The role and meaning of hospital food for culturally and linguistically diverse patients

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Using a descriptive qualitative design guided by a social constructionist approach, four focus groups were conducted with participants from Asian, Mediterranean, Arabic, and Indian Subcontinent communities at a major Australian metropolitan health service. Purposively recruited participants included former inpatients or caregivers who discussed their experiences in face-to-face focus groups. Thematic analysis revealed three key themes: 1) Familiar food as a source of comfort in an unfamiliar environment, 2) Cultural traditions as wisdom for health and healing, and 3) Culturally appropriate food as a physical support to recovery. Findings highlight the multifaceted role of culturally appropriate hospital food beyond basic nutrition, including its ability in supporting emotional well-being, cultural identity, and physical healing when feeling already vulnerable amid the unfamiliar daily activities of hospital wards These insights underscore the need to reframe hospital food services policies and practices to prioritise cultural sensitivity, enhancing patient-centered care and reducing health inequities. Future efforts should focus on scalable, culturally inclusive menu designs that address systemic barriers through codesign and improve patient satisfaction and clinical outcomes. Nutrition & Dietetics Hospital food Culturally and linguistically diverse (CALD) Food well-being Patient-centred care Cultural identity Introduction Food choices and dietary patterns are shaped by life experiences, social contexts, traditions, beliefs, values, and expectations (Smith et al., 2012). Admission to hospital can be a disruptive experience (Alzahrani, 2021) which places people in a social environment which is not necessarily tailored to their identity, experience or culture. For example, complex healthcare and foodservice systems often create tension between patient-centred care and structured meal routines (Ottrey et al., 2018). Understandings of the role and meaning of food in health have evolved in recent years, beyond is biological or instrumental purposes (Nordström et al., 2013). This shift in perspective prompted the development of the concept of Food Well-Being (FWB), as described by Block et al. (2011). Their holistic framework encompasses the positive psychological, physical, emotional, and social relationships people have with food at both the individual and societal levels. The FWB framework includes five key domains: food socialization (learning about food through culture and family), food literacy (understanding and applying nutrition knowledge), food marketing (how marketing influences food perceptions and choices), food availability (access to diverse food options), and food policy (regulatory impacts on food systems). A more comprehensive approach to understanding the role of food in health and wellbeing is highly relevant to menu choices during hospital admissions, as it suggests that patient meals should not only meet nutritional needs but also enhance emotional comfort, cultural relevance, and social connection. Meeting patient food needs holistically has the potential to play an important role in enhancing patient satisfaction, recovery, and overall well-being improving hospital experience. Such a comprehensive approach is echoed in the ESPEN guideline on hospital nutrition, which provides 56 recommendations prioritizing patient perspectives in diet prescription and delivery (Thibault et al., 2021). For instance, Recommendations 5 and 22 highlight the need to incorporate patient preferences (e.g., cultural or timing-related) and monitor food intake collaboratively to support recovery and prevent underfeeding. The role and meaning of hospital food in recovery Hospital food plays a crucial role in patient recovery; however, malnutrition remains a significant issue in hospital settings. International research indicates between 20% - 50% of inpatients are affected by either pre-existing or hospital acquired malnutrition (Cass & Charlton, 2022; Correia et al., 2014; Franklin, 2014) and up to 62% experience dehydration at some point in their admission (Rowat et al., 2012). Both have a significant impact on recovery, and are associated with numerous adverse outcomes, including increased complications, longer hospital stays, higher treatment costs, and increased mortality (Barker et al., 2011; Correia et al., 2014; Rowat et al., 2012). While food quality is generally good, other factors like presentation, timing, and individual preferences can affect intake during hospital admissions (McGlone et al., 1995). Adapting hospital diets to patient perspectives and preferences may optimize intake and reduce malnutrition risk (Thibault et al., 2021). Specifically, Recommendation 5 emphasizes respecting cultural, religious, and personal food preferences (e.g., vegetarian or gluten-free options) to enhance emotional well-being and satisfaction, while Recommendation 17 advocates for texture-modified diets that consider patient acceptability to improve consumption in vulnerable groups. Many patients struggle with reduced appetite and physical changes due to illness, leading to inadequate nutrition and hydration (Larsen & Uhrenfeldt, 2013). Patients may also struggle to utilise standard feeding equipment (Johnstone et al., 2015) or be offered culturally inappropriate options (Hartley & Hamid, 2002). Recommendations to address these issues centre around the provision of nutritionally adequate, appetising meals tailored to patients' needs and preferences (Greig et al., 2018), and the inclusion of both patients and healthcare staff in improvement initiatives for food services (Abid et al., 2023). However, the meaning attributed to food by patients as part of healing and recovery in hospital has received far less attention in the literature. Food can be an important source of physical and mental health comfort during illness (Locher et al., 2005) and integrating comfort food “intended to trigger recollections of pleasant childhood experiences and feelings of caring and healing” (Wood & Vogen, 1998, p. 192) into hospital menus may improve meal acceptance and promote patients' well-being (Soares et al., 2024). However, systemic constraints may not align with patients’ cultural and social contexts, undermining patient centred care and negatively impacting on both wellbeing and recovery (Ottrey et al., 2018). Not engaging with patients' cultural needs also reduces choice and opportunities to align care with personal preferences, with 79% of inpatients in one Canadian study found to value locally sourced and culturally traditional foods as important during hospital admissions (Agarwal et al., 2013). The provision of culturally competent healthcare, which also addresses other intersectional aspects of the patient's social context, is therefore a prerequisite for improving patient satisfaction, reducing health inequity, and enhancing the quality and safety of care (Aishammari et al., 2019). However, the broader psychological, emotional and social dimensions of hospital food are under-represented in current research literature, suggesting emerging and more holistic understandings of its role and meaning for patients in hospital is an emerging area of inquiry. This is an important gap in the literature about the relationship between hospital food, health and wellbeing, giving the practical implications of improving food services to improve patient experience, recovery and outcomes. There is a clear need to extend our current understanding of hospital food from a mere dietary intervention to a culturally embedded experience with the potential to shape recovery in both positive and negative ways. The aim of this study was therefore to explore the perceptions, of former CALD hospital patients and carers regarding the role and meaning of hospital food in their recovery. Methods This study employed a descriptive qualitative research design using focus groups to explore the perceptions of CALD patients regarding the role and meaning of hospital food in their recovery. A social constructionist approach guided the research, acknowledging that meanings are co-constructed through social interactions and shaped by cultural and contextual factors (Phillips, 2023). This approach was appropriate because a descriptive qualitative design allowed for an in-depth exploration of CALD patients lived experiences and nuanced perceptions regarding hospital food in their recovery. Additionally, the social constructionist perspective ensured that the study captured the dynamic, culturally embedded meanings that emerge through social interactions, aligning with the study holistic approach to understanding the role and meaning of food during hospital admissions. Setting and Participants The study was conducted at a major metropolitan health service in Australia that serves a vibrant and rapidly growing region with a diverse population of nearly one million people, including both urban and semi-rural communities. The service delivers over 800,000 occasions of care annually, and includes four acute hospitals, one community hospital and various community-based and outreach services (Western Health, 2024). With a workforce exceeding 12,500 staff, the service caters to a multicultural community, reflecting a broad spectrum of socioeconomic backgrounds and health needs. While this service provides care for patients from over 150 linguistic and cultural backgrounds, the hospital menu remains largely reflective of an Anglo-European palate. The menu is not available in languages other than English, making it difficult for many culturally diverse patients to understand what meals are provided in hospital. Recruitment and Participants To ensure representation from key cultural groups, purposive sampling was used to recruit participants from the four largest admitted CALD communities represented in inpatient statistics?: Asian (Vietnamese, Chinese, Filipino), Mediterranean (Italian, Greek, Croatian, Maltese), Arabic (Middle Eastern and North African, including Sudanese, Ethiopian, Lebanese, and Egyptian), and Indian Subcontinent (Indian, Sri Lankan, Pakistani, Bangladesh). Eligible participants were recent inpatients at the health service or their caregivers. Inclusion criteria required participants to be aged 18 years or over, identify with one of the four targeted cultural communities, have experience of consuming hospital food or observing a loved one consume food during an admission, and be willing to participate in a one-hour focus group discussion. Exclusion criteria included cognitive impairment that would prevent the provision of informed consent and being unable to communicate in a language for whom an interpreter was unavailable. Participants were recruited via the health service Consumer Advisor Register, in collaboration with the Consumer Partnerships Manager. Recruitment efforts included direct verbal and written invitations, notification in monthly Consumer Partnership newsletter, posters displayed in hospital outpatient areas, and outreach through cultural community networks. Participants were provided with an information sheet outlining the study purpose, procedures, and confidentiality assurances. Explicit, written informed consent was obtained before participation, and interpreters were arranged as needed to enable consent and completion of focus group participation. Data Collection Focus groups were chosen to facilitate discussion and collective reflection among participants who shared similar cultural backgrounds and hospital experiences. Unlike individual interviews, focus groups allow for the exploration of collective experiences and social interactions, which can lead to deeper insights into how people interpret and negotiate meanings within their cultural and social contexts (Kidd & Parshall, 2000) . The interactive nature of focus groups enables participants to engage in discussion, challenge or build on each other’s viewpoints, and articulate perspectives they may not have expressed in a one-on-one setting (Asbury, 1995). Focus groups also facilitate the identification of common themes and patterns while also capturing divergent perspectives, enhancing the depth and validity of qualitative findings (Hennink et al., 2019). Four separate focus groups were conducted for each of the targeted CALD communities: Asian (n=8), Mediterranean (n=8), Arabic (n=6)), and Indian (n=6). All groups lasted approximately 60 minutes and were held face to face in a private meeting room at the health service. Trained facilitators (VC) led and supported (VB) each discussion, with an interpreter provided on the request of one participant. The Consumer Partnerships Manager for the health service was also present to provide additional participant support. A bespoke semi-structured interview guide was developed based on a review of existing literature and the research team’s professional experience. Key topics included the role of food in comfort and recovery during hospitalisation, perceptions of hospital food quality, variety, and cultural appropriateness, experiences with familiar and traditional foods during hospital stays and preferences and suggestions for improving culturally inclusive menu options. All focus groups were audio-recorded and transcribed verbatim. Data Analysis A thematic analysis approach, guided by Braun and Clarke’s (2021) six step framework, was employed to systematically identify, analyse, and report patterns and themes across the focus group discussions. Data analysis began with familiarisation, where focus group recordings were transcribed via software, and listened to by one researcher (VC) to ensure accuracy and promote immersion in the data. Initial coding was conducted inductively, with the same researcher generating descriptive codes that attempted to capture participants expressed meanings without preconceived categories, reflecting the study’s social constructionist lens. These codes were then grouped into preliminary themes by identifying patterns through discussion with all research team members, using reflective discussions to ensure interpretive consistency and mitigate individual bias. We were particularly careful to identify and challenge potential biases, such as prioritising a biological or instrumental perspective of hospital food. In the theme development phase, codes were organized into broader categories, and two superordinate themes emerged: one on the roles and meanings of hospital food (reported here) and another on experiences and preferences for culturally appropriate food (reported elsewhere). Themes were refined through an iterative process or review and discussion, revisiting transcripts to verify alignment with raw data and adjusting theme labels for clarity. Finally, reporting involved selecting illustrative quotes to evidence themes, and ensure participant voices were foregrounded. Trustworthiness The methodology of this study was designed to uphold the trustworthiness of its qualitative findings, aligning with Guba’s Model of Trustworthiness as operationalized by the Rosalind Franklin-Qualitative Research Appraisal Instrument (RF-QRA) (Henderson & Rheault, 2004). Focus groups fostered rich, interactive discussions reflective of their lived experience. Transferability was supported by purposive sampling of participants from the four largest CALD communities at the health service, complemented by detailed descriptions of their cultural contexts and hospital experiences, which may potentially enable application of the findings to similar multicultural healthcare settings. Dependability was ensured via an audit trail, including verbatim transcription of audio-recorded focus groups, and documentation of the iterative thematic analysis process using NVivo. Confirmability was addressed through reflexivity, with field notes documenting researcher observations and potential biases (e.g., the disciplinary lenses of the research team members), and triangulation across multiple focus groups to identified shared themes. These strategies collectively supported the construction of findings that authentically reflect CALD patients’ perceptions of hospital food and its role in their recovery. Researcher Positionality As qualitative researchers using a social constructionist approach, we acknowledge that our personal background has influenced design, data collection, and analysis of this study. The first author (VC) is a senior clinical dietitian at the health services, and clinician researcher with experience in exploring the nutrition assessment, interventions and support in varied patient populations. The Second author (VB) is a senior food service dietitian employed at the health service, and with experience in patient meal experiences, menu design and evaluation. The third author (DH) is an occupational therapist and clinician researcher employed at the health service and has extensive experience in partnering and co-producing research with CALD communities. The final author (BR) is an operations manager for food services at the health service. No members of the research team belonged to a CALD community as defined in the local context, and we acknowledge this is a significant limitation of this study. Ethical Considerations This study received ethics approval from the health service Low Risk Ethics Committee (LNR 105352). All participants provided written informed consent, and confidentiality was maintained by anonymising transcripts and ensuring data storage security. Participation was voluntary and withdrawal was permitted at any stage without consequence. Participants received financial reimbursement in accordance with health services’ consumer remuneration protocol. Findings Three themes were identified describing both the role and the meaning of hospital food during admissions: 1) Comfort from familiar food in an unfamiliar hospital environment, 2) Cultural traditions as a source of wisdom about health and healing, and 3) Culturally appropriate food as a physical aid to recovery. These themes were present to a greater or lesser degree across all the CALD groups in the study. Comfort from familiar food in the unfamiliar hospital environment Much of the meaning attached to hospital food was derived from its ability to provide a familiar cultural experience during the disruption and distress of a hospital admission, which was the strongest theme in the data. Familiar food in hospital was described as a powerful source of comfort for CALD patients, which supported their emotional wellbeing and recognised their culture. Participants across groups craved foods that mirrored their home traditions, viewing them as an express recognition of their identity which offered solace amidst illness. Participants described a strong desire to experience familiar flavours during their hospital admission; “Anyone from West Africa, yes, wants the pepe soup… that’s what they crave for it should be spicy, like chili” . Similarly, an Asian participant valued authenticity, even if the dish offered by the hospital was imperfect: “I really love the idea to bring more authentic for patients… at least 70, 80% we can… pick that food that bring us, you know, like the choice to eat and make us feel better.” Mediterranean patients also echoed this, finding comfort in familiar dishes like wedges: “Food was such a comfort… when she saw them, it was like, Ah, something familiar.” Familiar foods, even in simplified forms, can therefore offer a meaningful connection to the socio-cultural contexts of the patient’s life in the community. For some participants, familiar foods also provided connections to historical and/or ethnic senses of identity and belonging. [Nihari] is so in Indian dishes, this is one of the only dish which has travelled from the bottom of the food chain to the top of the food chain… more famous between the poors and then was adopted by the kings. Culturally appropriate food also profoundly influenced CALD patients’ emotional well-being, promoting comfort by serving as a source of pleasure and contentment by supporting their cultural identity during hospitalisation. Participants across groups emphasized how food reflecting their traditions provoked positive emotions, which countered the emotional toll of illness. As described by an Indian participant: “When you’re sick, you want familiar and you want something that you used to… something that gives people comfort and happiness” . Mediterranean participants similarly found emotional consolation in familiar offerings. One described how simply receiving a dish like lasagna was more than just a pleasurable sensory experience; “To me, it’s an emotional and mental thing too… that’s a real big boost to how you’re feeling” . These emotional reactions were linked to pride in their heritage and fostered a sense of inclusion and validation that enhanced their hospital experience. Beyond comfort, familiarity served as a critical buffer against the vulnerability and alienation of the hospital environment, enhancing participants’ sense of safety and control. An Asian participant recounted their father’s cancer treatment, noting, He’s facing this really scary illness and diagnosis, and on top of that, he’s having to navigate this completely foreign healthcare system … I think that if he had food that was also familiar to him, it would have been a really big comfort … this is like something that I can look at in this scary environment, that at least I am familiar with. This underscores how unfamiliar settings can amplify distress and feelings of dislocation, with familiar food acting as a tangible anchor. Mediterranean participants also ascribed this benefit to culturally appropriate hospital food and emphasised the value of predictability; “When you’re sick, it’s nice to know what you’re expecting. You stick to what you know, and what you know you’re going to be somewhat satisfied.” Across cultures, familiarity in hospital food mitigated the unfamiliarity of hospitalisation, supporting emotional resilience and recovery by making the unfamiliar feel less daunting. Cultural traditions as wisdom about health and healing CALD patients viewed their cultural food traditions as a source of wisdom about health and healing, attributing therapeutic properties to ingredients that have enhanced health across generations. Indian participants emphasised the key role of turmeric, garlic, and onion in their cuisine, perceiving them as essential health tools rather than just flavours. One participant explained, Indian cooking will always have turmeric. So turmeric is one of the base, so I think what would have happened years and years ago … there would be some witch doctor somewhere, and he would have figured out that turmeric has got some very good healing abilities and sort of added into the curry. This perspective frames food as a culturally embedded form of preventative and restorative care, reflecting long held knowledge that patients still value in the hospital context. In some cases, these traditions were also linked to religious identity such as the following example from Asian cultures; “A lot of them are Buddhism or Taoism. They love the, you know, the bok choy, the tofu, the black fungus. There's so many healthy stuff in vegetarian diet”. Modern health trends were also integrated into longer standing cultural wisdom, as described by one participant in the Indian focus group: “ For breakfast again, fruits and mixed berries, corn flakes, a protein shake, almond, oat or soy milk”. These beliefs in the intrinsic health benefits of some foods underscore the participants desire for hospital menus to incorporate culturally significant elements as a means of supporting their recovery. The availability of culturally appropriate food was recognised as having the potential to promote agency and continuity in care, as these foods would continuing being used for their health effects after discharge from hospital. Culturally appropriate food as a physical aid to recovery In addition to their cultural meaning, CALD patients also understood hospital food as a biological support for recovery, valuing its nutritional content as a direct contributor to healing. A Mediterranean participant highlighted the role of protein in promoting healing; “I'd rather have food that makes my healing quicker. The trick with salad is there's enough protein or something sitting in there, like the tuna and the chicken” . Effective food-based support for recovery were often shared among communities and also encompasses non-nutrient characteristic such as food texture, as described by a Middle Eastern participant: “In our culture where, for example, a kid is teething, kind of porridge that has meat inside it as well, and it's savory, and we have usually just distributed to other families” . These beliefs about (hospital) food reflects a pragmatic focus on food that enhance physical outcomes, and views food as an important source of fuel and symptom relief. The physical ease and accessibility of consuming food also emerged as a critical factor, particularly when illness diminished patients’ capacity to feed themselves. A West African participant emphasised this, stating, “People, when we sick, people are lazy to chew. Because they just want something that they can just drink,” pointing to the preference for liquid or softer foods that accommodate weakened states. Mediterranean participants also identified food options which reduce mental health symptoms; “It’s good to have colour, like your vegetables, colour might brighten up your mood ”. While the previous theme described hospital food as an expression of culture, this theme demonstrates how cultural beliefs are specifically applied to health and recovery in the hospital environment. Discussion This study reveals that CALD hospital patients perceive food as a multifaceted contributor to their recovery, which supports cultural identity, provides physical nourishment, offers emotional support, and enables social connection. Participants across all included cultural groups affirmed that the food they consume during hospital admissions carries significant importance far beyond bodily sustenance. Their perceptions closely reflect the holistic orientation of the Food Well-Being framework (Block et al., 2011 ), by encompassing the psychological, physical, and social dimensions of hospital food. These findings affirm that consuming hospital food is a culturally embedded experience that can mitigate the disruptive impact of hospital admission, offering comfort in an unfamiliar setting, validating cultural wisdom, and supporting physical and psychological recovery. Their perspectives underscore the need to reframe hospital food services to better support person-centred care in a culturally sensitive and authentic way. The finding that familiar food serves as a powerful source of comfort in the unfamiliar hospital environment confirms that understanding patients preferred food offerings during hospital admissions are an essential part of person-centred care for CALD patients. It affirms the outcomes of previous research about the role of familiar food in enhancing feelings of safety and wellbeing for hospitalised patients (Alzahrani, 2021 ; Locher et al., 2005 ). This is reinforced by the ESPEN guideline, which recommends prioritizing patient perspectives in hospital food services to enhance safety and equity (Thibault et al., 2021 ; Recommendation 5 on cultural adaptations; Recommendation 17 on texture modifications for older patients to improve acceptability and intake). However, hospital food services face considerable challenges to meeting patient food preferences and needs, while also ensuring nutritional adequacy and remaining within their budgets (Lalande et al., 2024 ; Ottrey et al., 2018 ; Raj et al., 2023 ). The Anglo-European bias in the hospital menu at this health service, and many others in Western countries, confirms the systemic barriers to providing culturally appropriate food options to CALD patients. Given the many health and wellbeing benefits identified by participants in this study, hospitals should prioritise the provision of culturally appropriate food options to enhance both patient satisfaction and clinical outcomes from hospital admission. Culturally appropriate food options significantly enhance emotional well-being, possibly offering some protection around the psychological toll of illness. Hospitalisation can have a significantly negative effects on patient mental health (Alzahrani, 2021 ), which in turn has a negative impact on their overall recovery. Access to comfort foods have been found to improve meal acceptability (Soares et al., 2024 ), and the link between food and mood is well established in the scientific literature (Flaskerud, 2015 ). McKerchar et al., ( 2020 ) proposes a rights-based approach to improving food availability for culturally diverse communities, which frames access to culturally appropriate food as a human right aligned with cultural identity and health equity. By reframing food as a health right, the policy discourse may shift from regarding meeting the needs of CALD patients as optional to recognising it is an essential aspect of their healthcare experience and outcomes. The perception of cultural traditions as wisdom about health and healing identifies a valuable resource and important strength that CALD patients bring to the hospital context. Some have advocated for integrating cultural perspectives into healthcare food frameworks; however, these calls often reflect an instrumental or interventional approach (Loy, 2024 ; Nordström et al., 2013 ). Nevertheless, hospitals could leverage cultural wisdom by incorporating ingredients like turmeric or garlic into menus, to improve their alignment with patient preferences and values and enhance feelings of trust and safety in care. However, healthcare worker cultural knowledge and competence has been identified as a significant barrier to implementing culturally appropriate foods (Raj et al., 2023 ) and therefore preparatory capacity building will be required before hospitals can benefit from traditional knowledge. Culturally appropriate food may contribute to addressing critical gaps in hospital nutrition, by enhancing physical recovery through the alignment of nutritional needs with cultural identity. Adequate nutrition during hospital admissions reduced complications (Barker et al., 2011 ; Correia et al., 2014 ), while the provision of culturally inappropriate food hinders intake and potentially increases the risk of malnutrition (Hartley & Hamid, 2002 ). ESPEN Recommendation 22 further supports this by advising patient-involved monitoring of intake during realimentation after procedures, while Recommendation 21 emphasizes gradual, preference-based feeding post-GI events to minimize malnutrition risks (Thibault et al., 2021 ). Given that malnutrition is estimated to cost global healthcare systems between $ 2–3 trillion per year (Jumrani & Rai, 2020 ), the economic argument for investing in culturally resonant, easy-to-eat meal options is strong. Understanding the economic impact of better access to culturally appropriate foods during hospital admissions will be important to the scalability of these innovations in the longer term. Many of the foods discussed by participants were relevant across multiple cultures, and so the provision of culturally appropriate food does not therefore require the development of a huge range of food options. An inclusive menu featuring shared staples like soup (congee), customisable with condiments, could enhance patient experience and overall well-being in a feasible and sustainable manner. Participants in this study did not expect their cultural needs to be met perfectly, and previous research has found patients have relatively low expectations of what hospitals are able to provide (Johns et al., 2010 ). Collaborative partnerships between CALD patients and communities and local healthcare providers are likely to be the most effective way of developing better food services which satisfactorily meet everyone’s needs (Abid et al., 2023 ). Limitations This study has several limitations that should be considered when interpreting its findings. First, the purposive sampling of participants from only four CALD communities—Asian, Mediterranean, Arabic, and Indian Subcontinent—within a single metropolitan health service in Australia may limit their transferability to other cultural groups or healthcare settings. Additionally, the recruitment of participants who could communicate in English or languages with available interpreters may have excluded people with limited language proficiency or those from more recently arrived populations with smaller pools of available interpreters. This sampling bias could underrepresent the full spectrum of cultural understandings of the role and meaning of hospital food. Second, the focus group methodology may have constrained individual expression due to social dynamics or dominant voices within groups, despite efforts to facilitate equitable participation. The presence of representatives from the health service may also have subtly influenced participants to moderate critical views about hospital food services, introducing a potential social desirability bias. Furthermore, the thematic analysis, though rigorous, was conducted within a social constructionist framework that prioritised emergent meanings over quantitative measures of food intake or nutritional outcomes, limiting the ability to directly link cultural understandings to clinical outcomes. Conclusion This study described the role and meaning of hospital food for CALD patients from their perspective, revealing its contribution to comfort, cultural identity, and physical recovery within the disruptive context of hospital admissions. Familiar foods are a buffer against vulnerability, provide links to valued cultural wisdom and practically support optimal nutrition, indicating their multidimensional impact on patient health and wellbeing. These findings extend prior research by highlighting how culturally appropriate foods reduce emotional distress and promote positive emotional experiences while dealing with acute illness. By framing food as a culturally embedded experience, this study underscores the potential benefits of improving cultural diversity in hospital menus and food services. Future research should build on these insights by exploring the scalability, economic feasibility and benefits of co design in successfully implementing culturally inclusive hospital menus across diverse healthcare settings, addressing systemic barriers like financial constraints, presumed knowledge or insight and staff capacity. Quantitative studies could measure the impact of culturally tailored food on clinical outcomes (e.g., malnutrition rates, length of stay, patient satisfaction and nutritional factors, impact of food wastage), complementing the depth of analysis provided by qualitative studies. Engaging a broader range of CALD communities through multilingual methodologies could uncover further nuances in cultural understandings of hospital foods. Ultimately, collaborative co-design projects with CALD patients, healthcare providers, and policymakers are needed to develop practical, sustainable and meaningful menu solutions, that ensure hospital food not only nourishes the body but also honours cultural identities and promotes holistic healing. References Abid, M. H., Shehri, N. A., Din, S. M. S. U., & Nofeye, J. A. (2023). Leveraging an Experience-Based Codesign Approach to Improve the Inpatient Food Service Experience. Global Journal on Quality and Safety in Healthcare, 6(3), 89-95. https://doi.org/10.36401/JQSH-23-2 Agarwal, E., Ferguson, M., Banks, M., Batterham, M., Bauer, J., Capra, S., & Isenring, E. (2013). 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Canadian Journal of Dietetic Practice and Research, 79(2), 48-54. https://doi.org/10.3148/cjdpr-2018-002 Hartley, B. A., & Hamid, F. (2002). Investigation into the suitability and accessibility of catering practices to inpatients from minority ethnic groups in Brent. J Hum Nutr Diet, 15(3), 203-209. https://doi.org/10.1046/j.1365-277x.2002.00364.x Henderson, R., & Rheault, W. (2004). Appraising and Incorporating Qualitative Research in Evidence-Based Practice. Journal of Physical Therapy Education, 18(3), 35-40. http://findarticles.com/p/articles/mi_qa3969/is_200401/ai_n10298227/pg_7/files/8611/pg_7.html Hennink, M. M., Kaiser, B. N., & Weber, M. B. (2019). What Influences Saturation? Estimating Sample Sizes in Focus Group Research. Qualitative Health Research, 29(10), 1483-1496. https://doi.org/10.1177/1049732318821692 Johns, N., Hartwell, H., & Morgan, M. (2010). Improving the provision of meals in hospital. The patients’ viewpoint. Appetite, 54(1), 181-185. https://doi.org/https://doi.org/10.1016/j.appet.2009.10.005 Johnstone, P., Alexander, R., & Hickey, N. (2015). Prevention of dehydration in hospital inpatients. British Journal of Nursing (BJN), 24(11), 568-570, 572-563. https://doi.org/10.12968/bjon.2015.24.11.568 Jumrani, J., & Rai, V. N. (2020). 1 - The unacceptable status quo: malnutrition challenges of the developed and developing world. In O. P. Gupta, V. Pandey, S. Narwal, P. Sharma, S. Ram, & G. P. Singh (Eds.), Wheat and Barley Grain Biofortification (pp. 1-25). Woodhead Publishing. https://doi.org/https://doi.org/10.1016/B978-0-12-818444-8.00001-8 Kidd, P. S., & Parshall, M. B. (2000). Getting the Focus and the Group: Enhancing Analytical Rigor in Focus Group Research. Qualitative Health Research, 10(3), 293-308. https://doi.org/10.1177/104973200129118453 Lalande, A., Patterson, K., Gadhari, N., Macneill, A. J., & Zhao, J. (2024). Evaluating Patient Experience with Food in a Hospital-Wide Survey. Canadian Journal of Dietetic Practice and Research, 85(3), 122-131. https://doi.org/10.3148/cjdpr-2023-027 Larsen, L. K., & Uhrenfeldt, L. (2013). Patients' lived experiences of a reduced intake of food and drinks during illness: a literature review. Scand J Caring Sci, 27(1), 184-194. https://doi.org/10.1111/j.1471-6712.2012.00977.x Locher, J. L., Yoels, W. C., Maurer, D., & van Ells, J. (2005). Comfort Foods: An Exploratory Journey Into The Social and Emotional Significance of Food. Food and Foodways, 13(4), 273-297. https://doi.org/10.1080/07409710500334509 Loy, M. H. (2024). From plate to planet: culturally responsive culinary practices for health system innovation [Perspective]. Frontiers in nutrition, 11. https://www.frontiersin.org/journals/nutrition/articles/10.3389/fnut.2024.1476503 McGlone, P., Dickerson, J. W. T., & Davies, G. J. (1995). The feeding of patients in hospital: a review. Journal of the Royal Society of Health, 115(5), 282-288. https://doi.org/10.1177/146642409511500504 McKerchar, C., King, P., Lacey, C., Abel, G., & Signal, L. (2020). Rights-based approaches to improving food availability for tamariki Māori: A narrative literature review and theory-based synthesis. new Zealand Journal of Indigenous Scholarship, 9(3), 237-248. . Nordström, K., Coff, C., Jönsson, H., Nordenfelt, L., & Görman, U. (2013). Food and health: individual, cultural, or scientific matters? Genes & Nutrition, 8(4), 357-363. https://doi.org/10.1007/s12263-013-0336-8 Ottrey, E., Porter, J., Huggins, C. E., & Palermo, C. (2018). "Meal realities" - An ethnographic exploration of hospital mealtime environment and practice. J Adv Nurs, 74(3), 603-613. https://doi.org/10.1111/jan.13477 Phillips, M. J. (2023). Towards a social constructionist, criticalist, Foucauldian-informed qualitative research approach: Opportunities and challenges. SN social sciences, 3(10), 175. https://doi.org/10.1007/s43545-023-00774-9 Raj, M., Oleschuk, M., Chapman-Novakofski, K., & Levine, S. K. (2023). Perceived Facilitators and Barriers to Implementing Culturally Inclusive Diets into Hospitals and Long-Term Care Facilities. Journal of the American Medical Directors Association, 24(10), 1503-1507. https://doi.org/10.1016/j.jamda.2023.04.018 Rowat, A., Graham, C., & Dennis, M. (2012). Dehydration in Hospital-Admitted Stroke Patients. Stroke, 43(3), 857-859. https://doi.org/10.1161/STROKEAHA.111.640821 Smith, K. C., Kromm, E. E., Brown, N. A., & Klassen, A. C. (2012). "I come from a black-eyed pea background": the incorporation of history into women's discussions of diet and health. Ecol Food Nutr, 51(1), 79-96. https://doi.org/10.1080/03670244.2012.635574 Soares, N. C., Cunha, I. C., & Silva, N. R. R. (2024). (Re)pensar a gastronomia hospitalar a partir da tendência comfort food. Contribuciones A Las Ciencias Sociales, 17(13), e13510. https://doi.org/10.55905/revconv.17n.13-155 Thibault, R., Abbasoglu, O., Ioannou, E., Meija, L., Ottens-Oussoren, K., Pichard, C., Rothenberg, E., Rubin, D., Siljamäki-Ojansuu, U., Vaillant, M. F., & Bischoff, S. C. (2021). ESPEN guideline on hospital nutrition. Clinical Nutrition, 40(12), 5684–5709. https://doi.org/10.1016/j.clnu.2021.09.039 Western Health. (2024). Annual report 2023-2024 . Western Health https://www.westernhealth.org.au/AboutUs/CorporatePublications/Documents/AnnualReport/Western%20Health%20Annual%20Report%202023-2024%20FINAL.pdf Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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and dietary patterns are shaped by life experiences, social contexts, traditions, beliefs, values, and expectations (Smith et al., 2012). Admission to hospital can be a disruptive experience (Alzahrani, 2021) which places people in a social environment which is not necessarily tailored to their identity, experience or culture. For example, complex healthcare and foodservice systems often create tension between patient-centred care and structured meal routines (Ottrey et al., 2018). Understandings of the role and meaning of food in health have evolved in recent years, beyond is biological or instrumental purposes (Nordstr\u0026ouml;m et al., 2013).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis shift in perspective prompted the development of the concept of Food Well-Being (FWB), as described by Block et al. (2011). Their holistic framework encompasses the positive psychological, physical, emotional, and social relationships people have with food at both the individual and societal levels. The FWB framework includes five key domains: food socialization (learning about food through culture and family), food literacy (understanding and applying nutrition knowledge), food marketing (how marketing influences food perceptions and choices), food availability (access to diverse food options), and food policy (regulatory impacts on food systems). A more comprehensive approach to understanding the role of food in health and wellbeing is highly relevant to menu choices during hospital admissions, as it suggests that patient meals should not only meet nutritional needs but also enhance emotional comfort, cultural relevance, and social connection. Meeting patient food needs holistically has the potential to play an important role in enhancing patient satisfaction, recovery, and overall well-being improving hospital experience. Such a comprehensive approach is echoed in the ESPEN guideline on hospital nutrition, which provides 56 recommendations prioritizing patient perspectives in diet prescription and delivery (Thibault et al., 2021). For instance, Recommendations 5 and 22 highlight the need to incorporate patient preferences (e.g., cultural or timing-related) and monitor food intake collaboratively to support recovery and prevent underfeeding.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe role and meaning of hospital food in recovery\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHospital food plays a crucial role in patient recovery; however, malnutrition remains a significant issue in hospital settings. International research indicates between 20% - 50% of inpatients are affected by either pre-existing or hospital acquired malnutrition (Cass \u0026amp; Charlton, 2022; Correia et al., 2014; Franklin, 2014) and up to 62% experience dehydration at some point in their admission (Rowat et al., 2012). Both have a significant impact on recovery, and are associated with numerous adverse outcomes, including increased complications, longer hospital stays, higher treatment costs, and increased mortality (Barker et al., 2011; Correia et al., 2014; Rowat et al., 2012).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile food quality is generally good, other factors like presentation, timing, and individual preferences can affect intake during hospital admissions (McGlone et al., 1995). \u0026nbsp;Adapting hospital diets to patient perspectives and preferences may optimize intake and reduce malnutrition risk (Thibault et al., 2021). Specifically, Recommendation 5 emphasizes respecting cultural, religious, and personal food preferences (e.g., vegetarian or gluten-free options) to enhance emotional well-being and satisfaction, while Recommendation 17 advocates for texture-modified diets that consider patient acceptability to improve consumption in vulnerable groups.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Many patients struggle with reduced appetite and physical changes due to illness, leading to inadequate nutrition and hydration (Larsen \u0026amp; Uhrenfeldt, 2013). Patients may also struggle to utilise standard feeding equipment (Johnstone et al., 2015) or be offered culturally inappropriate options (Hartley \u0026amp; Hamid, 2002). Recommendations to address these issues centre around the provision of nutritionally adequate, appetising meals tailored to patients\u0026apos; needs and preferences (Greig et al., 2018), and the inclusion of both patients and healthcare staff in improvement initiatives for food services (Abid et al., 2023). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, the meaning attributed to food by patients as part of healing and recovery in hospital has received far less attention in the literature. Food can be an important source of physical and mental health comfort during illness (Locher et al., 2005) and integrating comfort food \u0026ldquo;intended to trigger recollections of pleasant childhood experiences and feelings of caring and healing\u0026rdquo; (Wood \u0026amp; Vogen, 1998, p. 192) \u0026nbsp;into hospital menus may improve meal acceptance and promote patients\u0026apos; well-being (Soares et al., 2024). However, systemic constraints may not align with patients\u0026rsquo; cultural and social contexts, undermining patient centred care and negatively impacting on both wellbeing and recovery (Ottrey et al., 2018). Not engaging with patients\u0026apos; cultural needs also reduces choice and opportunities to align care with personal preferences, with 79% of inpatients in one Canadian study found to value locally sourced and culturally traditional foods as important during hospital admissions (Agarwal et al., 2013). The provision of culturally competent healthcare, which also addresses other intersectional aspects of the patient\u0026apos;s social context, is therefore a prerequisite for improving patient satisfaction, reducing health inequity, and enhancing the quality and safety of care (Aishammari et al., 2019).\u003c/p\u003e\n\u003cp\u003eHowever, the broader psychological, emotional and social dimensions of hospital food are under-represented in current research literature, suggesting emerging and more holistic understandings of its role and meaning for patients in hospital is an emerging area of inquiry. This is an important gap in the literature about the relationship between hospital food, health and wellbeing, giving the practical implications of improving food services to improve patient experience, recovery and outcomes. There is a clear need to extend our current understanding of hospital food from a mere dietary intervention to a culturally embedded experience with the potential to shape recovery in both positive and negative ways. The aim of this study was therefore to explore the perceptions, of former CALD hospital patients and carers regarding the role and meaning of hospital food in their recovery.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study employed a descriptive qualitative research design using focus groups to explore the perceptions of CALD patients regarding the role and meaning of hospital food in their recovery. A social constructionist approach guided the research, acknowledging that meanings are co-constructed through social interactions and shaped by cultural and contextual factors (Phillips, 2023). This approach was appropriate because a descriptive qualitative design allowed for an in-depth exploration of CALD patients lived experiences and nuanced perceptions regarding hospital food in their recovery. Additionally, the social constructionist perspective ensured that the study captured the dynamic, culturally embedded meanings that emerge through social interactions, aligning with the study holistic approach to understanding the role and meaning of food during hospital admissions. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSetting and Participants\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted at a major metropolitan health service in Australia that serves a vibrant and rapidly growing region with a diverse population of nearly one million people, including both urban and semi-rural communities. The service delivers over 800,000 occasions of care annually, and includes four acute hospitals, one community hospital and various community-based and outreach services (Western Health, 2024). With a workforce exceeding 12,500 staff, the service caters to a multicultural community, reflecting a broad spectrum of socioeconomic backgrounds and health needs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile this service provides care for patients from over 150 linguistic and cultural backgrounds, the hospital menu remains largely reflective of an Anglo-European palate. The menu is not available in languages other than English, making it difficult for many culturally diverse patients to understand what meals are provided in hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRecruitment and Participants\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo ensure representation from key cultural groups, purposive sampling was used to recruit participants from the four largest admitted CALD communities represented in inpatient statistics?: Asian (Vietnamese, Chinese, Filipino), Mediterranean (Italian, Greek, Croatian, Maltese), Arabic (Middle Eastern and North African, including Sudanese, Ethiopian, Lebanese, and Egyptian), and Indian Subcontinent (Indian, Sri Lankan, Pakistani, Bangladesh).\u003c/p\u003e\n\u003cp\u003eEligible participants were recent inpatients at the health service or their caregivers. Inclusion criteria required participants to be aged 18 years or over, identify with one of the four targeted cultural communities, have experience of consuming hospital food or observing a loved one consume food during an admission, and be willing to participate in a one-hour focus group discussion. Exclusion criteria included cognitive impairment that would prevent the provision of informed consent and being unable to communicate in a language for whom an interpreter was unavailable.\u003c/p\u003e\n\u003cp\u003eParticipants were recruited via the health service Consumer Advisor Register, in collaboration with the Consumer Partnerships Manager. Recruitment efforts included direct verbal and written invitations, notification in monthly Consumer Partnership newsletter, posters displayed in hospital outpatient areas, and outreach through cultural community networks. Participants were provided with an information sheet outlining the study purpose, procedures, and confidentiality assurances. Explicit, written informed consent was obtained before participation, and interpreters were arranged as needed to enable consent and completion of focus group participation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Collection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFocus groups were chosen to facilitate discussion and collective reflection among participants who shared similar cultural backgrounds and hospital experiences. Unlike individual interviews, focus groups allow for the exploration of collective experiences and social interactions, which can lead to deeper insights into how people interpret and negotiate meanings within their cultural and social contexts (Kidd \u0026amp; Parshall, 2000) . The interactive nature of focus groups enables participants to engage in discussion, challenge or build on each other\u0026rsquo;s viewpoints, and articulate perspectives they may not have expressed in a one-on-one setting (Asbury, 1995). Focus groups also facilitate the identification of common themes and patterns while also capturing divergent perspectives, enhancing the depth and validity of qualitative findings (Hennink et al., 2019).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFour separate focus groups were conducted for each of the targeted CALD communities: Asian (n=8), Mediterranean (n=8), Arabic (n=6)), and Indian (n=6). All groups lasted approximately 60 minutes and were held face to face in a private meeting room at the health service. Trained facilitators (VC) led and supported (VB) each discussion, with an interpreter provided on the request of one participant. The Consumer Partnerships Manager for the health service was also present to provide additional participant support. A bespoke semi-structured interview guide was developed based on a review of existing literature and the research team\u0026rsquo;s professional experience. Key topics included the role of food in comfort and recovery during hospitalisation, perceptions of hospital food quality, variety, and cultural appropriateness, experiences with familiar and traditional foods during hospital stays and preferences and suggestions for improving culturally inclusive menu options. All focus groups were audio-recorded and transcribed verbatim.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA thematic analysis approach, guided by Braun and Clarke\u0026rsquo;s (2021) six step framework, was employed to systematically identify, analyse, and report patterns and themes across the focus group discussions. Data analysis began with familiarisation, where focus group recordings were transcribed via software, and listened to by one researcher (VC) to ensure accuracy and promote immersion in the data. Initial coding was conducted inductively, with the same researcher generating descriptive codes that attempted to capture participants expressed meanings without preconceived categories, reflecting the study\u0026rsquo;s social constructionist lens.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese codes were then grouped into preliminary themes by identifying patterns through discussion with all research team members, using reflective discussions to ensure interpretive consistency and mitigate individual bias. We were particularly careful to identify and challenge potential biases, such as prioritising a biological or instrumental perspective of hospital food. In the theme development phase, codes were organized into broader categories, and two superordinate themes emerged: one on the roles and meanings of hospital food (reported here) and another on experiences and preferences for culturally appropriate food (reported elsewhere). Themes were refined through an iterative process or review and discussion, revisiting transcripts to verify alignment with raw data and adjusting theme labels for clarity. Finally, reporting involved selecting illustrative quotes to evidence themes, and ensure participant voices were foregrounded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTrustworthiness\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe methodology of this study was designed to uphold the trustworthiness of its qualitative findings, aligning with Guba\u0026rsquo;s Model of Trustworthiness as operationalized by the Rosalind Franklin-Qualitative Research Appraisal Instrument (RF-QRA) (Henderson \u0026amp; Rheault, 2004). Focus groups fostered rich, interactive discussions reflective of their lived experience. Transferability was supported by purposive sampling of participants from the four largest CALD communities at the health service, complemented by detailed descriptions of their cultural contexts and hospital experiences, which may potentially enable application of the findings to similar multicultural healthcare settings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDependability was ensured via an audit trail, including verbatim transcription of audio-recorded focus groups, and documentation of the iterative thematic analysis process using NVivo. Confirmability was addressed through reflexivity, with field notes documenting researcher observations and potential biases (e.g., the disciplinary lenses of the research team members), and triangulation across multiple focus groups to identified shared themes. These strategies collectively supported the construction of findings that authentically reflect CALD patients\u0026rsquo; perceptions of hospital food and its role in their recovery.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResearcher Positionality\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs qualitative researchers using a social constructionist approach, we acknowledge that our personal background has influenced design, data collection, and analysis of this study. The first author (VC) is a senior clinical dietitian at the health services, and clinician researcher with experience in exploring the nutrition assessment, interventions and support in varied patient populations. The Second author (VB) is a senior food service dietitian employed at the health service, and with experience in patient meal experiences, menu design and evaluation. The third author (DH) is an occupational therapist and clinician researcher employed at the health service and has extensive experience in partnering and co-producing research with CALD communities. \u0026nbsp; The final author (BR) is an operations manager for food services at the health service. No members of the research team belonged to a CALD community as defined in the local context, and we acknowledge this is a significant limitation of this study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical Considerations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethics approval from the health service Low Risk Ethics Committee (LNR 105352). All participants provided written informed consent, and confidentiality was maintained by anonymising transcripts and ensuring data storage security. Participation was voluntary and withdrawal was permitted at any stage without consequence. Participants received financial reimbursement in accordance with health services\u0026rsquo; consumer remuneration protocol.\u003c/p\u003e"},{"header":"Findings","content":"\u003cp\u003eThree themes were identified describing both the role and the meaning of hospital food during admissions: 1) Comfort from familiar food in an unfamiliar hospital environment, 2) Cultural traditions as a source of wisdom about health and healing, and 3) Culturally appropriate food as a physical aid to recovery. These themes were present to a greater or lesser degree across all the CALD groups in the study.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eComfort from familiar food in the unfamiliar hospital environment\u003c/h4\u003e\n\u003cp\u003eMuch of the meaning attached to hospital food was derived from its ability to provide a familiar cultural experience during the disruption and distress of a hospital admission, which was the strongest theme in the data. Familiar food in hospital was described as a powerful source of comfort for CALD patients, which supported their emotional wellbeing and recognised their culture. Participants across groups craved foods that mirrored their home traditions, viewing them as an express recognition of their identity which offered solace amidst illness. Participants described a strong desire to experience familiar flavours during their hospital admission; \u003cem\u003e\u0026ldquo;Anyone from West Africa, yes, wants the pepe soup\u0026hellip; that\u0026rsquo;s what they crave for it should be spicy, like chili\u0026rdquo;\u003c/em\u003e. Similarly, an Asian participant valued authenticity, even if the dish offered by the hospital was imperfect: \u003cem\u003e\u0026ldquo;I really love the idea to bring more authentic for patients\u0026hellip; at least 70, 80% we can\u0026hellip; pick that food that bring us, you know, like the choice to eat and make us feel better.\u0026rdquo;\u003c/em\u003e Mediterranean patients also echoed this, finding comfort in familiar dishes like wedges: \u003cem\u003e\u0026ldquo;Food was such a comfort\u0026hellip; when she saw them, it was like, Ah, something familiar.\u0026rdquo;\u003c/em\u003e Familiar foods, even in simplified forms, can therefore offer a meaningful connection to the socio-cultural contexts of the patient\u0026rsquo;s life in the community. For some participants, familiar foods also provided connections to historical and/or ethnic senses of identity and belonging.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e[Nihari] is so in Indian dishes, this is one of the only dish which has travelled from the bottom of the food chain to the top of the food chain\u0026hellip; more famous between the poors and then was adopted by the kings.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCulturally appropriate food also profoundly influenced CALD patients\u0026rsquo; emotional well-being, promoting comfort by serving as a source of pleasure and contentment by supporting their cultural identity during hospitalisation. Participants across groups emphasized how food reflecting their traditions provoked positive emotions, which countered the emotional toll of illness. As described by an Indian participant: \u003cem\u003e\u0026ldquo;When you\u0026rsquo;re sick, you want familiar and you want something that you used to\u0026hellip; something that gives people comfort and happiness\u0026rdquo;\u003c/em\u003e. Mediterranean participants similarly found emotional consolation in familiar offerings. One described how simply receiving a dish like lasagna was more than just a pleasurable sensory experience; \u003cem\u003e\u0026ldquo;To me, it\u0026rsquo;s an emotional and mental thing too\u0026hellip; that\u0026rsquo;s a real big boost to how you\u0026rsquo;re feeling\u0026rdquo;\u003c/em\u003e. These emotional reactions were linked to pride in their heritage and fostered a sense of inclusion and validation that enhanced their hospital experience.\u003c/p\u003e\n\u003cp\u003eBeyond comfort, familiarity served as a critical buffer against the vulnerability and alienation of the hospital environment, enhancing participants\u0026rsquo; sense of safety and control. An Asian participant recounted their father\u0026rsquo;s cancer treatment, noting,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHe\u0026rsquo;s facing this really scary illness and diagnosis, and on top of that, he\u0026rsquo;s having to navigate this completely foreign healthcare system \u0026hellip; I think that if he had food that was also familiar to him, it would have been a really big comfort \u0026hellip; this is like something that I can look at in this scary environment, that at least I am familiar with.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis underscores how unfamiliar settings can amplify distress and feelings of dislocation, with familiar food acting as a tangible anchor. Mediterranean participants also ascribed this benefit to culturally appropriate hospital food and emphasised the value of predictability; \u003cem\u003e\u0026ldquo;When you\u0026rsquo;re sick, it\u0026rsquo;s nice to know what you\u0026rsquo;re expecting. You stick to what you know, and what you know you\u0026rsquo;re going to be somewhat satisfied.\u0026rdquo;\u003c/em\u003e Across cultures, familiarity in hospital food mitigated the unfamiliarity of hospitalisation, supporting emotional resilience and recovery by making the unfamiliar feel less daunting.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCultural traditions as wisdom about health and healing\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCALD patients viewed their cultural food traditions as a source of wisdom about health and healing, attributing therapeutic properties to ingredients that have enhanced health across generations. Indian participants emphasised the key role of turmeric, garlic, and onion in their cuisine, perceiving them as essential health tools rather than just flavours. One participant explained,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIndian cooking will always have turmeric. So turmeric is one of the base, so I think what would have happened years and years ago \u0026hellip; there would be some witch doctor somewhere, and he would have figured out that turmeric has got some very good healing abilities and sort of added into the curry. \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis perspective frames food as a culturally embedded form of preventative and restorative care, reflecting long held knowledge that patients still value in the hospital context. In some cases, these traditions were also linked to religious identity such as the following example from Asian cultures;\u0026nbsp;\u003cem\u003e\u0026ldquo;A lot of them are Buddhism or Taoism. They love the, you know, the bok choy, the tofu, the black fungus. There\u0026apos;s so many healthy stuff in vegetarian diet\u0026rdquo;.\u0026nbsp;\u003c/em\u003eModern health trends were also integrated into longer standing cultural wisdom, as described by one participant in the Indian focus group: \u0026ldquo;\u003cem\u003eFor breakfast again, fruits and mixed berries, corn flakes, a protein shake, almond, oat or soy milk\u0026rdquo;.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese beliefs in the intrinsic health benefits of some foods underscore the participants desire for hospital menus to incorporate culturally significant elements as a means of supporting their recovery. The availability of culturally appropriate food was recognised as having the potential to promote agency and continuity in care, as these foods would continuing being used for their health effects after discharge from hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCulturally appropriate food as a physical aid to recovery\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to their cultural meaning, CALD patients also understood hospital food as a biological support for recovery, valuing its nutritional content as a direct contributor to healing. A Mediterranean participant highlighted the role of protein in promoting healing; \u003cem\u003e\u0026ldquo;I\u0026apos;d rather have food that makes my healing quicker. The trick with salad is there\u0026apos;s enough protein or something sitting in there, like the tuna and the chicken\u0026rdquo;\u003c/em\u003e. Effective food-based support for recovery were often shared among communities and also encompasses non-nutrient characteristic such as food texture, as described by a Middle Eastern participant: \u003cem\u003e\u0026ldquo;In our culture where, for example, a kid is teething, kind of porridge that has meat inside it as well, and it\u0026apos;s savory, and we have usually just distributed to other families\u0026rdquo;\u003c/em\u003e. These beliefs about (hospital) food reflects a pragmatic focus on food that enhance physical outcomes, and views food as an important source of fuel and symptom relief. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe physical ease and accessibility of consuming food also emerged as a critical factor, particularly when illness diminished patients\u0026rsquo; capacity to feed themselves. A West African participant emphasised this, stating, \u003cem\u003e\u0026ldquo;People, when we sick, people are lazy to chew. Because they just want something that they can just drink,\u0026rdquo;\u003c/em\u003e pointing to the preference for liquid or softer foods that accommodate weakened states. Mediterranean participants also identified food options which reduce mental health symptoms; \u003cem\u003e\u0026ldquo;It\u0026rsquo;s good to have colour, like your vegetables, colour might brighten up your mood\u003c/em\u003e\u0026rdquo;. While the previous theme described hospital food as an expression of culture, this theme demonstrates how cultural beliefs are specifically applied to health and recovery in the hospital environment.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study reveals that CALD hospital patients perceive food as a multifaceted contributor to their recovery, which supports cultural identity, provides physical nourishment, offers emotional support, and enables social connection. Participants across all included cultural groups affirmed that the food they consume during hospital admissions carries significant importance far beyond bodily sustenance. Their perceptions closely reflect the holistic orientation of the Food Well-Being framework (Block et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2011\u003c/span\u003e), by encompassing the psychological, physical, and social dimensions of hospital food. These findings affirm that consuming hospital food is a culturally embedded experience that can mitigate the disruptive impact of hospital admission, offering comfort in an unfamiliar setting, validating cultural wisdom, and supporting physical and psychological recovery. Their perspectives underscore the need to reframe hospital food services to better support person-centred care in a culturally sensitive and authentic way.\u003c/p\u003e\u003cp\u003eThe finding that familiar food serves as a powerful source of comfort in the unfamiliar hospital environment confirms that understanding patients preferred food offerings during hospital admissions are an essential part of person-centred care for CALD patients. It affirms the outcomes of previous research about the role of familiar food in enhancing feelings of safety and wellbeing for hospitalised patients (Alzahrani, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Locher et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). This is reinforced by the ESPEN guideline, which recommends prioritizing patient perspectives in hospital food services to enhance safety and equity (Thibault et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Recommendation 5 on cultural adaptations; Recommendation 17 on texture modifications for older patients to improve acceptability and intake). However, hospital food services face considerable challenges to meeting patient food preferences and needs, while also ensuring nutritional adequacy and remaining within their budgets (Lalande et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Ottrey et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Raj et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The Anglo-European bias in the hospital menu at this health service, and many others in Western countries, confirms the systemic barriers to providing culturally appropriate food options to CALD patients. Given the many health and wellbeing benefits identified by participants in this study, hospitals should prioritise the provision of culturally appropriate food options to enhance both patient satisfaction and clinical outcomes from hospital admission.\u003c/p\u003e\u003cp\u003eCulturally appropriate food options significantly enhance emotional well-being, possibly offering some protection around the psychological toll of illness. Hospitalisation can have a significantly negative effects on patient mental health (Alzahrani, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), which in turn has a negative impact on their overall recovery. Access to comfort foods have been found to improve meal acceptability (Soares et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), and the link between food and mood is well established in the scientific literature (Flaskerud, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). McKerchar et al., (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) proposes a rights-based approach to improving food availability for culturally diverse communities, which frames access to culturally appropriate food as a human right aligned with cultural identity and health equity. By reframing food as a health right, the policy discourse may shift from regarding meeting the needs of CALD patients as optional to recognising it is an essential aspect of their healthcare experience and outcomes.\u003c/p\u003e\u003cp\u003eThe perception of cultural traditions as wisdom about health and healing identifies a valuable resource and important strength that CALD patients bring to the hospital context. Some have advocated for integrating cultural perspectives into healthcare food frameworks; however, these calls often reflect an instrumental or interventional approach (Loy, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Nordstr\u0026ouml;m et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Nevertheless, hospitals could leverage cultural wisdom by incorporating ingredients like turmeric or garlic into menus, to improve their alignment with patient preferences and values and enhance feelings of trust and safety in care. However, healthcare worker cultural knowledge and competence has been identified as a significant barrier to implementing culturally appropriate foods (Raj et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) and therefore preparatory capacity building will be required before hospitals can benefit from traditional knowledge.\u003c/p\u003e\u003cp\u003eCulturally appropriate food may contribute to addressing critical gaps in hospital nutrition, by enhancing physical recovery through the alignment of nutritional needs with cultural identity. Adequate nutrition during hospital admissions reduced complications (Barker et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Correia et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), while the provision of culturally inappropriate food hinders intake and potentially increases the risk of malnutrition (Hartley \u0026amp; Hamid, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). ESPEN Recommendation 22 further supports this by advising patient-involved monitoring of intake during realimentation after procedures, while Recommendation 21 emphasizes gradual, preference-based feeding post-GI events to minimize malnutrition risks (Thibault et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Given that malnutrition is estimated to cost global healthcare systems between \u003cspan\u003e$\u003c/span\u003e2\u0026ndash;3 trillion per year (Jumrani \u0026amp; Rai, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), the economic argument for investing in culturally resonant, easy-to-eat meal options is strong. Understanding the economic impact of better access to culturally appropriate foods during hospital admissions will be important to the scalability of these innovations in the longer term.\u003c/p\u003e\u003cp\u003e Many of the foods discussed by participants were relevant across multiple cultures, and so the provision of culturally appropriate food does not therefore require the development of a huge range of food options. An inclusive menu featuring shared staples like soup (congee), customisable with condiments, could enhance patient experience and overall well-being in a feasible and sustainable manner. Participants in this study did not expect their cultural needs to be met perfectly, and previous research has found patients have relatively low expectations of what hospitals are able to provide (Johns et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Collaborative partnerships between CALD patients and communities and local healthcare providers are likely to be the most effective way of developing better food services which satisfactorily meet everyone\u0026rsquo;s needs (Abid et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study has several limitations that should be considered when interpreting its findings. First, the purposive sampling of participants from only four CALD communities\u0026mdash;Asian, Mediterranean, Arabic, and Indian Subcontinent\u0026mdash;within a single metropolitan health service in Australia may limit their transferability to other cultural groups or healthcare settings. Additionally, the recruitment of participants who could communicate in English or languages with available interpreters may have excluded people with limited language proficiency or those from more recently arrived populations with smaller pools of available interpreters. This sampling bias could underrepresent the full spectrum of cultural understandings of the role and meaning of hospital food.\u003c/p\u003e\u003cp\u003e Second, the focus group methodology may have constrained individual expression due to social dynamics or dominant voices within groups, despite efforts to facilitate equitable participation. The presence of representatives from the health service may also have subtly influenced participants to moderate critical views about hospital food services, introducing a potential social desirability bias. Furthermore, the thematic analysis, though rigorous, was conducted within a social constructionist framework that prioritised emergent meanings over quantitative measures of food intake or nutritional outcomes, limiting the ability to directly link cultural understandings to clinical outcomes.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study described the role and meaning of hospital food for CALD patients from their perspective, revealing its contribution to comfort, cultural identity, and physical recovery within the disruptive context of hospital admissions. Familiar foods are a buffer against vulnerability, provide links to valued cultural wisdom and practically support optimal nutrition, indicating their multidimensional impact on patient health and wellbeing. These findings extend prior research by highlighting how culturally appropriate foods reduce emotional distress and promote positive emotional experiences while dealing with acute illness. By framing food as a culturally embedded experience, this study underscores the potential benefits of improving cultural diversity in hospital menus and food services.\u003c/p\u003e\u003cp\u003eFuture research should build on these insights by exploring the scalability, economic feasibility and benefits of co design in successfully implementing culturally inclusive hospital menus across diverse healthcare settings, addressing systemic barriers like financial constraints, presumed knowledge or insight and staff capacity. Quantitative studies could measure the impact of culturally tailored food on clinical outcomes (e.g., malnutrition rates, length of stay, patient satisfaction and nutritional factors, impact of food wastage), complementing the depth of analysis provided by qualitative studies. Engaging a broader range of CALD communities through multilingual methodologies could uncover further nuances in cultural understandings of hospital foods. Ultimately, collaborative co-design projects with CALD patients, healthcare providers, and policymakers are needed to develop practical, sustainable and meaningful menu solutions, that ensure hospital food not only nourishes the body but also honours cultural identities and promotes holistic healing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbid, M. H., Shehri, N. A., Din, S. M. S. U., \u0026amp; Nofeye, J. A. (2023). Leveraging an Experience-Based Codesign Approach to Improve the Inpatient Food Service Experience. 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Appetite, 54(1), 181-185. https://doi.org/https://doi.org/10.1016/j.appet.2009.10.005 \u003c/li\u003e\n\u003cli\u003eJohnstone, P., Alexander, R., \u0026amp; Hickey, N. (2015). Prevention of dehydration in hospital inpatients. British Journal of Nursing (BJN), 24(11), 568-570, 572-563. https://doi.org/10.12968/bjon.2015.24.11.568 \u003c/li\u003e\n\u003cli\u003eJumrani, J., \u0026amp; Rai, V. N. (2020). 1 - The unacceptable status quo: malnutrition challenges of the developed and developing world. In O. P. Gupta, V. Pandey, S. Narwal, P. Sharma, S. Ram, \u0026amp; G. P. Singh (Eds.), Wheat and Barley Grain Biofortification (pp. 1-25). Woodhead Publishing. https://doi.org/https://doi.org/10.1016/B978-0-12-818444-8.00001-8 \u003c/li\u003e\n\u003cli\u003eKidd, P. S., \u0026amp; Parshall, M. B. (2000). Getting the Focus and the Group: Enhancing Analytical Rigor in Focus Group Research. 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Contribuciones A Las Ciencias Sociales, 17(13), e13510. https://doi.org/10.55905/revconv.17n.13-155 \u003c/li\u003e\n\u003cli\u003eThibault, R., Abbasoglu, O., Ioannou, E., Meija, L., Ottens-Oussoren, K., Pichard, C., Rothenberg, E., Rubin, D., Siljam\u0026auml;ki-Ojansuu, U., Vaillant, M. F., \u0026amp; Bischoff, S. C. (2021). ESPEN guideline on hospital nutrition. Clinical Nutrition, 40(12), 5684\u0026ndash;5709. https://doi.org/10.1016/j.clnu.2021.09.039\u003c/li\u003e\n\u003cli\u003eWestern Health. (2024). \u003cem\u003eAnnual report 2023-2024\u003c/em\u003e. Western Health https://www.westernhealth.org.au/AboutUs/CorporatePublications/Documents/AnnualReport/Western%20Health%20Annual%20Report%202023-2024%20FINAL.pdf \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Western Health","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hospital food, Culturally and linguistically diverse (CALD), Food well-being, Patient-centred care, Cultural identity","lastPublishedDoi":"10.21203/rs.3.rs-8032650/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8032650/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study explored the perceptions of Culturally and Linguistically Diverse (CALD) hospital patients regarding the role and meaning of hospital food in their recovery. Using a descriptive qualitative design guided by a social constructionist approach, four focus groups were conducted with participants from Asian, Mediterranean, Arabic, and Indian Subcontinent communities at a major Australian metropolitan health service. Purposively recruited participants included former inpatients or caregivers who discussed their experiences in face-to-face focus groups. Thematic analysis revealed three key themes: 1) Familiar food as a source of comfort in an unfamiliar environment, 2) Cultural traditions as wisdom for health and healing, and 3) Culturally appropriate food as a physical support to recovery. Findings highlight the multifaceted role of culturally appropriate hospital food beyond basic nutrition, including its ability in supporting emotional well-being, cultural identity, and physical healing when feeling already vulnerable amid the unfamiliar daily activities of hospital wards These insights underscore the need to reframe hospital food services policies and practices to prioritise cultural sensitivity, enhancing patient-centered care and reducing health inequities. Future efforts should focus on scalable, culturally inclusive menu designs that address systemic barriers through codesign and improve patient satisfaction and clinical outcomes.\u003c/p\u003e","manuscriptTitle":"The role and meaning of hospital food for culturally and linguistically diverse patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-06 06:43:13","doi":"10.21203/rs.3.rs-8032650/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"57d64ea8-ac1c-456d-8ed6-63ea54ea1e75","owner":[],"postedDate":"November 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":57447370,"name":"Nutrition \u0026 Dietetics"}],"tags":[],"updatedAt":"2025-11-06T06:43:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-06 06:43:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8032650","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8032650","identity":"rs-8032650","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}