Patient perceptions on hospital food service at Teaching Hospital, Karapitiya

Background: Hospital diet is an integral part of the management of in-ward patients. The quality of hospital food plays a major role in determining the overall satisfaction of patients with regards to their hospital stay. Objective: To investigate the level of patient satisfaction with regards to the diet supplied at Teaching Hospital (TH), Karapitiya. Methods: A descriptive, cross sectional study was conducted among 316 patients who received inward treatment at TH Karapitiya and consumed hospital diet. Data were collected using an interview-administered questionnaire and analyzed using SPSS statistical software. Results: During the study period, only 27% of the in-ward patients consumed hospital diet. Of 316 included in the analysis, 13.6% rated hospital diet “good”, 59.7% “fair”, and 26.6% “unsatisfactory”. Patients were satisfied with the quantity of all types of food provided (above 85%), time of food distribution (90%), temperature of food (85%) and texture (86%). However, 31% of patients were unsatisfied with taste, 40% were unsatisfied with the smell of food and 29% were unsatisfied with the diversity of food provided. No significant association was found between overall satisfaction regarding food service and the patients' age, gender, ethnicity, educational level or length of hospital stay. Conclusions: Patient perception on hospital food service at TH, Karapitiya was mostly favourable although patients were less satisfied about the quality of food. The proportion who consumed hospital food was low. Attempts must be taken to enhance the taste, smell and the diversity of food provided.


Introduction
Hospital diet is an essential component of patient recovery and well being (1).Diet consumed during hospital stay forms an integral part of patient management, therefore provision and consumption of a balanced diet is essential to speed up the recovery.These meals can provide a nutritional model for patients requiring dietary management, when tailored to their specific health conditions.Hence, every hospital food service must target to provide food that meets nutritional requirements, satisfies the patient and are microbiologically safe (2).
The quality of the food served while in the hospital plays a major role in patients' satisfaction with their overall hospital experience (3).It is reported that in-patients evaluate food service quality based on various factors such as taste, texture, variety, nutritional quality, sanitation, temperature, portion size, meal time, and servers' characteristics (4-6).
Therefore, the attitude and the satisfaction of patients regarding hospital food service depend largely on these factors.
Despite its role as an essential contributor for recovery of patients, hospital food has a wide reputation for being tasteless, overcooked and unappetizing (7).Improvement of hospital food services remains a constant challenge due to many tangible and intangible aspects related to quality, ranging from menu items, portion size, taste, temperature, texture and variety of food to tray presentation, sanitation, offering nutritional information and responsiveness to food problems (8)(9)(10)(11)(12).
According to the Hospital Manual published by the Ministry of Health, Sri Lanka a patient's diet for a day is the entire requirement of food for a period of 24 hours, starting from 12 noon on a particular day to 12 noon of the following day (13).Medical Officer in charge has to determine the diet as it is regarded as a part of the management.All government hospitals in Sri Lanka provide diet free of charge to in-ward patients.Some patients, however, prefer food brought from their homes.A situational analysis performed by the principal investigator in four major hospitals in Galle and Ratnapura districts revealed that only a limited number of in-ward patients consumed hospital food: 25% in Teaching Hospital, Karapitiya,12% in Teaching Hospital,Mahamodara,30% in General Hospital,Ratnapura and 20% in Base Hospital,Embilipitiya (unpublished data).The major reasons for poor consumption according to the key informants were tastelessness, unpleasant aroma of food and shyness to eat hospital food.
Regular attempts to review the quality and patient satisfaction of hospital food are of paramount importance to reap the benefits of this service.Conducting research on above aspects is mandatory to identify the deficiencies in the hospital food service and to explore the expectations of consumers with regards to the standards of meals provided to them.Such measures are useful in improving overall patient satisfaction and to prevent plate wastage due to poor meal quality.This study was conducted to assess the patient perceptions on hospital food with regard to menu, amount, hygiene, timeliness, taste and texture.

Methodology
This study was a descriptive, cross-sectional study, conducted at the Teaching Hospital (TH), Karapitiya which is the only tertiary care institution in southern Sri Lanka.Study sample included patients who received in-patient care from the medical, surgical, eye, Ear, Nose and Throat (ENT), neurosurgical and orthopedic wards and consumed hospital food th during a period of 3 months from 25 July 2013.A total of 316 patients were enrolled to the study and this included only the patients who consumed a normal hospital diet and could understand and respond to the questionnaire.Critically ill patients and those who were not on normal diet were excluded.
A pre-tested, interview-administered questionnaire was used to collect data on client satisfaction with regards to hospital food service.Data on basic sociodemographic profile of the participants were also collected.All data were collected by the principal investigator in order to minimize the interviewer bias.Informed consent was obtained from the eligible patients before data collection.Ethical approval for the study was obtained from the Ethical Review Committee, Faculty of Medicine, and University of Colombo.Institutional approval was obtained from the Director, TH, Karapitiya.Chi-squire test was used to determine the statistical significance of associations between variables.A probability level of 0.05 was considered as the critical value for statistical significance.

Results
A total of 316 patients on normal hospital diet were interviewed on perceived satisfaction with regards to hospital diet.During the study period, only 27% of the inward patients consumed hospital diet (Number of patients who consumed hospital diet/ average mid night total*100).Characteristics of the study participants are given in Table 1.
In reporting the adequacy of the food provided, nearly 91% of the respondents stated that rice was adequately supplied.Approximately 85% were satisfied with the amount of fish given.Some patients had not received certain food items despite their requests (e.g. about 23.7%.respondents stated that they did not receive fish even though they requested a fish diet).Overall, the proportion of patients who did not consume the different types of food provided ranged from 5% to 30%.Patients' responses on the adequacy of the meals and the proportion who consumed different types of food are summarized in the Table 2.
Patients' views on taste, smell, texture and diversity of the food were studied to determine the perceived level of satisfaction with regards to the quality of hospital diet.Approximately 30% of the patients reported that the taste was not satisfactory and 40% said that the smell was unsatisfactory.The majority were satisfied with the texture, temperature and the timeliness of the food provided.However, over 26% mentioned that the overall quality of the food was unsatisfactory.The level of patient satisfaction regarding the different aspects of hospital food service is shown in Table 3.About 33.5% (n=106) of the patents mentioned that they did not consume the whole diet provided.Poor taste (17.7%), food being in excess (10.1%) and inability to eat due to their illness (5.7%) were the reasons highlighted for failure to consume the whole diet.
The association between the overall satisfaction regarding hospital diet and the characteristics of the patients such as age, gender, ethnicity, marital status, education and length of hospital stay was assessed using Chi square test (Table 4).There was no significant association between any of the above variables and the overall quality of the hospital diet except marital status of the patients, where more unmarried persons rated quality of diet as unsatisfactory.

Discussion
The findings of this study revealed that the majority of the in-ward patients do not consume hospital food.Among patients who consume hospital diet, overall quality of food service was perceived as satisfactory by the majority.However, the taste, aroma and diversity of food were rated unsatisfactory by more participants when compared to other aspects of hospital food service.
In public health care institutions in Sri Lanka, where health care is provided free of charge, it is not unusual for the patients to perceive hospital food as an extended facility provided by the hospital, not as a part of patient management.In this study, most respondents did not consider it as a right or privilege.Therefore, some patients were of the opinion that it is not fair to comment on hospital food service.Some patients were not concerned about the quality of the food service, as they were on a short stay and some believed that they were receiving a special diet with less salt and spices due to their illness, therefore it is necessarily tasteless.Even though these opinions were not surveyed in a formal manner, these perceptions were voiced by the patients during the interviews.
According to our findings more female patients (58%) were taking hospital meals.Although statistical significance of this finding could not be ascertained within the present study design, we hypothesize that it could be a reflection of the prevailing cultural practice, where females bear the sole responsibility in food preparation.As a result, when male patients are admitted, usually the female partners provide home-made food for them.However, when females are admitted, their male partners are not capable of providing homecooked meals and thus, they are compelled to eat hospital food.In a similar study conducted in United Kingdom, Li-Jene et al. reported that the consumption of hospital meal is more in females ( 14), although Kim and colleague found no difference in hospital meal consumption with regards to sex of the patients (11).
Majority (55.7%) of patients taking hospital meals in this sample were between 19-60 yrs.As most of the in-ward patients are likely to be in this age group our sample is likely to be representative sample of hospital in-ward patients.The demographic pattern in Sri Lanka also indicates that a higher percentage of persons are found in this age group (15).The least number of patients were in less than 18 years age group.Patients of this age category are mostly dependents and these patients are frequently visited by their family members.This may be the reason for them not to accept hospital foods.Li-Jen et al. reported that hospital food consumption is higher in the oldest age group ( 14).Kim and co-workers reported that the consumption rates are not significantly different between age groups (11).
Interestingly, only one third of patients who were taking hospital food were economically dependent.Contrary to the popular belief that hospital diets are consumed by the poor, this indicates that even people with a regular income are willing to consume hospital diet.This exerts a positive impression toward the hospital diet.
In this study, more than 80% of patients said that they were satisfied with the quantity of all food items provided.Most of subjects were satisfied with the texture, time of delivery and temperature of the meal but the proportion satisfied with the taste, aroma and variety of food was lower.Studies conducted in Canada and Saudi Arabia have reported similar results (9,16).
With regards to delivery of meals, most consumers were satisfied with the cleanliness of utensils, timeliness of distribution of food and the attitudes and behaviour of serving staff.More than 90% mentioned that the attitudes of the staff were good or satisfactory.However, this could be due to the reluctance of the patients to make any adverse comment on the hospital staff for the fear that it might affect their hospital care.Although a selfadministered questionnaire would have been the ideal method for data collection, during the pilot study it was found that the response rate was poor with this method.
Overall satisfaction towards the hospital meal was very low with only 13.6% of patients rating that food service was good.Although the majority rated it as fair, a considerable proportion of the study sample (26.6%) were unsatisfied with overall food service.Although these results are in accordance with the existing findings (17), a closer look at consumer satisfaction with respect to different aspects of food service reveals interesting complexities.
According to this study, cleanliness, time of food distribution and attitudes of staff are not in keeping with the overall satisfaction of the meal.The majority of patients rated these aspects as good, despite stating that overall food service was fair or unsatisfactory.This study has a few limitations.We could not exclude response bias due to the tendency of respondents to give favorable responses regarding the diet, because the interviewer was a medical officer.However, such patients would have only voiced favourable responses, thus it cannot explain the high levels of dissatisfaction seen among the participants.In addition, some patients were consuming hospital diet on an irregular basis.The perception of those patients would not have been comparable to those who consumed meals regularly, although both groups were considered together in assessing overall satisfaction with food service.The third source of bias relates to the current illnesses and the treatments of participants, which may have affected the appetite and the taste for foods, interfering with their appraisal.

Conclusion
The patient perception on the hospital food service at TH Karapitiya was fair.The rate of hospital food consumption was considerably low.Attempts need to be taken to enhance the taste, smell and the diversity of food provided.Regular supervision and 'surprise observations' must be conducted to maintain the standards of food service.Continuous monitoring and evaluations must be carried out including consumer surveys in order to identify the areas needing improvement.Norms should be developed regarding the food services of the hospitals.

Table 2 :
Patient perceptions regarding the adequacy of the meal provided and the percentage who consumed each food item

Table 3 :
Distribution of the level of patient satisfaction on the food service of Teaching Hospital, Karapitiya

Table 4 :
Distribution of level of satisfaction of the hospital food service according to the characteristics of the patients Jen et al. and O'  Hara et al.reported that there is no association between patients' perception of meal and age, gender, length of stay and the gross income (9,14).On the contrary, Dube et al. confirmed that such individual characteristics influenced perception of hospital food (18).