Barriers and facilitators to implementing a pilot produce prescription program in a community health setting in Toronto, Canada

Abstract

Background

Produce prescription programs (PRx) are gaining traction in Canada and globally as an approach to promote food security and healthy diets. Unison Health and Community Services (Unison), a community health centre in Toronto, Canada, piloted a PRx program to promote food access and healthy eating for adults with experiences of food insecurity and chronic disease risk factors. In this study, we explored the barriers and facilitators to implementing a pilot PRx program in a community health setting to inform program improvements, including opportunities to better meet participant health needs and preferences.

Methods

Participant follow-up calls, focus group discussions, and semi-structured key informant interviews were conducted in person and online. Detailed call logs and interview transcripts were analyzed thematically using a hybrid inductive-deductive approach guided by the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators to program implementation.

Results

Key themes were identified across the five domains of the CFIR: (i) Innovation, (ii) Outer Setting, (iii) Inner Setting, (iv) Individuals, and (v) Implementation Process. In total, 19 themes were selected across 14 CFIR constructs, including six inductive sub-themes. The main barriers included the outdoor and public designs of the market, reduced staffing on the clinical team, and a lack of communication infrastructure between primary care providers, program providers, and program participants. Key facilitators included the integration of the PRx pilot into existing Unison programs, the inclusion of nutrition education workshops, and the person-centered and adaptable approach adopted by program providers. These facilitators supported participant referrals and program satisfaction, contributing to participants’ desire to continue engaging in the program.

Conclusions

This study, guided by the CFIR, revealed valuable insights into the barriers and facilitators that may influence the implementation of a PRx program in community health settings. Study findings emphasize the importance of team-based care to ensure program adaptability and support a person-centered approach. Identifying key champions within primary care teams is needed to strengthen referral pathways and communication with program providers. Future PRx programs may consider incorporating opportunities for knowledge sharing with participants and community-building activities to address important needs related to social connection, community belonging, and mental health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-025-02987-8.

Background

Social prescribing offers a mechanism to bridge the gap between health and social supports. It is a model of care that takes a holistic and person-centered approach to advance action on the social determinants of health by facilitating access to non-medical resources [1]. Social prescribing was first piloted in Ontario in 2018 through the launch of Rx: Community Social Prescribing [2]. This initiative supported 11 community health centres in Ontario to promote patient access to social and community supports through social prescribing [2]. Social prescribing initiatives have continued to emerge across the country. Notable examples include the Red Cross’ Financially Assisted Social Prescribing (FASP) Collective in Hamilton, Ontario which aims to connect the health and social sectors to improve health equity and informed care [3]. Other key developments include produce prescription (PRx) programs [4–7], a type of social prescribing initiative that aims to improve food access and healthy eating, a growing public health concern in Canada [8].

In recent years, Canadian studies on PRx programs have assessed participant interactions and experiences, along with health and behaviour outcomes [4, 5, 9]. The findings of these studies have demonstrated the potential for reducing barriers to food access by increasing the acceptability of food support programs and reducing participants’ need to rely on other supports, such as food banks [5, 6]. In addition, they have assessed how the provision of free and fresh foods can improve food access while simultaneously addressing important health needs [4]. While these programs have produced evidence to suggest a positive impact on the health and well being of participants, some have encountered challenges related to participant enrollment and satisfaction. Factors include stigma associated with food charity models, barriers to participation such as transportation and mobility, and limited familiarity with produce and cooking methods [4, 7]. To improve program access, delivery, and integration within primary care and community health settings, further research is needed on the implementation of PRx programs across diverse settings.

PRx programs are a potential strategy for promoting food security and enhancing access to healthy foods. As of 2022, the prevalence of food insecurity across Canadian provinces was 17.8%, increasing from 15.9% in 2021 [10, 11]. In Toronto, Canada as many as 1 in 4 households (24.9%) were affected by food insecurity in 2023 [12]. The health impacts of food insecurity have been disproportionately felt by low-income households [13–18]. Studies have shown that when low-income households have insufficient access to healthy and fresh produce, their diets include a higher proportion of calorie-dense foods with minimal nutritional benefits, leading to an elevated risk of chronic disease [13–18]. Examples of chronic diseases that may result from a diet high in processed and calorie-dense foods include type 2 diabetes, hypertension, and obesity [19]. Several studies have also identified a link between poor diet quality and depression and anxiety [20–22]. The need to address these health challenges associated with food insecurity is being increasingly recognized in Food Charters across various regions and cities in Canada [23]. For example, the City of Toronto’s Food Charter outlines commitments to promote food security, including sponsorship of nutrition-based programs and services to promote health and prevent diet-related chronic diseases [24]. Since its launch in 2001, various health promotion initiatives to improve food access have been implemented in alignment with the Food Charter and the City’s Poverty Reduction Strategy [25]. These initiatives include the expansion of nutrition programs throughout schools and the creation of community gardens [25, 26]. Building on these efforts are initiatives that explore the role of community resources, made accessible through social prescribing, in promoting food access.

In response to growing food access needs in the City of Toronto, Unison Health and Community Services (Unison) developed a food-based social prescribing initiative [27]. Unison is a non-profit, community-based health centre with several locations in Northwest Toronto. In the spring and summer months of 2024, Unison piloted its PRx program at its Keele and Rogers location, where food security has been identified as a community priority. The program uniquely provided free weekly access to fresh produce at a Green Market, combined with nutrition education workshops to promote healthy eating. The goals of the PRx program were to promote food access, healthy eating, and self-management of chronic disease risk factors among low-income adults. To better understand the successes and challenges faced during the implementation of Unison’s pilot PRx program, we sought to explore the perspectives and experiences of program participants and providers. The purpose of this study was therefore to (i) identify and describe the barriers and facilitators to program implementation, and (ii) offer recommendations for program improvement. To our knowledge, no Canadian studies have examined the barriers and facilitators to implementing a pilot PRx program that combines the provision of free produce with nutrition education in a community health setting in Ontario. The findings from this study may inform opportunities for scale-up and considerations to better meet the health needs of program participants.

Methods

PRx Program Components

Unison’s PRx program began in May 2024 and continued until August 2024. The program was designed and implemented by Unison’s Program Manager and a registered dietitian, and it was supported by a community health worker. From the clinical team, the program had support from the Clinical Services Manager, along with the physicians and nurse practitioners who participated in referrals. The point of entry to the program was referral-based, and all participants were referred by either their primary care provider or the program’s registered dietitian. The program was comprised of 3 key components: (i) weekly access to free and high-quality fresh fruits and vegetables, (ii) monthly, in-person nutrition education workshops led by the program’s registered dietitian, and (iii) monthly one-on-one follow-up calls with the registered dietitian or community health worker, during which participants created SMART (Specific, Measurable, Achievable, Relevant, and Time-Bound) goals, and reviewed these goals in subsequent calls.

Access to Fresh Produce

Unison established a Green Market, through which they provided access to low-cost, fresh produce for the community on a weekly basis during the spring and summer months. The Green Market project was funded by United Way Greater Toronto to operate annually for three years, aiming to address food insecurity and access to local produce. The market was available to the public and operated outdoors, located across the road from the Keele and Rogers site. The logistics for the free produce component of the PRx program were facilitated through the Green Market. Participants in the PRx program received vouchers on a weekly basis to redeem free fruit and vegetables from the Green Market. A key feature of the market included a highlighted produce item for the week, for which recipients received additional information about the product, how to prepare it, and the associated benefits.

In-Person Nutrition Education Workshops

Every month, participants in the PRx program attended in-person nutrition education workshops at the Keele and Rogers location. The workshops were led by the program’s registered dietitian, and the curriculum focused on improving food literacy, increasing self-efficacy for healthy eating, and providing participants with the knowledge and skills to prepare healthy meals. Throughout the program, participants were required to attend all four in-person sessions, during which they would receive their Green Market vouchers for the next 3 to 4 weeks. Participants also received an additional food voucher valued at $10 to purchase produce at the Green Market after attending each in-person session.

Follow-Up Calls and Support

Program participants received follow-up calls monthly from either the program’s registered dietitian or community health worker. These calls offered an opportunity to answer questions regarding the program and its various components, receive feedback on the barriers and facilitators to accessing the program, and review the SMART goals participants set.

PRx Program Participants

Enrollment into the program occurred in spring 2024 between April 1st and May 17th. Adults aged 18 years or older living on low-income, experiencing food insecurity, and residing in the Greater Toronto Area met the inclusion criteria for the program. Additionally, in order to be eligible for the PRx program, participants had to (i) be referred by a primary care physician or nurse practitioner at Unison, (ii) live with at least one of the following chronic disease risk factors: high blood pressure, high cholesterol, high blood sugar, overweight, or obesity, (iii) be able to attend the monthly in-person sessions, and (iv) be able and willing to commit to engaging with all program components. In total, 16 participants were recruited for the pilot program, all of whom were introduced to the research objectives and study team at the time of enrollment through consent forms. Of the 16 participants, only 14 completed the full 16-weeks, as two withdrew their participation in the program within the first month.

Data Collection

Qualitative data were collected from participants and program providers through various methods. Individual follow-up calls (n = 54) were conducted with participants (n = 14) throughout the duration of the 16-week program. Calls occurred monthly and were led by the program’s registered dietitian (CM) and community health worker (NI). Detailed records from each follow-up call, including participant responses to questions regarding their experiences in the program, were tracked, along with notes on progress made toward achieving SMART goals.

Following the completion of the program, a focus group discussion was held with program participants (n = 13) to learn more about their experiences with the program and the benefits they perceived. These discussions also provided participants with the opportunity to share suggestions for improvement. The focus group was conducted in person at the Keele and Rogers site and was approximately an hour in duration. The discussion was led by a University of Guelph researcher (AD) who was not directly involved with program operations, and a Unison team member (CM). The discussion was recorded using multiple audio devices and transcribed by a student on the study team (RH). It was communicated to participants that they would not be identified, and their feedback would not affect future participation in the program or provision of health care services at Unison. A translator was present during the focus group discussion to provide support for participant language needs.

Finally, a total of five key informants contributed to data collection using semi-structured interviews. These key informants, all of whom work with Unison and contributed to the PRx program in various capacities, included a community health worker, clinic manager, program manager, registered dietitian, and a primary care physician. Interviews aimed to gain insights on the challenges, successes, and opportunities related to program implementation. The data collected during these interviews were reviewed by several key informant participants to allow for comments or corrections. The development of the interview guide was informed by the Consolidated Framework for Implementation Research (CFIR) [28], and was adapted and refined based on a prior study focused on developing an implementation plan for a PRx program [29]. Please see Additional File 1 for Key Informant Interview and Participant Focus Group guides. These interviews were conducted and transcribed by a student on the research team (RH) between October 2024 and January 2025 using MS Teams. Key informant interviews ranged between 20 and 50 minutes in length.

Data Analysis and Conceptual Framework

Audio recordings of interviews and the focus group were transcribed to produce verbatim transcripts. Interview and focus group transcripts, as well as notes taken during follow-up phone calls, were thematically analyzed [30] using a hybrid inductive-deductive approach [31], guided by the CFIR [28, 32] to incorporate both data- and theory-driven results in the analysis. For this study, the CFIR was used to identify barriers and facilitators that contributed to the implementation of the program, and recommendations for future iterations of the program. To facilitate this approach, data were independently coded by two students on the research team (MF, RH) according to the CFIR constructs, and consensus meetings were held to discuss emergent codes and themes and ensure data saturation (MF, RH, AD). Additional sub-themes were identified and reviewed by the research team to capture data-driven insights. Using multiple data sources allowed for triangulation in our analysis [33], providing a more thorough understanding of participant experiences and program provider perspectives.

The CFIR has been widely used within healthcare settings and community-based programs to understand the barriers and facilitators to the effectiveness of an implementation [28]. The framework is intended to guide the collection and analysis of data from those with influence in an innovation or program, and was recently updated in 2022 based on user feedback [28]. The five domains and the associated constructs of the CFIR, including how they encompass the unique characteristics of Unison’s PRx program, are outlined below in Table 1. Within each domain are several constructs intended to guide qualitative data analysis, however, only those that were considered relevant to Unison’s PRx program were selected for coding. All data sources were analyzed using NVIVO qualitative data analysis software. This project has been reviewed by the University of Guelph Research Ethics Board for compliance with federal guidelines for research involving human participants (REB# 24-07-013). All participants provided written consent at the beginning of each interview and focus group and were advised that they may withdraw their participation from the project at any time.

Table 1.

CFIR adaptation for Unison’s PRx program

CFIR Domain	Unison PRx Adaptation	Constructs
Innovation: The “thing” being implemented	Characteristics of the PRx program	1.1 Design
Outer Setting: The setting in which the Inner Setting exists	The community health services system within the City of Toronto	2.1 External Pressure: Societal Pressure
Inner Setting: The setting in which the innovation is implemented	Unison Health & Community Services	3.1 Relational Connections 3.2 Communications 3.3 Culture: Recipient-Centeredness 3.4 Relative Priority 3.5 Available Resources 3.6 Access to Knowledge & Information
Individuals: The roles and characteristics of individuals	Team members from the programs team and clinical services	4.1 Implementation Leads 4.2 Innovation Deliverers 4.3 Innovation Recipients 4.4 Characteristics: Need
Implementation Process: The activities and strategies used to implement the innovation	The process used by Unison team members to implement the program	5.1 Engaging: Innovation Deliverers 5.2 Tailoring Strategies

Results

The results below are representative of the data collected from follow-up calls, focus group discussions, and key informant interviews. Key themes are described in further detail according to the five domains of the CFIR: (i) Innovation, (ii) Outer Setting, (iii) Inner Setting, (iv) Individuals, and (v) Implementation Process. A total of 19 themes were identified across 14 CFIR constructs, including 6 inductive sub-themes. These themes are outlined below in Table 2. Of the 19 themes, 4 were related to implementation barriers, and 15 were related to implementation facilitators. The implementation facilitators contributed to the ability of providers to deliver the program and overall participant satisfaction with the program. The barriers identified presented challenges to the referral pathway and the continuation of the program. Overall, data collected from program participants were predominantly facilitators, including features of the program that contributed to both their ability and willingness to participate. Conversely, key informants focused on highlighting barriers to implementation, as well as potential opportunities for improvement.

Table 2.

Themes developed from the CFIR constructs

CFIR Construct	Implementation Determinant	Theme
Domain: Innovation
Design	Facilitator	Integration into existing Unison programs
	Barrier	Outdoor, public market creating wait times and seasonal limitations
	Facilitator	Enabling the referral pathway through existing EMR processes
Domain: Outer Setting
Societal Pressure	Facilitator	Sharing knowledge of social prescribing and PRx models
Domain: Inner Setting
Relational Connections	Facilitator	Inter-departmental relationships at Unison
Communications	Barrier	Referral pathways between providers and participants
Culture: Recipient-Centeredness	Facilitator	Shared values for participant needs
Relative Priority	Barrier	Physician time and ability to address health holistically
Available Resources: Funding	Barrier	Limited funding to sustain program operations
Available Resources: Materials and Equipment	Facilitator	Access to high quality produce
Access to Knowledge and Information	Facilitator	Registered dietitian sharing food knowledge and skills
Domain: Individuals
Implementation Leads	Facilitator	Creating opportunities for success
Innovation Deliverers	Facilitator	Cultivating an inclusive and respectful environment for participants
Innovation Recipients: Exceeding expectations for the program	Facilitator	Helping family members to practice healthy habits
	Facilitator	Supporting program participant mental health
	Facilitator	Fostering a sense of community belonging through social connections
Characteristics: Need	Facilitator	Addressing the food security needs of Toronto residents
Domain: Implementation Process
Engaging: Innovation Deliverers	Facilitator	Identifying key champions for the program
Tailoring Strategies	Facilitator	Adapting to participant needs through person-centered care

Domain 1: Innovation

The Innovation domain refers to the “thing” that is being implemented, which in the case of this study is the Unison pilot PRx program. The following are several key design features of the program that served either as barriers or facilitators to program implementation.

1.1 Design

Unison’s PRx program design was integrated into several pre-existing programs and processes within the health centre, which contributed to the operations of the program and the referral pathway.

1.1.1 Integration into existing Unison programs

The program was embedded into the pre-existing Green Market that operated outside throughout the spring and summer months across the street from the Keele and Rogers location.

“I do have a coupon model built into my program already … I think that was well done just because that mechanism was already there for the market. And so it was just connecting with [Key Informant 4’s] coupon. It just made sense.” [Key Informant 1, Community Health Worker].

The operations for the Green Market had already been established, and program staff indicated that it was easy to add the PRx program into the market.

1.1.2 Outdoor, public market creating wait times and seasonal limitations

The Green Market was available to the public and not exclusively for PRx participants, and therefore long lines to access produce presented a challenge for program providers and participants. Key Informant 1 elaborated on this, indicating “We’re seeing 100 to 200 people on average, which is very large scale for a program … I think the biggest challenge that people were facing was the wait times in line.”

Public access and long lines created challenges for participants, limiting their ability to access the full variety of produce offered at the Green Market. Overall, the long lines were viewed as a barrier to participation in the program, and while program providers made attempts to create separate lines and adjust accordingly, participants often had to wait for several hours to receive their produce. Additionally, because of limited funding and the design of the market, the Green Market was held outdoors, and access was limited to only a few months out of the year.

“If they could expand it into the winter months. That’s difficult, I know it would be more expensive. But you know, people could use that produce all year round. [Key Informant 5, Physician].

Key informants indicated that food insecurity is something that impacts people all year long, and some may lose access to fresh produce during fall and winter when the Green Market and PRx program are not available.

1.1.3 Enabling the referral pathway through existing EMR processes

The referral pathway was another process integrated into existing structures at Unison. Practitioners could refer participants to the program using the Electronic Medical Record (EMR) system, which made it more accessible for primary care providers to include referrals in their regular practice.

“We try to make things very simple and very streamlined for the primary care providers. All is needed is to go onto our EMR, we call it PSS [PS Suite EMR]… to refer clients, like how providers do with other programs and services. Providers don’t need to complete a separate form or assessment form.” [Key Informant 3, Program Manager].

“They had the internal referral tab that the providers could [use to] refer the clients … they could refer them directly from the EMR.” [Key Informant 2, Clinic Manager].

However, while the Unison clinical team expressed that they were aware and supportive of this pathway, it was unclear whether it was being utilized during the referral process.

“There was probably some sort of a referral through the software, like there always is, but … I didn’t use that very much.” [Key Informant 5, Physician].

This design feature was an important aspect of the program that made it more accessible for primary care providers to refer participants, but highlights the importance of ensuring they have received the proper information and training to successfully use the feature.

Domain 2: Outer Setting

The Outer Setting is the setting within which the Inner Setting exists, and it recognizes external factors and processes that may influence program planning and implementation. Unison’s pilot PRx program existed within the primary care and community health services system within the City of Toronto.

2.1 Societal Pressure – Sharing knowledge of social prescribing and PRx models

This theme reflects how the rise in social prescribing in Canada influenced the creation of this program. The existence of PRx programs in nearby communities encouraged the Unison team to develop a similar program.

“The original idea came from, me and [Key Informant 4] … when we attended the Alliance for Healthier Communities Conference last year, we heard this amazing presentation from … the Guelph [Community Health Centre]. They did some work around [produce prescription] and we totally were amazed and inspired by that. And then after, we went back to the office and said, “Hey, you know what? Let’s do something about that”. So, [Key Informant 4] took it upon herself and developed a program from scratch.” [Key Informant 3, Program Manager].

The positive results shared by other programs influenced the creation of a program that could address the increased food security needs of participants.

Domain 3: Inner Setting

3.1 Relational Connections – Inter-departmental relationships at Unison

The Unison programs team made significant efforts to connect with the clinical team and shared the importance of health promotion programming.

“We went to primary care meetings the months prior to promote the program … to promote, to let the primary care staff know … that the program is happening.” [Key Informant 1, Community Health Worker].

The team made it a priority to share program information and resources, including potential benefits to program participants, with physicians and nurse practitioners that were new to the organization.

“When I meet with physicians when they are new to Unison, I’ll have an opportunity to meet them and just explain what we do. I would encourage [them] to really encourage [their] clients to attend our programs. That will help us to help [them] do [their] job better because when [clients are] healthier, they don’t come see [providers] that often.” [Key Informant 3, Program Manager].

In addition, the existence of the PRx program within the Green Market model was made possible by pre-existing partnerships with other programs at Unison.

“Within my role, I’m able to connect the program with what they need. For example, the Green Market. Instead of purchasing separately for the produce prescription program, we’re able to incorporate that element into the Green Market.” [Key Informant 3, Program Manager].

The connections between internal Unison departments facilitated communication and resource sharing that helped to support program implementation.

3.2 Communications – Referral pathways between providers and participants

The referral pathway to the program was through a Unison primary care provider or the program’s registered dietitian. This was a necessary step to participate in the PRx program. The results of this analysis suggested a lack of awareness of the PRx program among the clinical team. If the physicians or nurse practitioners were not aware of the program or did not communicate the program details to the participant, the participant may not be aware of the opportunity.

“I still think the clients not knowing about the program because their provider doesn’t know about the program. I think that’s just a big knowledge gap there, because if you’re only getting into the program by referral, and your provider doesn’t promote it, doesn’t remember it … I think that’s a little gap there just to physically get into the program.” [Key Informant 1, Community Health Worker].

However, even if the physician shares program information, the participant must feel comfortable to identify they experience food insecurity.

“They need to be referred to us and they need to be sharing about food insecurity, about all those challenges that they face.” [Key Informant 4, Registered Dietitian].

“Sometimes clients don’t want to give their personal information”. [Key Informant 2, Clinic Manager].

If the environment in the visit does not support the participant to feel comfortable sharing about food insecurity, the provider may not know they are eligible to participate.

3.3 Culture: Recipient-Centeredness – Shared values for participant needs

Key informants all demonstrated a shared value about the importance of adapting a person-centered approach to the program and addressing the unique needs of participants.

“I cannot run a program without addressing the financial aspect of things. People need access to food. They need some sort of financial support … when we want to talk about health overall, I need to address how people can access [resources] to support their health.” [Key Informant 3, Program Manager].

They also routinely took participant feedback and program observations into consideration and identified ways the program could be adapted in the future to better meet participant needs.

“[During] the in-person sessions I was the one cooking for clients to teach them how to do it. I really wanted to see clients be involved with that. Not only me cooking, but having clients involved.” [Key Informant 4, Registered Dietitian].

This shared value for person-centered delivery contributed to the dedication of the team to offer a program that addressed the food security needs of participants, while maintaining a focus on their evolving priorities.

3.4 Relative Priority – Physician time and ability to address health holistically

Referrals for participants in the program were from both the registered dietitian and primary care providers. However, decreased staffing levels at Unison resulted in an increased workload for the clinical team and a potential barrier to entry for the program.

“The clinical team of care has been understaffed … for more than a year now. We’re missing quite a few positions where we were having difficulty hiring. Providers were already at their maximum capacity trying to help [serve] clients and to try to push something else more on their plate … I don’t think that would have been fair for them.” [Key Informant 2, Clinic Manager].

For the clinical team, it can be challenging to address food insecurity when there are other pressing issues, such as illness or injury, that have brought an individual in to see a nurse practitioner or physician.

“It’s very rare that physicians or [nurse practitioners] would be able to find time to address [patient’s] food security issues” [Key Informant 3, Program Manager].

Key informants from the clinical team indicated that there is limited time during appointments, and they need to focus on the primary reason that has brought the patient in.

“Usually, when they come in for their appointments, we’re focused on whatever the medical issue is at hand.” [Key Informant 5, Physician].

Capacity and time constraints among primary care providers may limit opportunities to discuss food security and available program supports.

3.5 Available resources

3.5.1 Funding – Limited funding to sustain program operations

Resource-based barriers to program implementation include access to consistent and reliable funding.

“… the program is very costly, because we are offering free access to fresh produce on a weekly basis for a couple of months to see results. It’s very costly.” [Key Informant 3, Program Manager].

Key informants identified high operating costs due to the provision of fresh produce, and without secured funding, future iterations of the program would not be possible.

“We didn’t get a [designated grant] to run this program, we decided to use [part of] my chronic disease prevention program budget to pilot this.” [Key Informant 4, Registered Dietitian].

Purchasing fresh produce for a PRx program results in high overhead costs, and consistent funding is necessary for program continuation. Program providers noted that while the existing operations of the Green Market supported the initial implementation of the PRx program, this also meant there was limited ability to track costs specific to the program. This presented challenges for program planning and budgeting.

3.5.2 Materials & Equipment – Access to high quality produce

The variety and quality of the fruits and vegetables were a highlight of the program according to both key informants and program participants.

“Premium quality produce is definitely the highlight.” [Key Informant 3, Program Manager].

Participants and their families were able to try new things, and the produce was fresh and long-lasting.

“I like the variety, I’m able to cook, and also my family members were able to try the fruits and vegetables that were provided. The quality was better than something that I would be able to get at the [grocery store].” [Participant 6].

“Produce was fresh so it could be used for up to … a week or more.” [Key Informant 5, Physician].

The provision of varied, fresh, and high-quality produce increased satisfaction with the program and may have facilitated an increase in produce consumption for participants and their families.

3.6 Access to Knowledge and Information – Registered dietitian sharing food knowledge and skills

One of the key themes identified across all interviews and the focus group was the importance of sharing knowledge. Not only were participants provided with free access to produce, but they were provided with knowledge of the benefits of each item and how they can be prepared.

“I would see [the vegetables], but I wouldn’t buy them because … I don’t even know what this is. The fact that they would give us that vegetable, but also they would give me a paper with a description of the vegetable and other ways of cooking it, that was the extras on top.” [Participant 8].

This feature of the program encouraged participants to try foods they might not have known about before.

“I used [recipes] from the [market], they are great. Otherwise, I wouldn’t know what to do with the beets!” [Participant follow-up call 59159].

Nutrition education workshops, ongoing support from a registered dietitian, and additional produce resources and recipes enhanced participants’ knowledge and empowered them to make use of the produce they received.

Domain 4: Individuals

In the CFIR, the Individuals domain encompasses the roles and characteristics of the individuals involved or impacted by the innovation. For Unison’s pilot PRx program, this includes clinical team members, a community health worker, a registered dietitian, the program manager, and program participants.

4.1 Implementation Leads – Creating opportunities for success

Those who led the efforts to implement and coordinate the program made sure both the program and the providers were equipped with the tools and resources necessary to carry out activities and deliver a positive experience for participants. This included ensuring that the program had the necessary resources for referrals and operations.

“Within my role, I’ve been able to … make sure there [are] funds available, make sure the program staff at the Green Market understand how that integration works. I think that has been going very well.” [Key Informant 3, Program Manager].

“I was the one. I was the one recruiting, I was the one doing all the activities, the presentation, calling clients, developing forms, picking recipes, [and being] involved with the Green Market education to support clients to eat those fruits and vegetables that were not familiar.” [Key Informant 4, Registered Dietitian].

Referrals into the program were done in part by the clinical team, but a significant majority of participants were referred by Key Informant 4.

“Out of the 16 clients that we recruited, I recruited ten clients, and only six clients … were referred by their healthcare provider from Unison.” [Key Informant 4, Registered Dietitian].

Without the support of these leaders for funding, planning, and participant referrals, the program may not have been possible.

4.2 Innovation Deliverers – Cultivating an inclusive and respectful environment for participants

The providers involved with delivering the program were supportive of both the success of the program and the overall experiences of the participants. Feedback from program participants and key informants indicated those delivering the program contributed to positive experiences among participants.

“Everybody in the program, they … make you feel like you’re home. They’re really helpful. They’re so caring.” [Participant 9].

Participants formed meaningful connections with program providers, fostered by the team’s consistent presence and ongoing support. The commitment appeared to result in increased engagement and willingness to participate in the program.

“Even though you have the tools, sometimes it’s really hard to implement them. So to have somebody like [Key Informant 1] calling you and having to answer to her, or to yourself more or less, is really beneficial because … a lot of times I felt like I really want to do this, but I know this call is coming and I know I have to be truthful to myself. So I’m going to go and make a healthier choice … I found having somebody to answer to is really beneficial’. [Participant 3].

“You do get to build a bond and a trust with [participants]. That was also very nice.” [Key Informant 1, Community Health Worker].

The positive feedback provided by participants suggests the connections they made with PRx program providers positively influenced their experience with the program and their motivation to make healthy lifestyle changes.

4.3 Innovation Recipients

Participants identified factors related to holistic health that facilitated a positive experience with the program and exceeded their expectations.

4.3.1 Helping family members to practice healthy habits

By participating in the program, participants were able to share the produce they received with their children or other family members.

“My son wouldn’t eat vegetables [except for] lettuce … and now he’s eating all the vegetables. Because of the way I [cook] it, he’s asking for more.” [Participant 2].

“A lot of vegetables I didn’t like. But my sister loved them. And it gave me a way of giving her a healthier lifestyle.” [Participant 3].

This provided an opportunity for the benefits of the program to extend beyond its direct reach and have an influence on the food security and nutrition needs of participants’ family members.

4.3.2 Supporting program participant mental health

Throughout the focus group and follow-up calls, several participants shared mental health challenges they were experiencing, and how it impacted their experience with the program. For some, participation in the program seemed to improve their symptoms and their level of motivation for a healthier lifestyle.

“Before the program, I was going through depression. I never said anything to anyone. …I didn’t want to see anybody. Just secluded myself. And from the start of the program … it somehow lifted me out from being in that dark space.” [Participant 2].

However, for others, their mental health challenges were a barrier to their motivation to fully participate in the program. During the participant follow-up calls with PRx program providers, one participant disclosed how their mental health was impacting them.

“[Participant] disclosed they [have] been dealing with depression recently, so they know their goals have been lack[ing]. [Participant] explained their eating habits have been bad, they’ve been having lots of fast food and junk food, not a lot of motivation.” [Participant follow-up call 59159].

The program may help to support the mental health of some participants, but for others, the mental health challenges they experience are a barrier to participation and they may require additional support.

4.3.3 Fostering a sense of community belonging through social connections

Beyond the provision of fresh produce, participants indicated that the program provided them with an opportunity to socialize and build community.

“For me, it wasn’t just the vegetables and the fruits that I [got] that helped so much, especially when I’m out of work. It was the fact that every week I was interacting with the group and [having] good laughs, and it became almost like a routine, almost expecting, it’s Wednesday tomorrow, and I’m going to go really early and get to talk to people. It was the whole thing together that made it a really good experience, more than I expected.” [Participant 6].

They shared that their time spent at the Green Market was a chance to see their friends and connect with program providers.

“A lot of us would come early to avoid the lines and stuff like that, so it started off as that. We would be coming early to get first in line sort of thing. But then … after a week or two, it was like, I want to go there early because I know my friends are going to be there. I’m going to have more time to speak with my friends and to … share things with the facilitators.” [Participant 9].

While the long lines were identified as a barrier for some, others indicated that they enjoyed going early to talk to friends. This aspect of socialization also contributed to the knowledge the participants gained from the program. During a follow-up call, a participant indicated that they “didn’t know how to use summer squash, but ended [up] … figuring it [out] from someone at the market” [Participant follow-up call 111624].

This program paved the way for social connections among participants and between participants and other patrons at the Green Market, and this became an important feature that contributed to program uptake, shared knowledge, and positive experiences.

4.4 Characteristics: Need – Addressing the food security needs of Toronto residents

The implementation of this program responded to a very important need within the community.

“I would say for us, it helped a lot with the financial part because that’s the part that I need.” [Participant 8].

Participants and key informants indicated that the increasing cost of food, coupled with job and financial instability, led to an increased need among participants for programs that can address food insecurity. Key Informant 5 indicated that Unison has “so many patients who can’t afford groceries, let alone healthy groceries,” which may suggest that, in addition to food prescription models, policy-level change is necessary to reduce barriers to food access.

Key informants noted financial barriers increased following the COVID-19 pandemic and resulted in a growing need for programs to address food insecurity.

“The pandemic did a lot of damage, I would say, to everything. A lot of people lost their job. Their income is not as it was or should be.” [Key Informant 2, Clinic Manager].

“I think we started this [program]because of COVID. Again, it was first the physical access to fruits and veggies that were difficult during COVID. And then when everything [opened up], still there was limitations to go to the store. Some people were scared to go as well.” [Key Informant 4, Registered Dietitian].

Responding to the growing food access needs of Unison participants was a key factor in the development and implementation of the program.

Domain 5: Implementation Process

Finally, the Implementation Process was shaped by the active engagement of key program leaders and clinical team members, as well as by the program providers’ ability to adopt a person-centered approach.

5.1 Engaging Innovation Deliverers – Identifying key champions for the program

While there were challenges engaging the clinical team in the referral pathway, there were some providers that seemed to be champions for the program and for the food security needs of participants.

 “I’ve seen some physicians taking clients to our food pantry to access food … I think I just need to identify clinicians who are willing to do that because I know it would be unrealistic to expect everybody to do it.” [Key Informant 3, Program Manager].

Key informants indicated that while they might not be able to engage with the entire clinical team, there may be an opportunity to identify key champions to promote the program and refer participants.

“So maybe instead of working with all primary care staff, maybe find champions from each location and work[ing] with maybe one or two doctors. That could work as well. Instead of working with everyone.” [Key Informant 4, Registered Dietitian].

The team recognized that while not all providers would have the capacity to support the program, engaging with those that do could improve their ability to connect with potential participants and increase referrals.

5.2 Tailoring Strategies – Adapting to participant needs through person-centered care

Throughout the implementation, the team leading the innovation demonstrated they were willing to modify the program to fit local contexts and the needs of the participants. Participant feedback was taken into consideration at several points during implementation, including during the in-person nutrition education workshops and on the follow-up calls.

“With the one-on-one appointments over the phone, they were able to tell us what was working for them and what was not working. I think the follow-ups are very important for us to learn what is working for clients, what is not, and what needs to be changed, or how we can try to change that or tailor according to their needs.” [Key Informant 4, Registered Dietitian].

Program providers offered additional information where possible to support participants introducing fruits and vegetables to their diets.

“Based on their feedback, for example, a lot of time they were saying this month I received eggplant and okra, and I don’t know what to do with that … I can bring an extra recipe to teach [participants] how to do [that] next month.” [Key Informant 4, Registered Dietitian].

Finally, participants physical needs were taken into consideration at the Green Market.

“I have mobility issues and going … to [the Green Market table] would have been impossible for me. But the [staff] were always … [getting] me the fruit and vegetables, made sure I got a nice selection of fruit and vegetables, and they brought them to me.” [Participant 3].

In addition, the program providers arranged to have the support of a translator during the focus group discussion to reduce language barriers. Participants appreciated the person-centered approach of the program, and the efforts that program providers made to adapt to their unique needs and priorities. These adjustments ensured that all participants had the opportunity to receive the same benefits from the program.

Discussion

In this study, we analyzed qualitative data to identify and describe the barriers and facilitators experienced by program providers and participants during the implementation of Unison’s pilot PRx program. A total of 14 constructs from the CFIR were used to identify 19 themes, including 6 inductive sub-themes. This analysis can be used to guide the development and implementation of future PRx programs in community health settings that combine the provision of free produce alongside nutrition education. These findings contribute to the growing body of literature on social prescribing and PRx programs in Canada.

At the level of the CFIR’s Innovation domain, our analysis found that combining the PRx program with existing Unison programs and processes was a facilitator for both participants and program providers. Integration into existing processes was achieved by incorporating the referral pathway into the health centre’s EMR system. Feedback from the clinical team suggests that this feature reduced their administrative burden and facilitated referrals into the program. This is consistent with several evaluations of PRx programs in the United States, which found that physicians claimed the referral process was more accessible when it was added to existing software [34, 35]. These findings highlight an opportunity to reduce the administrative burden that may be associated with the creation of a new program and subsequent referrals. Integration into EMR systems may serve as a helpful tool for physicians to discuss food security and the programs available to address it. Additionally, our results emphasized the importance of equipping primary care providers with the tools and training supports needed to build awareness and strengthen the referral pathway to the PRx program. Increasing awareness about the important role of food and nutrition in health among primary care may help foster dialogue between physicians and their clients about food security and existing programs available to address nutrition and food access needs. Future programs may consider such approaches to ensure clinical teams are thoroughly informed about the available supports and equipped with the necessary resources to consider food access needs in their practice, including referral to relevant programs and services.

While incorporating the referral pathway into the EMR helped streamline entry to the program, combining the operations of the program with the Green Market presented a different set of opportunities and challenges. The inclusion of the PRx program into Unison’s existing Green Market enabled the team to preserve financial resources while leveraging existing assets. However, it also presented several barriers, including the outdoor and public design of the market. The outdoor market limited program duration to spring and summer, but key informants noted that people need access to produce all year. In Canada, fresh produce tends to increase in price during the winter months due to the inability to grow locally and resulting import fees [36]. Therefore, for those experiencing financial insecurity, it can be even more challenging to afford produce during the winter. Developing a program that can be operationalized all year is critical to maintaining these supports for participants in need. In addition to operating outdoors, the public design was also identified as a barrier, as it presented challenges for participants who work or have other commitments during the day and may not be able to dedicate several hours to wait for produce. Other studies have used a public market model, including a PRx program in Guelph, Ontario, which utilized an existing community sliding-scale market [7]. However, Guelph has a significantly smaller population compared to Toronto, which may explain why long lines were not presented as a challenge for participants in that study [7]. Future market-based models in urban and densely populated areas might consider opportunities to reduce wait times for participants, such as designated pick up times.

In the Outer Setting, our findings identified the main facilitator to be the rise in social prescribing initiatives, including PRx models, and the influence this had on program providers at Unison. The creation of the program was influenced by other initiatives in Southern Ontario, which demonstrated that PRx may be an effective way to address the needs of low income and food insecure populations [6, 7]. Our findings suggest that sharing knowledge and experiences can be an effective way to influence the development of other programs and identify ways to better meet community food access needs.

Within the Inner Setting, our study found that knowledge sharing was a key facilitator for the program. The inclusion of nutrition education workshops promoted knowledge sharing with participants and was a unique and highly valued component of the program. It was especially valuable to have a registered dietitian on the team with expertise in food and nutrition to serve as a trusted source of knowledge for participants. While other Canadian PRx programs have referred participants to existing nutrition supports within their community health centre [7], the embedded feature of nutrition education workshops within Unison’s PRx program, which were delivered on Green Market days, encouraged program participation and attendance. This approach aligns with findings from studies in the United States which have demonstrated the importance of incorporating nutrition education into PRx programs to maximize effectiveness [37–39]. Participant perspectives suggest the inclusion of knowledge sharing increased their engagement with the program, along with their understanding of both the importance and appeal of eating fruits and vegetables.

The main barrier within the Inner Setting was the clinical team’s limited time and capacity to address food insecurity with participants and facilitate referrals to the program. Our findings indicate that low staffing levels and competing priorities during appointments presented challenges for primary care providers to find the time to refer participants. This is consistent with findings in other studies that suggest staff time and availability is a barrier to program implementation [35]. Additionally, even when physicians have the time and capacity to ask questions regarding food security, our findings suggest that participants may not always feel comfortable disclosing this information. This underscores the critical role that primary care providers have in the referral pathway, and highlights the need for physicians to facilitate a sense of safety and trust during the appointment to encourage participants to openly share about their experiences with food insecurity.

At the Individual level, the main facilitators were the dedication of program providers to creating a successful program and including opportunities for social connection, community-building, and mental health improvements. Through the Green Market, follow-up calls, and nutrition education workshops, PRx participants had several opportunities to connect with program providers and other participants. Opportunities to connect with program providers facilitated increased feelings of trust and motivation for the program, and created a safe space for participants to socialize, learn and make healthy choices. Other PRx programs in Canada have utilized a model that incorporates home delivery of fresh produce [6], and while this is a great option that can remove barriers to access, the in-person component of a market model contributes to community-building opportunities and, as our findings suggest, may have positive impacts on participant mental health. This is in alignment with the findings of other Canadian studies that found participants enjoyed the social benefits of engaging with providers and other participants [6]. Our findings suggest that market-based PRx programs can be an effective way to offer community-building opportunities and should create an accessible and social environment to contribute to connections among participants and between participants and program providers.

At the level of the Implementation Process, key facilitators included identifying champions for program success. Our findings suggest that even without full engagement from all departments, there is an opportunity to identify key champions who can advocate for the program and participants. Additionally, our study highlights the need for program providers to adopt a person-centered approach to continuous program improvements to meet the unique needs of the participants and facilitate a positive experience with the program. Unison’s PRx program demonstrated responsiveness to participant needs, in contrast to previous studies that have been criticized for employing a top-down, paternalistic approach based on expert assumptions on what participants need [40]. Our results indicate that by considering participant needs, PRx program providers can create a safe and inclusive program for participants, fostering an environment in which they can form meaningful connections. For Unison’s program, these connections, particularly with staff, seemed to increase participant engagement with the program. The team-based care approach adopted at Unison, which involved collaboration between clinical staff and allied health workers, was key to embedding a person-centered approach to respond to the evolving needs of participants. This approach aligns with other PRx studies that found collaboration among multidisciplinary teams helped identify participants struggling with food insecurity [41]. Future PRx programs would benefit from adopting a collaborative or team-based approach to care, in addition to considering local contexts and the needs of participants. We recommend that PRx programs allow for continuous feedback on how they can be improved, and to adapt as participant needs evolve.

The facilitators described in the five domains above highlight how PRx programs can be thoughtfully designed to reduce barriers to food access. However, it is important to acknowledge that while PRx programs can help to promote food access, we recognize the complexity of food insecurity, and that it cannot be solved by one approach alone. The need for advocacy at multiple levels has been acknowledged by other researchers, who recognize that community-based food programs must exist concurrently with broader public policy reform [42, 43] [43]. Their studies suggest that additional action beyond community programs is needed to create lasting change and decrease food insecurity, including policy reforms for income and housing, and financial supports for food affordability [43]. The results of our study identified similar challenges that suggest the need for broader reforms. Participants in Unison’s PRx program identified that income was a barrier they faced when accessing food outside of the program, and this highlights the need for multi-level strategies to address food insecurity. Policy changes for sufficient incomes and stable housing are crucial for long-term impact [42, 43]. Ultimately, initiatives such as Unison’s PRx program are a valuable approach to reducing food insecurity that have an opportunity to create change at the community-level by increasing access to knowledge among a priority population and fostering a sense of a food-based community among participants.

Strengths and potential limitations

This study has several strengths and limitations. A major strength of this study was the use of the CFIR to guide both data collection and analysis. Our study demonstrates how the CFIR can be used to assess barriers and facilitators to implementing a pilot PRx program in community health settings. The most recent updates to the framework have created a more expansive set of constructs through which to analyze the data collected, allowing us to expand our results across additional constructs. Furthermore, our hybrid inductive-deductive approach allowed us to be more thorough and recognize themes arising directly from the data. An additional strength was the short time frame between program implementation, data collection, and data analysis, as there was less potential for recall bias. Our study should be considered in the context of the following limitations. During the data collection phase, Unison staff were present during the focus group discussion. While this may have supported a sense of familiarity, it presents the potential for observer bias in results, as some participants may not have felt as comfortable discussing the true barriers they faced during the program. Finally, there are potential limitations to the generalizability of our findings due to a small sample size. While the pilot program only enrolled a small number of participants due to financial and resource constraints, multiple data sources allowed for triangulation in our qualitative analysis, which enabled a more comprehensive understanding of participant experiences and program provider perspectives.

Conclusions

The barriers and facilitators identified through this study present several opportunities for future iterations of PRx programs to better meet the needs of participants. Although barriers such as the public, outdoor market setting and communication infrastructure between program providers and the clinical team presented challenges for referrals and participants, participant perspectives indicated a strong interest in continued participation in the program and pointed to several benefits. Program features that fostered social and community connections, such as nutrition education workshops and the Green Market, were key facilitators of a positive participant experience with the program. At Unison, the community health worker and registered dietitian were key champions for knowledge translation, facilitating collaboration between departments, and ensuring the program was responsive to participant needs. Our findings indicate that these were all important facilitators for the implementation of the program. Primary care and community health settings seeking to implement PRx programs might look for opportunities to incorporate sharing knowledge with participants on the use and benefits of produce, such as through nutrition education workshops or nutrition-focused knowledge translation materials. In addition, market-based PRx programs may consider formalized community- and capacity- building opportunities to leverage the socialization that is already occurring at the market and influence a positive participant experience. Finally, future programs should engage with key champions within their organization, taking a team-based approach to care that can help facilitate program referrals, and might consider how the referral pathway can be integrated into existing infrastructure within their organization. Ultimately, this study contributes to emerging literature exploring the implementation of PRx programs and integration within primary care in community health settings. Further studies should assess how the inclusion of nutrition education in PRx programs may increase the long-term sustainability of fruit and vegetable intake beyond program duration.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

Produce Prescription

PRx

Consolidated Framework for Implementation Research

CFIR

Electronic Medical Record

EMR

Author contributions

AC, CM, and NI contributed to program implementation. RH completed data collection and transcription. MF and RH independently coded the data. MF, RH, AD partook in consensus meetings to discuss emergent codes and themes. MF wrote the first draft of the paper and AD contributed to the final write-up. All authors reviewed the manuscript.

Funding

The PRx program delivered by Unison Health and Community Services was supported in part by Ontario Health and United Way Greater Toronto. MF and RH were supported by the University of Guelph Department of Human Health Sciences to complete this work.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This project has been reviewed by the Research Ethics Board for compliance with federal guidelines for research involving human participants (REB# 24-07-013). All participants provided informed consent to participation. Written consent was collected at the beginning of each interview and focus group, and participants were advised that they may withdraw their participation from the project at any time. The research was conducted in accordance with the Declaration of Helsinki ethical principles for medical research involving human participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.