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Mal J Nutr 26(2): 141-155, 2020
Development of a tool to measure patients’ satisfaction
of hospital foodservice in a government hospital
1 1* 1
Mariem Boughoula , Rosita Jamaluddin , Nurul Aqmaliza Abd Manan , Hazizi
1 2
Abu Saad & Muhammad Sharim Ab Karim
1
Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences,
2
Universiti Putra Malaysia, Selangor, Malaysia; Department of Food Service and
Management, Faculty of Food Science and Technology, Universiti Putra Malaysia,
Selangor, Malaysia
ABSTRACT
Introduction: Dissatisfaction towards the quality of foodservice can affect several
important aspects such as nutritional intake and financial burden. The effect of
dissatisfaction towards nutritional aspect can be observed via a decline in dietary
intake. Therefore, reliable and valid questionnaires are important to measure
patients’ satisfaction with hospital foodservice. The main purpose of this study
was to investigate the construct validity and reliability of a developed questionnaire
in a local setting. Methods: A questionnaire adapted from previous studies and
consisting of 27 statements from four dimensions, was administered to a total of
277 hospitalised patients in a government hospital. Factor analysis and reliability
analysis were conducted using SPSS version 25. Results: Principal component
of factor analysis revealed that the final questionnaire contained four main
foodservice dimensions, namely food properties, staff and meal service reliability,
customisation, and physical and social aspects. The reliability analysis revealed
that the Cronbach’s alpha value ranged from 0.55 to 0.84 for these foodservice
dimensions. The analysis showed that the alpha value differed from one dimension to
another such as food properties (α=0.84), staff and meal service reliability (α=0.67),
customisation (α=0.69) and physical and social aspects (α=0.55). Conclusion:
Twenty-seven questionnaire items were retained because their factor loadings were
greater than 0.35. Therefore, the questionnaire on patients’ satisfaction towards
hospital foodservice was considered reliable and valid. The classification of the four
dimensions provided detailed information of the satisfaction level, relationship and
influence on the foodservice dimensions, which contributed to satisfaction towards
hospital foodservice.
Keywords: Patients’ satisfaction, hospital food, hospital foodservice, reliability,
validity, factor analysis
INTRODUCTION 2002). The term satisfaction can be
The importance of patients’ satisfaction defined as the experience of a customer
towards foodservice stems from its ability using a service and can evoke positive
to influence the overall satisfaction on feelings (Namkung & Jang, 2007). In
hospital care quality (Demir & Celik, health care service, patients’ satisfaction
__________________________
*Corresponding author: Associate Professor Dr. Rosita Jamaluddin
Faculty of Medicine and Health Sciences, Department of Nutriton and Dietetics,
Universiti Putra Malaysia, Serdang, Selangor, Malaysia
Tel: (6)(03)89472467; Fax: (6)(03)89426769; E-mail: rositaj@upm.edu.my
doi: https://doi.org/10.31246/mjn-2019-0047
142 Boughoula M, Jamaluddin R, Abd Manan NA et al.
can also be defined as an evaluation of service were responsiveness, assurance,
a patient’s experience of health care reliability, empathy and tangibility.
services via their cognitive and emotional However, because it was derived from a
reactions (Keegan & McGee, 2003). From service/hospitality setting rather than
the definition, satisfaction is always a healthcare setting, SERVQUAL failed
related with service. Thus, this indicates to produce clear dimensions for hospital
that a strong relationship exists between service because the evaluation of
patients’ satisfaction and health care hospital service by patients is different
service, especially foodservice (Wright, when compared with customers from
Comelly & Capra, 2006). other service industries (Babakus &
Modernisation of the healthcare Mangold, 1991; Johns & Howard, 1998).
industry has shown many improvements Shortly after SERVQUAL was
in almost every aspect of the component. developed, Deluco & Cremer (1990)
In a hospital setting, the foodservice conducted a telephone interview with
department often undergoes upgrading 223 randomly selected adults in Ohio
in almost every aspect to improve to determine consumers’ perceptions
quality, as well as patients’ satisfaction. on the quality of hospital foods, food-
The influence of patients’ satisfaction related service, clinical service, and
towards foodservice affects the overall their importance. Four years later, Dube
satisfaction towards hospital care et al. (1994) developed a questionnaire
quality (Ganasegeran et al., 2015). to determine the overall satisfaction
Several studies have shown that the with meals and with foodservice, and
satisfaction towards hospital foodservice satisfaction with 26 specific foodservice
is influenced by different factors such as attributes. Food quality was the main
food quality, interpersonal dimension, predictor of the survey. Seven dimensions
and physical environment (Naithani representing patients’ perceptions of
et al., 2009; Hartwell, Edwards & foodservice were identified: food quality,
Symonds, 2006; Stanga et al., 2008). The service timeliness, service reliability, food
measurement of patients’ satisfaction temperature, attitude of the staff who
becomes an important tool to measure deliver the menus, attitude of the staff
the quality given to patients. However, who serve the meals, and customisation
the measurement of satisfaction in a (Dube et al., 1994).
hospital setting is difficult to analyse The Acute Care Hospital Foodservice
because it involves the degree of feeling Patient Satisfaction Questionnaire
towards a service and is influenced by (ACHFPSQ) developed by Capra et al.
other factors. (2005) was the first reliable and valid
There are various tools often used questionnaire to measure patients’
to measure patients’ satisfaction with satisfaction towards hospital foodservice
hospital food or foodservice. (Deluco (Capra et al., 2005). The questionnaire
& Cremer, 1990; Dube, Trudeau & was initially developed to measure
Belanger, 1994; Capra et al., 2005). patients’ satisfaction with acute care
The earliest tool used to evaluate the hospital foodservice and contained
satisfaction towards a service is the 16 statements relating to four factors
Service Quality (SERVQUAL) model. This describing food quality, meal service
model rose from a study by Parasuraman, quality, staff/service issues and physical
Zaithaml & Berry (1988) in which environment (Capra et al., 2005). Since
the tool stated that the dimensions then, the tool had been used widely
of customer satisfaction towards a to measure patients’ satisfaction with
Patients’ satisfaction towards hospital foodservice 143
hospital foodservice because it was MATERIAL AND METHODS
considered to be a comprehensive and Study design and data collection
complete tool. This is a cross-sectional study that
Numerous satisfaction surveys had was conducted in a 620-bed urban
been performed in Malaysia. However, the government hospital in Malaysia. The
results of these studies were too general duration for data collection for this
without studying the actual causes that study was three months. Prior to data
contribute to dissatisfaction towards collection, permission was obtained from
foodservice. This study will identify the the Ministry of Health (MOH) Malaysia
actual factors that are associated with and the Director of the hospital. Ethical
dissatisfaction in hospital foodservice. approval was granted by the Medical
The importance of this tool is that it Research Ethics Committee of the MOH
can be useful for assessing the level of Malaysia and the Medical Research
satisfaction towards hospital foodservice, Ethics Committee of the Faculty of
as well as patients’ perceptions towards Medicine and Health Sciences, Universiti
hospital meals. Dietitians can use the Putra Malaysia. Data collection involved
results obtained as a reference to improve hospitalised patients who fulfilled the
or modify any part of the foodservice inclusion criteria. Patients were recruited
components in order to enhance the based on the following inclusion criteria:
quality of hospital meals and to create consumed normal diet from hospital,
a positive perception among patients stayed at least two days in the ward
towards hospital meals, resulting in and able to give solid opinion. However,
an increase in food consumption. This patients were excluded from the study
research will create awareness among if they consumed therapeutic diet,
hospital foodservice personnel on the received enteral or parenteral nutrition,
actual foodservice dimensions that nil by mouth, and/or were unable to
influence food intake. Thus, the specific communicate well. The collected data
dimensions identified can ensure that were patients’ specific characteristics
meals provided meet the requirement (age, gender), and questionnaire
for patient recovery. In addition, the tool on patients’ satisfaction towards
will hopefully enable these personnels foodservice. A total of 562 respondents
to address issues pertaining to the high were interviewed. Out of that, 285 were
volume of food wastage. Data from this unable to complete the questionnaire
study can be used as baseline for further due to various reasons. As a result, only
research regarding hospital foodservice 277 respondents successfully completed
systems. the questionnaire. Approximately 116
The tool used in this study was patients were in second-class wards,
based on international studies and the while 161 were in third-class wards.
questions were modified to fit the local
hospital setting. There is no published Measurements
evidence that the tool used is valid and In this study, the satisfaction of
reliable for hospital setting in Malaysia. respondents towards hospital
Hence, this study was conducted to foodservice was measured using a
determine the construct validity and questionnaire adapted from studies by
reliability of the questionnaire using Capra et al. (2005), Hartwell, Edwards
factor analysis and reliability analysis.
144 Boughoula M, Jamaluddin R, Abd Manan NA et al.
& Beavis (2007), Hwang & Desombre questions in the staff issue dimension.
(2003), O’Hara et al. (1997), and Dube The questions were related to courtesy
et al., (1994). Initially, there were five and attitude of the staffs, punctuality
dimensions and a total of 31 items applied of the staff who served the food and
and used to measure the satisfaction other related questions. There were
level among hospitalised patients. seven questions in the dimension of
Quality of food is an important timeliness and reliability. The questions
dimension because this factor normally were mostly related with the suitability
gives a major influence on patients’ of mealtimes and the time provided
satisfaction during hospitalisation to finish the foods. The meal service
(Dube et al. 1994; Lau & Gregoire dimension had three questions and most
1998; Wright et al., 2006). In addition, of them were related with the quality of
according to previous literatures, the cutlery and crockery, and options given
interaction or communication between to patients. The last dimension was the
staffs and patients also influences environmental presentation containing
the satisfaction towards foodservice two questions in this dimension. The
(Dubé et al., 1994). The delay in food questions were related with the smell
delivery and serving by service staffs and noise of the ward.
can make patients less satisfied towards Items labelled as FQ1, FQ2, FQ3,
the quality of service (Stanga et al., FQ4, FQ7, FQ9, FQ10, FQ11, FQ12, SI1,
2003). Some studies suggested that SI2, SI4, MS1, MS2, PE1 and PE2 were
interpersonal or service aspects were the adapted from Capra et al. (2005), FQ5
most significant in contributing towards and FQ6 were adapted from Hartwell
patients’ satisfaction (Deluco & Cremer, et al. (2007), eight items labelled as
1990; Hartwell et al., 2007). Physical FQ13, FQ14, TR5, TR6, TR7, SI3, S15
environment factors, such as smell, and MS3 were adapted from Hwang &
colour, lighting and ambient temperature, Desombre (2003), while only four items
eating location and social variables can labelled as TR1, TR2, TR3 and TR4 were
also affect patients’ perceptions towards adapted from Dube et al. (1994), and an
hospital foodservice (Capra et al., 2005; item labelled as FQ8 was adapted from
Hartwell et al., 2006). Finally, other O’Hara et al. (1997).
important foodservice dimensions are The questions were modified to fit the
timeliness and reliability. Dubé et al. hospital setting as presented in Table 1.
(1994) stated that timeliness is related To measure satisfaction towards these
with the duration for eating and the time foodservice dimensions, a five-point
for staff to pick up the tray, whereas Likert scale was used as previously
reliability is more related to punctuality done by Capra et al. (2005). The scale
of the foodservice and service hours. was coded as “strongly dissatisfied”,
Based on the literature discussed “dissatisfied”, “average”, “satisfied” and
previously, five dimensions were “strongly satisfied”. The lowest value was
selected as follows: 1. Food quality, 2. coded as “strongly dissatisfied,” while
Timeliness and reliability, 3. Staff issue the highest value was coded as “strongly
4. Meal service quality and 5. Physical satisfied”. A score was given based on
environment. There were fourteen the answer - strongly dissatisfied was
questions in the food quality dimension. scored as 1, dissatisfied was scored as
The questions were related with food 2, average was scored as 3, satisfied
texture, quality of fish and meat, was scored as 4 and strongly satisfied
temperature, food flavour and other was scored as 5. The composite score,
food quality attributes. There were five that is the sum of all dimension scores,
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