Impact on staff of improving access to the school breakfast program: a qualitative study.

The US Department of Agriculture’s School Breakfast Program (SBP) started as a pilot project in 1966 and was made permanent in 1975.1 In 2010, the SBP operated in over 88,000 schools and served over 11.6 million children daily.1 Yet, the SBP is underutilized nationally and less than half of low-income children participate.2,3 Evidence shows there is an increased likelihood of higher nutrient intakes and more healthful diets among children and adolescents who consume breakfast.4,5 Yet 10% to 30% of children and adolescents skip breakfast, with breakfast skipping being more prevalent in girls, older children, and youth from lower socioeconomic backgrounds.4–6 Children and adolescents report a number of reasons for skipping breakfast, including not having enough time to eat in the morning, preferring to sleep rather than eat breakfast, not feeling hungry, or skipping breakfast as a strategy to control body weight.5,7–9 There is significant evidence of increased frequency of breakfast consumption protecting against overweight or obesity and breakfast consumers having a lower body mass index (BMI) compared with those who skip breakfast.5,10 Additionally, participation in the SBP has been found to be associated with a lower BMI.11 Breakfast consumption is associated with enhanced academic performance and cognitive ability.4,5,12 Evidence most strongly suggests a positive relationship between breakfast consumption and memory, but other benefits include increased concentration, creativity, reasoning, vocabulary and problem solving.5 Additional benefits of breakfast consumption, and in particular participation in the SBP, include improved school attendance and positive effects on students’ psychosocial function.4,5 The Diffusion of Innovation Theory (DOI) provides a framework that schools can apply when making changes to programs, such as the SBP.13,14 This framework describes how a novel idea is disseminated over time, emphasizing key characteristics of the process of implementation.15 The authors are unaware of any research to date that explores the aspects of expanding the SBP and using the DOI to guide the evaluation. Previous reports identified key school personnel and staff as critical players in the expansion of the SBP. Key personnel include the principal as a vital leader and enabler of policies and the foodservice director and managers as holding critical know-how and power to make appropriate changes.16,17 A number of other faculty and staff members, such as school nutrition personnel, custodians, teachers, and nurses, can be involved in a team approach to making changes to the SBP.18 Project BREAK! was the parent study to this project. The purpose of Project BREAK! was to test a 6-month pilot intervention, beginning at the start of the 2009–10 school year, to improve student participation in the reimbursable SBP through improving and expanding the SBP in high schools. Two intervention high schools added a convenient serving location in the school atrium that offered a grab-n-go menu more in line with the 2009 Institute of Medicine School Meals report (eg, more whole grains, low fat dairy) and encouraged SBP consumption by allowing eating in the hallway. The authors concluded that improving the availability of a healthy breakfast and accessibility to the SBP is feasible, efficacious and particularly beneficial to students most at risk for breakfast skipping, ie, girls, low income youth (Nanney, Coulter, Wang, et al unpublished data). Little is known about the influence of changes to the SBP from the point of view of key school personnel. The purpose of this study was to investigate how the changes made to the SBP influenced Project BREAK! schools from the perspectives of key personnel through the DOI framework. This knowledge will support the future development of strategies that maximize the potential benefits of the SBP, especially when considering the scalability of the intervention.