Diet satisfaction and associated factors among adult surgical orthopaedic inpatients at a teaching hospital in Lusaka province, Zambia; a hospital-based cross-sectional study

Orthopaedic injuries are common globally, affecting hundreds of millions of people [1]. According to literature, the global burden of orthopaedic injuries will continue to grow. In 1998 and 2001, injuries accounted for 16 and 11% respectively of the world’s disease burden [2]. Literature indicates that the prevalence of general disability associated with orthopaedic incidents is highest in sub-Saharan Africa [3, 4]. The most prevalent orthopaedic conditions are those associated with fractures, dislocations and sprains [4]. Most orthopaedic victims seek medical treatment in hospitals, where they may be admitted and become entirely or partially dependent on hospital meals. The goal of any service institution is to satisfy the needs of its’ clients. When patients visit hospitals, they have expectations that can either be met or not [5]. In both developed and developing countries, quality of food in hospitals is a common problem that contributes to low diet satisfaction [6]. One of the major challenges facing hospital administrators is the provision of quality meals that meet the expectations of patients [7].

Patients who are dissatisfied with hospital meals are likely to develop malnutrition due to reduced food intake [8–10]. However, improvement in the quality of food services is one of the strategies that can contribute to quick recovery of inpatients [11]. Moreover, improved food services have the capacity to influence nutritional status, which in turn is directly related with healing outcomes [12, 13]. According to published literature, quality of food in hospitals is also significantly associated with overall patient satisfaction [14]. There are multiple factors that contribute to satisfaction and one important predictor is the patients’ relationship with food [15]. Studies report that patient satisfaction is one of the recognized indicators that can be used to assess the quality of hospital food [6, 11, 12].

A study done in Saudi Arabia reported that 78.8% of the patients were satisfied with quality of hospital food [6]. A similar study conducted in Malaysia reported that although only 6.3% of the patients were not happy with hospital food, more than 50% of them supplemented hospital meals with outside food [8]. Despite most of the patients being satisfied with hospital food, a study in India indicated that 38.3% of them were dissatisfied with a monotonous diet [11]. However, results of a study in Greece suggested that most of the patients were satisfied with variety and quality of hospital meals [13]. In spite of the fact that most studies elsewhere report that patients are satisfied with overall food services, levels of satisfaction with specific diet elements may vary from country to country. There is paucity of information in developing countries such as Zambia on diet satisfaction of inpatients. Therefore, the purpose of this study was to evaluate diet satisfaction among adult surgical orthopaedic patients and establish associated factors. Results of this study may help identify gaps in meal provision and thereby contibute to formulation of policy aimed at improving the quality of hospital meals.

Results of this study suggest that most of the participants were not satisfied with the overall quality of hospital meals. This is in contrast to the findings of a study conducted in India, which reported that majority of the patients were satisfied with hospital food [25]. However, study conducted in Kenya found that majority of the respondents rated food services as average [25]. Other studies conducted in Saudi Arabia and Egypt have reported that more than half of patients interviewed were satisfied with hospital food [6, 26]. Possible reasons for the variation in satisfaction is that each hospital offers a unique menu, the target population, methodological influences and individual values of patients may vary [6, 24]. Further, unlike our study, the studies done in Kenya and Egypt did not target patients with one medical condition [6].

The role played by the Dietetics and Catering Departments in the provision of therapeutic and regular diets to inpatients is very important [27]. This is because the care and recovery of patients is significantly influenced by sound dietary and meal services [24]. It is important for dietitians and nutritionists to be concerned not only with nutrient intake but also other aspects of hospital food that may affect dietary adequacy of inpatients. An important aspect of food services that is worth investigating is diet satisfaction. Satisfaction is a valid measure used to assess quality of service delivery in hospitals [6].

One major finding of the current study is that nearly all (96.9%) patients were dissatisfied with the variety of food at the hospital. This finding is supported by the report from a relevant foodservice officer who disclosed that the major challenge faced by the catering department is lack of variety in the hospital menu. A similar study in a government hospital in India reported that the major aspect attributed to dissatisfaction was monotony of hospital food [7]. Another study done in Bangladesh reported that meals provided to the hospital were not wholesome [10]. However, our finding is in contrast to those of a study in Greece that reported that most of the patients were pleased with the variety of hospital meals [13]. The possible explanation for lack of variety in hospital menus is that funding to the catering department may differ based on a country’s hospital food policies. In addition, variation in hospital menus may be influenced by the importance hospital managers attach to patients’ nutritional status and its impact on clinical outcomes.

This study found that patients were happy with aspects of portion size, temperature and time of meal distribution. The findings of our study are supported by a study in India which indicated that patients were pleased with portion size and time of meal distribution [24]. A similar study in Saudi Arabia suggested that majority of the patients were satisfied with amount, temperature and time of meal distribution [6]. However, a study done in Greece reported that patients were not happy with the temperature at which food is served [13]. Variations in satisfaction on variables of temperature and time of meal distribution maybe explained by the type of food service system available in a hospital. For example, to assure that food is hot, the system used at the teaching hospital is to serve it as soon as possible while the food is still covered in buckets.

Findings of the current study indicate that there was no significant association between patient specific characteristics such as age, sex, length of hospital stay and overall satisfaction (p > 0.05). Similar to our study results, a study in Saudi Arabia reported age and sex as insignificant variables affecting patient satisfaction [6]. A study in Kenya suggested that age was not a predictor of patient satisfaction [28]. On the other hand, studies in Sri Lanka and Kuwait suggested that satisfaction was influenced by age [29, 30]. Studies that include younger persons and older persons in most cases report an association between age and overall satisfaction. Therefore, the composition of the study population may to some extent explain the differences in findings.

Improvement in the quality of food services is one of the strategies that can contribute to quick recovery of inpatients [11]. Moreover, improved food services have the capacity to influence nutritional status and length of stay of inpatients [12, 13]. Contrary to the results of the current study, a similar study reported a correlation between length of stay and overall satisfaction [11]. However, results of a study in a military hospital reported a significant negative relationship [29]. Results suggested that the longer patients stay in hospital, they become dissatisfied with the hospital environment [31]. The observation seems not to agree with our findings perhaps because of the sample size and specific patient group included.

A study in Kenya reported that education level influenced overall satisfaction with food services [28]. The study suggested that patients without formal education were more satisfied with food services than those with tertiary education [28]. Literature documents that patient satisfaction with hospital food is influenced by factors such as patient’s education and perceived need of nutrition care [32]. A study in India reported higher levels of satisfaction among patients with high income [29]. This was in contrast to the findings of a study in Saudi Arabia that documented low monthly income as being significantly associated with higher levels of satisfaction [6]. In tandem with the findings of another study in Kenya, our study found no significant association between education level, monthly income and diet satisfaction [26].

Although most of the patients may not have been satisfied with overall quality of hospital food, they were satisfied with aspects of portion size, temperature, and time of meal distribution. Therefore, the patients did not negatively evaluate all aspects of hospital food. In spite of the weaknesses highlighted, the findings of this study are helpful in resource-poor settings like Zambia to help identify gaps in the quality of hospital meals. In order for the hospital to met the expectations of orthopeadic patients, gaps in the food service system such as absence of a fixed menu and lack of certain food groups in the menu should be addressed. The findings of the study may influence policy direction to increase funding towards improvement of quality of regular meals and thus meet the expectations of hospitalized patients.