**1. Introduction**

At the onset of the SARS-CoV-2 (COVID-19) pandemic in the United States (US), metropolitan areas were the most highly impacted by the infection [1]. Rural areas were thought to have some protection from the virus inherently due to their sparse nature. Over time, however, this perceived protection of rural areas dwindled, thereby becoming the US's newest hot spot [1,2]. Unfortunately, as has been the normal trajectory with COVID-19, by September 2020 death rates in rural areas surpassed those in urban areas [1,3]. In fact, rural areas have been hit harder; roughly 1 in 434 rural Americans have died of COVID, compared to 1 in 513 urban Americans [4].

Rural local health departments (LHD) are key resources in their respective communities. Unfortunately, LHDs in rural areas are among the most understaffed and underfunded health departments in the nation [5,6]. While LHDs in rural areas serve smaller populations, these communities tend to have limited access to medical care [7,8], poor health outcomes [7–9], and experience health disparities related to risky health behaviors [7,10,11]. Leadership at most LHDs in metropolitan areas tends to be someone with a formal degree in public health [6]; in contrast, rural LHDs are three times as likely to be led by someone with a nursing degree [12–14]. Nurses are the linchpin that holds rural health departments together, especially considering rural LHDs frequently offer more direct clinical services [15,16]. Unfortunately, prior to the COVID-19 pandemic, there was an estimated

**Citation:** Beck, A.M.; Piontek, A.J.; Wiedenman, E.M.; Gilbert, A. Perceptions of COVID-19 Mitigation Strategies between Rural and Non-Rural Adults in the US: How Public Health Nurses Can Fill the Gap. *Nurs. Rep.* **2022**, *12*, 188–197. https://doi.org/10.3390/ nursrep12010019

Academic Editors: Richard Gray and Sonia Udod

Received: 6 January 2022 Accepted: 15 February 2022 Published: 2 March 2022

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36% decrease in staffing of public health nurses [17]. Therefore, rural area LHDs were likely the most impacted given much of their staff are nurses. This amalgamation of the need for public health nurses in rural areas, services provided by rural LHDs, and a global pandemic, left rural LHDs at risk of being overwhelmed—their communities would need to do their part to protect themselves.

Practices such as avoiding contact with others who are ill, social distancing, covering the nose and mouth when coughing or sneezing, washing hands or using approved hand sanitizer, and using face coverings when in public places are all recommendations established by the Centers for Disease Control and Prevention (CDC) to reduce the spread of COVID-19 [18]. It is also recommended that when a person falls ill with COVID-19-like symptoms that they remain quarantined and away from others [19]. It has been well documented that mitigation strategies decrease the spread of COVID-19 in community and healthcare settings [20–22]. However, these strategies are only effective if consistently followed.

Overall, Americans report agreement with public health mitigations; though, few of the respondents in these studies were from rural areas [23–25]. There is hope now with the approval of vaccines; however, there is still a concern for variants coupled with vaccine hesitancy. Rural areas, and states with large rural populations, are demonstrating some of the lowest vaccine rates in the nation [26]. The coalescing of low vaccination rates, rural populations' increased vulnerability to serious infection, increased vaccine hesitancy, and the concern for variants, means public health mitigation strategies will likely continue to be warranted [3,27]. Due to the likely need for ongoing mitigation strategies, the present study was designed to capture the perceptions of mitigation strategies among a sample of rural residents as compared to non-rural residents.
