This study explored the initiation, implementation, and institutionalization of nutrition programs from outside organizations or sources (NEPOS) in New York City public elementary schools. Having NEPOS in schools may augment the nutrition education that is taught in health, science or other classes, and thus help to alleviate public health issues associated with poor eating habits, such as obesity and diabetes. However, very little is known about the design and distribution of NEPOS as well as school personnel's beliefs and actions that facilitate NEPOS initiation, implementation, and institutionalization in schools. The study employed mixed-methods to investigate how many and what types of these programs from outside organizations are available in New York City public schools; how these programs are distributed among schools; and why and how schools make these NEPOS "work." These phenomena were explored with data from: organizations with NEPOS that had been implemented in New York City public schools (n=20); elementary schools in Brooklyn, Manhattan, and Queens (n=614); and school community members from a subset of schools with NEPOS (n=21). The primary data sources were surveys, publically available school and community-level data, and interviews. Data were analyzed using descriptive and inferential statistics as well as inductive and deductive coding. Findings suggest that during the 2011-2012 School Year, overall NEPOS were in only 39% of all schools; in 40% (n=163) of schools with greater than 75% students eligible for free and reduced price lunch (highest economic need) and in 45% (n=58) of neighborhoods where over 23.1% of children were obese (highest health needs). NEPOS that had in their mission to reach "high needs schools" did reach proportionally more schools in areas of highest economic and health need than schools in areas with less need. While the distribution of NEPOS varied by some school-based factors, e.g., student attendance and average state test score, need-based factors were overall more important in determining the distribution of NEPOS. Analysis of interviews with key school community members from a subset of the sample indicate that schools in New York City experienced the same barriers to having NEPOS as those in other parts of the country. Schools identified eating/health, academic/learning, and community benefits to having NEPOS. A major contribution of this study is that it provides in-depth insight into how school community members shared common, specific, and transferable actions as they initiate, implement, and institutionalize NEPOS in their schools. These are that: schools have to have one or more driving motivations for NEPOS, schools go through a process to choose appropriate NEPOS, schools build their own capacity for effectively implementing NEPOS, and once schools have NEPOS for a while they find way to legitimize the NEPOS by integrating them into the fabric of the school. Taken together these four domains may be thought of as parts of a "Progressive Model for Integrating NEPOS into Schools." This model can inform school practices and policy and serve as a starting point for future research.
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