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

Fach et al. BMC Primary Care (2025) 26:361 https://doi.org/10.1186/s12875-025-02987-8 BMC Primary Care Open Access RESEARCH Barriers and facilitators to implementing a pilot produce prescription program in a community health setting in Toronto, Canada Madison Fach1, Rose Holub1, Camille Machado2, Amy Cheng2, Natasha Ismail2 and Ashleigh Domingo1* 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. *Correspondence: Ashleigh Domingo Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creati vecommons.org/licenses/by-nc-nd/4.0/. Fach et al. BMC Primary Care (2025) 26:361 Page 2 of 16 Keywords Produce prescription, Social prescribing, CFIR, Barriers, Facilitators, Community health centres, Food insecurity, Chronic disease prevention, Health promotion 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 (...truncated)