Comparing outer setting drivers of implementation across rural and non-rural cancer centers in a multi-center financial navigation program.

471 Background: Our financial navigation (FN) intervention [Lessening the Impact of Financial Toxicity (LIFT)] demonstrated promise in reducing financial hardship among cancer survivors in pilot testing; however, expanding LIFT from a single-center pilot to an eight-center (4 rural, 4 non-rural) trial introduced implementation challenges, particularly for rural centers. Using the Consolidated Framework for Implementation Research (CFIR) 2.0, this qualitative analysis compared outer setting implementation drivers between rural and non-rural centers. Methods: Center financial navigators and research team members convened monthly for virtual technical assistance and implementation support sessions. This sub-analysis applied a hybrid deductive-inductive qualitative approach to examine technical assistance transcripts (N=55). Deductive coding organized content using the five domains of CFIR (i.e., outer setting, inner setting, individuals, process, and innovation), and then five inductive thematic analyses were conducted within each domain to identify emergent themes and sub-themes. Coding was conducted iteratively, with regular team meetings to ensure consensus and reliability, and transcripts were categorized by rurality to compare themes between rural and non-rural centers. Results: Comparative analysis of outer setting implementation drivers (7 themes, 46 sub-themes) revealed shared and distinct challenges across rural and non-rural centers. Common barriers included workforce shortages, limited resources for specific patient needs, and unpredictability of external resource application outcomes. Rural centers faced challenges related to capacity constraints (e.g., fewer institutional resources, smaller workforce) and often relied on hyperlocal partnerships and creative workarounds, with navigators assuming expanded roles, while non-rural center challenges were shaped more by the complexity of navigating large, multi-layered health systems and payer structures. Workforce strain was observed at both rural and non-rural centers (particularly as an effect of the COVID-19 pandemic), but non-rural challenges focused on turnover and administrative delays rather than persistent position vacancies. Non-rural centers also emphasized institutional data tracking to refine FN, engagement intensive but potentially more rewarding national aid sources (e.g., The Pink Fund), and navigating federal and large payer-level policies shaping FN. Conclusions: Outer setting implementation drivers influenced FN differently for rural and non-rural centers, with rural centers primarily contending with structural capacity and non-rural centers with system complexity. Scaling and tailoring FN interventions for cancer survivors may require adaptation that accounts for these unique challenges across rurality. Clinical trial information: NCT04931251 .