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Ulfa M, Aktas N, Rajikan R, Quoc Anh N, Reza Sobhani S. Food Security Challenges for Hospital Sustainability. JNFS 2024; 9 (4) :761-772
URL: http://jnfs.ssu.ac.ir/article-1-794-en.html
URL: http://jnfs.ssu.ac.ir/article-1-794-en.html
School of Medicine, Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta, Yogyakarta
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1 School of Medicine, Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta, Yogyakarta, Indonesia; 2 Master of Hospital Administration, Postgraduate Program, Universitas Muhammadiyah Yogyakarta, Yogyakarta Indonesia; 3 Department of Nutrition and Dietetics, Faculty of Health Sciences, Selcuk University, Konya, Turkey; 4 Dietetics Program, Center for Healthy Ageing and Wellbeing, Faculty of Health Sciences, University Kebangsaan Malaysia, Selangor, Malaysia; 5 Department of Food Microbiology and Molecular Biology, National Institute of Nutrition, Hanoi, Vietnam; 6 Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
Introduction
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This study explores the trends of research subjects in this field and the number of publications each year (Figure 3). The most notable trends proceeded between 2019 and 2020. The trends were on hospital food services, nutritional assessment and catering services in 2019. Research on food security, public health, and food insecurity was observed in 2020. Additionally, the trend for 2020 included sustainability, waste management, and food waste. These results indicated how these research topics had received increasing attention each year.
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Current trends focus on sustainability in hospitals and the management of waste and food waste. The average net of all organic waste (plastic, paper, and metal) was 441 g per patient per day, and the average yield of all food waste was 412 g per patient per day (Alharbi et al., 2020). The provision of medical care and associated support services, such as nutrition and maintenance, generates healthcare waste (Alharbi et al., 2021). Alharbi et al study mentioned that early discussions on the sustainability of the healthcare industry have centered on waste elimination and recycling as essential tactics for healthcare systems that support environmentally friendly practices due to the economic and environmental impacts of waste (Alharbi et al., 2021). In addition, to weakening local communities through the accumulation of hazardous waste on land, in water, and in the air, including APIs (Active Pharmaceutical Ingredients), medical waste will also affect the general population's health and the state of the country's economy (Chisholm et al., 2021). Furthermore, if general waste is adequately separated from healthcare waste, it can be collected for biofuels, boosting the nation's economy, and providing a wealth of sustainability options (Chisholm et al., 2021).
Geographical distribution
Different shades of black represent various levels of productivity. Therefore, the greater the production, the darker the shade of black would be. The top three countries producing the most documents illustrated in Figure 4 were the United States (n=69), Brazil (n=17), and Canada
(n=14).
According to the report, the United States ranked first as the nation with the most research on food safety and food security initiatives in hospitals compared to other nations. It ranked first in terms of citations. Meanwhile, Brazil came in second with regard to documents by country and became the last in terms of citations (Figure 5). Studies on food safety and food security in the hospitals in 71 countries were based on several articles. Using "Microsoft Excel 365" to create the map, the United States, Brazil, Canada, Australia, Italy, South Africa, the United Kingdom, India, China, and Malaysia were geographically divided to manifest scientific production by country (Figure 4). The top 10 nations by documents are displayed in the figures below, arranged by documents (Figure 4) and citations (Figure 5).
Trending topics
According to the bibliography periodicity
parameters of at least five words each year, the size or diameter represents the frequency of the author's keyword phrases. Table 1 presents the prevalence of terms including food (n=17378), health (n= 14164), care (n= 7770), waste (n= 7478), and hospital (n= 7295) from 2017 to 2021. In terms of trending topics, recent research has also highlighted that in response to this research, researchers have discovered food safety (Moreno et al., 2018, Shalowitz et al., 2017), food security (Badri-Fariman et al., 2021, Sackey et al., 2018, Shalowitz et al., 2017), and hospital food waste (Alshqaqeeq et al., 2020, Carino et al., 2021, Eriksson et al., 2020, Gomes et al., 2020, Malefors et al., 2019, Papargyropoulou et al., 2019, Rathnayake and Dalpatadu, 2020, Simzari et al., 2017)
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The established models of care support interdisciplinary teams and systemic methods. Numerous nutrition care procedures can be systematized to enhance efficiency, as they can be performed by operational and support employees, nurses, doctors, allied health professionals, administrators, and volunteers (Bell et al., 2021).
The staff that provides nutritious food for patients plays an essential role in hospital food safety. Food handlers are crucial in ensuring strict adherence to the process requirements for food safety (Al Banna et al., 2022, Asmawi et al., 2018). Poor hygiene among food handlers can make it hazardous to serve patients food, which can result in an outbreak of the disease throughout the hospital. Therefore, it is essential to maintain food safety in hospitals. Food safety is fundamental for hospital food service to patients, food service establishments, and regulatory agencies (Al Banna et al., 2022, Osaili et al., 2017). Unsatisfactory behavior at food service establishments is critical in developing foodborne illnesses (Al Banna et al., 2022).
During the COVID-19 period, additional steps must be considered to ensure food safety and protect the integrity of the food chain (World Health Organization, 2020) Workers are advised to wear gloves, to change them regularly, particularly after doing a task unrelated to food, and wash their hands whenever the gloves are changed or removed since human interaction with food is a significant factor determining the risk of food product contamination (Ceniti et al., 2021). The Food and Drug Administration (FDA) recommends four basic food safety processes: cleaning, segregating, cooking, and chilling (Food and Drug Administration, 2020). All surfaces that come into contact with food, containing dishware, utensils, and drinking equipment, need to be washed, rinsed, and sanitized. Protecting food workers from COVID-19 infection, preventing exposure to or transmitting the virus, and improving food hygiene and sanitation procedures are the greatest challenges confronting the food industry (Ceniti et al., 2021).
Public concerns about food safety and food security in the post-COVID-19 period are significant, and knowledge of the instruments to address them is restricted. Multiple protocols are needed to avoid unnecessary health risks. Protecting consumer health and safety requires effective food control systems (Han et al., 2021). The COVID-19 crisis is initiating to focus authorities' attention on important food security and health issues, including food security hazards and measures to reduce them and better communication with the public and the private food sector (Han et al., 2021). Moreover, the stakeholders, including the food industry, legislators, governments, and consumers, must all actively participate in implementing any alterations towards a more resilient future for food safety (Han et al., 2021). The pandemic's severe disease transmission and diverse patient needs have significant implications for hospital capacity and general efficiency. National healthcare systems must adapt to the novel situation in order to meet the challenges of the COVID-19 pandemic and remain viable in such circumstances (Pamučar et al., 2020). As the COVID-19 pandemic has all the specific characteristics, it is mandatory to continuously assess the strengths and weaknesses of healthcare systems. A comprehensive analysis should be conducted to develop a plan based on adaptive models of healthcare system organization.
Healthcare facilities are critical to the management, prevention and treatment of disease and contribute to sustainability. Hospital food services are still associated with hospital sustainability. It is critical to collect and utilize individual’s viewpoints in managerial roles and throughout the food supply chain for shifting towards to sustainable hospital food services (Carino et al., 2021). The hospital food supply chain can have an impact on environmental sustainability. In order to achieve permanent change , it is essential to have a thorough comprehension of how food service systems operate within the embedded healthcare and policy frameworks (Carino et al., 2021). In particular, the environmental impact of hospitals is significantly influenced by the foodservice industry (Carino et al., 2021). In a cost-constrained and patient-centered healthcare environment, hospital food services are under increasing scrutiny to reduce costs and the environmental impact of food waste (Goonan et al., 2014, Ofei et al., 2014, Williams and Walton, 2011). Alharbi et al. recognized that waste from government hospitals Saudi Arabia includes paper (27,000 tons), plastic (15,000 tons), food (10,000 tons), glass (8000 tons), and metal (7000 tons) each year. Unfortunately, none of the produced materials are recycled and wind up in landfills instead (Alharbi et al., 2021).
Hospital food services are still linked to hospital sustainability. Given the potential of health professionals contain as sustainability champions and the widespread communication of the relationship between environmental sustainability and health, hospitals are appealing for sustainability activities (Hubbert et al., 2020). The health system of each country uses a significant proportion of its financial and human resources, reflecting the economy’s sustainability (Alharbi et al., 2021). Environmental sustainability allows hospitals to focus more resources on patient care and reduce operating expenses. Sustaining successful interventions in practice is crucial to intensify practitioners' confidence in the benefits of implementing novel interventions, improving health outcomes, and facilitating research waste (Cowie et al., 2020). By improving hospital's surroundings and general impression and encouraging loyalty among patients concerned about the environment, sustainability can contribute to a better overall patient experience.
From the results of this study, it was identified that food security and food safety are components which support hospital sustainability. Assessment, challenges, measurement, status, sustainability, and access to healthcare are positively correlated with food security. The concept of food security is widely acknowledged in the extensive literature as being based on sustainability (Béné, 2020, Béné et al., 2019). Food security and nutrition must embrace sustainability in light of emerging trends including climate variability and the natural resource deterioration (Food and Agriculture Organization, 2020). Food safety considerations should be incorporated into sustainable and food security solutions from the outset (Vågsholm et al., 2020). In order to attain food security, needs food safety, public health, and sustainability must all considered as selecting the methods and tactics.
Meanwhile, food safety correlates with disease control, appropriate waste management, environmental health, health promotion, health education, and public health services. The value of training and retraining as a technique for improving staff knowledge and attitudes towards food safety and hygiene in healthcare facilities (Eslami et al., 2022). The hospital management must ensure that service providers comply with legislation and implement the necessary criteria for the food safety management system. Megatrends on a global scale, such as climate change, population growth and aging, urbanization, and increasing affluence, will impose new difficulties on the food safety industry and generate novel expectations on producers, manufacturers, marketers, retailers, and regulators (King et al., 2017). Despite numerous competing agendas and obstacles to change, there is a shared desire for ecologically friendly hospital food services. It was obvious that ideas for quick-fix practice modifications could be implemented, and stakeholders now have the opportunity to support these "quick wins" within their organizations (Carino et al., 2021). Policymakers can provide precise direction and support through policy and governance.
Conclusion
To support patients’ recovery in the hospital, hospital food services must not only supply nutritious food, but also ensure that the provided food is harmless for patient consumption and does not lead to food-borne illness. Food safety considerations include disease control, appropriate waste management, environmental health, health promotion, health education, and public health services. Focusing on the implementation of risk-based food safety assessments, these findings demonstrate that challenges, measurement, status, sustainability and access to health care were part of food security. In conclusion, food safety and food security are essential to achieve hospital sustainability and need to continue the discussion and awareness. The recommendation for hospitals, food service stakeholders, government, and the private sector is to enact policies and guidelines to provide information on food safety and security for hospital sustainability. To make progress in finding solutions to these challenges, the researchers must continue to utilize foundational scientific research to inform regulations and practices to increase food safety and food security to improve hospital sustainability.
Acknowledgments
The authors would like to thank Universities’ Muhammadiyah Yogyakarta (Indonesia), Selcuk University (Turkiye), University Kebangsaan Malaysia (Malaysia), National Institute of Nutrition Vietnam (Vietnam), and Mashhad University of Medical Sciences (Iran) for supporting this study.
Funding
There is no funding in this study.
Conflict of Interest
The authors declare that there is no conflict of interest in this study.
Authors' contributions
Ulfa M: Wrote the paper, conceived and designed the analysis, performed the analysis. Aktas N: Study conception and contributed data. Rajikan R: Study conception and designed the analysis. Quoc Anh N & Reza Sobhani S: Interpret the results. All authors reviewed the results and approved the final version of the manuscript.
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Food Security Challenges for Hospital Sustainability
Maria Ulfa; MD, PhD*1,2, Nazan Aktas; PhD3, Roslee Rajikan; PhD4, Nguyen Quoc Anh; PhD5 &
Seyyed Reza Sobhani; PhD6
Maria Ulfa; MD, PhD*1,2, Nazan Aktas; PhD3, Roslee Rajikan; PhD4, Nguyen Quoc Anh; PhD5 &
Seyyed Reza Sobhani; PhD6
1 School of Medicine, Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta, Yogyakarta, Indonesia; 2 Master of Hospital Administration, Postgraduate Program, Universitas Muhammadiyah Yogyakarta, Yogyakarta Indonesia; 3 Department of Nutrition and Dietetics, Faculty of Health Sciences, Selcuk University, Konya, Turkey; 4 Dietetics Program, Center for Healthy Ageing and Wellbeing, Faculty of Health Sciences, University Kebangsaan Malaysia, Selangor, Malaysia; 5 Department of Food Microbiology and Molecular Biology, National Institute of Nutrition, Hanoi, Vietnam; 6 Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| ARTICLE INFO | ABSTRACT | |
| REVIEW ARTICLE | Background: Food security and safety are becoming major concerns worldwide. Providing food security and safety in hospitals is particularly challenging since their populations are diverse in dietary and nutritional requirements and more vulnerable to foodborne illnesses. The aim of this research is to promote hospital sustainability by addressing food security and food safety. Method: This study uses a quantitative method with a bibliometric study approach. This research has 212 articles from the Scopus database. All the documents were collected simultaneously in August 2022. The selected article encompassed the years from 2017 to 2021, including document type, publication stage, source type, language, and subject area. The data was analyzed using VOSviewer and NVivo analytical tools. Results: The results of the studies on food security and safety increased from 2017-2022 with current trends in hospital sustainability, food waste, and waste management in food. Our study has identified four clusters: hospital food services, hospital sustainability, nutrition, and food safety. Food security is positively correlated with assessment, challenges, measurement, status, and sustainability (Pearson correlation score is 1). Disease control, proper waste management, and environmental health are all associated with food safety (Pearson correlation score ±0.79-0.64). Conclusion: Food safety and security are critical to achieve hospital sustainability, therefore awareness-raising efforts must continue. It is recommended that hospital stakeholders, food service providers; public and private sectors adopt policies and guidelines to disseminate information on food safety and security concerning hospital sustainability. | |
| Article history: Received: 24 Dec 2022 Revised: 15 Apr 2023 Accepted:21 Apr 2023 |
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| *Corresponding author: mariaulfa@umy.ac.id Kampus Terpadu UMY. Jl. Brawijaya, Kasihan, Bantul, Yogyakarta, Indonesia. Postal code: 55183 Tel: +62 274387656 |
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| Keywords: Food safety; Food security; Food services; Hospitals. |
Introduction
Food and nutrition play an essential role in the well-being and recovery of patients. Therefore, they deserve to be considered as an integral part of patient care, rather than simply an operational cost. For most patients, hospital food services are their only source of nutrition during hospitalization and are essential to healthcare management (Teka et al., 2022). Hospitals have the potential to take the lead and serve as a model for other sectors in educating communities on the significance of fresh, local, and sustainable food. Hospital food services aim to offer patients nourishing meals that support their rehabilitation and health, as well as accommodating the patients’ medical circumstances through healthy menu options (do Rosario and Walton, 2020). Several hospitals implement the HACCP (Hazard Analysis and Critical Control Points) system to guarantee nutritious meals (Osaili et al., 2017). Food servings in hospitals are at risk of getting contaminated. Food handlers ensure food safety and prevent foodborne illnesses (Lee et al., 2017). Inadequate food handling hygiene practices can result in unsafe serving of food to patients, which can cause a hospital-wide outbreak of the disease.
The issue of food safety and security has emerged as a significant global concern following the outbreak of COVID-19. Ensuring the safety of food service has been a significant challenge for producers, customers, and public health officials (Azanaw et al., 2019). Food needs to be handled with caution throughout its value chain, from production to preparation of food for consumption to prevent contamination by biological (algae, bacteria, fungi, and parasites), chemical (additives, pesticides, microbial, and plant toxins), and physical (fragments of stone, wood, and glass) hazards. Additionally, food safety is essential for customers, restaurants, and regulatory authorities worldwide (Al Banna et al., 2022). Osaili et al. also advocate for the importance of food safety for customers, restaurants, and regulatory bodies (Osaili et al., 2017). Furthermore, the hospital's food service plays a vital role in patient care as it is necessary for patient recovery and treatment.
Sustainability in hospitals is increasingly recognized as a crucial aspect of improving social and healthcare outcomes. Sustainability can be viewed as a quality area in healthcare, extending the responsibility of health services to both current and future patients (Mortimer et al., 2018). As socially impactful structures, hospitals are responsible for their patients' food safety and security due to food purchasing, energy use, and waste generation. Hospital food services contribute significantly to environmental and food security impact because they generate a significant sign throughout the entire food supply chain (production, distribution, preparation, consumption, and waste disposal) (Carino et al., 2020). Therefore, implementing sustainable approaches to decrease food waste in hospitals can minimize environmental impacts and operating expenses, and improve food security.
Bibliometric analysis is a widely used and rigorous technique for exploring and interpreting huge amounts of scientific data. In recent years, bibliometric analysis has become incredibly popular in business research (Donthu et al., 2021, Khan et al., 2021). Scholars utilize bibliometric analysis for various purposes, such as examining the intellectual framework of a particular area in the existing literature and identifying novel trends in the performance of articles and journals, collaboration patterns, and research constituents (Donthu et al., 2021). Previous studies on food security and safety through bibliometric analysis indicates that food security has been enhanced and research findings have gradually transitioned from theory to practice and become more useful and implementable (Li and Song, 2022). Furthermore, a systematic review from Carino et al. mentioned that hospital food supply chains demonstrate how environmental sustainability can be emphasized and assessed and the ways that qualified nutritionists and dietitians can participate (Carino et al., 2020). In the future, food security research needs to focus more on the manner of interaction and coordination among the economy, environment, and society, with the help of technological advances and policy management (Xie et al., 2021). In food safety, Future research should identify and deconstruct impediments to the application of safe food handling procedures by considering the type and frequency of training and the material presented (Tamene et al., 2022). This future research topic is linked with the objectives of this recent study.
This review aims to systematically identify and synthesize research on the sustainability of hospital food services across the food security and safety to improve the strategies of the hospital sustainability.
Materials and Methods
This research utilized a qualitative approach for the literature review. Using the database (https://www.scopus.com/), an acknowledged peer-reviewed journal worldwide was gathered. The Scopus database was searched using the keywords “foodAND security AND in AND hospital” or “food AND waste AND in AND hospital” from 2017 until 2021. The bibliometric map was subsequently created using three different analysis forms: Scopus menu search results, the analysis of software VOSviewer, and the analysis of software NVivo 12 Plus. The inclusion criteria for this research were five years from 2017 to 2021, document type select article exclusively, the publication stage was final, source type only from journal, only choose English language article, and the selected subject area were medicine, health profession, and environmental science.
Scopus search results were investigated using a descriptive approach according to year of publication, publisher, country, title of publication and research topic. Meanwhile, a bibliometric map of research progress based on the significant issue of food safety and food security in the hospital was established using VOSviewer. The obtained data were refined several times in order to obtain the best data on food safety and food security. The association between indicators, variables, and keywords utilized in previous studies was tested using the NVivo 12 program.
This correlation was concluded to assess the food safety and security in the hospital. The VOSviewer software was also applied to map the most prevalent terms used in research on hospital food safety and food security. Based on the keyword of the author or title, the context of food safety and security in the hospital was determined. Ultimately, the following inquiry was made: (TITLE-ABS-KEY (food AND security AND in AND hospital) OR TITLE-ABS-KEY (food AND waste AND in AND hospital)) AND (LIMIT-TO (PUBYEAR, 2021) OR LIMIT-TO (PUBYEAR, 2020) OR LIMIT-TO (PUBYEAR, 2019) OR LIMIT-TO (PUBYEAR, 2018) OR LIMIT-TO (PUBYEAR, 2017) OR LIMIT-TO (PUBYEAR, 2016) OR LIMIT-TO (PUBYEAR, 2015) OR LIMIT-TO (PUBYEAR, 2014) OR LIMIT-TO (PUBYEAR, 2013) OR LIMIT-TO (PUBYEAR, 2012)) AND (LIMIT-TO (SUBJAREA, "MEDI") OR LIMIT-TO (SUBJAREA, "ENVI") OR LIMIT-TO (SUBJAREA, "HEAL")) AND (LIMIT-TO (PUBSTAGE, "final")) AND (LIMIT-TO (DOCTYPE, "ar")) AND (LIMIT-TO (LANGUAGE, "English")) AND (LIMIT-TO (SRCTYPE, "j")). This search turned up 212 documents.
The investigation sorted the dimensions of analysis, the units using bibliometric searches, and mixed citations were implemented for the bibliometric study-co-authorships assisted in examining the social structure of the research field. Bibliographic coupling which employed multiple references shared by the two documents as a measure of comparison, co-occurrences to comprehend the patterns of document sets supporting the research, and co-citations, which may aid in identifying the conceptual framework of the study's subject were among the citations. The authors applied co-occurrence analysis of keywords, co-authorship analysis of significant authors and country distribution, co-citation analysis of cited sources, citation analysis of documents and organizations, and co-citation reference network analysis in food safety and security in the hospital research to generate and produce the figures and data from the cited articles.
Results
Collected articles
To eliminate any bias introduced by the expansion of the database, all data were collected at the same time frame, in August 2022. Figure 1 illustrates the processes used in this research to provide a comprehensive study image. Data were exported in the RIS export file format to disseminate information about the study maps. The inclusion of this study in selecting documents are year, document type, publication stage, source type, language, and subject area. From this inclusion, 212 articles were found for analysis.
Publication year
The annual trend in publications on food safety and food security in hospitals is demonstrated in Figure 2. The analysis of this study included 212 papers from 2017 to 2021. Data for this investigation was collected from 2017 to 2021. According to the investigations conducted during the past fifteen years, the number of articles on food safety and food security in the hospital has increased over the past five years, particularly in 2021. It reveals that food safety and food security intensified annually except in 2019; however it increased gain in 2020.
The issue of food safety and security has emerged as a significant global concern following the outbreak of COVID-19. Ensuring the safety of food service has been a significant challenge for producers, customers, and public health officials (Azanaw et al., 2019). Food needs to be handled with caution throughout its value chain, from production to preparation of food for consumption to prevent contamination by biological (algae, bacteria, fungi, and parasites), chemical (additives, pesticides, microbial, and plant toxins), and physical (fragments of stone, wood, and glass) hazards. Additionally, food safety is essential for customers, restaurants, and regulatory authorities worldwide (Al Banna et al., 2022). Osaili et al. also advocate for the importance of food safety for customers, restaurants, and regulatory bodies (Osaili et al., 2017). Furthermore, the hospital's food service plays a vital role in patient care as it is necessary for patient recovery and treatment.
Sustainability in hospitals is increasingly recognized as a crucial aspect of improving social and healthcare outcomes. Sustainability can be viewed as a quality area in healthcare, extending the responsibility of health services to both current and future patients (Mortimer et al., 2018). As socially impactful structures, hospitals are responsible for their patients' food safety and security due to food purchasing, energy use, and waste generation. Hospital food services contribute significantly to environmental and food security impact because they generate a significant sign throughout the entire food supply chain (production, distribution, preparation, consumption, and waste disposal) (Carino et al., 2020). Therefore, implementing sustainable approaches to decrease food waste in hospitals can minimize environmental impacts and operating expenses, and improve food security.
Bibliometric analysis is a widely used and rigorous technique for exploring and interpreting huge amounts of scientific data. In recent years, bibliometric analysis has become incredibly popular in business research (Donthu et al., 2021, Khan et al., 2021). Scholars utilize bibliometric analysis for various purposes, such as examining the intellectual framework of a particular area in the existing literature and identifying novel trends in the performance of articles and journals, collaboration patterns, and research constituents (Donthu et al., 2021). Previous studies on food security and safety through bibliometric analysis indicates that food security has been enhanced and research findings have gradually transitioned from theory to practice and become more useful and implementable (Li and Song, 2022). Furthermore, a systematic review from Carino et al. mentioned that hospital food supply chains demonstrate how environmental sustainability can be emphasized and assessed and the ways that qualified nutritionists and dietitians can participate (Carino et al., 2020). In the future, food security research needs to focus more on the manner of interaction and coordination among the economy, environment, and society, with the help of technological advances and policy management (Xie et al., 2021). In food safety, Future research should identify and deconstruct impediments to the application of safe food handling procedures by considering the type and frequency of training and the material presented (Tamene et al., 2022). This future research topic is linked with the objectives of this recent study.
This review aims to systematically identify and synthesize research on the sustainability of hospital food services across the food security and safety to improve the strategies of the hospital sustainability.
Materials and Methods
This research utilized a qualitative approach for the literature review. Using the database (https://www.scopus.com/), an acknowledged peer-reviewed journal worldwide was gathered. The Scopus database was searched using the keywords “food
Scopus search results were investigated using a descriptive approach according to year of publication, publisher, country, title of publication and research topic. Meanwhile, a bibliometric map of research progress based on the significant issue of food safety and food security in the hospital was established using VOSviewer. The obtained data were refined several times in order to obtain the best data on food safety and food security. The association between indicators, variables, and keywords utilized in previous studies was tested using the NVivo 12 program.
This correlation was concluded to assess the food safety and security in the hospital. The VOSviewer software was also applied to map the most prevalent terms used in research on hospital food safety and food security. Based on the keyword of the author or title, the context of food safety and security in the hospital was determined. Ultimately, the following inquiry was made: (TITLE-ABS-KEY (food AND security AND in AND hospital) OR TITLE-ABS-KEY (food AND waste AND in AND hospital)) AND (LIMIT-TO (PUBYEAR, 2021) OR LIMIT-TO (PUBYEAR, 2020) OR LIMIT-TO (PUBYEAR, 2019) OR LIMIT-TO (PUBYEAR, 2018) OR LIMIT-TO (PUBYEAR, 2017) OR LIMIT-TO (PUBYEAR, 2016) OR LIMIT-TO (PUBYEAR, 2015) OR LIMIT-TO (PUBYEAR, 2014) OR LIMIT-TO (PUBYEAR, 2013) OR LIMIT-TO (PUBYEAR, 2012)) AND (LIMIT-TO (SUBJAREA, "MEDI") OR LIMIT-TO (SUBJAREA, "ENVI") OR LIMIT-TO (SUBJAREA, "HEAL")) AND (LIMIT-TO (PUBSTAGE, "final")) AND (LIMIT-TO (DOCTYPE, "ar")) AND (LIMIT-TO (LANGUAGE, "English")) AND (LIMIT-TO (SRCTYPE, "j")). This search turned up 212 documents.
The investigation sorted the dimensions of analysis, the units using bibliometric searches, and mixed citations were implemented for the bibliometric study-co-authorships assisted in examining the social structure of the research field. Bibliographic coupling which employed multiple references shared by the two documents as a measure of comparison, co-occurrences to comprehend the patterns of document sets supporting the research, and co-citations, which may aid in identifying the conceptual framework of the study's subject were among the citations. The authors applied co-occurrence analysis of keywords, co-authorship analysis of significant authors and country distribution, co-citation analysis of cited sources, citation analysis of documents and organizations, and co-citation reference network analysis in food safety and security in the hospital research to generate and produce the figures and data from the cited articles.
Results
Collected articles
To eliminate any bias introduced by the expansion of the database, all data were collected at the same time frame, in August 2022. Figure 1 illustrates the processes used in this research to provide a comprehensive study image. Data were exported in the RIS export file format to disseminate information about the study maps. The inclusion of this study in selecting documents are year, document type, publication stage, source type, language, and subject area. From this inclusion, 212 articles were found for analysis.
Publication year
The annual trend in publications on food safety and food security in hospitals is demonstrated in Figure 2. The analysis of this study included 212 papers from 2017 to 2021. Data for this investigation was collected from 2017 to 2021. According to the investigations conducted during the past fifteen years, the number of articles on food safety and food security in the hospital has increased over the past five years, particularly in 2021. It reveals that food safety and food security intensified annually except in 2019; however it increased gain in 2020.
This study explores the trends of research subjects in this field and the number of publications each year (Figure 3). The most notable trends proceeded between 2019 and 2020. The trends were on hospital food services, nutritional assessment and catering services in 2019. Research on food security, public health, and food insecurity was observed in 2020. Additionally, the trend for 2020 included sustainability, waste management, and food waste. These results indicated how these research topics had received increasing attention each year.
Current trends focus on sustainability in hospitals and the management of waste and food waste. The average net of all organic waste (plastic, paper, and metal) was 441 g per patient per day, and the average yield of all food waste was 412 g per patient per day (Alharbi et al., 2020). The provision of medical care and associated support services, such as nutrition and maintenance, generates healthcare waste (Alharbi et al., 2021). Alharbi et al study mentioned that early discussions on the sustainability of the healthcare industry have centered on waste elimination and recycling as essential tactics for healthcare systems that support environmentally friendly practices due to the economic and environmental impacts of waste (Alharbi et al., 2021). In addition, to weakening local communities through the accumulation of hazardous waste on land, in water, and in the air, including APIs (Active Pharmaceutical Ingredients), medical waste will also affect the general population's health and the state of the country's economy (Chisholm et al., 2021). Furthermore, if general waste is adequately separated from healthcare waste, it can be collected for biofuels, boosting the nation's economy, and providing a wealth of sustainability options (Chisholm et al., 2021).
Geographical distribution
Different shades of black represent various levels of productivity. Therefore, the greater the production, the darker the shade of black would be. The top three countries producing the most documents illustrated in Figure 4 were the United States (n=69), Brazil (n=17), and Canada
(n=14).
According to the report, the United States ranked first as the nation with the most research on food safety and food security initiatives in hospitals compared to other nations. It ranked first in terms of citations. Meanwhile, Brazil came in second with regard to documents by country and became the last in terms of citations (Figure 5). Studies on food safety and food security in the hospitals in 71 countries were based on several articles. Using "Microsoft Excel 365" to create the map, the United States, Brazil, Canada, Australia, Italy, South Africa, the United Kingdom, India, China, and Malaysia were geographically divided to manifest scientific production by country (Figure 4). The top 10 nations by documents are displayed in the figures below, arranged by documents (Figure 4) and citations (Figure 5).
Trending topics
According to the bibliography periodicity
parameters of at least five words each year, the size or diameter represents the frequency of the author's keyword phrases. Table 1 presents the prevalence of terms including food (n=17378), health (n= 14164), care (n= 7770), waste (n= 7478), and hospital (n= 7295) from 2017 to 2021. In terms of trending topics, recent research has also highlighted that in response to this research, researchers have discovered food safety (Moreno et al., 2018, Shalowitz et al., 2017), food security (Badri-Fariman et al., 2021, Sackey et al., 2018, Shalowitz et al., 2017), and hospital food waste (Alshqaqeeq et al., 2020, Carino et al., 2021, Eriksson et al., 2020, Gomes et al., 2020, Malefors et al., 2019, Papargyropoulou et al., 2019, Rathnayake and Dalpatadu, 2020, Simzari et al., 2017)
| Table 1. Trending Topics of Keywords. | |||||||
| Word | Length | Count | Weighted Rate (%) | Word | Length | Count | Weighted Rate (%) |
| Food | 4 | 17378 | 2.5 | Diet | 4 | 1703 | 0.25 |
| Health | 6 | 14164 | 2.04 | Malnutrition | 12 | 1522 | 0.22 |
| Care | 4 | 7770 | 1.12 | Environmental | 13 | 1506 | 0.22 |
| Waste | 5 | 7478 | 1.08 | Covid | 5 | 1446 | 0.21 |
| Hospital | 8 | 7295 | 1.05 | Quality | 7 | 1401 | 0.2 |
| Human | 5 | 3637 | 0.52 | Household | 9 | 1388 | 0.2 |
| Service | 7 | 3486 | 0.5 | Patients | 8 | 1350 | 0.19 |
| Insecurity | 10 | 3366 | 0.48 | Dietary | 7 | 1331 | 0.19 |
| Nutritional | 11 | 3250 | 0.47 | Factors | 7 | 1327 | 0.19 |
| Security | 8 | 3054 | 0.44 | Cost | 4 | 1322 | 0.19 |
| Management | 10 | 2974 | 0.43 | Emergency | 9 | 1320 | 0.19 |
| Intake | 6 | 2944 | 0.42 | Research | 8 | 1255 | 0.18 |
| Risk | 4 | 2838 | 0.41 | Education | 9 | 1190 | 0.17 |
| Nutrition | 9 | 2701 | 0.39 | Community | 9 | 1168 | 0.17 |
| Social | 6 | 2231 | 0.32 | Population | 10 | 1130 | 0.16 |
| Humans | 6 | 2187 | 0.31 | Data | 4 | 1121 | 0.16 |
| Public | 6 | 1958 | 0.28 | Major | 5 | 1097 | 0.16 |
| Medical | 7 | 1871 | 0.27 | Primary | 7 | 1094 | 0.16 |
| Assessment | 10 | 1850 | 0.27 | Infection | 9 | 1053 | 0.15 |
| Water | 5 | 1792 | 0.26 | Department | 10 | 1034 | 0.15 |
Keyword analysis
The obtained keywords were analyzed using VOSviewer (Figure 6). VOSviewer is a program for the creation and visualization of bibliometric networks. The network visualization of each cluster is observed by differentiating the color code for each cluster (Figure 6). In this study, the employed colors are red, green, blue, and yellow. The network visualization represents all the articles with underlying themes that appeared frequently in our investigation in Figure 6 of this report. The bibliometric mapping of food safety and food security in hospitals was divided into four clusters using VOSviewer (Table 2). In Table 2, the four clusters are divided into four themes: cluster one (red color) discusses food service in hospitals (31%), cluster 2 (green color) introduces hospital sustainability (25%), cluster 3 (blue color) considers nutrition (24%), and cluster 4 (yellow color) discusses food safety (20%).
The obtained keywords were analyzed using VOSviewer (Figure 6). VOSviewer is a program for the creation and visualization of bibliometric networks. The network visualization of each cluster is observed by differentiating the color code for each cluster (Figure 6). In this study, the employed colors are red, green, blue, and yellow. The network visualization represents all the articles with underlying themes that appeared frequently in our investigation in Figure 6 of this report. The bibliometric mapping of food safety and food security in hospitals was divided into four clusters using VOSviewer (Table 2). In Table 2, the four clusters are divided into four themes: cluster one (red color) discusses food service in hospitals (31%), cluster 2 (green color) introduces hospital sustainability (25%), cluster 3 (blue color) considers nutrition (24%), and cluster 4 (yellow color) discusses food safety (20%).
| Table 2. The Themes’ Cluster of Keywords Analysis. | |||
| Themes’ Cluster | Items | Total | Rate |
| Cluster 1: Food service in hospital |
Catering service, child nutrition, demography, disease association, disease severity, epidemiology, follow-up, food insecurity, food security, food supply, health care access, health care delivery, health care facility, health status, hospital discharge, household, household income, housing, human, humans, multicenter study, poverty, prevalence, primary health care, primary medical care, public hospital, quality of life, rural area, rural population, social determinants of health, social status, social support, socioeconomic factors, socioeconomics | 34 | 31% |
| Cluster 2: Hospital Sustainability |
Climate change, coronavirus disease 2019, covid-19, economics, food, food waste, government, health care, health care cost, health care personnel, health care policy, health care system, health care utilization, hospital waste, organization and management, pandemic, pollution, procedures, recycling, refuse disposal, sars-cov-2, sustainability, sustainable development, traffic and transport, university hospital, waste disposal, waste management, world health organization | 28 | 25% |
| Cluster 3: Nutrition |
Body mass, body weight, caloric intake, diet, dietary intake, eating, feeding behavior, food assistance, food intake, food service hospital, fruit, hospital food service, hospital patient, hospitalization, hunger, malnutrition, meal, meals, nutrition, nutritional assessment, nutritional status, nutritional value, outcome assessment, patient satisfaction, plate waste, vegetable | 26 | 24% |
| Cluster 4: Food safety |
Anti-bacterial agents, anti-infective agent, diarrhea, drinking water, environmental monitoring, food contamination, food processing, hospital, hospital administration, hospital sector, hospitals, microbiology, public health, risk assessment, risk factor, risk factors, statistics and numerical data, waste water, wastewater, water pollutant, water pollutant chemical, water pollution | 22 | 20% |
Keyword relation
Table 3 exhibits the Pearson correlation between food security and food safety with assessment, challenges, measurement, status, sustainability, health care access, disease control, proper waste management, environmental health, health promotion, health education, and public health service. Pearson correlation coefficients ranged from 1 to 0.55. According to the top results, the point-biserial correlation coefficient revealed a positive association between the overall food security scores for assessment, challenges, and measurement, with a total value is 1. Moreover, the point-biserial correlation coefficient disclosed that food safety scores were positively associated with healthcare access, disease control, and proper waste management, with correlation values ranging from 0.86 to 0.78.
Discussion
Nutrition is an essential element of the patient recovery in hospitals. In an acute care setting, meeting patients' nutritional needs can be challenging due to several extenuating factors, containing patient appetite and clinical symptoms, food accessibility and availability, menu quality, food choices, and specific patient preferences (Keller et al., 2015). Credentialed nutritionists and dietitians are in an excellent position to positively influence all facets of the hospital food system positively (Carino et al., 2020). The leading cause of malnutrition in hospitals, and one factor which can exacerbated it, is reduced dietary intake during a hospital stay paired with increased energy requirements (Simzari et al., 2017). The provision of high-value malnutrition care needs to be treated as a severe health concern and appropriate measures need to be taken to promote government policies needs to be taken (Simzari et al., 2017).
Table 3 exhibits the Pearson correlation between food security and food safety with assessment, challenges, measurement, status, sustainability, health care access, disease control, proper waste management, environmental health, health promotion, health education, and public health service. Pearson correlation coefficients ranged from 1 to 0.55. According to the top results, the point-biserial correlation coefficient revealed a positive association between the overall food security scores for assessment, challenges, and measurement, with a total value is 1. Moreover, the point-biserial correlation coefficient disclosed that food safety scores were positively associated with healthcare access, disease control, and proper waste management, with correlation values ranging from 0.86 to 0.78.
Discussion
Nutrition is an essential element of the patient recovery in hospitals. In an acute care setting, meeting patients' nutritional needs can be challenging due to several extenuating factors, containing patient appetite and clinical symptoms, food accessibility and availability, menu quality, food choices, and specific patient preferences (Keller et al., 2015). Credentialed nutritionists and dietitians are in an excellent position to positively influence all facets of the hospital food system positively (Carino et al., 2020). The leading cause of malnutrition in hospitals, and one factor which can exacerbated it, is reduced dietary intake during a hospital stay paired with increased energy requirements (Simzari et al., 2017). The provision of high-value malnutrition care needs to be treated as a severe health concern and appropriate measures need to be taken to promote government policies needs to be taken (Simzari et al., 2017).
| Table 3. Relation of Hospital Sustainability Keywords. | ||
| Code A | Code B | Pearson correlation coefficient |
| Food security |
Assessment | 1 |
| Challenges | 1 | |
| Measurement | 1 | |
| Status | 1 | |
| Sustainable | 1 | |
| Health care access | 0,868 | |
| Food safety |
Disease control | 0,791 |
| Proper waste management | 0,787 | |
| Environmental health | 0,64 | |
| Health promotion | 0,563 | |
| Health education | 0,557 | |
| Public health service | 0,557 | |
The established models of care support interdisciplinary teams and systemic methods. Numerous nutrition care procedures can be systematized to enhance efficiency, as they can be performed by operational and support employees, nurses, doctors, allied health professionals, administrators, and volunteers (Bell et al., 2021).
The staff that provides nutritious food for patients plays an essential role in hospital food safety. Food handlers are crucial in ensuring strict adherence to the process requirements for food safety (Al Banna et al., 2022, Asmawi et al., 2018). Poor hygiene among food handlers can make it hazardous to serve patients food, which can result in an outbreak of the disease throughout the hospital. Therefore, it is essential to maintain food safety in hospitals. Food safety is fundamental for hospital food service to patients, food service establishments, and regulatory agencies (Al Banna et al., 2022, Osaili et al., 2017). Unsatisfactory behavior at food service establishments is critical in developing foodborne illnesses (Al Banna et al., 2022).
During the COVID-19 period, additional steps must be considered to ensure food safety and protect the integrity of the food chain (World Health Organization, 2020) Workers are advised to wear gloves, to change them regularly, particularly after doing a task unrelated to food, and wash their hands whenever the gloves are changed or removed since human interaction with food is a significant factor determining the risk of food product contamination (Ceniti et al., 2021). The Food and Drug Administration (FDA) recommends four basic food safety processes: cleaning, segregating, cooking, and chilling (Food and Drug Administration, 2020). All surfaces that come into contact with food, containing dishware, utensils, and drinking equipment, need to be washed, rinsed, and sanitized. Protecting food workers from COVID-19 infection, preventing exposure to or transmitting the virus, and improving food hygiene and sanitation procedures are the greatest challenges confronting the food industry (Ceniti et al., 2021).
Public concerns about food safety and food security in the post-COVID-19 period are significant, and knowledge of the instruments to address them is restricted. Multiple protocols are needed to avoid unnecessary health risks. Protecting consumer health and safety requires effective food control systems (Han et al., 2021). The COVID-19 crisis is initiating to focus authorities' attention on important food security and health issues, including food security hazards and measures to reduce them and better communication with the public and the private food sector (Han et al., 2021). Moreover, the stakeholders, including the food industry, legislators, governments, and consumers, must all actively participate in implementing any alterations towards a more resilient future for food safety (Han et al., 2021). The pandemic's severe disease transmission and diverse patient needs have significant implications for hospital capacity and general efficiency. National healthcare systems must adapt to the novel situation in order to meet the challenges of the COVID-19 pandemic and remain viable in such circumstances (Pamučar et al., 2020). As the COVID-19 pandemic has all the specific characteristics, it is mandatory to continuously assess the strengths and weaknesses of healthcare systems. A comprehensive analysis should be conducted to develop a plan based on adaptive models of healthcare system organization.
Healthcare facilities are critical to the management, prevention and treatment of disease and contribute to sustainability. Hospital food services are still associated with hospital sustainability. It is critical to collect and utilize individual’s viewpoints in managerial roles and throughout the food supply chain for shifting towards to sustainable hospital food services (Carino et al., 2021). The hospital food supply chain can have an impact on environmental sustainability. In order to achieve permanent change , it is essential to have a thorough comprehension of how food service systems operate within the embedded healthcare and policy frameworks (Carino et al., 2021). In particular, the environmental impact of hospitals is significantly influenced by the foodservice industry (Carino et al., 2021). In a cost-constrained and patient-centered healthcare environment, hospital food services are under increasing scrutiny to reduce costs and the environmental impact of food waste (Goonan et al., 2014, Ofei et al., 2014, Williams and Walton, 2011). Alharbi et al. recognized that waste from government hospitals Saudi Arabia includes paper (27,000 tons), plastic (15,000 tons), food (10,000 tons), glass (8000 tons), and metal (7000 tons) each year. Unfortunately, none of the produced materials are recycled and wind up in landfills instead (Alharbi et al., 2021).
Hospital food services are still linked to hospital sustainability. Given the potential of health professionals contain as sustainability champions and the widespread communication of the relationship between environmental sustainability and health, hospitals are appealing for sustainability activities (Hubbert et al., 2020). The health system of each country uses a significant proportion of its financial and human resources, reflecting the economy’s sustainability (Alharbi et al., 2021). Environmental sustainability allows hospitals to focus more resources on patient care and reduce operating expenses. Sustaining successful interventions in practice is crucial to intensify practitioners' confidence in the benefits of implementing novel interventions, improving health outcomes, and facilitating research waste (Cowie et al., 2020). By improving hospital's surroundings and general impression and encouraging loyalty among patients concerned about the environment, sustainability can contribute to a better overall patient experience.
From the results of this study, it was identified that food security and food safety are components which support hospital sustainability. Assessment, challenges, measurement, status, sustainability, and access to healthcare are positively correlated with food security. The concept of food security is widely acknowledged in the extensive literature as being based on sustainability (Béné, 2020, Béné et al., 2019). Food security and nutrition must embrace sustainability in light of emerging trends including climate variability and the natural resource deterioration (Food and Agriculture Organization, 2020). Food safety considerations should be incorporated into sustainable and food security solutions from the outset (Vågsholm et al., 2020). In order to attain food security, needs food safety, public health, and sustainability must all considered as selecting the methods and tactics.
Meanwhile, food safety correlates with disease control, appropriate waste management, environmental health, health promotion, health education, and public health services. The value of training and retraining as a technique for improving staff knowledge and attitudes towards food safety and hygiene in healthcare facilities (Eslami et al., 2022). The hospital management must ensure that service providers comply with legislation and implement the necessary criteria for the food safety management system. Megatrends on a global scale, such as climate change, population growth and aging, urbanization, and increasing affluence, will impose new difficulties on the food safety industry and generate novel expectations on producers, manufacturers, marketers, retailers, and regulators (King et al., 2017). Despite numerous competing agendas and obstacles to change, there is a shared desire for ecologically friendly hospital food services. It was obvious that ideas for quick-fix practice modifications could be implemented, and stakeholders now have the opportunity to support these "quick wins" within their organizations (Carino et al., 2021). Policymakers can provide precise direction and support through policy and governance.
Conclusion
To support patients’ recovery in the hospital, hospital food services must not only supply nutritious food, but also ensure that the provided food is harmless for patient consumption and does not lead to food-borne illness. Food safety considerations include disease control, appropriate waste management, environmental health, health promotion, health education, and public health services. Focusing on the implementation of risk-based food safety assessments, these findings demonstrate that challenges, measurement, status, sustainability and access to health care were part of food security. In conclusion, food safety and food security are essential to achieve hospital sustainability and need to continue the discussion and awareness. The recommendation for hospitals, food service stakeholders, government, and the private sector is to enact policies and guidelines to provide information on food safety and security for hospital sustainability. To make progress in finding solutions to these challenges, the researchers must continue to utilize foundational scientific research to inform regulations and practices to increase food safety and food security to improve hospital sustainability.
Acknowledgments
The authors would like to thank Universities’ Muhammadiyah Yogyakarta (Indonesia), Selcuk University (Turkiye), University Kebangsaan Malaysia (Malaysia), National Institute of Nutrition Vietnam (Vietnam), and Mashhad University of Medical Sciences (Iran) for supporting this study.
Funding
There is no funding in this study.
Conflict of Interest
The authors declare that there is no conflict of interest in this study.
Authors' contributions
Ulfa M: Wrote the paper, conceived and designed the analysis, performed the analysis. Aktas N: Study conception and contributed data. Rajikan R: Study conception and designed the analysis. Quoc Anh N & Reza Sobhani S: Interpret the results. All authors reviewed the results and approved the final version of the manuscript.
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Type of article: review article |
Subject:
public specific
Received: 2022/12/24 | Published: 2024/11/20 | ePublished: 2024/11/20
Received: 2022/12/24 | Published: 2024/11/20 | ePublished: 2024/11/20
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