*3.4. Perception on the Effectiveness of Public Health Measures for Preventing COVID-19*

When assessing participant perceptions for the effectiveness of public health measures to mitigate COVID-19 transmission, we found significant correlations between rurality and public health measures for guidelines recommending the wearing of facemasks (x2(2) = 16.486, *p* < 0.001), closing non-essential businesses (x2(2) = 14.324, *p* = 0.001), recommending people aged 70 and over or with a medical condition stay at home except for essential needs (x2(2) = 9.344, *p* = 0.009), and for non-essential workers to stay at home except to do basic shopping or because urgent medical care is required (x2(2) = 13.116, *p* = 0.001). For guidelines recommending the wearing of face masks, 78% of rural participants perceived this public health measure as moderately (33%) or highly effective (45%), while 62% of non-rural participants viewed this public health measure as moderately (39%) or highly (23%) effective. When asked about the closure of non-essential businesses, 91% of rural participants viewed this measure as moderately (29%) or highly (62%) effective, while 88% of non-rural participants reported this public health measure was moderately (49%) or highly (39%) effective. Among rural participants, 73% felt recommendations for those aged 70 and older or with a medical condition to stay home were moderately (48%) or highly (25%) effective. Among non-rural participants, 63% reported this was a moderately (52%) or highly (11%) effective public health measure. Seventy-nine percent of rural participants perceived public health measures recommending non-essential workers stay at home as moderately (38%) or highly (48%) effective. Among non-rural participants, 77% felt this was a moderately (50%) or highly (27%) effective public health measure for mitigating the spread of COVID-19. We did not find significant correlations between rurality and perceptions on the effectiveness of the public health measures of closing schools.

#### **4. Discussion**

Rurality was significantly associated with perceptions of the effectiveness of public health mitigation strategies including the wear of facemasks, limiting time indoors, avoiding large gatherings, closing non-essential businesses, and elderly and non-essential workers staying home unless required to go out. Further, rural areas demonstrated more concern for the wellbeing of family and friends compared to more urban areas. There appears to be a paradox whereby our findings suggest rural people think mitigations are effective; however, they may not actually partake in the same mitigations they deem effective. Prior research has found rural communities may not adhere to mitigations at the same rate as their urban counterparts [24,33–35]. There may be a disconnect between rural residents' perceptions and risk. Perhaps they deem the risk low since rural areas are dispersed, or perhaps it is related to social media misinformation [36]. Whatever the case may be, public health nurses may be the answer [37].

The higher the percentage of people reporting COVID-19 negatively impacting their work, financial security, mental health, physical health, and having enough food, the higher their perceived impact (severity) of the disease. In this instance, it may not be the severity of the disease process itself, but rather the implications surrounding being ill with the disease (i.e., not being able to work or loss of job). Those participants with higher percentages of worry related to contracting and transmitting COVID-19 correlated with an increased perception of susceptibility to the disease. In other words, they perceived themselves to be susceptible to contracting or transmitting the disease to others. The assessment finding related to the participants' perceptions of the effectiveness of individual behaviors for staying safe from COVID-19 parallels the HBMs construct of perceived benefits to the mitigation strategies. Those participants who reported specific mitigation strategies to be effective in curving the spread of the disease were essentially indicating these actions produced benefits in controlling the spread of COVID-19.

Historically, the role of the public health nurse may not have been well understood, until the world was faced with one of the deadliest pandemics in the last 100 years. Public health nurses began doing what they do best by working collaboratively with community partners to educate people on what they can do to control the spread of COVID-19 [38]. Communities learned what they needed to do to protect themselves and others from this disease. Once vaccines became available, public health nurses provided education to community partners in the efficacy of vaccines, proper storage of vaccines, and strategies to track multi-dose vaccine administration. Public health nurses continue to work with communities for vaccine administration and provide ongoing support and education for those still skeptical of the safety of the vaccines. The role of the public health nurse in conjunction with LHDs is to empower people through education. At a time of great uncertainty, one thing is clear—RNs who work within communities have the knowledge and skills to deliver factual and relevant information regarding mitigation strategies [38]. They are the backbone to addressing this nation's need to eradicate COVID-19. LHD nurses could be the link between perceptions of mitigation success and actual behaviors.

Local health departments and public health nurses are often well connected to the available resources in the community and can act as resource hubs for community members. As our study findings suggest, and previous studies have also reported [39,40], many individuals living in rural areas are concerned about not having enough food and income loss throughout the COVID-19 pandemic. Many LHDs maintain current community resource guides including local food pantries, income, utility, transportation, housing assistance programs, and many other social services. Public health nurses and LHDs can leverage their position and connection to these resources to help community members connect to the services they need.

As COVID-19 continues to be a public health crisis in the United States, and with vaccine rates continuing to lag in rural areas and states with large rural populations, findings from this study may provide opportunities to emphasize rural communities' concern for the well-being of others to address vaccine hesitancy. Effective COVID-19

immunization programs are evidence based [27], and previous studies have identified emphasizing the personal risks of failing to get the vaccine and the potential spread to others in the community as effective health communication messaging [41,42]. Further, researchers suggest tailoring messaging to appeal to the opinions and values of a subpopulation can increase their effectiveness [43–45]. Therefore, we provide the following recommendations for messaging aimed at rural communities in the United States:


#### *Limitations*

One limitation of the study was the cross-sectional nature in which data were collected; therefore, the results are correlational and causation cannot be determined. A second limitation was the relatively small sample size. A third limitation was that the sample was relatively small and a majority of white females who have reported higher threat perceptions of COVID-19 [46,48]. Although perceived barriers to COVID-19 transmission mitigation strategies were not assessed, future studies should be explored using this construct to gain a greater understanding to address these barriers for greater adherence to disease prevention. Using a qualitative approach to understanding the barriers could be beneficial in understanding specific communities' unique situations to reduce or eliminate recognized barriers. Another limitation to the current study was the fact that rural communities here had abnormally high income—likely due to the recruitment methodology (i.e., online). Lastly, we did not survey people about their actual behavior, only their perceptions of the effectiveness of mitigation strategies.
