TY - JOUR
AU1 - Cui,, Jialiang
AU2 - Mao,, Limin
AU3 - Rose,, Grenville
AU4 - Newman, Christy, E
AB - Abstract This study explored how social workers located in Sydney and Hong Kong conceptualised client empowerment. Further, it investigated these professionals’ perceived facilitators and barriers to their empowerment practices, based on an ecological framework. A cross-sectional online survey was used, where the original Empowerment Scale for clients with mental health issues was adapted to measure conceptualisation of client empowerment from social workers’ perspectives. Eighty-three social workers serving people with mental health issues (MHIs) in Sydney and eighty in Hong Kong responded. A two-factor model was generated suggesting that practitioners tend to conceptualise client empowerment into two aspects: a relation-based dimension and a resource-oriented one. Compared with their Sydney counterparts, the Hong Kong practitioners considered resource-oriented empowerment as more integral to client empowerment (t(161) = 4.17, p < 0.001). Several key factors were found to be independently associated with endorsement of the two-factor client-empowerment model by practitioners: perceived less support from medical specialists but more support from teams serving the same client, perceived benefits of social work training and, finally, beliefs in the importance of social workers’ role in client empowerment. The study highlights the multiple dimensions of client empowerment and a wide range of inter-professional and sociostructural factors enabling social workers’ practices that support empowerment. Our paper highlights the role of professional empowerment as a stepping stone to enable their client-empowerment practices through policy support and inter-professional collaboration. Client empowerment, mental health service delivery, social work Introduction Over recent decades, client empowerment has been increasingly considered a guiding principle for service design and implementation in the field of social work as well as that of mental health. Worldwide, not only is empowerment deeply ingrained as one of the fundamental social service values (Baistow, 1994); it has also been recognised as one of the major elements of mental health recovery (Leamy et al., 2011). And yet, despite it being one of the cornerstones in social service planning and delivery, empowerment remains an ill-defined concept in the literature, which has implications for social work practitioners in the field. The definition of empowerment varies considerably in the literature (Handler, 1996; Warner, 2000; Barnes and Bowl, 2001; Cattaneo and Chapman, 2010; Rivest and Moreau, 2015). One stream of conceptualisation tends to focus on it being a complex process with the aim of improving target individual clients’ self-determination, volitional control and capabilities to achieve self-defined desirable outcomes (Chamberlin and Schene, 1997; Dickerson, 1998; Zimmerman and Warschausky, 1998). Another influential stream of conceptualisation goes beyond individual-level processes and outcomes to encompass structural-level interventions that support clients to access new resources and opportunities by increasing upward social mobility (Nelson et al., 2001). Because of its lack of a standard definition, client empowerment with its current various conceptual approaches does, however, provide a rare opportunity to understand the unique interpretations and imagined implementations of this core principle of mental health practice, especially for front line service practitioners (Adams, 2008). There are a limited number of empirical studies, for example, documenting how social work practitioners have engaged with client-empowerment practices in providing mental health services. Predominantly, attention has been paid to enabling client behavioural changes at the individual level: self-determination (Ackerson and Harrison, 2000), identifying personal strengths (Fisher and Gosselink, 2008; Cohen, 2009; Song, 2011) and improving self-efficacy (Salzer, 1997; Linhorst et al., 2002). Practising client empowerment at the structural level, which ‘offers the best opportunities to enhance mental health’ (Nelson et al., 2001, p. 137), however, is largely absent from the empirical studies. To fill in this gap, this study aims to explore how individual- and structural-level client-empowerment approaches were interpreted and practised by front line social work practitioners during routine service provision to clients with mental health issues (MHIs) who were living in community settings in Hong Kong and Sydney. To enable a comprehensive exploration of various empowerment practices, a latent conceptual framework was developed on the basis of the Empowerment Scale for mental health consumers originally developed by Rogers et al. (1997,, 2010). The original Empowerment Scale contained five aspects with the potential to cover both indiviudal- and structural-level client-empowerment practices: ‘self-esteem/self-efficacy’, ‘power-powerless’, ‘community activism and autonomy’, ‘optimism and control over the future’ and ‘righteous anger’ (Rogers et al., 1997, p. 1042, 2010). This original client Empowerment Scale was further adapted in this study to expore client empowerment perceived by social work practitioners with further input from literature review and initial consultations with experts in both cities. The enactment of client empowerment by social work practitioners is subject to a range of influencing factors. The second aim of this study is to explore a range of intra-personal, inter-personal and broader socio-cultural (i.e. in the context of organisations, professional networks, policies and guidelines, and cultural norms) factors associated with perceptions of client empowerment and practices that facilitate client empowerment amongst these social work practitioners in different contexts (Hong Kong and Sydney in this paper). Existing literature, albeit scarce, suggests that key influencing factors of the enactment of client empowerment include practitioners’ considerations of their clients’ expectations and capabilities (Ackerson and Harrison, 2000; Linhorst et al., 2002); supportive organisational policies that allow sufficient staff–client consultation time (Ackerson and Harrison, 2000; Linhorst et al., 2002); and cultural norms and beliefs that endorse or hinder client empowerment (Yip, 2004; Tse et al., 2010; Tse et al., 2015). In addition, social work training that incorporates client empowerment is identified as an enabler (Schwartz, 2003). The multifaceted nature of client empowerment in theory and in practice suggests a need to investigate this in a more systematic approach, which is currently lacking in the field (Cyril et al., 2016). Inspired by the System Theory, a widely applied framework in social work research (Healy, 2005), in this paper, we propose a comprehensive ecological appraisal approach to assess both individual- and structural-level enablers of client empowerment identified by social work practitioners. Two cultural settings in the Asia Pacific region were chosen in our analysis: Sydney and Hong Kong. There are both similarities and differences between these settings in terms of social work practice. Speaking very generally, Sydney employs a Western and neoliberal-oriented service-provision model that emphasises client autonomy and self-management among people with MHIs. Hong Kong, a former British colony with deep-rooted Chinese heritage and strong contemporary connections with mainland China, employs a more hybrid (‘East-meets-West’-style) service-provision model, where family members take a prominent role in the shared care of people with MHIs. Despite these obvious differences, the publicly funded social service systems in both Sydney and Hong Kong have both retained remnants of an original British colonial governance system, and the professional training of social workers aligns with the highest of international standards in both locations (e.g. endorsing the Global Standards for Social Work Education and Training adopted by the International Association of Schools of Social Work and the International Federation of Social Workers). For social workers in Sydney and Hong Kong who serve people with MHIs in community settings, the following research questions were investigated in this paper: How do they conceptualise client empowerment? What key factors are associated with their perceptions of client empowerment and practices that support client empowerment? Method Sample and study design An anonymous online survey was conducted between August and December 2016. To be eligible, participants were required to: have obtained a formal social worker qualification of some variety (e.g. a bachelor’s degree in social work, accreditation by a government-recognised professional association), be currently employed to serve people with MHIs in community settings and have already worked in this or a similar role for more than one year. A range of sources were used to recruit a variety of social work professionals. In both Sydney and Hong Kong, an online survey advertisement was promoted through major community-based mental health organisations (e.g. Mental Health Coordinating Council in Sydney) and social worker professional bodies (e.g. the Australian Association of Social Workers, networks of social workers in mental health and their online forums in Hong Kong). For Hong Kong participants, a professionally translated Chinese version of the survey was available in addition to the English version. A total of 163 valid responses were analysed. The study was approved by the UNSW Human Research Ethics Advisory Panel G (HC16481). Measures The general section of the questionnaire contained basic socio-demographic information such as age, gender and ethnic background. For professional social work training and practice experiences, the survey assessed length of time working with people with MHIs and specific service settings. Conceptualisation of client empowerment To measure social work practitioners’ knowledge, beliefs of and attitudes towards client empowerment, the Empowerment Scale for people with MHIs (Rogers et al., 1997, 2010) was adapted and further piloted with experts and social workers in Sydney and Hong Kong before the survey’s formal launch. The original three components—‘self-esteem/self-efficacy’, ‘community activism and autonomy’ and ‘optimism and control over the future’—were slightly modified, as they are considered to be largely in line with client empowerment’s main emphasis on improving clients’ person competence, self-/volitional control and civic engagment (McLean, 1995; Chamberlin and Schene, 1997; Dickerson, 1998; Zimmerman and Warschausky, 1998; Holden et al., 2005). The other two original components were changed substantially based on expert consultations and preliminary findings at the pilot stage. First, the original ‘power-powerless’ component was replaced by items focusing on client–practitioner interactions. Finally, the original component of ‘righteous anger’, which refers to consumers’ negative emotional reactions caused by the lack of support, was not included. Instead, newly designed items about supportive enviroment (e.g. opportunities and resources) (Nelson et al., 2001; Cyril et al., 2016) were added into the survey. For each listed item, a four-point Likert scale, ranging from 1 (‘not important at all’) to 4 (‘very important’), was used. Key factors in client-empowerment practices Based on the literature review and following the ecological framework, we developed a number of micro-, meso- (e.g. client–practitioner relationships, connections with other health-care providers internally and externally) and macro-level (e.g. policies and guidelines, organisational and broader societal cultural values) factors anticipated as relevant to client-empowerment practices. Before the formal launch of the survey, this newly developed exploratory instrument was taken through a lengthy pilot phase in both Sydney and Hong Kong. Each statement was measured on a five-point Likert scale: 1 (‘strongly disagree’) to 5 (‘strongly agree’). Statistical analyses Descriptive statistics were used to summarise sample socio-demographic and work-related characteristics as well as participants’ knowledge, beliefs of and attitudes towards client empowerment. Exploratory factor analysis (i.e. Principal Component Analysis with Varimax rotation) was then applied to generate empirical (latent) data on client-empowerment conceptualisation. Standardised factor scores were used for further analysis. To further assess the similarities and differences between the two sites (Sydney versus Hong Kong), a number of purposefully selected sub-sample comparisons (due to limited sample sizes) were made using t-tests for continuous or ordinal variables and chi-square tests for categorical variables. Finally, using multivariable logistic regression, an a priori hierarchical model-reduction procedure was performed (Hosmer et al., 2013) to explore key factors associated with practitioners’ conceptualisation of client empowerment. All data analyses were performed in IBM SPSS Statistics 23 with the significance level set at p < 0.05 for two-sided tests. Results Sample characteristics Of the 163 social worker participants with valid responses (eighty from Sydney and eighty-three from Hong Kong), 58.9 per cent (n = 96) were female and the average age of the sample was thirty-two (age range: twenty-two to fifty-six) years old. A predominant majority of the Hong Kong participants (97.5 per cent) self-identified as having a Chinese or Hong Kong ethnic background. In contrast, while the vast majority (80.8 per cent) of Sydney respondents reported their ethnic heritage as Caucasain, there was a greater ethnic variety among the remaining minority (19.2 per cent), including, for example, Aboriginal, Filipino, Indian or Chinese. Around half of all respondents had a history of working with people with various MHIs for three years or longer (up to ten years). Sydney participants were more likely to be less experienced (e.g. less than three years) than those in Hong Kong (p = 0.025). The conceptualisation of client empowerment First and foremost, ‘believing in one’s strengths and seeing oneself as a capable person’ (corresponding to the self-efficacy aspect of client empowerment in Roger’s scale) was the most strongly endorsed (as ‘very important’) by the sample overall, with Hong Kong participants being more likely to endorse it than Sydney ones (p = 0.002; Table 1). Next, Sydney participants were more likely to endorse the aspect of ‘working together to have a positive impact on the community’ (corresponding to the community-mobilisation aspect in Roger’s scale). Hong Kong participants, in comparison, were more likely to endorse the aspect of ‘self-determination and control over one’s life’ (corresponding to the self-determination aspect in Roger’s scale). As shown in Table 1, the least endorsed aspect of client engagement for Sydney participants was the newly added one (i.e. ‘mobilising increased opportunities and enabling conditions’), whereas, for Hong Kong participants, it was the aspect replacing the power-sharing aspect in Roger’s scale (i.e. ‘developing balanced power relations between consumers and workers’). Table 1 Conceptualisation of client empowerment by social workers in Sydney and Hong Kong Mean (SD) p-value Whole group Hong Kong Sydney (N = 163) (n = 83) (n = 80) Believing in one’s strengths and seeing oneself as a capable person 3.82 (0.45) 3.93 (0.27) 3.71 (0.55) 0.002 Self-determination and control over one’s life 3.72 (0.51) 3.84 (0.40) 3.61 (0.58) 0.005 Developing balanced power relations between consumers and workers 3.61 (0.61) 3.68 (0.49) 3.55 (0.70) 0.21 Working together to have a positive impact on the community (e.g. advocacy, consumer-run groups) 3.59 (0.56) 3.55 (0.54) 3.63 (0.55) 0.38 Mobilising increased opportunities and enabling conditions (e.g. having access to new services, skills training) 3.59 (0.68) 3.83 (0.38) 3.36 (0.82) <0.001 Mean (SD) p-value Whole group Hong Kong Sydney (N = 163) (n = 83) (n = 80) Believing in one’s strengths and seeing oneself as a capable person 3.82 (0.45) 3.93 (0.27) 3.71 (0.55) 0.002 Self-determination and control over one’s life 3.72 (0.51) 3.84 (0.40) 3.61 (0.58) 0.005 Developing balanced power relations between consumers and workers 3.61 (0.61) 3.68 (0.49) 3.55 (0.70) 0.21 Working together to have a positive impact on the community (e.g. advocacy, consumer-run groups) 3.59 (0.56) 3.55 (0.54) 3.63 (0.55) 0.38 Mobilising increased opportunities and enabling conditions (e.g. having access to new services, skills training) 3.59 (0.68) 3.83 (0.38) 3.36 (0.82) <0.001 1 = not important at all; 2 = not important; 3 = somehow important; 4 = very important. Table 1 Conceptualisation of client empowerment by social workers in Sydney and Hong Kong Mean (SD) p-value Whole group Hong Kong Sydney (N = 163) (n = 83) (n = 80) Believing in one’s strengths and seeing oneself as a capable person 3.82 (0.45) 3.93 (0.27) 3.71 (0.55) 0.002 Self-determination and control over one’s life 3.72 (0.51) 3.84 (0.40) 3.61 (0.58) 0.005 Developing balanced power relations between consumers and workers 3.61 (0.61) 3.68 (0.49) 3.55 (0.70) 0.21 Working together to have a positive impact on the community (e.g. advocacy, consumer-run groups) 3.59 (0.56) 3.55 (0.54) 3.63 (0.55) 0.38 Mobilising increased opportunities and enabling conditions (e.g. having access to new services, skills training) 3.59 (0.68) 3.83 (0.38) 3.36 (0.82) <0.001 Mean (SD) p-value Whole group Hong Kong Sydney (N = 163) (n = 83) (n = 80) Believing in one’s strengths and seeing oneself as a capable person 3.82 (0.45) 3.93 (0.27) 3.71 (0.55) 0.002 Self-determination and control over one’s life 3.72 (0.51) 3.84 (0.40) 3.61 (0.58) 0.005 Developing balanced power relations between consumers and workers 3.61 (0.61) 3.68 (0.49) 3.55 (0.70) 0.21 Working together to have a positive impact on the community (e.g. advocacy, consumer-run groups) 3.59 (0.56) 3.55 (0.54) 3.63 (0.55) 0.38 Mobilising increased opportunities and enabling conditions (e.g. having access to new services, skills training) 3.59 (0.68) 3.83 (0.38) 3.36 (0.82) <0.001 1 = not important at all; 2 = not important; 3 = somehow important; 4 = very important. The exploratory factor analysis produced two (latent) factors of client empowerment as perceived by the social workers in the sample. The two-factor solution accounted for 59.5 per cent of the overall variance. Factor 1—relation-based empowerment—accounted for 31.4 per cent of the variance, covering aspects of self-efficacy, power sharing and community advocacy. Factor 2—resource-oriented empowerment—accounted for the another 28.1 per cent of the variance, covering aspects of self-determination and the newly added element of creating an enabling enviroment. Both factors included intra-personal, inter-personal and community-level client-empowerment dimensions (Table 2). For the whole sample, the Cronbach’s alpha is 0.59. Table 2 Conceptualisation of client empowerment: principle component analysis with varimax rotation* Factor loading Relation-based empowerment  Believing in one’s strengths and seeing oneself as a capable person 0.78  Developing balanced power relations between consumers and workers 0.68  Working together to have a positive impact on the community 0.65 Resource-oriented empowerment  Self-determination and control over one’s life 0.76  Mobilising increased opportunities and enabling conditions 0.88 Factor loading Relation-based empowerment  Believing in one’s strengths and seeing oneself as a capable person 0.78  Developing balanced power relations between consumers and workers 0.68  Working together to have a positive impact on the community 0.65 Resource-oriented empowerment  Self-determination and control over one’s life 0.76  Mobilising increased opportunities and enabling conditions 0.88 * Rotation method: Varimax with Kaiser normalisation. Table 2 Conceptualisation of client empowerment: principle component analysis with varimax rotation* Factor loading Relation-based empowerment  Believing in one’s strengths and seeing oneself as a capable person 0.78  Developing balanced power relations between consumers and workers 0.68  Working together to have a positive impact on the community 0.65 Resource-oriented empowerment  Self-determination and control over one’s life 0.76  Mobilising increased opportunities and enabling conditions 0.88 Factor loading Relation-based empowerment  Believing in one’s strengths and seeing oneself as a capable person 0.78  Developing balanced power relations between consumers and workers 0.68  Working together to have a positive impact on the community 0.65 Resource-oriented empowerment  Self-determination and control over one’s life 0.76  Mobilising increased opportunities and enabling conditions 0.88 * Rotation method: Varimax with Kaiser normalisation. For further sub-group comparisons, standardised factor scores were used. No difference was found in terms of Factor 1 (t(161) = 1.06, p = 0.29). There was, however, a significant difference in Factor 2 (t(161) = 4.17, p < 0.001), where Hong Kong practitioners perceived resource-oriented client empowerment as more integral than did their Sydney counterparts. Key factors influencing practitioners’ client-empowerment practices Based on the whole sample, the most common facilitators of client-empowerment practices, according to the social work practitioners, were their own professional training in social work, recent promotion (and related influences) of recovery-oriented mental health service delivery approaches, supportive co-workers in the same team, involvement of clients’ family and/or significant others in care provision and the belief that social workers are best placed to practise client empowerment through community-based mental health service provision (Table 3). Table 3 Key perceived facilitators and barriers of social workers’ client-empowerment practices Mean (SD) The most common facilitators  My social work training helps me to empower my clients 4.14 (0.79)  The promotion of recovery-oriented services in recent years facilitates my practice of empowering my clients 4.04 (0.69)  The team in which I am working supports me to empower my clients 3.94 (0.92)  The involvement of significant others (e.g. family members and close friends) helps me to empower my clients 3.84 (0.87)  Social work professionals are best placed to empower people with mental health issues in community-based health-care settings 3.84 (0.87) The most common barriers  Cultural norms POSE a challenge to the empowerment of my clients (reverse coded) 4.09 (0.72)  My current work-load PREVENTS me from effectively empowering my clients (reverse coded) 4.07 (0.95)  The medical dominance in the mental health service delivery system is now NOT DECLINING (reverse coded) 2.98 (1.05)  Society in general DISRESPECTS the rights of people with MHIs (reverse coded) 2.94 (1.19)  The medical specialists (e.g. psychiatrists, general practitioners) who are also working with my clients DO NOT SUPPORT me to empower my clients (reverse coded) 2.83 (1.04) Mean (SD) The most common facilitators  My social work training helps me to empower my clients 4.14 (0.79)  The promotion of recovery-oriented services in recent years facilitates my practice of empowering my clients 4.04 (0.69)  The team in which I am working supports me to empower my clients 3.94 (0.92)  The involvement of significant others (e.g. family members and close friends) helps me to empower my clients 3.84 (0.87)  Social work professionals are best placed to empower people with mental health issues in community-based health-care settings 3.84 (0.87) The most common barriers  Cultural norms POSE a challenge to the empowerment of my clients (reverse coded) 4.09 (0.72)  My current work-load PREVENTS me from effectively empowering my clients (reverse coded) 4.07 (0.95)  The medical dominance in the mental health service delivery system is now NOT DECLINING (reverse coded) 2.98 (1.05)  Society in general DISRESPECTS the rights of people with MHIs (reverse coded) 2.94 (1.19)  The medical specialists (e.g. psychiatrists, general practitioners) who are also working with my clients DO NOT SUPPORT me to empower my clients (reverse coded) 2.83 (1.04) 1 = strongly disagree; 2 = disagree; 3 = neither disagree nor agree; 4 = agree; 5 = strongly agree. Table 3 Key perceived facilitators and barriers of social workers’ client-empowerment practices Mean (SD) The most common facilitators  My social work training helps me to empower my clients 4.14 (0.79)  The promotion of recovery-oriented services in recent years facilitates my practice of empowering my clients 4.04 (0.69)  The team in which I am working supports me to empower my clients 3.94 (0.92)  The involvement of significant others (e.g. family members and close friends) helps me to empower my clients 3.84 (0.87)  Social work professionals are best placed to empower people with mental health issues in community-based health-care settings 3.84 (0.87) The most common barriers  Cultural norms POSE a challenge to the empowerment of my clients (reverse coded) 4.09 (0.72)  My current work-load PREVENTS me from effectively empowering my clients (reverse coded) 4.07 (0.95)  The medical dominance in the mental health service delivery system is now NOT DECLINING (reverse coded) 2.98 (1.05)  Society in general DISRESPECTS the rights of people with MHIs (reverse coded) 2.94 (1.19)  The medical specialists (e.g. psychiatrists, general practitioners) who are also working with my clients DO NOT SUPPORT me to empower my clients (reverse coded) 2.83 (1.04) Mean (SD) The most common facilitators  My social work training helps me to empower my clients 4.14 (0.79)  The promotion of recovery-oriented services in recent years facilitates my practice of empowering my clients 4.04 (0.69)  The team in which I am working supports me to empower my clients 3.94 (0.92)  The involvement of significant others (e.g. family members and close friends) helps me to empower my clients 3.84 (0.87)  Social work professionals are best placed to empower people with mental health issues in community-based health-care settings 3.84 (0.87) The most common barriers  Cultural norms POSE a challenge to the empowerment of my clients (reverse coded) 4.09 (0.72)  My current work-load PREVENTS me from effectively empowering my clients (reverse coded) 4.07 (0.95)  The medical dominance in the mental health service delivery system is now NOT DECLINING (reverse coded) 2.98 (1.05)  Society in general DISRESPECTS the rights of people with MHIs (reverse coded) 2.94 (1.19)  The medical specialists (e.g. psychiatrists, general practitioners) who are also working with my clients DO NOT SUPPORT me to empower my clients (reverse coded) 2.83 (1.04) 1 = strongly disagree; 2 = disagree; 3 = neither disagree nor agree; 4 = agree; 5 = strongly agree. The most common barriers, on the other hand, included cultural norms perceived as being unsupportive of client empowerment, social workers’ current work-load preventing them from practising client empowerment, the persistent medical dominance (i.e. being primarily disease-focused) in current service delivery models, the society in general being disrespectful of the rights of people with MHIs and medical specialist colleagues (who serve the same clients) being uncooperative or unsupportive of social workers’ empowerment practices (Table 3). These perceived facilitators and barriers covered intra-personal, inter-personal as well as broader socio-cultural factors. Multivariable modelling A final multivariable logistic regression was established to explore key factors associated with these practitioners’ conceptualisation of the two-factor (i.e. relationship-based and resource-oriented) client empowerment, following the previous exploratory factor analysis results. To produce the binary outcome variable for this, a summary score was first created for each participant by adding their two standardised factor scores. The summary scores were then recoded into binary using the median-split method. A selective range of covariables were entered into the initial model. Apart from age and duration of working with people with MHIs as background control variables, seven factors were added: city (Sydney versus Hong Kong), benefits from social work training, beliefs that social workers are best placed in promoting client empowerment, perceived support from work colleagues in the same team, perceived support from medical specialists serving the same client, perceived cultural norms regarding client empowerment and recent promotion of recovery-oriented mental health service delivery models. All these variables were recoded into binary by collapsing into agreement (strongly agree/agree) versus otherwise (strongly disagree/disagree/neither). By applying the ecological framework, our purposeful selection of these variables to be included in the multivariable analysis was based on extensive search of the literature as well as our initial exploration of bivariate associations with the outcome variable, using a lenient p < 0.10 as a screening process for independent variable inclusion (Hosmer et al., 2013). As shown in Table 4 (the final reduced model), after controlling for age and working history for people with MHIs, Sydney social workers were less likely than their Hong Kong counterparts to conceptualise client empowerement including both relation and resource aspects (adjusted odds ration (AOR) = 0.44, 95% confidence intervals (CIs) 0.22–0.88, p = 0.02). Apart from this geographic difference, perceiving less support from fellow medical specialists (AOR = 0.31, 95% CI 0.15–0.62, p = 0.001) but more support from other colleagues serving the same client (AOR = 2.79, 95% CI 1.31–5.92, p = 0.008), benefits of social work training (AOR = 2.78, 95% CI 1.14–6.80, p = 0.025) and believing social workers’ important role in client empowerment (AOR = 2.18, 95% CI 1.07–4.41, p = 0.031) were all independently associated with endorsement of the two-level client-empowerment conceptualisation. The final reduced model explained 19.5 per cent of the overall variance (χ2 = 25.8, df = 5, p < 0.001). Table 4 Key factors associated with two-factor client-empowerment conceptualisation by social work practitioners in Sydney and Hong Kong: multivariable logistic regression Adjusted odds ratio 95% CI p-value Sydney (ref. Hong Kong) 0.44 0.22–0.88 0.02 The medical specialists (e.g. psychiatrists, general practitioners) who are also working with my clients SUPPORT me to empower my clients 0.31 0.15–0.62 0.001 The team in which I am working supports me to empower my clients 2.79 1.31–5.92 0.008 My social work training helps me to empower my clients 2.78 1.14–6.80 0.02 Social work professionals are best placed to empower people with mental health issues in community-based health-care settings 2.18 1.07–4.41 0.03 Adjusted odds ratio 95% CI p-value Sydney (ref. Hong Kong) 0.44 0.22–0.88 0.02 The medical specialists (e.g. psychiatrists, general practitioners) who are also working with my clients SUPPORT me to empower my clients 0.31 0.15–0.62 0.001 The team in which I am working supports me to empower my clients 2.79 1.31–5.92 0.008 My social work training helps me to empower my clients 2.78 1.14–6.80 0.02 Social work professionals are best placed to empower people with mental health issues in community-based health-care settings 2.18 1.07–4.41 0.03 Table 4 Key factors associated with two-factor client-empowerment conceptualisation by social work practitioners in Sydney and Hong Kong: multivariable logistic regression Adjusted odds ratio 95% CI p-value Sydney (ref. Hong Kong) 0.44 0.22–0.88 0.02 The medical specialists (e.g. psychiatrists, general practitioners) who are also working with my clients SUPPORT me to empower my clients 0.31 0.15–0.62 0.001 The team in which I am working supports me to empower my clients 2.79 1.31–5.92 0.008 My social work training helps me to empower my clients 2.78 1.14–6.80 0.02 Social work professionals are best placed to empower people with mental health issues in community-based health-care settings 2.18 1.07–4.41 0.03 Adjusted odds ratio 95% CI p-value Sydney (ref. Hong Kong) 0.44 0.22–0.88 0.02 The medical specialists (e.g. psychiatrists, general practitioners) who are also working with my clients SUPPORT me to empower my clients 0.31 0.15–0.62 0.001 The team in which I am working supports me to empower my clients 2.79 1.31–5.92 0.008 My social work training helps me to empower my clients 2.78 1.14–6.80 0.02 Social work professionals are best placed to empower people with mental health issues in community-based health-care settings 2.18 1.07–4.41 0.03 Discussion To our knowledge, this is the first comprehensive quantitative study to explore front line social work practitioner’s perspectives on client empowerment in serving people with MHIs in community settings. A key contribution is the two-factor (latent) conceptualisation model, which reflects the importance of the inclusion of both relationship-based and resource-oriented aspects of client empowerment across intra-personal, inter-personal and broader socio-cultural levels. Underpinned by the ecological framework, our proposed model extends the original Empowerment Scale (Rogers et al., 1997, p. 1045). While the Empowerment Scale was originally developed through input from clients with MHIs, our model provides new insights from front line social work practitioners serving this population in the current climate. The proposed model not only confirms the importance of client-centred mental health service design and delivery, but also highlights the importance of supportive client–practitioner interaction and a broader enabling environment that facilitates inter-professional, multidisciplinary collaboration. Among our adapted five aspects of client empowerment, the ultimate importance of ensuring the cultivation of clients’ self-efficacy is valued, first and foremost, by social workers in both Syndey and Hong Kong. This finding aligns with the policy context of the current practice, as enhancing clients’ self-efficacy is broadly promoted in strength-based approaches as stipulated by policies and guidelines of mental health service delivery at both sites (Australian Health Ministers’ Advisory Council, 2013; Tsoi, 2016). Our two-factor conceptualisation model, however, further suggests that practitioners’ conceptualisation of client empowerment is often multifaceted (e.g. relation-based empowerment covers aspects of self-efficacy, power sharing and community advocacy). This finding extends previous knowledge that social workers providing mental health services tended to equate client empowerment simply with self-determination only (Ackerson and Harrison, 2000). Despite an ecological framework of practice gradually taking shape in the social work profession for over a century, previous studies suggest a trend that the micro and macro practice has been driven further apart in recent decades and primary attention has been increasingly given to micro interventions (Rothman and Mizrahi, 2014; Austin et al., 2016). A report on the social work workforce in the USA found that social workers devoted only 2 per cent of working hours weekly to macro-level social work practice (Rothman and Mizrahi, 2014). However, complex social problems like MHIs often require not only individual solutions, but also connections to the broad social context and sensitivity to structural issues such as social injustice (Bland, 2015). Findings from this paper encouragingly confirm that social work practitioners from both Sydney and Hong Kong support the multifaceted nature of client empowerment. Through a cross-cultural comparison lens, our innovative findings reveal some broader socio-cultural impacts on client empowerment for people with MHIs. Depsite the fact that the social work practitioners from both cities universally endorsed the relation-based empowerment (i.e. Factor 1—self-efficacy, power sharing and community advocacy), they differed to some extent in the latent conceptualisation model. In general, the Hong Kong practitioners were more likely to endorse the two-factor comprehensive model than those from Sydney. On the other hand, practitioners from Sydney perceived the resource-oriented empowerment (i.e. Factor 2—self-determination and creation of opportunities and enabling conditions) as less integral compared with practitioners from Hong Kong. A possible explanation for this is that, in recent years, while people with MHIs residing in Hong Kong are still predominantly regarded as ‘patients’ who need to be looked after by the health system, consumers in Australia have been increasingly enabled and encouraged to become involved in mental health service design and delivery (Australian Health Ministers Conference, 2009; Hospital Authority, 2010; NSW Mental Health Commission, 2014; Social Welfare Department & Hospital Authority, 2016). Thus, the importance of resource-oriented empowerment (i.e. self-determination and creating an enabling environment) becomes relatively more prominent in the Hong Kong context. Further studies are needed to explore these cultural differences. In practice, the two most common facilitators to practices that facilitate client empowerment, identified by the social work practitioners in this study, were social work training and the global movement towards promoting recovery-oriented mental service delivery models. From very early on, client empowerment has been one of the cornerstones of the recovery-oriented mental health service reform (Anthony, 1993; Leamy, 2011). This study provides further empirical evidence of this global movement and its local impact on social work practitioners from both cities. Unsupportive cultural norms as well as current workloads (the latter may impose serious restrictions on the length of each consultation episode) were identified by the social work professionals as the two most common barriers in client empowerment. Taken together, these results confirm that factors spanning from professional training, service guidelines and policies as well as societal stigma and discrimination against people with MHIs can exert substantial influence over individual social work practitioners’ practices of facilitating client empowerment (Ackerson and Harrison, 2000; Linhorst et al., 2002; Schwartz, 2003). Of note, individual client-related factors were not considered by the social workers as either major facilitators or barriers in this study. This contradicts previous findings from the literature which focused almost entirely on individual client-level factors (Ackerson and Harrison, 2000; Linhorst et al., 2002). Finally, the exploratory multivariable analysis clearly demonstrates that, apart from the socio-cultural and geographic differences between the two cities, three main facilitators were independently associated with the two-factor client-empowerment concept in practice. The three main facilitators, namely collegial support from the team co-managing the same clients (a proxy of inter-professional relationship), social work training and the firm belief in promoting client empowerment by social workers themselves, are consistent with the evolution of mental health service delivery towards more client-centred, multidisciplinary shared-care models. Perceived ‘support’ from medical specialists, however, was identified as the only barrier independently associated with the two-factor client-empowerment concept by the social work practitioners. A possible explanation for this is the persistent issue of medical dominance, particularly its much narrower and disease-focused interpretation of mental health conditions, and its overreliance on medical and behavioural interventions targeted at individual clients alone, both of which continue to be resisted by social work professionals (Yip, 2004; Albrithen and Yalli, 2015). It is also well documented that a professional hierarchy exists where mental health social workers are typically positioned lower in the ladder than medical specialists during clinic decision making (Thompson, 2011; Morley, 2014), and this may also explain why specialist support was described as a barrier, possibly suggesting the lack of supportive leadership in service delivery systems towards effective client empowerment. There are a number of limitations to this research. First, our study adapted the original Empowerment Scale designed for clients of mental health services (Rogers et al., 1997, 2010), as there is no validated client-empowerment measurement from social work or other professional practitioners’ perspectives. This newly adapted scale may be further tested and validated in future studies. While we found our two-factor client-empowerment conceptualisation model has the potential to be applied in the field, the psychometric properties and further acceptability and feasibility of this newly developed instrument need to be extensively tested before this can be confirmed. Second, we noted the different professional accreditation and governance procedures of social work practitioners in Sydney as compared to that in Hong Kong. For those in Sydney, professional registration as a social worker is not mandatory, but there is an established accreditation procedure to be a mental health social worker to enable the provision of private services to people with MHI in community settings. In contrast, in Hong Kong, social work professional registration is mandatory but accreditation of mental health social workers has not yet established. Despite these differences, similar purposive sampling approaches were used to recruit eligible participants in both cities. Finally, the limited sample size, self-reported data and the cross-sectional design preclude any definitive causal conclusions from this type of study. Conclusions By exploring the conceptualisation of client empowerment from the perspective of social work practitioners serving people with MHIs in community settings, this study provides new insights into training and supporting social workers’ front line services. Data from the exploratory online survey extend existing theoretical and empirical understandings of client empowerment to influences from inter-professional, organisational and workforce development and broader socio-cultural contexts. It sheds further light on the importance of professional empowerment through broader policy support and inter-professional collaboration to enable better client empowerment. To translate these findings into front line social workers’ everyday practices, particularly in the context of serving clients with enduring (and often severe) health conditions and complex needs, structured support from service delivery organisations and professional networks as well as societal norm changes towards client-centred, multidisciplinary service-provision models are called for. Funding This research was conducted as doctoral research within the Centre for Social Research in Health at UNSW Sydney, which receives funding from the Australian Government Department of Health and Ageing. Jialiang Cui is supported by an Australian Government Research Training Program Stipend Scholarship and Higher Degree Research Faculty Supported Research Funding from UNSW Arts and Social Sciences. Conflict of interest statement: The authors have no conflicts of interest to report with respect to the publication of this article. Reference Ackerson B. , Harrison W. 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TI - Understanding Client Empowerment: An Online Survey of Social Workers Serving People with Mental Health Issues
JF - The British Journal of Social Work
DO - 10.1093/bjsw/bcy057
DA - 2019-03-01
UR - https://www.deepdyve.com/lp/oxford-university-press/understanding-client-empowerment-an-online-survey-of-social-workers-XS11yDjJCO
SP - 335
VL - 49
IS - 2
DP - DeepDyve
ER -