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With rising rates of food insecurity (FI) during the pandemic, we implemented a clinic-based, community-supported agriculture program at 2 outpatient centers in low-income areas associated with an urban children’s hospital and evaluated (1) the program’s ability to reach FI families without preceding eligibility criteria, and (2) caregiver experiences and preferences for programming. Free boxes of produce were distributed weekly to caregivers of pediatric patients during a 12 week pilot period. Ability to reach the target population was measured by number of participating families and caregiver demographic information. We purposively sampled 31 caregivers for semistructured interviews on a rolling basis to understand program preferences. Content analysis with constant comparison was employed to code interviews inductively and identify emerging themes. Of 1472 caregivers who participated in the program, nearly half (48.3%) screened positive for FI, and 45% were receiving federal food assistance. Although many caregivers were initially “surprised” by the clinic-based program, they ultimately felt that it reinforced the hospital’s commitment to “whole health” and perceived it to be safer than other food program settings during the pandemic. Several programmatic features emerged as particularly important: ease and efficiency of use, kindness of staff, and confidentiality. This advocacy case study demonstrates that a community-supported agriculture program in the clinical setting is an acceptable approach to supporting food access during the pandemic, and highlights caregiver preferences for a sustainable model. Furthermore, our data suggest that allowing families to self-select into programming may streamline operations and potentially facilitate programmatic reach to families who desire assistance.

The coronavirus disease 2019 (COVID-19) pandemic deepened challenges for the nearly 1 in 4 children who were already food insecure (FI) in Philadelphia and created new barriers to food access for families who never previously struggled.1,2 This sustained period of FI has been driven by the convergence of numerous structural- and individual-level factors including: pandemic-related unemployment that disproportionately affected low-income families; school closures that curtailed regular access to federal lunch programs for >1 million children in Pennsylvania; and unprecedented demand for charitable food system resources compounded by social distancing measures that limited capacity to meet community need.3,5 Furthermore, although the severity of barriers to food access has fluctuated over time, their effect on FI has endured. In Philadelphia, the childhood FI rate is projected to reach 28.6% in 2022, from a prepandemic rate of 21%.1 

Produce access during the pandemic has proved particularly difficult for low-income families, a population with historically low rates of fruit and vegetable consumption.6,8 Both FI and poor diet quality have associations with children’s health, including increased rates of hospitalization and anemia, as well as increased risk of coronary heart disease, hypertension, and stroke in adulthood.9,13 Cost-subsidized, community-supported agriculture (CSA) programs, also known as seasonal farm shares, have been identified as a feasible and acceptable approach to addressing these disparities.14,16 Recent research also supports the effectiveness of subsidized CSA programs situated in clinical settings in improving diet quality.17,18 

Many social program models condition eligibility on disclosure of need through social risk screening tools.19 Emerging evidence suggests that prerequisite screening may exclude many who want support because of discordance between screening results and desire for resources.20,24 In pediatric settings, documentation of need in the child’s medical record may increase stigma and fear of negative repercussions that may deter program participation among families who would benefit.25,26 

This advocacy case study describes the implementation and evaluation of Farm to Families, a clinically-based, free CSA launched in response to intensified FI during the COVID-19 pandemic. In addition to meeting immediate need by providing free boxes of fruits and vegetables, we assessed whether a CSA situated in a pediatric clinical care setting is feasible and acceptable to pediatric caregivers, and the program’s ability to reach the intended population of FI families without preceding eligibility criteria.

Farm to Families was initiated at 2 Children’s Hospital of Philadelphia (CHOP) clinical care sites in West Philadelphia: 1 primary care site and 1 outpatient subspecialty care site. Poverty levels in the neighborhoods surrounding both CSA sites exceed 45%.27 In 2020, these outpatient centers saw a combined 374 635 patients; 31% were Black or African American, 11% Hispanic or Latino, and 44% had Medicaid.

The CHOP Office of Community Relations facilitated an expedited partnership with a local nonprofit, St. Christopher’s Foundation for Children (SCFC), that included delivery of produce boxes from a local cooperative of >100 organic family farmers. SCFC has collaborated with health care institutions in Philadelphia since 2010, operating a subsidized CSA to increase access to fresh produce in low-income neighborhoods.28 

The time and expertise of hospitalwide partners, including physicians, researchers, community relations experts, and child and family life specialists, informed program development and operations. Each location was operated primarily by a site manager, a designated hospital employee responsible for on-site logistics and produce box distribution, as well as volunteer hospital employees.

Farm to Families was implemented as a pilot program to provide a free box of organic fruits and vegetables to any family that visited the outpatient care sites. There were no eligibility, exclusion, or application criteria. Farm to Families operated once per week from July 7 to October 1, 2020, aligned with the sites’ hours of highest patient volume to maximize reach. Produce was ordered weekly from SCFC, and packaged and delivered to each site the morning of program operation, without a need for on-site refrigeration. Box contents varied weekly according to the farm cooperative’s produce availability. For the first 6 weeks of programming, boxes distributed at the outpatient subspecialty care site were supplied without cost by the United States Department of Agriculture’s Farmers to Families Food Box grant program, a federal initiative to purchase and distribute produce during the COVID-19 pandemic.29 Produce boxes were otherwise paid for by a combination of institutional funding and individual donations at the price of $14 per box.

Site managers and volunteers staffed tables in high-traffic areas of each clinic and invited caregivers to participate. The program was not advertised before initiation; thus, the initial participant population comprised families visiting the sites for appointments. A scheduled appointment was not a prerequisite for participation, and families were encouraged to return weekly. Boxes included a recipe card that identified the fruits and vegetables being provided and offered preparation suggestions. Tote bags to assist with transportation of the produce were printed with the web address of a searchable regional resource map (www.CommunityResourceConnects.org).

Most challenges to program implementation were related to the COVID-19 pandemic. Infection prevention measures limited the availability of on-site personnel for program staffing. The pandemic also increased the difficulty of predicting patient flow and volume, introducing challenges related to estimating the number of produce boxes each site had the capacity to distribute. To address this, each site received 50 produce boxes at program launch and increased distribution incrementally until capacity was reached. Weekly meetings were held with program staff to adjust the quantity of boxes per site and to troubleshoot operational difficulties.

One adult caregiver of each participating family completed a brief registration survey before receiving their first produce box. The survey was offered in English and Spanish, with an integrated text-to-voice option to address literacy barriers. Staff were available to read the survey questions aloud upon request; supplemental translation services were also available. Given heightened infection prevention measures, families were encouraged to complete the survey on their smartphone with use of a quick response code. If a caregiver did not have a smartphone or encountered technological challenges, a designated study tablet (iPad) was available for survey completion. Survey responses were recorded directly into Research Electronic Data Capture database software.30 

Caregivers were additionally offered participation in a semistructured telephone interview within 2 weeks of initial participation to explore their perceptions and preferences related to the CSA. Caregivers who opted-in for an interview were purposively sampled on a rolling basis to achieve representation across demographic characteristics, FI status, program site, and frequency of participation to contextualize qualitative findings. Interviews were conducted until thematic saturation was reached. At the conclusion of each interview, participants were again offered a text message providing food and other social resources. Interview participants received a $25 eGifter Choice gift card.

All study procedures were deemed exempt from review by the CHOP Committee for the Protection of Human Subjects.

Reach

Tracking the proportion of clinic visitors who received CSA boxes was not a goal of the program in its pilot phase. However, we measured reach in terms of patterns of box distribution that could inform full implementation of the program, including the number of produce boxes distributed weekly by site and participant demographic information. The registration survey included demographic questions, the Hunger Vital Sign 2-item FI screen, and questions about the caregiver’s participation in the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).31,33 All caregivers were offered a text message with food and other social resources.

Acceptability

Acceptability was measured by frequency of repeat program use, interest in future use, and qualitative findings. Repeat participation was tracked weekly, by participant name, at each Farm to Families site. Caregivers were offered the option to be notified if low-cost produce boxes were made available once the free pilot ended. A semi-structured interview guide was developed to explore program acceptability and elicit perceptions of specific program features, including operational structure, setting, and box contents (Supplemental Information).

Impact on Produce Preferences and Perceptions

The semistructured interview additionally assessed the impact of Farm to Families on participants’ produce preferences and perceptions. Questions explored how the produce box affected caregivers’ dietary and shopping patterns, attitudes toward produce consumption, and food preparation.

Frequencies and descriptive statistics are reported for all program participants. We conducted Fisher’s exact test, χ2 test, and 2 sample t tests to detect significant differences in demographic characteristics between all program participants and interview participants. Statistical analyses were performed using R version 4.1.1 (2021) and RStudio version 1.4 (2021) software packages.34,35 

Qualitative data were coded and analyzed using QSR NVivo 12 software.36 Dominant themes in the interview guide informed the development of a codebook. The constant comparison method was employed to guide an integrated approach in which inductive coding was used to expand upon the initial start list of codes and iteratively refine the codebook. A team of 3 researchers with qualitative research training coded the first 3 transcripts independently and then reconvened to update the codebook to reflect emerging themes. This team met weekly to assess interrater reliability and resolve coding disagreements through consensus.

Reach

During the pilot period, 2010 boxes of produce were distributed across the 2 program sites. Each site began by distributing 50 boxes per week, increasing incrementally to a maximum of 70 and 100 boxes at the primary care and subspeciality care sites, per week, respectively.

A total of 1472 unique caregivers participated in Farm to Families during the pilot period. Caregivers reported an average of 2.2 adults and 2.2 children in their household. Among program participants, 47.5% identified as Black or African American, 83.4% were female, and 41.7% were between the ages of 31 and 40 years. Nearly half (48.3%) screened positive for FI. Forty-five percent of participants were receiving WIC or SNAP benefits, with 37.5% receiving SNAP benefits and 23.6% receiving WIC benefits. The majority (56.3%) of caregivers opted in to receive a text message with information about food and other social resources (Table 1).

TABLE 1

Participant Demographics

Total Participants: 1472Interview Participants: 31P
N (%)N (%)
Age, y   .12 
 18 or under 32 (2.2) 2 (6.5)  
 19–30 280 (19.0) 4 (12.9)  
 31–40 613 (41.7) 14 (45.2)  
 41–50 353 (24.0) 4 (12.9)  
 51 or over 189 (12.8) 7 (22.6)  
Sex   .26 
 Female 1228 (83.4) 29 (93.0)  
 Male 235 (16.0) 2 (7.0)  
 Nonbinary 3 (0.2) 0 (0.0)  
Ethnicity   .99 
 Not Hispanic or Latino 1113 (75.6) 24 (77.4)  
 Hispanic or Latino 158 (10.7) 3 (9.7)  
 Unknown/not reported 201 (13.6) 4 (12.9)  
Race   .52 
 Black or African American 699 (47.5) 17 (54.8)  
 White 433 (29.5) 7 (22.6)  
 Asian American 92 (6.2) 2 (6.5)  
 American Indian/Alaska Native 28 (1.9) 1 (3.2)  
 >1 race 52 (3.5) 2 (6.5)  
 Native Hawaiian or other Pacific Islander 4 (0.3) 0 (0.0)  
 Other/not listed 73 (5.0) 0 (0.0)  
Household size, mean (SD)    
 Adults 2.2 (0.9) 2.3 (0.9) .54 
 Children 2.2 (1.2) 2.5 (1.4) .25 
FI    
 Yes 711 (48.3) 18 (58) .37 
SNAP benefits recipient    
 Yes 552 (37.5) 16 (51.6) .16 
WIC benefits recipient    
 Yes 348 (23.6) 11 (35.5) .19 
Repeat program use    
 Yes 214 (14.5) 16 (51.6) <.001*** 
Total program visits, mean (SD) 2.8 (2.4) 4.0 (3.3) .003*** 
Total Participants: 1472Interview Participants: 31P
N (%)N (%)
Age, y   .12 
 18 or under 32 (2.2) 2 (6.5)  
 19–30 280 (19.0) 4 (12.9)  
 31–40 613 (41.7) 14 (45.2)  
 41–50 353 (24.0) 4 (12.9)  
 51 or over 189 (12.8) 7 (22.6)  
Sex   .26 
 Female 1228 (83.4) 29 (93.0)  
 Male 235 (16.0) 2 (7.0)  
 Nonbinary 3 (0.2) 0 (0.0)  
Ethnicity   .99 
 Not Hispanic or Latino 1113 (75.6) 24 (77.4)  
 Hispanic or Latino 158 (10.7) 3 (9.7)  
 Unknown/not reported 201 (13.6) 4 (12.9)  
Race   .52 
 Black or African American 699 (47.5) 17 (54.8)  
 White 433 (29.5) 7 (22.6)  
 Asian American 92 (6.2) 2 (6.5)  
 American Indian/Alaska Native 28 (1.9) 1 (3.2)  
 >1 race 52 (3.5) 2 (6.5)  
 Native Hawaiian or other Pacific Islander 4 (0.3) 0 (0.0)  
 Other/not listed 73 (5.0) 0 (0.0)  
Household size, mean (SD)    
 Adults 2.2 (0.9) 2.3 (0.9) .54 
 Children 2.2 (1.2) 2.5 (1.4) .25 
FI    
 Yes 711 (48.3) 18 (58) .37 
SNAP benefits recipient    
 Yes 552 (37.5) 16 (51.6) .16 
WIC benefits recipient    
 Yes 348 (23.6) 11 (35.5) .19 
Repeat program use    
 Yes 214 (14.5) 16 (51.6) <.001*** 
Total program visits, mean (SD) 2.8 (2.4) 4.0 (3.3) .003*** 
***

Indicates statistical significance (P < .05).

Acceptability

The majority of program participants (77%) indicated interest in receiving information about Farm to Families if the program transitioned to a fee-for-service model. Among FI participants, 85.3% reported interest in future programming. A total of 215 (14.6%) families participated in the program more than once during the pilot period; of these, 62.8% returned once, 15.8% returned twice, and 21.4% returned 3 or more times. Among return participants, 49.3% screened positive for FI.

The majority (79.7%) of program participants consented to be contacted for a phone interview. After providing informed consent, 31 caregivers participated in a semistructured interview lasting ∼30 minutes, conducted by 2 research team members trained in qualitative interview methodologies. The caregivers interviewed were proportionally representative of all program participants on the basis of demographic characteristics (Table 1). Ten (32.3%) of the interviewees had repeat CSA participation at the time of interview; rates of repeat CSA participation were significantly higher among interviewed caregivers (51.6%) as compared with overall program participants (14.5%) by the end of the 12 week program pilot. Twelve of the 31 transcripts were double-coded to confirm interrater reliability over time, producing an average κ statistic of 0.84.

Five major features of Farm to Families emerged in the semistructured interviews as particularly important to programmatic acceptability: the trustworthiness of the clinical setting as a food provider during a pandemic; ease and efficiency of program use with the grab-and-go model located near an exit; quality of the produce provided; kindness of staff; and confidentiality and respect while participating so that there was “…no discrimination. Everybody felt equal.” [participant 22] (Table 2).

TABLE 2

Factors Related to Programmatic Acceptability

Factors Related to Programmatic AcceptabilityRepresentative Quotation
Clinical setting “Well, it was strange at first to be honest… But I think, because … the fact that they were allowed to be within the hospital and everything, gave us kind of that level of trust like, ‘Okay, like the foods clearly going to be fine and everything.’”[10]
“I like that the doctor’s office is kind of trying to cater to the whole family and not just, like, pushing medicine as a solution to sickness... I think it is a nice indicator that they’re looking at the whole picture.”[11] 
Ease and efficiency of program use “It was perfect because it was actually, it was at the entrance and exit. So, we did it as we were leaving. So, we just literally got our box and went right down to the parking garage.”[18] 
Quality of produce “Everything was fresh. It wasn’t like, you know, I didn’t feel like it was just, like, leftover food.”[7] 
Kindness of staff “I still love interacting with them. I walk in there, they know who my daughter and I are, and every week, they’re like, ‘Hey, it’s good to see you.’”[25] 
Confidentiality and respect “Like, around our neighborhood, you can go and get free boxes and stuff. But it’s everybody from the neighborhood. It’s people that you know that are, like, helping out. I would say, with the doctor’s office, it’s more, like, private. It’s more privacy. It’s more discreet. Nobody knows anything. Nobody judges you because everybody’s in line.”[26]
“It was an opportunity that was helping the parents that came into the hospital with their children with any needs with no discrimination. Everybody felt equal.”[22] 
Factors Related to Programmatic AcceptabilityRepresentative Quotation
Clinical setting “Well, it was strange at first to be honest… But I think, because … the fact that they were allowed to be within the hospital and everything, gave us kind of that level of trust like, ‘Okay, like the foods clearly going to be fine and everything.’”[10]
“I like that the doctor’s office is kind of trying to cater to the whole family and not just, like, pushing medicine as a solution to sickness... I think it is a nice indicator that they’re looking at the whole picture.”[11] 
Ease and efficiency of program use “It was perfect because it was actually, it was at the entrance and exit. So, we did it as we were leaving. So, we just literally got our box and went right down to the parking garage.”[18] 
Quality of produce “Everything was fresh. It wasn’t like, you know, I didn’t feel like it was just, like, leftover food.”[7] 
Kindness of staff “I still love interacting with them. I walk in there, they know who my daughter and I are, and every week, they’re like, ‘Hey, it’s good to see you.’”[25] 
Confidentiality and respect “Like, around our neighborhood, you can go and get free boxes and stuff. But it’s everybody from the neighborhood. It’s people that you know that are, like, helping out. I would say, with the doctor’s office, it’s more, like, private. It’s more privacy. It’s more discreet. Nobody knows anything. Nobody judges you because everybody’s in line.”[26]
“It was an opportunity that was helping the parents that came into the hospital with their children with any needs with no discrimination. Everybody felt equal.”[22] 

Brackets indicate interview participant number.

Impact on Produce Preferences and Perceptions

Qualitative interviews elucidated 4 major areas of impact of the Farm to Families program: reallocation of finances, household attitudes toward produce, children’s exposure to and acceptance of produce, and self-efficacy to purchase and prepare produce (Table 3).

TABLE 3

Impact of Program on Produce Preferences and Perceptions

Factors Related to Programmatic ImpactRepresentative Quotation
Reallocation of finances “Because then, that money could go toward something else for, like, meat or bread or anything else that we would need... But I always like to get the box first now because I don’t want to buy double produce of what I got in the box.”[26]
“...I’m trying to make the food I have last a month because I can only get food at the beginning of the month, and then the fruits in between every week has been a Godsend because I’ve been able to extend my food that long now.”[25] 
Household attitudes toward produce “It’s a different way, it is a healthier way of eating. And it’s a good way of introducing your kids, and not only just your kids, yourself and your family, to different things I’ve never tried.”[3]
“We never used to buy kale and, now, I love it. Because I never knew what to do with it… I don’t like it raw, but it’s really good cooked. So, I would have never knew that because I would have never bought it at the store.”[26] 
Children’s exposure to and acceptance of produce “I felt happy about it because I went home and I was able to go through the box with my children… some things we buy, some things we don’t. So, they got to explore a little, as well. I think it was just a nice surprise.”[4]
“They eat more fruits and vegetables. So, it’s really because we had it, because it was ready. It was here. So, now, I’ll be buying more of it when it runs out, because they get accustomed to eating it.”[8] 
Attitudes regarding purchase and preparation of produce “I never really went through the produce section like that, because, like I said, my children didn’t really expand or eat much. Now, I go in there and I have my normals that I always picked up… I’ve now picked up some more and, as I go through the produce, I look at things differently and I’m like, ‘Hm, what can I explore with this or that?’ So, it’s opened my horizon to a lot of different things.”[25] 
Factors Related to Programmatic ImpactRepresentative Quotation
Reallocation of finances “Because then, that money could go toward something else for, like, meat or bread or anything else that we would need... But I always like to get the box first now because I don’t want to buy double produce of what I got in the box.”[26]
“...I’m trying to make the food I have last a month because I can only get food at the beginning of the month, and then the fruits in between every week has been a Godsend because I’ve been able to extend my food that long now.”[25] 
Household attitudes toward produce “It’s a different way, it is a healthier way of eating. And it’s a good way of introducing your kids, and not only just your kids, yourself and your family, to different things I’ve never tried.”[3]
“We never used to buy kale and, now, I love it. Because I never knew what to do with it… I don’t like it raw, but it’s really good cooked. So, I would have never knew that because I would have never bought it at the store.”[26] 
Children’s exposure to and acceptance of produce “I felt happy about it because I went home and I was able to go through the box with my children… some things we buy, some things we don’t. So, they got to explore a little, as well. I think it was just a nice surprise.”[4]
“They eat more fruits and vegetables. So, it’s really because we had it, because it was ready. It was here. So, now, I’ll be buying more of it when it runs out, because they get accustomed to eating it.”[8] 
Attitudes regarding purchase and preparation of produce “I never really went through the produce section like that, because, like I said, my children didn’t really expand or eat much. Now, I go in there and I have my normals that I always picked up… I’ve now picked up some more and, as I go through the produce, I look at things differently and I’m like, ‘Hm, what can I explore with this or that?’ So, it’s opened my horizon to a lot of different things.”[25] 

Brackets indicate interview participant number.

Many caregivers explained that receiving weekly produce boxes enabled the reallocation of finances and alleviated some stress related to food access. Several caregivers experiencing FI described how this supplemental food made it easier to “stretch” their federal benefits through the month.

Another common theme reported by caregivers was that the CSA boxes cultivated favorable attitudes toward produce and healthy eating among members of their household. Furthermore, many caregivers suggested that the CSA altered their family’s beliefs about foods that were previously viewed unfavorably. As 1 caregiver explained: “It's a different way, it is a healthier way of eating. And it's a good way of introducing your kids, and not only just your kids, yourself and your family, to different things I've never tried.” [participant 3]

Most caregivers also reported that the CSA improved children’s exposure to and acceptance of produce and described improvements to their children’s overall diets as a result of participation. Several caregivers also emphasized their children’s curiosity about unfamiliar fruits and vegetables included in the box. One caregiver described how the program affected her family’s diet: “They eat more fruits and vegetables… because we had it, because it was ready. It was here. So, now, I'll be buying more of it when it runs out, because they get accustomed to eating it.” [participant 8]

Finally, participation in the CSA fostered caregivers’ desire and comfort level to purchase and prepare fruits and vegetables. Caregivers valued the opportunity to sample new produce items before spending limited funds to purchase them and indicated that the boxes expanded opportunities for healthy meal planning.

This advocacy case study demonstrates the feasibility and acceptability of a clinic-based, free CSA during the COVID-19 pandemic, offered without prerequisite screening in clinics serving low-income families. It also highlights this model’s potential to improve produce access among participating families and positively impact their exposure to and interactions with produce, even during an unprecedented time of stress and financial strain. Furthermore, the disproportionate rate of FI among program participants (48.3%) as compared with the general population of Philadelphia (21%), in conjunction with recent literature documenting discordance between social risk screening results and desire for social resources, suggests the promise of a model that allows families to self-select into programming.1,22,23 This strategy has the added benefit of eliminating the administrative burden of implementing screening while reaching families who desire assistance, not only those who screen positive for FI.

The qualitative data highlight key programmatic features of a free, clinic-based CSA that is acceptable to caregivers, including ease and efficiency of program use, produce quality, kindness of staff, and confidentiality and respect while participating. These findings suggest areas of emphasis for program replication because caregivers reported that these factors were among the most important in their decision to participate.

Caregivers reported that program participation mitigated some barriers to obtaining food by reducing the frequency of shopping trips and enabling reallocation of finances to needs other than food. These findings are particularly significant during a time when federal nutrition programs and the emergency food system struggle to meet increased demand, and high-need families are harder to reach through traditional channels.5,37,38 Furthermore, this advocacy case study corroborates existing evidence that clinically based, social-risk programming can successfully reach and serve FI families.14,21,39,40 Because most caregivers were interested in receiving text message-based information about community resources, our findings also highlight an opportunity for health care institutions to leverage existing programs to connect families with social support services.

Interview participants also indicate that the CSA cultivated favorable attitudes toward produce, increased interest in purchasing produce, and built confidence in preparing produce through exploration of recipes and exposure to new ingredients. The impact of the program on families’ consumption of fruits and vegetables corroborates previous evidence that a cost-subsidized CSA can address the dual health risks of FI and poor diet quality by increasing the household availability and acceptability of produce.14,18 This finding holds particular importance during a pandemic when access to healthy foods is further reduced.6 

This advocacy case study also demonstrates the immense value of community–clinical partnerships, particularly during a pandemic when a rapid approach is essential to meet families’ urgent FI needs. Operationalizing SCFC’s Farm to Families model at CHOP and leveraging their established relationship with local farmers facilitated access to produce boxes on an accelerated timeline.

Although the Farm to Families pilot program demonstrates successful implementation of a clinic-based, free CSA during the pandemic, our study has several limitations. The program may not have consistently reached families experiencing the deepest levels of FI because these families may lack the financial, child care, or transportation resources to visit the doctor’s office and participate in the program with the same regularity as families who do not face these challenges. To address this, future study will evaluate the feasibility of a home delivery option. Additionally, surveys and interviews were completed by 1 member of each household, therefore responses may not reflect the experience of every person in the home. Although we took steps to ensure representative sampling for interviews, participants who agreed to be interviewed may have viewed the program more favorably than those who did not. Additionally, it is possible that participants with higher levels of repeat participation may have had preexisting positive perceptions of produce unrelated to the program that influenced their decision to return. Because this was a pilot program serving families on a first-come, first-served basis with a predetermined number of CSA boxes, we cannot accurately predict participation patterns over time, or the proportion of clinic visitors who would participate if program capacity were increased. Further study is needed to understand the optimal frequency and duration of the program.

This advocacy case study demonstrates the feasibility, acceptability, and impact of a free CSA based in a pediatric health care setting during a time of increased FI. Furthermore, the program’s implementation without preceding eligibility criteria suggests that allowing families to self-select into programming may streamline operations and potentially facilitate programmatic reach to families who desire assistance. Future work will optimize pricing structures as we transition to a low-cost produce box model, and evaluate the impact of home-delivery.

We thank St. Christopher’s Foundation for Children, as well as Children’s Hospital of Philadelphia (CHOP) Department of Family Relations, CHOP Advanced Practice Nurses Manager Andrea Bailer, MSN, CRNP, the Garden at CHOP Karabots Pediatric Care Center, and CHOP Office of Community Relations for their partnership in implementing the Farm to Families program sites at CHOP. We also thank the clinical teams who contributed to program operations at each site.

Ms Reilly, Ms Patel, Ms Freedman, and Dr Cullen conceptualized and designed this advocacy study, and participated in all stages of program implementation and evaluation, manuscript drafting, and review; Ms Brown contributed to the conceptualization and design of the study, participated in all stages of program implementation and evaluation, designed the data collection tools, supervised data collection, conducted the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Virudachalam contributed to study design and data evaluation, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

    Abbreviations
     
  • CHOP

    Children’s Hospital of Philadelphia

  •  
  • COVID-19

    coronavirus disease 2019

  •  
  • CSA

    community-supported agriculture

  •  
  • FI

    food insecurity/food insecure

  •  
  • SCFC

    St. Christopher’s Foundation for Children

  •  
  • SNAP

    Supplemental Nutrition Assistance Program

  •  
  • WIC

    Special Supplemental Nutrition Program for Women, Infants, and Children

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Competing Interests

CONFLICT OF INTEREST DISCLAIMER: The authors have indicated they have no conflicts of interest relevant to this article to disclose.

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