction with intervention: Differences between respondents and non-respondents to a postal questionnaire. Br J Clin Psychol 34(3):397–405. https://doi.org/10.1111/j.2044-8260.1995.tb01474.x Stuntzner-Gibson D, Koren PE, DeChillo N (1995) The youth satisfaction questionnaire: What kids think of services. Families in Society 76(10):616–624. https://doi.org/10.1177/104438949507601004 Turchik JA, Karpenko V, Ogles BM, Demireva P, Probst DR (2010) Parent and adolescent satisfaction with mental health services: Does it relate to youth diagnosis, age, gender, or treatment outcome? Commun Ment Health J 46:282–288. 10.1007/s10597-010-9293-5 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3859764","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":266857882,"identity":"f7850949-3cec-48b8-a532-32971cb035fd","order_by":0,"name":"Pelinsu Bulut Ozer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDUlEQVRIie2RsWrDMBCGTxjk5RKvhpQ8gzfXZMirxHTI2ilk6CBT0KQHSKF06Tt0ljhoF5PZQ6D10rmlSwcXKoFdCok1F6pvuUPcd/ySAAKBP0kktCuZbQC2GqfAbMN9ChsUO6lrjXxQ0KPAj2Kk7vd7lDyuKrrsCPK0lLP3u8MZT+4FvG0IljN9UimUEXQjCYpdKVPz8Io8bQXb7QlwujqpZE0paCLINU4hqxgRTewSHEmWPbeCsBuU21758ikNswofFNcnlYiYRymUCybXWKj2+rx+dHdhwqj9GrEeezGiD+wW8zy+MM326rBMkqf25XOzmMdqJFhff4VIV6DB85PZ8VGix4YDgUDgn/INy4tjhkAq3AkAAAAASUVORK5CYII=","orcid":"","institution":"Istanbul Bilgi University","correspondingAuthor":true,"prefix":"","firstName":"Pelinsu","middleName":"Bulut","lastName":"Ozer","suffix":""},{"id":266857883,"identity":"e1c4ac78-13f0-4292-a51b-59f96694b5b3","order_by":1,"name":"Sibel Halfon","email":"","orcid":"","institution":"Istanbul Bilgi University","correspondingAuthor":false,"prefix":"","firstName":"Sibel","middleName":"","lastName":"Halfon","suffix":""}],"badges":[],"createdAt":"2024-01-13 10:14:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3859764/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3859764/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49713756,"identity":"74e4f77f-400e-4a9d-b9df-951f81562ff4","added_by":"auto","created_at":"2024-01-16 20:43:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":224222,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eExperience of Service Quality Confimatory Factor Analysis Path Diagram\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote. \u003c/em\u003eESQ = Experience of Service Questionnaire; Env = ‘\u003cem\u003eEnvironment\u003c/em\u003e’ factor\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3859764/v1/1a38bf8e73dcbaaf4d5b31bf.png"},{"id":50907514,"identity":"2b0a949c-7298-49fd-a424-dec219f00024","added_by":"auto","created_at":"2024-02-09 11:08:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":542860,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3859764/v1/4fc9643e-0b56-4784-911a-c9a2a6111107.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Satisfaction in Mental Health Care: Examining Psychometric Properties of Experience of Service Questionnaire in a Turkish Population","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHealth services are services offered to meet health-related needs, focusing on the physical and mental well-being of the person (Aslantekin et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Experiences of health services reported by the patient are considered to be a crucial aspect of quality of care; therefore measurement of these experiences became increasingly vital in ameliorating the quality of the health services. Experience of health services may also become useful for evaluating new treatments and practices when public health policies are concerned. Another benefit of measuring experiences of health services is its reflections on treatment outcomes; such that positive experinces with health services are generally associated with more gains and more positive outcomes (Crow et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2002\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHealth services may comprise a variety of different factors including the relationship between the patient and the service provider (doctor, therapist etc.), patient's expectations, and also the readiness to provide the service (competence of the staff, environmental factors etc.). Within the framework of psychological health services, it has been determined that the relationship between the patient and the therapist is at the core of perceived service quality. The care received from the therapist is an important component of the mental health service experience (Parasuraman et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e1985\u003c/span\u003e). When patients are satisfied with the mental health service that they receive, they tend to show more compliance and cooperation within the treatment (Anderson et al., 1998) and show more treatment gains (Crow et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). One qualitative study investigated what \u0026lsquo;satisfaction with service\u0026rsquo; means to adolescent patients and showed that a good mental health service was described as a secure place where adolescent patients could freely express themselves and felt that they were treated humanely (Biering \u0026amp; Jensen, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Deriving from these descriptions, it is clear that adolescents put much focus on the therapy relationship when they evaluate their satisfaction with mental health care. In addition to care received from the therapist, other elements of the treatment were also shown to contribute positively to the perceived mental health service. These included certain aspects of the environment such as accessibility, transportation, facility, and staff (Attride-Stirling, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2002\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eMental Health Service, Patient Caharcteristics and Therapeutic Gains\u003c/h3\u003e\n\u003cp\u003eThere is a growing area of study that investigate the relationship between patient satisfaction with mental health services and therapeutic gains. Shapiro et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1997\u003c/span\u003e) in their psychometric study, measured for convergent validity through parents\u0026rsquo; reports of problem behaviors and found that satisfaction was significantly related with parents\u0026rsquo; outcome reports as well as therapists\u0026rsquo; ratings of therapeutic progress. Day et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) also showed that with children/youth aged 8\u0026ndash;18, satisfaction with treatment was significantly associated with clinical outcomes as rated by parents. In addition some studies also suggest a bidirectional relationship between patient\u0026rsquo;s experience/satisfaction and treatment outcome: as patients showed advancements in therapy, they also became more satisfied with the service they received (Kennedy, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Similarly, many of the patients who evaluated their experience negatively show this dissatisfaction during their treatment process: Stallard (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e1995\u003c/span\u003e) showed that parents\u0026rsquo; of adolescents who were more dissatisfied with therapy attended fewer sessions, dropped out of treatment, or were reluctant to fill out the survey.\u003c/p\u003e \u003cp\u003eThe literature on factors affecting the experience of the patient on mental health services are quite scarce. Crow et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2002\u003c/span\u003e) lay out two distinct factors: firstly, factors that are related to patient rather than the actual quality of the provided mental health service (e.g., patient characteristics, health status and expectations) and secondly factors that are actually related to health service delivery (e.g. staff number, qualifications, facility arrangements etc.). However when patients\u0026rsquo; satisfaction is being measured, the objective health service care delivery arrangements are rather irrelevant, and patient-related factors are more prominent in shaping their perception of satisfaction and experience (Crow et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2002\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhen factors about patients\u0026rsquo; characteristics are examined, literature conveys mixed results on sociodemographic properties such as age and sex in relation to satisfaction with the service experience (Turchik et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Copeland et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Stuntzer-Gibson et al., 1995). Turchik et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) showed that satisfaction (reported both by the parent and the child) differentiated in relation to the age of the child: ages 14\u0026ndash;16 showed less satisfaction than ages 16\u0026ndash;18. On the contrary, Stuntzer-Gibson et al. (1995) showed that younger youth were more satisfied with mental health services that they have received. Copeland et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2004\u003c/span\u003e) conducted a study with both children\u0026rsquo;s own treatment satisfaction ratings and parents\u0026rsquo; satisfaction ratings of their children\u0026rsquo;s treatment, and demonstrated that children\u0026rsquo;s ratings may depend on their age and sex. Other studies also demonstrated that adolescent males were more satisfied with mental health services than their female peers (Shapiro et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1997\u003c/span\u003e; Stuntzer-Gibsonet al. 1995). In a recent study by Barber et al (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), results conveyed no significance in the relationship between satisfaction and sociodemographic variables. Similarly Garland et al. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2007\u003c/span\u003e) did not find any significance between satisfaction and age-gender however a small significance was found between satisfaction and race: being Caucasian associated with higher satisfaction levels.\u003c/p\u003e \u003cp\u003eReasons for referral and distress levels are other factors that are researched in satisfaction of health services studies. Studies show that child/adolescent patients presenting with severe behavioral disorders report significantly lower satisfaction in mental health services than patients with other symptoms (Barber et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Garland et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; Godley et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e1998\u003c/span\u003e). Godley et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e1998\u003c/span\u003e), Garland et al. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2000\u003c/span\u003e) and Barber et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) found that youth problem severity level as reported by themselves was associated with their satisfaction level. Turchik et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) showed that adolescents with a disruptive disorder diagnosis reported lower satisfaction scores than adolescents with other diagnoses (mood disorders, depression, adjustment disorders, anxiety disorders). On the other hand, Stuntzer-Gibson et al. (1995) found that severity of referral problems showed no significant relationship with children\u0026rsquo;s experience of mental health service. As outlined above, the literature on patient characteristics is rather mixed and therefore require more research when the experience of mental health services is considered.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMeasurement of Mental Health Service Experience\u003c/h2\u003e \u003cp\u003eSelf-report methods that include patient feedback and satisfaction are the most common methods of measurement to assess perceived health service. Even though there are various scales that aim to measure the experience of received mental health care with adults, however scales that aim to measure child/adolescent mental health services are scarce (Brown et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGarland et al. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2000\u003c/span\u003e) developed the Multidimensional Adolescent Satisfaction Scale that focused on adolescents\u0026rsquo; satisfaction of mental health services. Data gathered from adolescents (ages 13\u0026ndash;18) yield a four-factor structure (clinician characteristics, meeting needs, effectiveness, conflict with the clinician). The scale showed good reliability and validity was supported with reasons for terminating treatment. Similarly, Shapiro et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1997\u003c/span\u003e) also developed The Youth Client Satisfaction Questionnaire; a tool consisting of 17 items that can be administered to adolescent samples (ages 11\u0026ndash;17). Results of this study conveyed a two-factor structure: (1) relationship with the clinician and (2) benefits of the treatment. This study also demonstrated significant relationships of convergent validity between parental satisfaction and and therapeutic gains as reported by the parents.\u003c/p\u003e \u003cp\u003eOther psychometric studies account for both parents\u0026rsquo; and children/adolescents\u0026rsquo; reports of their mental health treatment experience. Day et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) developed the Child and Adolescent Service Experience (ChASE) applied on 132 children/adolescents and their parents. Resuls indicated a three-factor structure (relationship, confidentiality and session activities). Another youth scale was developed by Stuntzner-Gibson et al. (Youth Satisfaction Questionnaire; 1995) which consisted of five global questions about mental health treatment. Evaluating 165 youth responses, scale was unidimensional and showed adequate reliability. Brannan et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e1996\u003c/span\u003e) developed the Satisfaction Scales (parent and adolescent forms) and found a four-factor structure for both versions: (1) access and convenience, (2) child\u0026rsquo;s treatment process and relationship with the therapist, (3) parent and family services, (4) global satisfaction. In all of these psychometric studies, relationship with the clinician seems to be a common factor for the experience of mental health services.\u003c/p\u003e \u003cp\u003eExperience of Service Questionnaire (ESQ; Attride-Stirling, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; Brown et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) also aims to measure the service satisfaction of children/young people and their families. ESQ includes self-report forms for both parents and children (two separate forms for ages 9\u0026ndash;11 and 11\u0026ndash;18). The two separate child forms aim to take into account the developmental level of the child. All forms are parallel to each other, the questions are asked in the same order, with only minor adjustments to suit the age of the child. In the psychometric study of ESQ, a two-factor solution was found. The first factor was named '\u003cem\u003eCare\u003c/em\u003e'; this factor consisted of items focusing on the relationship between the patient and the therapist. The second factor, '\u003cem\u003eEnvironment\u003c/em\u003e', consisted of items related to the environmental factors of treatment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eAims of the Current Study\u003c/h2\u003e \u003cp\u003eThe literature on mental health care satisfaction is very limited. One of the two studies in Turkey on mental health care services was conducted by Erciş et al. (2020) where they focused on adult psychiatric patients\u0026rsquo; experiences upon their discharge. In this study, User\u0026rsquo;s Satisfaction in Psychiatric Services Questionnaire by Nilsen and Johanneseen (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) was translated into Turkish and was administered to the psychiatric patients upon discharge. Main results showed that satisfaction levels were associated with the duration of time spent with the patient, and staff unavailability was correlated with dissatisfaction. This result may also point to the importance of clinician-patient relationship and the care received. In another interview-based qualitative study that was conducted by World Health Organization and Ministry of Health on Syrian refugees receiving mental health care and psychosocial support, the results showed that the satisfaction level and \u0026lsquo;having needs met\u0026rsquo; were high among participants (Kahiloğulları et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo our knowledge, there were no other studies that focused on measuring experiences with mental health services in Turkey. In addition, the measurement tools to investigate satisfaction with mental health care for child/adolescent treatment settings are also lacking. Due to the gap in this area, the development of tools for measuring the satisfaction of mental health care gain importance. They may provide insight to patients\u0026rsquo; experiences, and help improve the quality of services. Therefore, the purpose of this study is to adapt the Experience of Service Questionnaire (ESQ) Parent form and examine its psychometric properties. With this current study, we aim to present a tool for measuring the perceived satisfaction of mental health care in Turkey and aim to contribute to the usage of this tool in child/adolescent clinical health care settings.\u003c/p\u003e \u003cp\u003eDeriving from the literature findings outlined above, we hypothesize that;\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe factor strucutre of ESQ parent form will resemble its original study and reveal a two-factor structure.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSatisfaction with mental health services will be significantly related to clinical outcomes; higher treatment gains will be associated with higher satisfaction levels.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSatisfaction with mental health services will be lower for patients showing more severe symptoms at the start of treatment; parents of children showing comorbid symptoms will report lower satisfaction.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eDue to the mixed literature on sociodemographic characteristics, the direction of hypotheses is not indicated for the relationship between satisfaction with mental health services and the sociodemographic characteristics (age, gender) of the child.\u003c/p\u003e \u003c/div\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe sample of this study consists of the parents who received psychotherapy services for their children at Istanbul Bilgi University Psychological Counseling Center where different types of psychotherapeutic support are provided for children/adolescents and families. Before starting treatment, families are screened to exclude patients (both children and parents) with psychosis, substance abuse, eating disorders and serious risk of harm to self or others.\u003c/p\u003e \u003cp\u003e All parents who agreed to participate filled out a consent form informing them about the purposes of the study. In total the sample of the study consisted of 242 parents whose children underwent a psychotherapy treatment. The average age of this parent sample was 39.59 (\u003cem\u003esd\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6.37), and 88% of the questionnaires were filled out by mothers. As for the socioeconomic level, 70% of the parents reported that their family belonged to low to middle income bracket. Parental education level showed that 37% of parents who have participated in this study were elementary, 50% were high school, and 13% were university graduates.\u003c/p\u003e \u003cp\u003eDemographic information for children who have received treatment will also be presented since parent participants reported their satisfaction with their child\u0026rsquo;s treatment process. Children\u0026rsquo;s age range varied from 5 to 17 (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8.31, \u003cem\u003esd\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.92), with 64% being boys. Referral reasons for children were determined using the pretreatment Child Behavior Checklist (CBCL) scores. Parallel to CBCL subscales, referral reason categories included \u003cem\u003einternalizing\u003c/em\u003e (showing clinical symptoms of anxiety, depression, somatic problems), \u003cem\u003eexternalizing\u003c/em\u003e (showing clinical symptoms of aggressiveness, rule-breaking behavior, adjustment and attention problems) and \u003cem\u003ecomorbid\u003c/em\u003e problems (showing clinical symptoms of both internalizing and externalizing symptoms). Children\u0026rsquo;s reasons for referral rates were as follows; 53% internalizing, 24% externalizing and 23% comorbid problems. In addition, families were offered different types of treatment from the university\u0026rsquo; counseling center depending on the availability of these treatments and therapists. The types of treatment that families participated can be listed as follows: 64% child-adolescent therapy, 4% family therapy, and 32% group therapy services.\u003c/p\u003e \u003cp\u003eDemographics for both parent participants and children who have received the therapy are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDemographic Characteristics of the Parent Sample and Children in Treatment (N\u0026thinsp;=\u0026thinsp;242)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eN %\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eM (sd)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParent Age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.59 (6.37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParent Sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e213 (88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83 (34)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 (30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89 (37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e121 (50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergraduate/Graduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild Age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.31 (2.92)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild Sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e155 (64)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReason of Referral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternalizing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e128 (53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExternalizing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment Type Received\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild-Adolescent Therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e155 (64)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily Therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup Therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77 (32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eInstruments\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eSociodemographic Form\u003c/h2\u003e \u003cp\u003eSociodemographic form was utilized to collect demographic information of families applying to university\u0026rsquo;s Psychological Counseling Center. The form includes questions about child's age, sex, referral reason, as well as the education and income level of the family and the age of the parents.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eExperience of Service Questionnaire (ESQ) Parent Form\u003c/h2\u003e \u003cp\u003eThe original scale was first developed by Attride-Stirling (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2002\u003c/span\u003e) to measure the psychological support service provided within the framework of the Child and Adolescent Mental Health Service (CAMHS) in England. Later the sample size was expanded by Brown et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) to examine its psychometric properties. ESQ Parent form is a 3-point Likert type scales (0\u0026thinsp;=\u0026thinsp;\u003cem\u003enot true\u003c/em\u003e, 1\u0026thinsp;=\u0026thinsp;\u003cem\u003epartially true\u003c/em\u003e, 2\u0026thinsp;=\u0026thinsp;\u003cem\u003eabsolutely true\u003c/em\u003e) consisting of 12 questions measuring the perceived satisfaction level of the patient receiving mental health services. The original study of ESQ showed that the measurement tool conveyed good reliability for \u003cem\u003eCare\u003c/em\u003e factor (\u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.75) and acceptable reliability for \u003cem\u003eEnvironment\u003c/em\u003e factor (\u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.60).\u003c/p\u003e \u003cp\u003eIn order to adapt the original scale to Turkish, two clinicians who are experts in the field of clinical psychology translated and then back translated the scale items. The final version of the translation was presented to the evaluation of four clinical psychology faculty members with different theoretical backgrounds and at least 15 years of experience. The scale took its final form as a result of the adjustments made in line with the suggestions of the evaluators.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eChild Behavioral Checklist\u003c/h2\u003e \u003cp\u003eThe Child Behavioral Checklist (CBCL) was initially developed to include the ages from 6 through 18, however later adapted to younger ages too CBCL/1.5-5 (Achenbach, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1991\u003c/span\u003eb; Achenbach \u0026amp; Rescorla, 2000). Items refer to emotional and behavioral problems that yield 3 subscales: \u0026lsquo;Internalizing Problems\u0026rsquo; (e.g., depression or anxiety problems), \u0026lsquo;Externalizing Problems\u0026rsquo; (e.g., aggression or rule-breaking behavior) and \u0026lsquo;Total Problems\u0026rsquo;. Caregiver rates the child on items between 0 (\u003cem\u003enot at all\u003c/em\u003e), 1 (\u003cem\u003esometimes\u003c/em\u003e) and 2 (\u003cem\u003emost of the time\u003c/em\u003e). Item ratings are then summed up to a raw score on subscales mentioned above. Minor adaptations of CBCL/1.5-5 occur because of the age factor. Original scale showed good internal consistency for both forms (\u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.97) and test-retest reliability (for CBCL 1.5-5 \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.90, for CBCL 6\u0026ndash;18 \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.94) (Achenbach \u0026amp; Rescorla, 2000).\u003c/p\u003e \u003cp\u003eCBCL 6\u0026ndash;18 and 1.5-5 were adapted to Turkish (Erol et al. 1995; Erol \u0026amp; Şimşek, 2001). The reliability and validity of CBCL revealed adequate results: test-retest reliability coefficient of Total Problems was .94 and internal consistency coefficient was .93.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003e Sociodemographic forms and Child Behavior Checklist (CBCL) were filled out by the parents at the start of treatment. In all treatment types, children were at the focus of the treatment process however regular parent meetings were also conducted. At the end of the treatment, CBCL was again collected from the parents to capture the symptomatic change of their children. ESQ was also presented to the parents at that time to measure their satisfaction and experience with treatment process.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData Analytic Strategy\u003c/h2\u003e \u003cp\u003eAn Exploratory Factor Analysis (EFA) followed by a Confirmatory Factor Analysis (CFA) were conducted to measure the construct validity of the ESQ. While conducting factor analysis, the sample was divided into two and EFA and CFA were applied to different data sets. Cronbach's Alpha coefficient was calculated for the internal consistency analysis of the scale. As for the discriminant validity, a multivariate analysis of variance (MANOVA) was conducted between the ESQ factors and the treatment characteristics. In line with our hypotheses, treatment characteristics involved referral reason categories (internalizing problems, externalizing problems, and comorbid problems), and treatment outcome levels (significant clinical change and no significant clinical change).\u003c/p\u003e \u003cp\u003eTreatment outcome was measured via calculating Reliable Change Index (RCI; Jacobson and Truax, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e1991\u003c/span\u003e) of CBCL Total Problems scores. RCI measures the change between pretreatment and post treatment scores while accounting for the measurement error. For each patient a RCI score was calculated using the formula below:\u003c/p\u003e \u003c/div\u003e \u003cp\u003e(adjusted pretreatment scores \u0026ndash; post treatment scores) / standard error of measurement\u003c/p\u003e \u003cp\u003eThese scores reflected the clinical change for each patient. As RCI proposes, scores falling under 1.96 represent \u0026lsquo;no clinical change\u0026rsquo; whereas scores that are over 1.96 represent \u0026lsquo;significant clinical change\u0026rsquo; (Jacobson \u0026amp; Truax, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e1991\u003c/span\u003e). Using these RCI scores, participants were categorized into two groups: ones with significant clinical change and others with no significant clinical change. These two categories were used as independent variables to analyze whether satisfaction with mental health services differed depending on therapeutic outcome. SPSS 21 and AMOS 26 programs were used for analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eExploratory Factor Analysis\u003c/h2\u003e \u003cp\u003eEFA was conducted using the Principal Component Analysis with direct oblimin roataion on the 12 items of the scale. The items' suitability for factor analysis was evaluated by examining their Kaiser Meyer Olkin (KMO) value and Bartlett Sphericity value. It was found that the KMO value of the items was .87 and the Bartlett Sphericity value was statistically significant (\u003cem\u003eχ2\u003c/em\u003e (66)\u0026thinsp;=\u0026thinsp;626.84, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Moreover, all items had communality scores above .30 and were suitable for factor analysis.\u003c/p\u003e \u003cp\u003eAs a result of EFA, a two-factor solution with an eigenvalue greater than 1 explained 65% of the variance. Similar to the psychometric properties of the original scale, the first factor which explains the 55% of the variance, was named '\u003cem\u003eCare\u003c/em\u003e', The second factor, which explains 10% of the variance and was name '\u003cem\u003eEnvironment\u003c/em\u003e'. The first factor consists of 9 items in total (1, 2, 3, 4, 5, 6, 7, 11, 12) and examines the patient's experience with the therapist (e.g., \u0026lsquo;\u003cem\u003eIt was easy to talk to the people who have seen my child\u0026rsquo;\u003c/em\u003e or '\u003cem\u003eMy views and worries were taken seriously\u003c/em\u003e'). The second factor consists of 3 items (8, 9, 10) and focuses on environmental factors of the treatment ('\u003cem\u003eThe facilities here are comfortable - e.g. the waiting area\u003c/em\u003e.' or '\u003cem\u003eIt was quite easy to get to the place where the appointments are\u003c/em\u003e\u0026rsquo;). The results showing the factor structure are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eExploratory Factor Analysis for Experience of Service Questionnaire\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eDescriptives\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eFactor Loadings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCommmunalities\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003esd\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFactor 1: Care; 9\u003c/em\u003e items. Eigenvalue: 6.55, Variance: 54.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. I feel that the people who have seen my child listened to me\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.83\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. It was easy to talk to the people who have seen my child\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.81\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. I was treated well by the people who have seen my child\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.79\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. My views and worries were taken seriously\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.86\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. I feel the people here know how to help with the problem I came for\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.71\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. I have been given enough explanation about the help available here\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.81\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. I feel that the people who have seen my child are working together to help with the problem(s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.72\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. If a friend needed similar help, I would recommend that he or she come here\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.75\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. Overall, the help I have received here is good\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.88\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFactor 2: Environment;\u003c/em\u003e 3 items. Eigenvalue: 1.26, Variance: 10.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. The facilities here are comfortable (e.g. waiting area)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.60\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. The appointments are usually at a convenient time (e.g. don\u0026rsquo;t interfere with work, school)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.69\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. It is quite easy to get to the place where the appointments are.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.51\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eConfimatory Factor Analysis\u003c/h2\u003e \u003cp\u003eCFA was conducted with the robust maximum likelihood method (MLR) to examine the statistical fit of the two-factor structure obtained by EFA. In this analysis, the ratio of Chi square to the Degrees of Freedom (\u003cem\u003eχ2/df\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;5), Root Mean Square Error (sRMR\u0026thinsp;\u0026lt;\u0026thinsp;.08), Comparative Fit Index (CFI\u0026thinsp;\u0026gt;\u0026thinsp;.90), Tucker-Lewis Index (TLI\u0026thinsp;\u0026gt;\u0026thinsp;.90) and Root Mean Square Errors of Approximation (RMSEA\u0026thinsp;\u0026lt;\u0026thinsp;.08) values were used for comparison. The first analysis showed marginally acceptable results.\u003c/p\u003e \u003cp\u003eThe model suggested adding covariances of the error values between Item 4 ('\u003cem\u003eMy views and worries were taken seriously'\u003c/em\u003e) and Item 6 ('\u003cem\u003eI have been given enough explanation about the help available here\u003c/em\u003e\u0026rsquo;). When the analysis was repeated with this modification, the model achieved acceptable values. The model fit values were as follows; \u003cem\u003eχ2/df\u003c/em\u003e: 1.78, sRMR: .066, CFI: .90, TLI: .87 and RMSEA: .080. All items loaded significantly on their factors. The path diagram showing the standardized factor loadings is presented in Fig.\u0026nbsp;1.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eReliability\u003c/h2\u003e \u003cp\u003eCronbach Alpha internal consistency coefficients of the two factors were examined to analyze the reliability level. Item-total correlations for the \u003cem\u003eCare\u003c/em\u003e factor ranged between .617 and .818, and the internal consistency coefficient was found to be \u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.92. For the \u003cem\u003eEnvironment\u003c/em\u003e factor, item-total correlations ranged between .410-.470 and the internal consistency coefficient was determined as \u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.65.\u003c/p\u003e \u003cp\u003eIn addition, the results of the correlation analysis between the subscales showed that the \u003cem\u003eCare\u003c/em\u003e and \u003cem\u003eEnvironment\u003c/em\u003e factors were positively and significantly related to each other (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.47, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eDiscriminant Validity\u003c/h2\u003e \u003cp\u003eThe results of the MANOVA was evaluated with respect to a significance level of 0.01 derived from Bonferroni correction. Results showed that the referral reason did not have a discriminatory effect on ESQ results (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.087). Exploratory analyses on child\u0026rsquo;s gender (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.09) and age (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.97) also did not reveal any significance.\u003c/p\u003e \u003cp\u003eAs for treatment outcome, patients\u0026rsquo; calculated RCI scores (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.53; \u003cem\u003esd\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.76) show that 57% of these patients showed significant clinical change. The results of the MANOVA demonstrate that patients showing higher therapeutic gains (as measured by parent-rated CBCL Total Problems RCI), show significantly higher satisfaction in ESQ as reported by the parents (F(2,239)\u0026thinsp;=\u0026thinsp;4.71; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.01; Wilk\u0026rsquo;s \u003cem\u003eΛ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.95; \u003cem\u003eη2\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.05). When different ESQ factors are investigated, participants with significant clinical change showed higher scores on ESQ \u003cem\u003eCare\u003c/em\u003e factor (F(1,242)\u0026thinsp;=\u0026thinsp;8.88; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.003; \u003cem\u003eη2\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.05). The comparison between ESQ \u003cem\u003eCare\u003c/em\u003e factor means shows that the group with significant clinical change has reported a higher levels of satisfaction (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16.33, \u003cem\u003esd\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.76) than the group who has not showed a clinical change (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14.93, \u003cem\u003esd\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.39). As for the ESQ \u003cem\u003eEnvironment\u003c/em\u003e factor, the MANOVA results approach to a significance level (F(1,242)\u0026thinsp;=\u0026thinsp;3.04; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.02, \u003cem\u003eη2\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.03). Again, the comparison between the means of ESQ \u003cem\u003eEnvironment\u003c/em\u003e factor shows that that the group with significant clinical change has reported a higher levels of satisfaction on this factor (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.88, \u003cem\u003esd\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.25) than the group who has not showed a clinical change (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.98, \u003cem\u003esd\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.32).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is the first to examine the psychometric properties of ESQ in a clinical sample in Turkey. The findings of the study convey that the instrument shows good reliability and validity results. The scale showed a two-factor structure similar to the original study of the scale. The first factor was named \u003cem\u003eCare\u003c/em\u003e because it consisted of items involving the relationship with the therapist, and the second factor was named \u003cem\u003eEnvironment\u003c/em\u003e because it consisted of items focusing on environmental conditions of the treatment setting.\u003c/p\u003e \u003cp\u003eThe internal consistency of the first factor, \u003cem\u003eCare\u003c/em\u003e, shows a good relability score. This is not surprising since the literature is very consistent on the importance of the relationship between the therapist and the patient when experience of health services are concerned (Crow et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; Parasuraman et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e1985\u003c/span\u003e). However the internal consistency of the \u003cem\u003eEnvironment\u003c/em\u003e factor in the original scale was also only at an acceptable level (\u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.60). It has been argued by the authors of the original scale that the reliability is low due to the small number of items loading on this factor (Brown et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Other studies should repeat this factor analysis with larger and different samples in order to further investigate the effects of environmental factors on mental health care experiences.\u003c/p\u003e \u003cp\u003eThe first-run confirmatory factor analysis results suggested modification indices to correlate the error terms between the items indicated below:\u003c/p\u003e \u003cp\u003eItem 4: \u0026lsquo;\u003cem\u003eMy views and worries were taken seriously\u003c/em\u003e\u0026rsquo; and\u003c/p\u003e \u003cp\u003eItem 6: \u0026lsquo;\u003cem\u003eI have been given enough explanation about the help available here\u003c/em\u003e\u0026rsquo;\u003c/p\u003e \u003cp\u003eThese items were found to be conceptually similar and probably rated in a similar fashion. These modifications had a positive effect on the fit of the model. In addition, all items loaded significantly on relevant factors which could be interpreted as support for construct validity.\u003c/p\u003e \u003cp\u003eParallel to our hypothesis, discriminant validity results convey that satisfaction level was significantly associated with the level of therapeutic gains. The group that had made more gains showed higher satisfaction especially for \u003cem\u003eCare\u003c/em\u003e factor. This result is in accordance with findings from previous studies that highlight the relationship between treatment outcomes and satisfaction with mental health care (Garland et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; Shapiro et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1997\u003c/span\u003e). These two variables may have a bidirectional relationship where satisfaction increasing treatment retention and improvement as well as gains in treatment increasing the satisfaction experienced in the therapy. Other studies focusing on this relationship also demonstrated that there were no significant relationship between satisfaction and treatment outcome (Lambert et al. 1998; Shapiro et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1997\u003c/span\u003e). On a closer look, in these studies the treatment outcome measures were gathered from the youth rather than the parent. Lambert et al. (1998) found that only parent ratings (but not the youth) were significantly related to perceived clinical improvement. Similar results were reported by Shapiro et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1997\u003c/span\u003e) study where multiple informants were included. This might be an important distinction in terms of differentiating the perspectives of both therapy gains and satisfaction levels. Different studies have outlined that the relationship between parent and children ratings of satisfaction of mental health service were only reaching a moderate level, but generally low and inconsistent (Copeland et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Turchik et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Some of the previous studies on this issue suggest that children's service experience satisfaction is lower than that of parents (Barber et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Brown et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). This may be one of the causes of why parents\u0026rsquo; satisfaction ratings were more discriminant of treatment outcome. Copeland et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2004\u003c/span\u003e) underline in their study that children\u0026rsquo;s ratings of satisfaction are more complex and that they shouldn\u0026rsquo;t be inferred from the ratings of the parents. In addition, Turhcik et al. (2011) also discuss that the difference in ratings may be due to children\u0026rsquo;s own motivation in starting treatment rather than being brought to treatment. Analyzing the differences between children and parents may also shed light on to how each group sees mental health care services. Thus further research should be focused on investigating different perspectives of families and children in mental health settings.\u003c/p\u003e \u003cp\u003eIn addition, the \u003cem\u003eEnvironment\u003c/em\u003e factor in ESQ despite failing to reach the significance level, showed a trend towards becoming significant. This result may indicate that there needs to be an increase in the sample size in order to further give evidence for the effect of treatment outcome on satisfaction with \u003cem\u003eEnvironment\u003c/em\u003e factor. This factor also showed relatively low internal consistency in both the original study and in our study sample due to small number of items. The factor structure not being too strong may result in a lower discriminant validity too. The result may also indicate that the \u003cem\u003eCare\u003c/em\u003e factor, in other words the care received from the therapist may be more prominent in treatment outcome. Literature generally highlights issues regarding cooperation, compliance to treatment, treatment retention and alliance in relation to satisfaction with care (Day et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Hawley \u0026amp; Weisz, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Shapiro et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1997\u003c/span\u003e). Further research may focus on how environmental factors are related to treatment satisfaction.\u003c/p\u003e \u003cp\u003eContrary to what was hypothesized, the relationship between satisfaction with mental health service and referral reason was not significant in discriminant validity analyses. We predicted that comorbid pre-treatment problems would indicate severe and mixed symptoms, thus negatively affecting the satisfaction level. These comorbid problems were assumed to create difficulties in forming the therapeutic alliance and hinder the care received from the therapist. The results did not show such a relationship. There are other studies that also found no significant relationship between these two constructs. Stuntzer-Gibson et al. (1995) for instance, show no relationship between satisfaction and severity too. However studies that found a significant relationship between pretreatment symptoms and satisfaction, focus on behavioral/disruptive symptomatology or specific diagnoses rather than comorbidity (Turchik et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Hasler et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Conduct disorder in youth for example was found to be a reliable pretreatment symptomatology that negatively affects treatment satisfaction (Barber et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Unfortunately our study did not draw distinctions between types of internalizing, externalizing and comorbid problems. For instance, the externalizing group in our study included patients other than severe behavioral disturbances (e.g., hyperactivity and attention disorder symptoms). Another limitation on this issue is that there is a screening procedure for patients who are admitted to the university\u0026rsquo;s counseling center. The exclusion criteria for the patients include psychosis, risks of harming self or other, severe conduct disorder behaviors. This exclusion criteria may have caused an elimination of patients who show the most severe behavioral/emotional disturbances before the treatment process starts. We believe that these factors may have affected the results of the relationship between referral reason and satisfaction levels in our study. Rather than grouping symptoms, future studies could focus on different diagnoses and how each of them is represented in terms of mental health care satisfaction. Also, repeating the validity of this scale in other clinical settings such as hospitals and psychiatric facilities could give more insight into how satisfaction levels of treatment with high-risk children and adolescents function.\u003c/p\u003e \u003cp\u003eThe relationship between mental health care satisfaction and other treatment characteristics has been rarely investigated (Brown et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Garland et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). This study put forth a significant relationship between the level of therapy gains and satisfaction of mental health services. However there is still a need to explore the function of this scale with different constructs such as; treatment retention, treatment duration, therapeutic alliance, patient treatment expectations and motivation.\u003c/p\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Directions for Future Research\u003c/h2\u003e \u003cp\u003eOne important limitation of the study, and the one that is being discussed in most self-rated satisfaction measures, is that there may be a sample selection bias in measuring satisfaction in health services (Crow et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). The difficulty in delivering service experience questionnaires to participants who drop out of treatment (and therefore may have low satisfaction with mental health services) may lead to this selection bias (Garland et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). One other study again shows that patients who were non-respondents of satisfaction scales were the patients who dropped out of treatment and the ones who had fewer sessions (Stallard, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e1995\u003c/span\u003e). The fact that these patients were reluctant to fill out these surveys is one important indicator that patients with a strong level of dissatisfaction with mental health services may be out of reach and therefore may be left out of these psychometric studies. Other studies focusing on this area again report and discuss \u0026lsquo;inflated satisfaction scores\u0026rsquo; (Brannan et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e1996\u003c/span\u003e; Brown et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Brown et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) argue that these scores in satisfaction scales may be attributable to social desirability issues on self-reports as well as biased sampling where only the most satisfied patients report their experiences. In order to prevent this, future studies should measure service experience satisfaction not only at the end of treatment but also at different stages of treatment, which will enable a more diverse sample. In addition, patient/treatment characteristics of participants who refuse to fill out satisfaction scales should also be examined more closely in order to make a comparison. Self-reports can also be problematic in terms of exaggeration or social desirability (Eysenck, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). Especially some patients might have though that their therapists could access their answers and may have reported their satisfaction in a more positive fashion too. These may have resulted in a high level of satisfaction ratings among participants.\u003c/p\u003e \u003cp\u003eThis study also only incorporated one parent\u0026rsquo;s ratings. Considering the discrepancy between the parent and child ratings, future research can also focus on gathering reports from other members of the family (e.g., the other parent) who have been a part of the treatment process. Other family members may have different views on treatment and therefore have different satisfaction levels. This may be crucial in terms of explaining cross-informant discrepencies.\u003c/p\u003e \u003cp\u003eAnother limitation is the overall sample size. The current study was conducted with a relatively small sample size and with low diversity. Different age groups, races/ethnicities and different diagnoses should be included in prospective studies. In the current study, older ages that correspond to adolescence were not very well represented in the patient sample. The gender variability was also not very sufficient. These issues in the sample may have negatively affected the relationship between sociodemographic factors and satisfaction. Larger sample sizes with more variability would shed more light on how different age groups and different genders function in terms of reporting mental health care satisfaction.\u003c/p\u003e \u003cp\u003eLastly, therapist characteristics were not included in this study. Garland et al. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2007\u003c/span\u003e) have underlined the importance of therapist characteristics as much as treatment characteristics. The study shows therapists\u0026rsquo; experience level being in a significant relationship with satisfaction level; however this was also outlined as the first study to investigate this relationship (Garland et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). More research should focus on how therapists\u0026rsquo; orientation, demographic characteristics, expectations, interpersonal skills and how these relate to patients\u0026rsquo; satisfaction levels.\u003c/p\u003e \u003cp\u003eMeasurement tools for the evaluation of psychological health services for children are very limited in the literature (Barber et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Instruments on satisfaction and experiences about mental health services is especially scarce. In light of this current study, the psychometric properties of the ESQ scale have been shown to be at an acceptable level. There is still a need to continue testing the psychometric properties of this scale in different studies with different populations in order to examine its use in Turkey. Satisfaction with mental health care is an indicator of quality of service, however it is bounded by variables that are not directly related to the quality of the service received. Patient factors, or other factors surrounding the treatment should be investigated in order to better understand the phenomenon of health care satisfaction. This study aims to contribute to a gap that exists in the literature about evaluating health services and act as a pioneer to help the measurement of experiences in mental health services in Turkey.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eThis study was partially supported by the Scientific and Research Council of Turkey: Project No: 121K733. The authors have no relevant conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained ftom the ethics committee of Istanbul Bilgi University (No: 2021-40024-48; Dat: 6.10.2021). Informed consent was obtained from all participants included in the study. The data that support the findings is a clinical data that is confidential, therefore it is not publicly available.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eBoth authors contributed to the conception and the design of the study. Material preparation, data collection and analysis were performed by Pelinsu Bulut Ozer. The first draft of the manuscript was written by Pelinsu Bulut Ozer and subsequents comments and revisions were provided by Sibel Halfon. All authors approve the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAchenbach TM (1991) Manual for the Child Behavior Checklist/4\u0026ndash;18 and 1991 Profile. 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Commun Ment Health J 46:282\u0026ndash;288. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10597-010-9293-5\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Patient satisfaction, Treatment outcome, Child Psychotherapy, Measurement of health care experience","lastPublishedDoi":"10.21203/rs.3.rs-3859764/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3859764/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective: Measuring satisfcation with psychological health services is important in clinical settings in order to evaluate the benefits of treatment. Past research has shown that relationship with clinician is at the core of satisfaction reports. However, measurement tools focusing on patients’ psyhcological health care experiences are rather scarce. The objective of this study is to adapt the Experience of Service Questionnaire (ESQ) Parent form and examine its psychometric properties in a Turkish population.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethod: ESQ Parent form was translated into Turkish and was presented to parents (N = 242) of children who have completed their treatment in a university’s psychological counseling center. Child Behavior Checklist (CBCL) was also gathered from parents pre- and post-treatment in order to measure symptomatic gains and investigate their associations with satisfaction with treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults: Factor analysis revealed a two-factor solution (‘Care’ and ‘Environment’) similar to questionnaire’s original structure. In addition, discriminant validity results showed that participants showing higher therapeutic gains (as measured by CBCL) show significantly higher satisfaction in ESQ.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConclusions: This study is the first to measure satisfaction in psychological health care settings in Turkey, and therefore aims to contribute to a gap in the field. Results indicate a significant association between treatment outcome and satisfaction levels. Also, adapted measurement tool demonstrates adquate reliability and validity scores supporting it’s use in clinical settings.\u003c/p\u003e","manuscriptTitle":"Satisfaction in Mental Health Care: Examining Psychometric Properties of Experience of Service Questionnaire in a Turkish Population","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-16 20:43:25","doi":"10.21203/rs.3.rs-3859764/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ac489184-8ceb-4282-8199-45ef3fe7d411","owner":[],"postedDate":"January 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-09T11:00:01+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-16 20:43:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3859764","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3859764","identity":"rs-3859764","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}