Table 2.

Summary of rural barriers and facilitators of lung cancer screening Implementation.

Environmental context	Level of influence	Type of influence	Barrier or facilitator	Example from qualitative data
Institutional environment	Systems	Patient communication	Facilitator	Use of language common to rural communities during lung cancer screening shared-decision making conversations Shared decision-making training tailored to rural Veterans who currently smoke and may fear screening results
		Resource availability	Facilitator	Use of tool to manage patients being screening to ensure future care is coordinated Mobile CT screening or screening done at community clinics (CBOCs)
			Barrier	Lack of access to rural clinics
		Workload	Barrier	High personnel turnover Lower priority among healthcare services
	Provider	Attitudes and beliefs	Barrier	Lack of centralized and specialized care for cancer screening and treatment
		Knowledge	Barrier	Lack of knowledge of screening program activities and/or importance
		Skills and capabilities	Barrier	Time delays in screening and coordination of care in rural settings Lack of centralized screening program that manages and coordinates care Lack of radiologist use of standardized reporting system for lung cancer screening results
	External	Institutional networks	Facilitator	Regional educational programs by specialists
		Incentives	Facilitator	Offering monetary incentives for referring for screening
Patient environment	Patient	Modifiable vulnerabilities	Barrier	Patient need for transportation Poor living conditions Lack of education
			Facilitator	Development of telephone or video clinic Scheduling screening on day when patient is already coming to the medical center or area Lung cancer screening education specific for rural patients Mailings to increase awareness of lung cancer screening among rural patients
	Ecological modifiers	Community	Barrier	Lack of discussions on health behaviors in rural communities Misinformation Rural norms and culture may not focus on some healthcare practices

Data obtained in 2020 to 2021 from interviews with radiology and primary care staff and providers and lung cancer screening program directors at 10 VAs participating in an enterprise-wide initiative, VA partnership to increase access to lung screening (VA-PALS); CBOC stands for community based outpatient clinic.