Unpacking scalability in produce prescription: A qualitative implementation science investigation using the Consolidated Framework for Implementation Research

The purpose of this study was to Produce prescription (PPR) programs aim to improve fruit and vegetable (FV) access and health outcomes by providing FVs and nutrition education to participants with low income. While PPRs show promise in increasing FV intake and reducing food insecurity, more research is needed to understand effective implementation. To determine how PPRs work in different settings, and to describe implementation characteristics. In-depth interviews were conducted with PPR project implementers using a semi-structured guide based on the Consolidated Framework for Implementation Research (CFIR). PPR sites were selected through maximum variation and interviewees at each site were selected using snowball sampling. Interviews were recorded, transcribed, and coded using NVivo software using a deductive codebook, with two researchers coding each interview. Interviewees included 33 individuals across 13 PPR projects. The analysis identified themes across CFIR constructs: (i) project characteristics (e.g. eligibility, nutrition education, adaptations to local context, relative advantage, cost), (ii) characteristics of individuals (e.g. participants, food retailers, healthcare staff, role delineation, networks), (iii) evidence (e.g. economic impact, FV Intake, household food security and health-related outcomes, scope and impact), (iv) implementation climate (e.g. project genesis, alignment with organization values, leadership engagement, geography, technology), and (v) challenges (e.g. COVID-19 impacts, capacity limitations). Interviewees also provided recommendations for resources that would be helpful in their PPR implementation, such as "plug and play" materials to reduce setup burden. This study highlights PPR implementation characteristics, which can elucidate which features may be most effective in particular contexts. There was also an identified need for further investigation into fostering healthcare organization buy-in and engagement.