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The American Journal of Occupational Therapy logoLink to The American Journal of Occupational Therapy
. 2018 Mar 14;72(3):7203205050p1–7203205050p9. doi: 10.5014/ajot.2018.025379

The Comfortable Cafeteria Program for Promoting Student Participation and Enjoyment: An Outcome Study

Susan Bazyk 1,✉, Louise Demirjian 2, Frances Horvath 3, Lauri Doxsey 4
PMCID: PMC5915230  PMID: 29689174

An occupational therapist–led program was found to build cafeteria supervisors’ and students’ capacity to create a positive mealtime environment.

Abstract

A mixed-methods design was used to explore the outcomes of a 6-wk, occupational therapist–led Comfortable Cafeteria program designed to build cafeteria supervisors’ and students’ capacity to create a positive mealtime environment so that all students can successfully participate in and enjoy a healthy meal and socialization with peers. Students whose scores were in the low and mid-range at the outset had statistically significant improvements in pretest–posttest visual analog scale ratings of participation and enjoyment. Cafeteria supervisors demonstrated statistically significant improvements in their perceptions of knowledge and skills to supervise and to encourage healthy eating. Qualitative findings add further insight into the program, suggesting that students learned prosocial values (e.g., being kind, helping others), supervisors actively encouraged positive social interaction, and occupational therapists enjoyed implementing the program and recognized positive supervisor and student changes as a result of integrating services in the cafeteria.

The health-promoting school model advanced by the World Health Organization (WHO) was developed to provide an organizing framework for comprehensive health promotion to create school environments that support the physical and mental health of all students (Jané-Llopis & Barry, 2005). In addition, WHO’s (2001) World Health Report called for schools to enable students to develop positive mental health. These models in these reports are based on WHO’s (1986) Ottawa Charter for Health Promotion, which emphasizes a settings-based approach to support health and notes that “health is created and lived by people within the settings of their everyday life; where they learn, work, play and love” (p. 3). The focus of this research is on the evaluation outcomes of the Comfortable Cafeteria program—a universal, schoolwide program developed by occupational therapists to foster the enjoyable participation and health of all students (Demirjian, Horvath, & Bazyk, 2014).

Positive mental health is reflected in feeling good emotionally and doing well functionally in everyday tasks (Keyes, 2007). People who are mentally healthy and feel happy demonstrate greater degrees of everyday functioning (Keyes, 2007) and healthy behaviors (Rasciute & Downward, 2010). Conditions that promote positive mental health include participation in enjoyable activities that result in positive emotions, use of personal strengths, and development of positive environments (e.g., caring adults) that foster positive emotions (Fredrickson, 2001; Seligman, 2002).

Nonacademic parts of the school day (lunch, recess, and extracurricular activities) can significantly contribute to student mental health. Research has demonstrated that when students enjoy lunch, have good friends, and perceive school personnel as supportive and caring, they feel more connected to school. These feelings of connectedness, in turn, enhance classroom engagement, academic performance, and school completion rates (Blum, 2005). It has also been found that when the cafeteria environment is pleasant, students eat more of their lunch and have fewer behavior problems (Center for Ecoliteracy, 2010).

The cafeteria is also an important context for promoting students’ physical health and social interaction, teaching mealtime skills, preventing behavioral challenges, and fostering positive values. Students obtain about half of their daily nutrients from food eaten at school, so it is essential that they eat a nutrient-packed lunch (Alliance for a Healthier Generation, 2014). Emotionally, students need time to relax, take a break from classroom work, and socialize with peers so they can return to class prepared to learn. A well-thought-out lunch period can foster the development of context-specific skills, such as how to engage in meaningful conversations, demonstrate appropriate mealtime manners, choose healthy foods, and be a good friend. Because lunch is a time when students with disabilities and mental health challenges are included with their peers without disabilities, it also provides an opportunity to shape important values such as respect for differences (e.g., cultural, functional, physical) and the importance of including everyone (Heyne, Wilkins, & Anderson, 2012). Finally, interventions provided in natural settings during daily routines are more likely to be applied consistently, leading to the development of new skills and values (Shumway-Cook & Woollacott, 2007).

Although the cafeteria can be one of the best contexts for promoting healthy eating and social interaction, cafeteria supervisors are typically not provided with the professional development and support to effectively do their jobs (Moore, Murphy, Tapper, & Moore, 2010). The typical cafeteria adult-to-child ratio is 1 to 50, which often results in supervisors who are stressed and responding in a reactive manner to poor behavior (Moore et al., 2010). An additional challenge to supervisors is that students with disabilities or mental health needs may also struggle to successfully participate during lunchtime because of sensory processing or social–emotional challenges (Heyne et al., 2012). Although targeted programs such as the use of “lunch buddies” to promote friendship and fun between students with and without disabilities have been proposed (Elledge, Cavell, Ogle, & Newgent, 2010; Heyne et al., 2012), universal programs aimed at building supervisors’ and students’ capacity to create positive cafeteria experiences are lacking.

Best practice in schools emphasizes the integration of related services (e.g., occupational therapy, physical therapy, speech therapy) in the general education classroom and nonacademic settings (lunch, recess) when possible, offering opportunities to contribute to health promotion and prevention efforts for all students in addition to addressing the needs of those with identified disabilities or mental health challenges (Bazyk & Cahill, 2015; Handley-More, Hollenbeck, Orentlicher, & Wall, 2013). With the growing movement to a multitiered system of support, including universal, schoolwide promotion (Tier 1), targeted prevention (Tier 2), and intensive intervention (Tier 3), it is important for related service providers to envision, articulate, and advocate for expanded services at each of these tiers throughout the school day (Bazyk & Cahill, 2015). For example, because occupational therapy’s scope of practice includes engagement in occupation to promote health in the areas of eating and mealtimes and social participation, integrating service in the cafeteria can be instrumental in contributing to schoolwide health promotion and prevention efforts (American Occupational Therapy Association, 2013).

Every Moment Counts: Promoting Mental Health Throughout the Day is an occupational therapist–led mental health promotion initiative funded by the Ohio Department of Education’s Office of Exceptional Children. Guided by a public health approach to mental health, the focus of this initiative is to help all children and youth become mentally healthy to succeed in school, at home, and in the community. A major goal of Every Moment Counts has been the development, implementation, and evaluation of model programs (Comfortable Cafeteria, Refreshing Recess, Leisure Matters) and embedded strategies designed to promote successful and enjoyable participation throughout the day (http://www.everymomentcounts.org).

As a part of Every Moment Counts, the Comfortable Cafeteria program was developed and implemented by occupational therapists to assist cafeteria supervisors in developing the knowledge and skills needed to create positive lunch experiences, help all students participate successfully in and enjoy lunch, and foster inclusion of students with disabilities or mental health challenges. In this study, we sought to evaluate the meaning and impact of the Comfortable Cafeteria program from the perspective of the students, cafeteria supervisors, and occupational therapists who implemented the program. The research questions were as follows:

  1. Does participation in the Comfortable Cafeteria program affect student perceptions of participation in and enjoyment of lunchtime?

  2. Does participation in the Comfortable Cafeteria program result in cafeteria supervisors’ enhanced knowledge of and perceived ability to be effective cafeteria supervisors?

  3. What is occupational therapists’ overall assessment of the Comfortable Cafeteria program after implementation?

Method

Research Design

We used a mixed-methods design to evaluate student and cafeteria supervisor outcomes (Research Questions 1 and 2). A single-group pretest–posttest survey of students and supervisors (quantitative) was combined with qualitative analysis obtained from student and supervisor interviews (qualitative). To address the third question, written reflections were obtained from the occupational therapists after program implementation. The institutional review board at Cleveland State University approved the study.

Participants

First, we recruited a purposeful sample of 4 Midwestern school-based occupational therapists who had completed Every Moment Counts’ building capacity initiative (Bazyk et al., 2015), ensuring their understanding of a public health approach to mental health, to implement the Comfortable Cafeteria program and take part in this study. After receiving the school principal’s permission to implement the program, these therapists implemented the Comfortable Cafeteria program during lunch, one grade level of students at a time. Students in kindergarten through Grade 4 attending four different suburban schools participated in this study over a 2-yr period (2014–2015). In addition to the occupational therapists, study participants also included all students and cafeteria supervisors who participated in the program. Written informed consent was obtained from participants before data collection.

Intervention: Comfortable Cafeteria Program

The Comfortable Cafeteria program, developed by occupational therapists (Demirjian et al., 2014) on the basis of current evidence, is a 6-wk occupation-based program integrated into the cafeteria 1 day/wk during the lunch period. Although developed by occupational therapists, the program can be implemented by other school professionals who have a vested interest in creating a positive lunchtime experience (e.g., speech therapists, school counselors). The program is based on the following vision statement: “Our school will provide pleasant and positive mealtimes so that students will enjoy eating food and socializing with peers and adults.” To implement the program, the occupational therapy practitioner provides a combination of (1) education to cafeteria supervisors and other relevant stakeholders (e.g., principal, teachers) using a variety of strategies, including an orientation session and written materials; (2) embedded weekly activities to address the weekly theme; and (3) ongoing coaching of supervisors to model positive social interaction, offer activity suggestions, and problem solve challenges and solutions.

Each week emphasizes a theme (how to create a comfortable cafeteria, be a good friend, have a mealtime conversation, include others, appreciate sensory differences, and make healthy food choices) with a small lesson and user-friendly materials (e.g., bookmarks, posters, information sheets) to share with the cafeteria supervisors and students. All of the instructions (e.g., 10 Steps to Success) and materials needed to learn about, plan, and implement the program are available for free on the Every Moment Counts website (http://www.everymomentcounts.org). After the 6-wk program, occupational therapists are encouraged to visit the cafeteria routinely (e.g., 1–2×/mo) to reinforce program concepts, problem solve, and offer support. The 4 occupational therapists who implemented the Comfortable Cafeteria program for this study received an orientation to the program and ongoing coaching from the therapists who developed the program to ensure implementation fidelity (Demirjian et al., 2014).

Procedures and Data Collection

Student Data.

To measure students’ perception of participation and enjoyment during lunch, we developed a 4-item visual analog scale (VAS). The VAS is a graphic scale that is used to rate a person’s subjective experience of the phenomenon of interest (e.g., feeling, attitude, functional ability), allowing for increased sensitivity in evaluation findings compared with a traditional Likert scale (Gorrall, Curtis, Little, & Panko, 2016; Wewers & Lowe, 1990). The VAS is a straight 100-mm line with anchored ends and labels at each end that describe extreme boundaries of the experience (e.g., not fun, fun). Participants place a vertical hatch mark through the line at the position that best represents their current perception of the experience. Scoring the VAS involves measuring in millimeters the distance from the left end of the scale to the participant’s hatch mark (0–100).

Before completing the VAS survey, the occupational therapists implementing the program provided scripted verbal instructions and a demonstration of how to score the VAS using a sample item. Each question was read aloud to the students before they responded to ensure that all students understood the question. Four questions focused on participation and enjoyment:

  1. How much did you enjoy time at lunch?

  2. How friendly are the lunch supervisors?

  3. How friendly are the students at lunch?

  4. How much did you enjoy conversations during lunch?

The pretest was administered 1 wk before the start of the program, and the posttest was administered 1 wk after completion of the program, during teacher-approved class time. Qualitative data were obtained by means of a short focus group (10 min), transcribed verbatim, with a convenience sample of one group of second-grade students after the last week of the program. Students were asked the open-ended question, “What did you learn from the Comfortable Cafeteria program?”

Supervisor Survey Data.

On the basis of the information provided to cafeteria supervisors during implementation of the Comfortable Cafeteria program, we developed a 12-item survey including questions focusing on the knowledge, skills, and resources needed to supervise lunch (4 items), ability to encourage healthy eating (1 item), ability to promote positive social interaction and a warm social atmosphere (3 items), support needed to supervise lunch (1 item), and knowledge and skills to promote positive behavior and resolve conflicts (3 items). Supervisors rated each of the 12 discrete statements on a Likert scale on which 1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, and 5 = strongly disagree. Pretests were completed before the start of the program, and the posttest was completed 1 wk after the last week of the program. Qualitative data included a short interview (10 min), transcribed verbatim, with a convenience sample of two cafeteria supervisors of second-grade students after the last week of the program. Supervisors were asked the open-ended question, “What did you think about and learn from the Comfortable Cafeteria program?”

Occupational Therapist Data.

After implementation of the program, the four occupational therapists provided typed written reflections on four open-ended questions:

  1. What are the overall strengths of the program?

  2. What are the limitations of the program?

  3. How did the students respond to the program?

  4. How did the supervisors respond to the program?

Data Analysis

Raw scores for the student VAS surveys and cafeteria supervisor surveys were entered into R (Version 2.14.1; R Foundation for Statistical Computing, Vienna, Austria). We compared pretest and posttest scores on the items using a matched-pair t test with significance set at .05. An inductive textual analysis of all of the qualitative data (student focus group, cafeteria supervisor interviews, and occupational therapists’ written reflections) using open coding was completed, yielding themes in the data (Silverman, 2011). To enhance credibility, triangulation in the form of multiple data analysts was used (Patton, 2002).

First, the written documents for each data set were read individually by the first author and three graduate occupational therapy students to gain a sense of the whole, followed by a detailed reading of the data, noting relevant and recurring statements, concepts, and words related to the open-ended questions. Relevant statements were clustered into themes, relationships between themes were explored, and verbatim quotes from the data were identified to create a rich structural description of the experience. Member checking was used to enhance credibility by having the occupational therapists read each data set and initial themes to ensure accurate depiction of the data.

Results

The Comfortable Cafeteria program was implemented six different times, one grade level of students (kindergarten through fourth grade) at a time, by four occupational therapists representing four different suburban Midwestern schools during the 2014–2015 school year. Because it was a principal-approved, school-sponsored universal program, all students, both with and without disabilities or mental health challenges, were included in all of the cafeteria lunch sessions and participated in the program. The number of students present in the cafeteria varied depending on the size of the school and ranged from approximately 100 to 150 students.

Student Pretest–Posttest Results and Focus Group Findings

A total of 366 students completed both the pretest and the posttest VAS. On the basis of pretest scores, we grouped students into three categories: high enjoyers (65%), with average scores ranging from 76 to 100 on a 100-mm scale; mid-enjoyers (27%), with average scores ranging from 26 to 75; and low enjoyers (8%), with average scores ranging from 0 to 25. The matched-pair t test revealed statistically significant improvements from pretest to posttest (p < .00) in both the low enjoyer and the mid-enjoyer groups on each of the four survey questions (Table 1). The low enjoyers (6%–12% of students) rated their perceptions of enjoyment and friendliness at the onset of the program as extremely low, with average pretest scores ranging from 5 to 7 on a 100-mm scale. At the conclusion of the program, the low enjoyers’ perceptions of these areas had increased significantly, with an average increase of 48 points at posttest. Average pretest scores for the mid-enjoyers hovered around the midpoint (53) with a statistically significant increase of about 13 points at the posttest (66). Not included in the table are data for the high enjoyers (about 65% of participants) because statistically significant improvements in pretest and posttest scores were not found as a result of a ceiling effect.

Table 1.

Pretest–Posttest Student VAS Responses: Student Perceptions of Participation and Enjoyment in the Cafeteria

Survey Question No. of Students, n (%) Average Pretest Score Average Posttest Score p <
Low enjoyers (initial score = 0–25)
 1. How much did you enjoy time at lunch? 28 (7.65) 6.21 52.94 .00
 2. How friendly are the lunch supervisors? 35 (9.56) 7.63 32.34 .00
 3. How friendly are the other students at lunch? 20 (5.46) 5.08 53.94 .00
 4. How much did you enjoy conversations during lunch? 41 (11.26) 5.83 54.17 .00
Mid-enjoyers (initial score = 26–75)
 1. How much did you enjoy time at lunch? 106 (28.96) 53.14 65.18 .00
 2. How friendly are the lunch supervisors? 111 (30.33) 52.59 59.38 .01
 3. How friendly are the other students at lunch? 103 (28.14) 53.73 69.78 .00
 4. How much did you enjoy conversations during lunch? 73 (19.94) 53.25 68.58 .00
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Note. N = 366. Score range = 0–100. VAS = visual analog scale.

An analysis of the focus group transcript of 10 second-grade students talking about what they learned from the program yielded the theme of the importance of positive behavior and social interactions, with students providing examples such as “use good manners,” “help other people,” “not bully,” and “not make fun of people.” Other comments reflected empathy toward peers with statements such as “everyone has feelings” and needing to “stand up for your friends” and “be kind.”

Cafeteria Supervisor Pretest–Posttest Results and Interview Findings

A total of 18 participating cafeteria supervisors completed both the pretest and the posttest surveys. On average, the cafeteria supervisor-to-student ratio was 1 to 50, with each school having 2–3 supervisors per lunch period with the number of students ranging from 100 to 150. The majority of the cafeteria supervisors (90%) were paid part-time staff, all of whom had received no prior training in being a cafeteria supervisor. Frequency data reported in Table 2 indicate that at posttest most of the participants (94%–100%) agreed or strongly agreed with the knowledge, belief, and action statements related to their ability to effectively supervise lunch at posttest compared with pretest (74%–93%). Additionally, the matched-pair t test revealed statistically significant improvements from pretest to posttest on items related to having the knowledge, skills, and resources needed to supervise (p < .05) and the ability to encourage healthy eating (p < .00). Although not statistically significant at the p < .05 level, two other areas were close—being able to promote positive social interaction and a warm social atmosphere (p < .06) and having the support needed to supervise lunch (p < .06).

Table 2.

Pretest–Posttest Survey: Cafeteria Supervisors’ Perceptions

Content Area (no. of questions) Strongly Disagree or Disagree, % Neutral, % Strongly Agree or Agree, % p <
Pretest Posttest Pretest Posttest Pretest Posttest
Possesses the knowledge, skills, and resources needed to supervise (4) 0 12 14 6 74 94 .05
Able to encourage healthy eating (1) 0 0 11 0 89 100 .00
Able to promoting positive social interaction and a warm social atmosphere (3) 0 0 2 0 91 100 .06
Has the support needed to supervise lunch (1) 11 0 6 0 83 100 .06
Possesses the knowledge and skills to promote positive behavior and resolve conflicts (3) 0 0 7 4 93 96 .11
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Note. n = 18.

An analysis of the interview transcript of two cafeteria supervisors reflecting on their perceptions of the Comfortable Cafeteria program yielded the following themes. First, supervisors recognized that the students enjoyed and benefited from the program. They stated that “students liked the activities and looked forward to them,” “the program has increased conversations during lunch,” and “students are making more attempts to scatter to other tables to make new friends.” Second, supervisors acknowledged that they applied what they learned. One supervisor offered, “I think the program has helped me to implement it with other grades.” The other supervisor made a point of recognizing the important social aspects of lunchtime—that “this is their social time.” Both reflected on new ways of interacting with the children, with one stating, “I’m always trying to get them to try something new. ‘Why don’t you sit with that friend over there? I see there aren’t many people over there . . . you can learn more about them.’ Sometimes . . . all they need is a little encouragement.”

Occupational Therapist Reflections

Four occupational therapists, each with 10 or more yr of experience in school-based practice, implemented the Comfortable Cafeteria program during the lunch session for one grade level (one full class of students ranging from kindergarten through fourth grade) 1–2 times during the 2014–2015 school year. Three themes emerged from the data.

Students Enjoyed and Learned From the Activities.

The participants noted that the “students loved the program” and enjoyed the weekly activities. One stated, “They are very engaged and excited about doing something new.” Another indicated that the students “verbalized enjoying the weekly activities, especially the special guest week and trying healthy foods weeks.” The therapists all agreed that the students “really seemed to grasp an understanding of the concepts” being taught, resulting in positive changes in social and behavioral skills. One therapist noted,

The children responded well to all of the structured activities as well as the extra attention. Negative behaviors (yelling, running, etc.) were minimized and the children demonstrated some nice carry over of social skills while expanding their interests in healthy fruits and vegetables.

Others noted better socialization, especially among those who struggled to make friends, and improved mealtime manners, including cleaning up.

Supervisors Were Receptive to New Information and Demonstrated New Skills.

One participant stated, “The supervisors were receptive and open to the handouts provided and weekly plans.” Several participants observed supervisors demonstrating new skills in the areas of positive social interaction (e.g., “supervisors strive to talk with the students at lunch”) and behavior management (e.g., “better able to control lunch room behavior”). Another stated, “I feel they gained a better understanding of sensory processing and how lunch time can be sensory overload for a lot of our students.” Finally, therapists noted that the cafeteria supervisors began to contribute by “bringing in music,” “engaging students in more conversations,” and “wanting to implement the program with more grades in the school.”

Therapists Enjoyed Implementing the Program and Developing Relationships With Students and Cafeteria Supervisors.

The occupational therapists all agreed that learning how to implement the program was easy because of the user-friendly website. They also valued the content prepared for the students, saying, “The program has a lot of important lessons for the kids.” Several indicated that they enjoyed the program and “time spent with children in the natural setting of lunch.” Another stated, “I love how it helped me form relationships with cafeteria staff and students not on my caseload.” Finally, participants recognized that “they became another adult resource” in the cafeteria, a setting that typically has only 1 or 2 adult supervisors. One stated, “The supervisors appreciated the extra help and having extra adults interacting with the children.” Although the majority of the practitioner feedback was positive, implementation challenges were noted. Two therapists indicated that it was difficult “coordinating schedules to get the program started.” Another noted, “The only limitation was time. I would have liked to include other grades as well.”

Discussion

This study explored the outcomes of a universal cafeteria program designed to build cafeteria supervisors’ and students’ capacity to promote students’ successful participation (eating lunch, being a good friend, engaging in mealtime conversations) and enjoyment (interacting with peers and adults) from the perspective of participating students, cafeteria supervisors, and occupational therapists.

Pretest–posttest results for the first research question indicated statistically significant improvements in all four areas related to participation and enjoyment among students who initially scored in the low and middle ranges. These results suggest that this 6-wk (1 day/wk) program emphasizing engagement in enjoyable occupations relevant to eating lunch and empowering cafeteria workers to be positive supervisors may be effective in transforming negative student experiences into positive ones, thus promoting feelings of emotional well-being and developing a positive school climate (Blum, 2005; Fredrickson, 2001). The most significant improvement in scores occurred among the low enjoyers and were related to their enjoyment of lunch and conversations and perceptions of peer friendliness. As such, this universal program led by occupational therapists may be effective in both health promotion (Tier 1) and targeted prevention (Tier 2) for students at risk of not enjoying and not participating successfully during lunch. Findings support those of previous studies documenting the positive effects of integrating occupational therapy services in natural school contexts (Bazyk et al., 2009; Blackwell & Dunn, 2016) to enhance the participation of all students and thus maximize the impact of occupational therapy services in schools.

Supervisor pretest–posttest results addressed the second research question and indicated statistically significant improvements in perceptions of having the knowledge and ability to supervise lunch and encourage healthy eating. Although not statistically significant, improvements in believing they had support to do their jobs and promote positive social interaction and a warm social atmosphere were also found. Qualitative findings from two supervisor interviews appear to support and extend the results by suggesting that supervisors’ enhanced knowledge and skills enabled them to apply what they learned during other lunch periods even when the occupational therapist was not present in the cafeteria. Moreover, supervisors expressed being more tuned in to tangible strategies for creating a positive environment such as the impact of enjoyable activities (e.g., students looked forward to the activities) and importance of social interaction and inclusion (e.g., encouraging conversation and friendship with students who are sitting alone).

These findings support the growing use of school-based coaching as a capacity-building strategy to promote the application of new knowledge and skills in day-to-day practice by school personnel (Poglinco et al., 2003). Although the Comfortable Cafeteria program involved coaching over 6 wk, best practices in coaching indicate that coaching needs to be deeply embedded and ongoing. Providing ongoing coaching after the implementation of the Comfortable Cafeteria program may enhance supervisors’ ability to promote positive social interaction and behavior in the cafeteria.

Qualitative findings from occupational therapists’ reflections on program implementation revealed that therapists enjoyed and valued interacting with supervisors and students in the cafeteria and recognized their role in building supervisors’ capacity to be effective in their job and helping students to develop important skills and enjoy their lunch. Reflections also suggest that the program’s combination of professional development, activity demonstrations, and coaching was effective in shaping cafeteria supervisor knowledge and skills specific to behavior management, positive social interaction, and appreciation of sensory differences. In a similar way, Blackwell and Dunn (2016) found that relationship building, effective translation of therapy intervention, and teacher openness to learning and using new strategies were important ingredients of occupational therapy embedded in early childhood classrooms.

The occupational therapists also noted that students enjoyed and learned from the weekly activities, resulting in positive changes in social interaction and mealtime behaviors. This suggests that even short lessons and activities embedded in the cafeteria have the potential to shape students’ thinking and behavior, supporting theories of skill learning that indicate that practice of meaningful activities in natural contexts is most effective for achieving new skills (Shumway-Cook & Woollacott, 2007). Finally, although the occupational therapists found it easy to learn the Comfortable Cafeteria program from the user-friendly website, one challenge noted was related to coordinating schedules to initiate the program. Bose and Hinojosa (2008) also found that the greatest challenge associated with providing integrated services is finding the time for occupational therapists and relevant school personnel to meet and plan embedded services.

Limitations

Although this study’s results are strengthened by the use of a combination of quantitative and qualitative data from the perspective of students, supervisors, and occupational therapists, a limitation is that without the use of a control group, we are unable to infer causality—that is, that the intervention was responsible for the documented outcomes. Obtaining a control group was not feasible because we could not acquire different cafeteria supervisors to oversee a lunchtime control group to prevent spillover effects. Replication of this research using a stronger design (e.g., a randomized controlled trial) would strengthen the results and generalizability. Moreover, more extensive qualitative data in the form of more participants and longer interviews and focus groups would strengthen qualitative outcomes.

Implications for Occupational Therapy Practice

By integrating the Comfortable Cafeteria program during lunchtime, occupational therapy practitioners can build cafeteria supervisors’ capacity to effectively create a positive environment for all students to participate in and enjoy eating their meal and socializing with peers, thus contributing to school health promotion and prevention efforts. Study findings have the following implications for occupational therapy practice:

  • Embedding occupational therapy services in the cafeteria that involve a combination of educational strategies, enjoyable activities, and coaching may be an efficient and effective way to promote positive behavior and social interaction, friendships, meaningful conversations, inclusion, appreciation of sensory differences, and healthy eating.

  • Occupational therapy practitioners need to identify other school contexts in addition to the classroom that may benefit from their expertise (e.g., recess, restrooms) and advocate for opportunities to embed services in these settings to reflect the full scope of occupational therapy practice.

Conclusion

The Comfortable Cafeteria program, developed to create cafeteria environments that support the mental and physical health of all students, reflects the current emphasis on health-promoting schools (Jané-Llopis & Barry, 2005). Study findings suggest that this 6-wk program, involving integrated occupational therapy services, was successful in building the capacity of cafeteria supervisors to create a positive mealtime environment, which resulted in significant improvements in perceptions of participation in and enjoyment of lunchtime and mealtime conversations among students with perceived low and mid-levels of participation and enjoyment at the outset. Qualitative findings suggest that students learned prosocial values, supervisors encouraged positive social interaction, and occupational therapy practitioners recognized their role in building cafeteria supervisors’ capacity to effectively create positive cafeteria experiences for students.

Acknowledgments

Funding for this research was provided by the Ohio Department of Education, Office of Exceptional Children. This study was registered with ClinicalTrials.gov (NCT02949063).

There are no copyright restrictions to the use of documents from Every Moment Counts. However, please cite and credit the source when copying all or part of the materials. The Every Moment Counts website and all of the Every Moment Counts documents were supported in whole or in part by the U.S. Department of Education, Office of Special Education Programs (Award H027A130158-13A, CFDA 84.027A, awarded to the Ohio Department of Education). The opinions expressed herein do not necessarily reflect the policy or position of the U.S. Department of Education, Office of Special Education Programs, and no official endorsement by the department should be inferred.

Contributor Information

Susan Bazyk, Susan Bazyk, PhD, OTR/L, FAOTA, is Project Director, Every Moment Counts, Cleveland, OH, and Professor, Occupational Therapy Program, School of Health Sciences, Cleveland State University, Cleveland, OH; s.bazyk@csuohio.edu.

Louise Demirjian, Louise Demirjian, MA, OTR/L, is Occupational Therapy Consultant, Every Moment Counts, Cleveland, OH.

Frances Horvath, Frances Horvath, BS, OTR/L, is Occupational Therapist, Constellation Schools: Parma Community, Parma, OH.

Lauri Doxsey, Lauri Doxsey, MEd, OTR/L, is Occupational Therapist, Hudson City Schools, Hudson, OH.

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