Hungry in hospital; Healthy in prison? H.J. HARTWELL and J.S.A. EDWARDS The Foodservice and Applied Nutrition Research Group, School of Services Management, Bournemouth 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 extremely 5 = Neither dislike nor like 9 = Like extremelyHome Restaurant Restaurant – traditional and fast foodAirlineSchoolMilitaryHospital

Institutional Stereotyping Home Home (Cardello et al, 1996) Full-service Restaurant Fast Food School Food Service Military Food Service Airline Food Service Hospital Food Service Acceptability

Institutional Stereotyping Institutional Stereotyping

Institutional Stereotyping Institutional Stereotyping

Institutional Stereotyping Institutional Stereotyping

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) from a plated and bulk system of foodservice delivery Collect food consumption data for a period of 3 consecutive days (n=279) from a plated and bulk system of foodservice delivery Questionnaires/interviews conducted to collect the perceptions and expectations of patients (n=615) Questionnaires/interviews conducted to collect the perceptions and expectations of patients (n=615) Interviews and focus groups conducted with stakeholders in hospital food service - medical staff, caterers, dietitians, hospital managers, patients/visitors, pharmacy, ward hostess Interviews and focus groups conducted with stakeholders in hospital food service - medical staff, caterers, dietitians, hospital managers, patients/visitors, pharmacy, ward hostess Participant observation as a ward hostess Participant observation as a ward hostess

Data Collection - Plated meal system

Data Collection - Bulk trolley system

Nutritional Intake

Patient Satisfaction

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 Soup Main Course Youngs Fish Pie Fish Pie Locally caught Fish Pie Dessert 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 MalemeanFemalemean Hospitals provide a healthy and nutritious meal4.3 I prefer food that I am familiar with 4.5 The ingredients in foods are important to me4.3The ingredients in foods are important to me4.4 I prefer food that I am familiar with4.2Hospitals provide a healthy and nutritious meal4.1 It is important to me where the ingredients have come from 4.1It is important to me where the ingredients have come from 3.8 The majority of menu choices are appealing to me4.0The majority of menu choices are appealing to me3.6 I would like to know more about the dishes on the menu 3.5I 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 3.5I 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 3.4Basic 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 3.0During the production process branded foods are produced professionally and with care 3.1 I would like to see more familiar brands2.8I would like to see more familiar brands3.0

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

…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 dont eat we will be in hospital for longer and all we want to do is go home – patient

Prison Foodservice in England 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)

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 Selection Data collection methods methods 4 Male Prisons 2 Female Prisons 2 Young Offenders Institutes 1 Private Contract

The Prison Menu FoodQuantity Breakfast cereal (various)Various (± 30g) Full fat milk284 g Tea bags13 g Coffee whitener10 g Sugar, white20 g Brown or white bread2 slices Jam25 g Spread10 g Typical Breakfast Meal

The Prison Menu Typical Midday & Evening Meals DayMiddayEvening Day 1Vegetarian Pasta Bake Chicken & Mushroom Pie Halal Jamaican Beef Patti Corned Beef & Pickle Roll Jacket Potato & Coleslaw Vegetable Supreme Chicken Supreme Halal Chicken Curry Grilled Gammon Pork Pie Salad Day 2Vegetable Pancake Roll Breaded fish Cheese & Beano Grill Cheese & Tomato Roll Jacket Potato & Tuna Bean & Vegetable Curry Chicken Chasseur Halal Beef Casserole Fish in Parsley Sauce Vegetable Quiche Salad

Food Preparation Staffing Prison officers – Both uniformed and civilian Prisoners – Cooks Specialist cooks Kitchen porters Service Prison officers Prisoners

Food Consumption

Nutritional Intake NutrientUnit Standard Male Diet Recom- mend- ations Standard Female Diet Recom -mend- ations Standard YOI Diet Recom- mend- ations MeanSD MeanSD MeanSD Energykcal MJ Proteing Total Fatg Carbohydrateg

Macronutrient Contribution

Macronutrient Contribution

Macronutrient Contribution

Sodium Intake NutrientUnit Study 1 Standard Male Diet Study 2 Standard Male Diet Study 2 Standard Female Diet Study 2 Standard YOI Diet Recom- mend- ations MeanSD MeanSD Mea nSD MeanSD Sodiummg Salt 10.4g11.6g10.7g10.0g6.0g

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 Nutrition Research Group John S.A. Edwards, PhD., Dr honoris causa (Örebro University, Sweden) Professor of Foodservice Heather J. Hartwell, Heather J. Hartwell, PhD., Registered Nutritionist