Www.bournemouth.ac.uk Hungry in hospital; Healthy in prison? H.J. HARTWELL and J.S.A. EDWARDS The Foodservice and Applied Nutrition Research Group, School.

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Hungry in hospital; Healthy in Hungry in hospital; Healthy in prison?prison?

H.J. HARTWELL and J.S.A. EDWARDSH.J. HARTWELL and J.S.A. EDWARDS

The Foodservice and Applied Nutrition Research The Foodservice and Applied Nutrition Research Group, School of Services Management, Group, School of Services Management,

Bournemouth UniversityBournemouth University



Institutional Stereotyping

Subjects were asked

to rate their

anticipated

acceptability of 12

food items served in a

variety of settings

Eggs, toast, steak,

burger, pie, coffee etc

(Cardello, 1996)

1 = Dislike extremely5 = Neither dislike nor like9 = Like extremely

HomeHomeRestaurantRestaurant – traditional and fast foodAirlineAirlineSchoolSchoolMilitaryMilitaryHospitalHospital


Institutional Stereotyping

HomeHome (Cardello et al, 1996)

Full-service RestaurantFull-service Restaurant

Fast FoodFast Food

School Food ServiceSchool Food Service

Military Food ServiceMilitary Food Service

Airline Food ServiceAirline Food Service

Hospital Food ServiceHospital Food Service

Acceptability


Institutional Institutional StereotypingStereotyping

4

4.5

55.5

6

6.5

77.5

8

8.5

Chocola

te S

hake

Pizza

White

Bre

ad

Chocola

te C

ake

Peaches in

Syr

up

Gravy

Min

ced B

eef

Lik

ing

Unlabelled


Institutional StereotypingInstitutional Stereotyping

4

4.55

5.5

66.5

7

7.58

8.5

Chocola

te S

hake

Pizza

White

Bre

ad

Chocola

te C

ake

Peaches in

Syr

up

Gravy

Min

ced B

eef

Lik

ing

Unlabelled Labeled as Institution


Institutional StereotypingInstitutional Stereotyping

4

4.55

5.5

66.5

7

7.58

8.5

Chocola

te S

hake

Pizza

White

Bre

ad

Chocola

te C

ake

Peaches in

Syr

up

Gravy

Min

ced B

eef

Lik

ing

Unlabelled Labeled as Institution Actual


Hospitals

Hospital food often has a poor image, even before entering hospital, patients generally anticipate poor quality and low acceptance.

200 out of 500 patients were undernourished on admission and 75%

had lost weight while in hospital

McWhirter & Pennington (1994)


The Challenge of Hospital Foodservice

• Unwilling customers• Customers anxious, frightened, removed from

security of home• Alien environment, surrounded by strangers• Loss of privacy• Surrounded by ‘superior’ knowledgeable staff• Eating needs have to fit in with medical routine• Unnatural eating position• Meal times imposed• Menu choice made early


The NHS hospital is an 842 acute

bed site, serving approximately

800 meals at each main mealtime.


Study Design

• Collect food consumption data for a period of 3 consecutive days (n=279) Collect food consumption data for a period of 3 consecutive days (n=279) from a plated and bulk system of foodservice deliveryfrom a plated and bulk system of foodservice delivery

• Questionnaires/interviews conducted to collect the perceptions and Questionnaires/interviews conducted to collect the perceptions and expectations of patients (n=615)expectations of patients (n=615)

• Interviews and focus groups conducted with stakeholders in hospital food Interviews and focus groups conducted with stakeholders in hospital food service - medical staff, caterers, dietitians, hospital managers, service - medical staff, caterers, dietitians, hospital managers, patients/visitors, pharmacy, ward hostesspatients/visitors, pharmacy, ward hostess

• Participant observation as a ward hostessParticipant observation as a ward hostess


Data Collection - Plated meal system


Data Collection - Bulk trolley system


Nut

ritio

nal I

ntak

e Nutrient/day Male Age Range 54-86 yrs Female Age Range 34-89 yrs Recommended/

day Plate system

( n = 8)

Bulk system ( n = 9 )

Recommended/day

Plate system

( n = 23 )

Bulk system ( n = 22 )

Energy (kcal)*

50-59yr 2550 60-64yr 2380 65-74yr 2330 75+ yr 2100

1308 299

1184 331

19-49yr 1940 50-74yr 1900 75+ 1810

1309 399

1134 252

Energy (MJ)* 50-59yr 10.60 60-64yr 9.93 65-74yr 9.70 75+ yr 8.77

5.5 1.2

5.0 1.4

19-49yr 8.10 50-74yr 7.96 75+ 7.61

5.5 1.7

4.8 1.0

Protein (g)* 53.3

51 15 50 13.5 46.5 48.3 13 45.1 13

Fat (% Energy)*

35 38 35 35 39 38

CHO (% Energy)*

50 50 51 50 50 49

Vitamin C (mg)**

40 78 42 64 29 40 94 68 75 23

Iron (mg)** 8.7 7.0 2.0 7.3 2.5 19-50yr 14.8 50+yr 8.7

7.0 2.1 7.4 2.4

Folate (g)** 200

139 45 144 67 200 153 49 145 47

*Recommendations from Dietary Reference Values(Department of Health 1991) **Recommendations from The Nutritional Guidelines for Hospital Catering (Department of Health 1995) Estimated Average Requirement (EAR) with PAL=1.4 Reference Nutrient Intake (RNI)


Plated system Trolley system Plate Kitchen Plate Trolley

11.6% None - food remaining sentto staff restaurant

5.9% 20.5%

Food Wastage According to Meal Service System


Pat

ient

Sat

isfa

ctio

n Plate

system

Trolley system

Items Mean Mean Before: meal experience (Expectation)

How much are you looking forward to your meal? 4.51 4.91* How appealing do you think that the meal will be? 4.81 4.77

How tasty do you think the food will be? 4.8 4.87 How satisfied do you expect to be with your meal? 5.01 5.11

After: meal experience (Perception) How well did the portion size match expectation? 5.54 5.85 *

How would you rate the presentation of your meal? 5.14 5.58 * How appealing was the meal? 4.58 5.27 *

Were the food items served at the correct temperature? 1.21 1.86 * How tasty was your food? 5.05 5.60 *

How satisfied were you with your meal? 5.10 5.72 * How happy were you with the choice available? 5.14 5.03

How would you rate the overall standard of catering in this hospital?

5.85 6.75 *

* denotes significant difference (p<0.05) (1=highly negative response to 7/9=highly positive response)


• Patient expectation/perception

• Empathy and emotional support from staff


Study Design

Imagine this menu was presented for you to choose from for tomorrow. Please make a choice from each course on the following

sample menu;Starter

Tomato Soup Chefs Special hearty Tomato Soup

Heinz Tomato SoupMain Course

Youngs Fish Pie Fish Pie

Locally caught Fish PieDessert

Cadburys Chocolate Sponge and Cadburys Chocolate Sauce

Legendary Chocolate Sponge and Chocolate Sauce

Chocolate Sponge and Chocolate Sauce

Hartwell, H, and Edwards, J.S.A (2008) Descriptive menus and branding in hospital foodservice – a pilot study. International Journal of Contemporary Hospitality Management, (in press)


Results – issues of importance

Male mean Female mean

Hospitals provide a healthy and nutritious meal 4.3 I prefer food that I am familiar with 4.5

The ingredients in foods are important to me 4.3 The ingredients in foods are important to me 4.4

I prefer food that I am familiar with 4.2 Hospitals provide a healthy and nutritious meal 4.1

It is important to me where the ingredients have come from

4.1 It is important to me where the ingredients have come from

3.8

The majority of menu choices are appealing to me 4.0 The majority of menu choices are appealing to me 3.6

I would like to know more about the dishes on the menu

3.5 I would like to know if any brands of foods are used on the menu

3.6

During the production process branded foods are produced professionally and with care

3.5 I would like to know more about the dishes on the menu

3.5

I would like to know if any brands of foods are used on the menu

3.4 Basic dish descriptions do not help my decision in choosing an item from the menu

3.2

The ingredients in popular branded foods are of a higher quality when compared to unbranded food products

3.0 During the production process branded foods are produced professionally and with care

3.1

I would like to see more familiar brands 2.8 I would like to see more familiar brands 3.0



Discussion


Discussion


Study Design

Profile accumulation technique (PAT):

• The best things about...are...

• The reasons why they are best are…

• The things that are not so good about...are...

• The reasons why they are not so good are…

• 41 usable forms obtained, mostly self-filled, 6 completed by amanuensis.

Johns N, Hartwell H and Morgan M (2009) Evaluating the patient experience: using Profile Accumulation Technique (PAT)


PROFILE OF RESPONDENT COMMENTS

0

5

10

15

20

25

30

35

40

45

50

Foods &food quality

Choice Servicestaff

Being caredfor

Timing &routine

Meals &lifestyle

Relativefood quality

Servicequality

Foodquantity

Relativeservicequality

Positive items

Negative items


‘…what we need is basic care, the food that we want, it should be hot, it should be well presented and well cooked. If we don’t eat we will be in hospital for longer and all we want to do is go home’ – patient


Prison Foodservice in Prison Foodservice in EnglandEngland

Edwards, J.S.A., Hartwell, H.J., Reeve, W.G. and Schafheitle, J. (2007). The diet of prisoners in England. British Food Journal. 109(3). 216-232.


The Challenge of Prison Foodservice

• Relieves boredom and monotony of a routine existence

• Catalyst for aggression, particularly at meal times

• Obvious/easy target and vehicle for complaints

• Used as a currency and to barter on the ‘underground economy’

• Used to bully and influence


Study Design

Random

Kitchen/service area observation

3-days data from cyclical menus

Standard recipes & menus

Unstructured interviews

Prison SelectionPrison Selection

Data collection Data collection

methodsmethods

4 Male Prisons2 Female Prisons2 Young Offenders Institutes

1 Private Contract


The Prison Menu

Food Quantity

Breakfast cereal (various) Various (± 30g)

Full fat milk 284 g

Tea bags 13 g

Coffee whitener 10 g

Sugar, white 20 g

Brown or white bread 2 slices

Jam 25 g

Spread 10 g

Typical Breakfast Meal


The Prison Menu

Typical Midday & Evening Meals

Day Midday Evening

Day 1 Vegetarian Pasta BakeChicken & Mushroom PieHalal Jamaican Beef PattiCorned Beef & Pickle RollJacket Potato & Coleslaw

Vegetable SupremeChicken SupremeHalal Chicken CurryGrilled GammonPork Pie Salad

Day 2 Vegetable Pancake RollBreaded fishCheese & Beano GrillCheese & Tomato RollJacket Potato & Tuna

Bean & Vegetable CurryChicken ChasseurHalal Beef CasseroleFish in Parsley SauceVegetable Quiche Salad


Food Preparation

Staffing

Prison officers – Both uniformed and civilian

Prisoners –

Cooks

‘Specialist’ cooks

Kitchen porters

ServicePrison officersPrisoners


Food Consumption


Nutritional Intake

Nutrient UnitStandard

MaleDiet

Recom-mend-ations

Standard Female

Diet

Recom-mend-ations

StandardYOIDiet

Recom-mend-ations

Mean SD Mean SD Mean SD

Energy kcal 3042 87 2550 3007 471 1940 3115 561 2755

MJ 12.80 0.37 10.6 12.64 1.96 8.1 13.13 2.53 11.51

Protein g 104.6 7.4 55.5 98.1 5.2 45 98.4 5.4 55.2

Total Fat g 119.2 3.2

130.9 30.1 108.3 32.2

Carbohydrate g 413.9 18.2

385.5 44.8 465.6 78.8


Macronutrient Contribution

0 5 10 15 20 25 30 35 40 45 50 55 60

Study 2 S

tanda

rd Y

OI Diet

Study 2 S

tanda

rd F

emale Diet

Study 2 S

tanda

rd M

ale Diet

Study 1 S

tanda

rd M

ale Diet

Carbohydrate of which Saturated Fat Total Fat

%



0 5 10 15 20 25 30 35 40 45 50 55 60

Study 2 S

tanda

rd Y

OI Diet

Study 2 S

tanda

rd F

emale Diet

Study 2 S

tanda

rd M

ale Diet

Study 1 S

tanda

rd M

ale Diet


%



0 5 10 15 20 25 30 35 40 45 50 55 60

Study 2 S

tanda

rd Y

OI Diet

Study 2 S

tanda

rd F

emale Diet

Study 2 S

tanda

rd M

ale Diet

Study 1 S

tanda

rd M

ale Diet


%


Sodium Intake

Nutrient Unit

Study 1Standard

MaleDiet

Study 2Standard

MaleDiet

Study 2Standard FemaleDiet

Study 2Standard

YOIDiet

Recom-mend-ations

Mean SD Mean SDMea

n SD Mean SD

Sodium mg4096 1286 4534 847 4208 268 3912 706 1600

Salt 10.4g 11.6g 10.7g 10.0g 6.0g


Menu Balance

• Healthy options

• Able to select a range of meals

• Similar to WW2 diet• Monotony-repetition

• Fruit

• Vegetables


Prisoners are provided with a high standard of food, which with some exceptions, enables them choose a healthy, nutritionally balance diet; which in the main they do.

Prisons have attempted to provide meals which conform with the balance of good health.


Hospital or Prison?


Foodservice and Applied Foodservice and Applied Nutrition Research GroupNutrition Research Group

John S.A. Edwards,John S.A. Edwards,PhD., Dr honoris causa (Örebro University, Sweden)

Professor of Foodservice

Heather J. Hartwell, Heather J. Hartwell, PhD., Registered Nutritionist

Www.bournemouth.ac.uk Hungry in hospital; Healthy in prison? H.J. HARTWELL and J.S.A. EDWARDS The Foodservice and Applied Nutrition Research Group, School.

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