Table 1.

Navajo Fruit and Vegetable Prescription (FVRx) best practices and challenges^*

Step	Building team	Stakeholder engagement	Recruitment	Educational sessions	Evaluation & quality improvement	Rx redemption	Family Follow-up
Definition	To make the CHT successful and to fill the minimum required roles/responsibilities to implement the programme	People and entities the CHT needs to build relationships with to have a successful programme	How to engage and recruit patients and families	These are conducted by CHT (or CHT team designees) for families. Education must be partnered with voucher distribution.	Patient forms and 6-month follow-up. Qualitative improvement	How vouchers can be used and redeemed at stores	The visit that happens 6 months after the last educational session
Best practices	Consider feasibility checklist to assess CHT readiness Define which team members will be community outreach members Encourage team approach (trust, respect, shared responsibility, open communication) from the outset of programme Consider someone in public health/community outreach for team leader (e.g. PHN, CHR, etc.) Fit roles and responsibilities with existing work flow (e.g. recruitment in clinic where providers currently see patients) Assign team members to specific roles Small teams tend to work well when they are community-based Larger teams tend to work well when they are clinically based Include FVRx duties into JD Bring on nutritionists/dieticians Delineate who holds, writes/signs vouchers on team	Build personal connections with store owners so that if problems arise they can be dealt with directly. Engage stores to help with recruitment Invite store manager to CHT meetings Work closely with local chapter – host education sessions at the chapter and present at meetings Invite CHR/PHN supervisor to trainings/education sessions Incorporate the work into strategic plans of organisations/facilities Have a clear point person on CHT who spearheads strategy for community engagement activities Create a ‘network map’ and referral process to drive the strategy around stakeholder engagement Partner with local growers Partner with churches Engage local school leadership	Look through Electronic Medical Records, flag based on BMI, discuss with patient in person Identify eligible patients during provider visits Present at local schools Integrate recruitment into existing school/child programmes (e.g. NM FACE (Family and Child Education), Head Start, etc.) Have details of education sessions set when recruiting Use a tool to help document contacts to follow up Establish a participation agreement with participant at onset Share past-participant testimonials, invite community members to help recruit Emphasise that different caregivers can attend with child participants; Encourage ‘bring everyone!’ environment Advertise food demos and involvement of kids in cooking Set timeline for recruitment and stick within that frame	Use a structured, evidence-based curriculum to guide session delivery Group sessions work well Create planning checklists for sessions Define roles of each CHT member for each session (e.g. kids activities, cooking demo, vouchers, set up, clean up) Before session, fill out what can be done on surveys ahead of time Have at least three CHT members present to support the sessions Consider family comfort and confidentiality during education sessions Host hands-on food demos, involve kids! Offer other incentives in addition to vouchers to increase attendance Set time and date for the next session at the present one, or have a set schedule for the 6-month period When creating session schedule, anticipate holidays and work schedules Host one session a month for 1–1·5 h (first session 2 h) Encourage family centred participation Supplement curriculum with traditional knowledge; Navajo Wellness Model; Introductions by clan to bring families together Breakout kids from parents for part of session Ask families to share recipes and food budgeting tips Have kids help with clean up (before giving incentives) Practice hand washing before food demos Involve past participants as peer coaches Debrief after educational sessions Follow-up with those who miss session in a timely manner	Ongoing, open, timely communication with participants Understand what communication modes work best to reach families Have point person on team and at COPE for QI and evaluation Organise data forms by session before submitting to COPE Double check to ensure correct patient ID on forms Clear communication and timelines around submitting survey forms At first session provider does intake forms During session have a point person on CHT to distribute and collect forms	Clearly communicate acceptable/not acceptable items that can be purchased with vouchers to families Remind participants where/how to use vouchers at each session Designate store liaison on CHT. This person will give feedback to team on store issues and share information on food needed for demos Have a list of growers that accept vouchers	Schedule appointment with families for 6 months after last educational session Get multiple contacts from families (cell, address, family/contacts, etc.) Give incentives for 6 months follow-up to families (at least compensation for travel) Have family contact team/provider if they move or change their number Encourage families to continue to participate as peer coach
Look out for	Unclear roles and responsibilities of team members Turnover amongst team members Strained decision-making Size of team not functional within setting or workflows	Limited support from supervisors/leadership. Find ways to engage them and get support early on Partnerships with schools can be complicated due to rescheduling frequency in inclement weather, especially in the winter. Only partial commitment from external stakeholders	Passive recruitment (sending out letters, phone calls without in person meeting) is not as effective as active, in-person recruitment Stigma/perception of food benefit programme Families think it will interfere with other benefits (WIC, TANF) Participant uncertainty, lack of commitment Rather than promoting ‘free food’, highlight healthy food at no cost Rolling enrolment/recruitment periods get complicated quickly.	Difficulty finding location for sessions (look in clinic, fitness centres, consider families may want privacy) Home visits might stretch providers too thin Cooking demos at home visits or make ups are challenging	Lack of clarity around how data is being reported after it is collected Changing forms over the course of multiple cycles Consistency of wording throughout all forms and programme Hard to get intake/exit done in one session	Low redemption rates ID numbers missing on vouchers	Families change phone number or address Barriers to families participating in follow-up (gas, scheduling, etc.)

CHT, Community Health Team; PHN, Public Health Nursing; CHR, Community Health Representative; JD, job description; TANF, Temporary Assistance for Needy Families; COPE, Community Outreach and Patient Empowerment; WIC, Women, Infants, and Children.

^*Developed in conjunction with FVRx teams, based upon provider experiences operating the Navajo FVRx programme at individual sites.