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ORIGINALS

Diversity and diet in hospital. Design of a questionnaire on assessment of cultural adaptation*

María Dolores Cano-Caballero Gálvez,¹ María Martínez Pozo,² María Angustias Lazuen Alcón,³ Guillermina Urbano García^2
1Licenciada en Antropología, Diplomada en Enfermería, Profesora de la Escuela Universitaria de Enfermería Virgen de las Nieves, Granada, España. ²Diplomada en Enfermería, Enfermera del Hospital Universitario San Cecilio, Granada, España. ³Licenciada en Antropología, Diplomada en Enfermería. Enfermera del Hospital Universitario San Cecilio, Granada, España

Manuscript received by 9.04.2007
Manuscript accepted by 18.07.2007

Index de Enfermería [Index Enferm] 2008; 17(2): 87-91
*This study was financied by the Consejería de Salud of the Junta de Andalucía, Spain

How to cite this document

Abstract

A reality nowadays is the increase of immigrant population in hospitals so, we must adapt, our attentions, as nurses, to the necessities of the patients we care for. Objectives: to assess the possibilities of introducing participative methodology in order to face social-health problems within the frame of a health institution; to assess the capacity of hospital nursing Units in order to introduce culturally adapted attentions; to design and introduce assessments of the patient's cultural adaptation levels regarding diet in the nursing registers.
A methodology based on action-participation was used, where actors became active participants in the research. On the one hand, the collaborators of the current study were immigrants, who had told us about their experiences with hospital diet. Methodology was based on discussion groups and they participated in workshops celebrated in the hospital kitchen as experts in the elaboration of the most representative dishes of their culture. On the other part, some nurses were asked to participate in carrying out the questionnaire on cultural adaptation regarding diet, a participation that was validated afterwards. Finally, kitchen staff also collaborated in these activities.
Groups of immigrants allowed us to get closer to their experiences regarding diet, and also to learn in the workshops how to prepare traditional dishes of their countries of origin. Nurses and specialists collaborated through focal groups to find variables that could determine the degree of cultural adaptation of the person we were caring for. It is not yet easy to introduce changes in hospitals to achieve that attentions will be adapted to other cultures. The incorporation of assessment scales on cultural adaptation can be a first resource for nurses to get aware of the cultural differences of the population they are caring for.
Key-words: Diet. Cultural Diversity. Questionnaire on Assessment. Cultural Adaptation. Immigrant population. Participative research.

Introduction

    Nutrition is a physiological activity that is defined within its social-cultural scope and contains a biological aspect (nourishing), a psychological one (appetite) and asocial one (symbolic potential), with a capacity of conditioning substantially many of our daily experiences and even of giving them sense.¹ From the point of view of anthropology, nutrition was analysed as a social and cultural fact; ingredients and cooking techniques have often been associated to representations, beliefs and practices, both material and symbolic (structuralism) that, in addition to meeting biological needs, they meet social needs (functionalism). We must bear in mind the temporal and spatial nature of this fact in the frame of dynamics of behaviour of the groups and the social economical situations.² A strong-based gastronomy always has to observe supra-biological food factors, such as the biological and cultural ones, not forgetting the scientific criterion offered by dietetics.³
    One of the social changes we are currently experiencing in Spain and Andalusia is immigration, a fact that is reflected in hospitals according to the increase of patients coming from different cultures. This situation has to encourage us, health professionals to introduce changes in the attention and cares strategies of this social group.^4-6 Nursing, as a profession, has to confer a humanistic dimension to nursing cares, as it fosters the discovery of a cultural perspective of individuals.^7,8 Immigration is a new reality and the hospital has to show itself sensitive in front of this phenomenon. As M. Lininger proposes,^9,10 we have to adapt our attentions to the cultural features of the people we are caring for; diet allows us to know about these differences and may be a good resource for a first approach. Another important support in our research was the prospect of action-participation method,¹¹ by which, we aimed to know "other people's" perspective, letting them share the results of the research. The participants in the research became transmitters of this process by building a place for dialogue between subjects.¹² We try actors in this study to become protagonists. Their opinions and contributions have been essential for the development of the current research.
    The objectives of the current study were: to know about the possibilities of introducing participative methodology to deal with social-health problems in a health institution; to assess the capacity of Hospital Nursing Units to introduce nursing cares culturally adapted; and to design and introduce in the nursing registers the assessment of the level of cultural adaptation of the patient in matters of diet.

Methodology

    The study design was based on a participative research where immigrants, nurses and kitchen professionals took part. Such methodology refers to specific procedures to carry on with a research that diverges from traditional approaches. We took into account the perspectives and subjectivity of the individuals involved in order to elaborate both the menus that were to be prepared in the workshops and the questionnaire of assessment.
    The institution selected for the current study was University Hospital "San Cecilio"; in Granada, in the internal medicine (infectious cases), obstetrics, surgery and urology.
    Participants belonged to three groups:
    a)Immigrants having arrived to Spain recently that had been in hospital as patients and could manage to describe cooking traditions and habits of their culture of origin. The first contact was made during their staying in hospital, where, in addition to asking them for their collaboration, we assessed the possibility of expressing in Spanish and the knowledge on their culture of origin. The objective was to know about their diet habits, how they were fulfilled in hospital and to ask them for their contribution.
    b)Kitchen staff (cooks and kitchen porters). They were included depending on their interest in participating in the study and their availability.
    c)Nursing professionals in the Units that were selected for the study, that have been mentioned before.
    We tried to include in the study immigrants coming from different origins: South American, African, both Maghribians and Sub-Saharan, and also Oriental and European people. The contact with immigrants was performed with the collaboration of nurses working in the units of bed-confinement for adults, that supplied us with the information on the patients.
    Research was carried out as stated below:
    a) Group 1: 5 women from different nationalities (1 Japanese, 1 Moroccan, 2 Colombian and 1 Ecuadorian).
    Group 2: 3 men (Argentinian, Saharan and Syrian), 4 women (2 Argentinian, 1 Cuban and 1 Romanian).
    Group 3: 2 men (Moroccan and Ecuadorian),y 3 women (Indian, Panamanian, Moroccan).
    Group 4: 1 man (Spanish, married to Moroccan woman), 5 women (Moroccan, Argentinian, Ecuadorian, Colombian and Cuban).
    Group 5: 5 women (2 Moroccan, 1 Senegalese, 1 Romanian and 1 Colombian).
    All the participants were adults and their age comprised between 25 and 50.
    b) 3 integration workshops performed in the hospital kitchen. Immigrant women, kitchen staff, a cook and several kitchen porters participated in the workshops. They prepared five traditional dishes from the different cultures of origin.
    c) Focal group that included the nursing professionals for them to contribute the key points that would determine de degree of cultural adaptation, with the participation of 7 nurses.
    d) Conduction of a questionnaire of assessment of the degree of cultural adaptation of the immigrant patient. It was performed on the individual's admission in the hospital Unit.

Results

a) Discussion group. They appreciate differences in the taste of the food they prepare, especially in the use of dressings, ways of preparation and elaboration; for many of them, this factor makes hospital food less appetizing. In general, their religious habits are observed (pork, alcohol, etc), but not all the times, that is why they have to be constantly alert. "They cook a pork bone and they tell you 'no, there is no pork in it', but we know it quickly because of the smell and the colour of the broth, whitish, whitish, whitish... our soup does not have this colour" (Moroccan woman, Group 1).
    Some of the participants tell about the cultural differences regarding food properties: "Because, it is true that pork is more infectious. For people with wounds, it is terrible eating pork here. You know, in my country things are different, for example, a patient in hospital cannot go out and eat pork, nor chochos, or lupin seeds, as they call them here. (Colombian woman, Group 1).
    Women that have just given birth offered us some reference regarding the importance of diet for the production of mother's milk and how they considered some food adequate, depending on the place of origin: "A pregnant or a breastfeeding woman cannot eat cabbage. No, she cannot, because if she is breastfeeding the baby, she will damage the baby's belly" (Senegalese woman, group 5).
    They miss some more flavour in the elaboration of dishes and they think that essential elements are lost during preparation, what differs substantially from the elaboration they make at home.
    Food is a precious gift having an important physiological and symbolic component, both for healing and as a social link. Diet changes were introduced accordingly to the time they had been in Spain, so adapting progressively to the tastes typical of the area where they live: "during the first years I made it as I used to do in my country, but gradually I have been getting used to Spanish food, then I cook it as they do it here." (Cuban woman, group 4).
    They look for support in their own relatives or in other patients to cover the necessities that hospital cannot. Sharing food is a sign of mutual affect: "Well, at the beginning you do not know the other, but eventually you speak with them: 'What are you going to have? Well, a girl' Then from that moment on, her husband arrives, then her mother and she asks about this and that. If you are in hospital for some days, they even bring you food: 'Taste this; eat that'..." (Panamanian woman, group 3).
    Eating schedules are considered adequate, even better than those outside the hospital. Regarding professional treatment, they think the treatment they receive varies depending on the person that cares for them. Most of them regard it as good the professional attention they receive; only some of them have undergone some kind of misunderstanding with the staff that has not gone too far.
    Some of them talk about the difficulties of been in hospital, far from their country and having little familiar backing, a situation that is considerably alleviated by the support of the patients sharing their room and the room mate's relatives. They often prefer being in shared rooms than individually: "the good thing of all this is that the patients and even the relatives around them in the hospital room create some kind of family" (Ecuadorean man, group 3).

b) Workshops on integration of knowledge. The result was a co existential experience of the kitchen staff and the guest immigrants, where the importance of finding links among cultures was highlighted. We realized how easy is to establish personal relationships when dealing with food matters among people coming from different cultures.
    Six traditional dishes from the origin countries were prepared in the kitchen of the hospital, with the peculiarity that most of them were elaborated using the same products normally employed in the hospital diet: Chicken in milk sauce (Romania), Rice in Indian style (India), Bandeja Paisa (meat, legumes and sausage) and Arepa (corn bread) from Medellín (Colombia), gilthead bream with vegetables and rice (Senegal).
    Kitchen staff and immigrant women assessed positively the experience, as it was useful to acquire new cooking notions. At the same time, immigrant women became cooking instructors for kitchen staff.
    Audio-visual material was gathered, both pictures and video on the different ways of elaboration and the workshop environment. The food that was prepared was tasted by kitchen staff, immigrants and researchers.

c) Nominal Group with nursing professionals. The members of the meeting were expert nurses and the staff of the unities object of the study. We tried to recognise which aspects had nurses to bear in mind for the assessment regarding immigrant diet. The most relevant questions and conclusions agreed by the group were the following:
    -Nutrition is a necessity and nursing has to know how the individual will solve it.
    -The language gap can be sometimes a serious difficulty.
    -Covering this necessity satisfactorily is essential to grant appropriate attention.
    -In order to cover such necessity, the nurse bears a rather independent role and at the same time a difficult task in hospital.
    -It is important for the individual to get recovered completely
    -Every situation is different, depending on the culture.
    -It is essential to take preferences regarding diet into account, in order to provide an adapted attention.
    -In hospital it is difficult to design a diet adapted to the taste and culture of the patients.
    -When the patient has been for a long time in Spain, the food he/she is offered in hospital suits his/her preferences better.

    Regarding the factors to be observed for the assessment of immigrant patients' cultural adaptation in diet questions, it was agreed as follows:
-Habitual diet and reasons for its choice.
-Tastes and preferences in matters of diet. Possibility of covering such preferences in Spain.
-Meal schedules.
-Knowledge of Spanish food and its assessment.
-Suggestions.
    Upon this information, we designed a straightforward instrument that allowed nurses to know rapidly the degree of immigrant patient's adaptation to diet in the moment of his admission in hospital [see Chart 1]. It was a first step to consider, if necessary, a more in-depth assessment and the adoption of preventive measures to solve possible nutritional and dietary deficits and to make sure that the patient will receive attention adapted to his/her needs.

d) Validation of the questionnaire. The elaboration of the questionnaire answered to the necessity of having at disposal a measuring instrument to allow us to optimise time and to schedule nursing performance aimed at introducing dietary adaptations to prevent possible nutritional deficits. Once designed, the questionnaire was distributed in the June-October period in the Units object of study and among the researchers in their working shift. Up to 50 questionnaires were handed over, that they meant more than half of the immigrant patients in hospital [see Table 1].
    According to nurses, the difficulty in carrying out such assessment was determined by the lack of time and their reluctance to change their caring practice when the nature of patients varies.
    The results obtained showed that dietary adaptations proposed by nurses were basically focused in preserving the patient's religious principles, especially if they follow Islamism (pork), whereas other adaptations based on tastes or tradition are not observed so thoroughly.
    Most of the participants in the survey showed a good adaptation to Spanish diet and cooking habits and meal timetables. Most of them were Latin Americans, and they evidenced an optimum degree of adaptation in dietary matters. Following up were Muslims, showing a low degree of nutritional adaptation for religious reasons; however, granting them a pork-free diet, the adaptation degree got improved. The biggest adaptation problem was found in individuals coming from Oriental cultures (Chinese, Korean, Vietnamese...), who refuse to eat the food served in hospital and they eat only what their families bring them. In addition to this, communication problems arise, as they hardly speak Spanish, so the conduction of the assessment was harder in those cases when a translator was not present.

Discussion

    Immigration should not be regarded as a problem, but as an unavoidable process that gives us the opportunity of a cultural interchange, of learning from others, of exchanging knowledge.^5,13 Coexistence among cultures allows knowledge exchange and mutual learning. Diet can be a good reason for such knowledge. Most immigrants around us are glad to be asked and to be counted on in order to improve their care, that is why they correspond satisfactorily when we ask for their collaboration.
    Cultural demonstrations modify the value attributed to food, so knowing them is helpful to propose beneficial alternatives and to get an adequate nutrition for patients, better attention and full satisfaction. In addition, it helps controlling negative practices such as the coming and going of food in the hospital rooms eluding hygienic-sanitary conditions.
    Creating links between diet and cultural factors allowed us for culturally adapted cares. Participative methodology showed itself suitable to get information in order to make this goal possible. Discussion groups produced recipes and combinations adequate to the different situations of health and disease. In general, there were plenty of contributions and they offered useful information about their stay in hospital and their experience with food, their beliefs and values and their diet. It should be highlighted that most participants contributed by telling us their experiences and a feedback was established among the components of the group in dietary matters.
    Participants explained us the different ways of cooking food in their countries and the adaptations of dishes to Spanish context. We discovered that the fusion of the knowledge of different cultures favours variety, increasing the number of elaborations and self-enrichment. We could verify that immigrant population acquires dietary habits where elements both from the two cultures live together.¹⁴
    We know that the value that a concrete element for an individual can improve or be detrimental for subjective health. The amount of remedies, food, infusions and other methods used in order to restore health or to avoid illness are varied and, in occasions, what in a culture can be considered beneficial, in other it can be considered harmful, as it was concluded in the discussion groups with immigrants. It is important for nurses to know it in order to increase the quality of their attention and getting closer to the population they care for.
    Knowledge exchange workshops allowed a joint work of cooking professionals, immigrants and nurses, acting all of them at once as trainers and trainees of each other. The climate of collaboration where everyone else is recognised as a valid interlocutor, meant a rather positive effect on the space of coexistence created for that purpose, but particularly we observed the beneficial effects that self-esteem triggered in immigrant participants.
    Through nurses it was possible for us to verify which aspects are important to assess diet and nutrition in immigrant people, although taking care of immigrants bearing in mind their tastes and preferences is less habitual and harder to be assumed. Again, it was highlight the difficulty that clinical nurses find in introducing changes in daily routines. Likewise, the dichotomy between the necessity of deeper knowledge and the rejection to the adoption of new working routines was stressed during the process of validation of the questionnaire of assessment of cultural adaptation to hospital diet. However, we are sure that the feasibility of this instrument will be granted by its practical utility¹⁵ and the simplicity of its administration. It is a supporting instrument for the diagnostic of sanitary situations that will be more frequent in our sanitary institutions, and so it will help professionals to solve care situations that are quite familiar to us.

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