Navigating the COVID pandemic in rural America: lessons learned from rural public health officials

Introduction

The pandemic negatively affected rural America by exposing the vulnerability of the population. After the initial wave of the pandemic, rural communities saw higher coronavirus disease (COVID) incidence and mortality rates than urban counterparts across the country, with Midwest and American Indian/Alaska Native (AI/AN) rural populations having the highest rates (1,2). Vaccination rates continued to be suboptimal, especially in rural communities, since the introduction of COVID booster vaccines (2). The pandemic proved how chronically underfunded and underserved the rural public health system was (2,3). Public health officials served as informative leaders during the pandemic, especially early on, as disease prevention and mitigation strategies were enacted. In some rural communities, public health officials are the only health officials serving the area.

Significant differences in COVID vaccination rates exist between rural and urban counties in Wisconsin. Urban counties with populations over 50,000 tend to have higher vaccination rates compared to rural counties with populations under 50,000 (4). For instance, Dane County, which is relatively urban and home to the state capital, has a population of 552,536, with 80% of residents having completed the primary vaccine series and 28% having received the 2023–2024 booster [Wisconsin Department of Health Services (WDHS), 2020]. Conversely, Taylor County, a more rural area with 20,318 residents, had only 35% of its population vaccinated with the primary series and just 8% with the 2023–2024 booster (4). Overall, rural America encountered more than 10% lower COVID primary series vaccine rates than urban communities (5). Research covering rural versus urban comparisons of vaccination rates found rural communities had significantly and consistently lower vaccination rates for COVID (6-8).

This study builds on limited, existing research on rural community vaccine acceptance by exploring key characteristics and/or barriers to high vaccine acceptance among rural counties in Wisconsin. Additionally, this research will go beyond exploring barriers to vaccine acceptance and COVID mitigation by also focusing on strategies used by county public health officials to combat these barriers throughout the pandemic. Research has found the leading factors affecting vaccination rates to be vaccine availability, access to vaccines, and personal beliefs on vaccinating which can be influenced by peers, organizations, trust in the government or health systems, vaccine safety, vaccine effectiveness, and health literacy (9-11). Previously reviewed studies focused on investigating barriers to vaccination and improving COVID vaccination rates found people are more likely to get vaccinated if the vaccine is recommended by their physician, pharmacist, or someone they trust, such as a family member, community leader, or friend, and they fully understand the health benefits, safety, and effectiveness of the vaccine (12,13).

A study involving interviews with public health officials in Wisconsin found that misinformation spread through social media challenged the promotion of the COVID vaccines and additional public health recommendations, leading them to develop strategies to combat misinformation (14). The COVID pandemic was met with political divisions in media outlets that further increased misinformation during this time. While one news source may provide positive commentary regarding the pandemic and public guidelines, another may be politically charged and present a more negative perspective, which could be quickly disseminated to further oppose public health measures (15). For some rural communities, public health officials were the first and potentially only line of information regarding COVID pandemic mitigation and safety guidelines. Understanding how public health officials navigated new information, misinformation, and disinformation in rural communities would offer additional insight into the challenges faced by rural public health systems and any effective messaging or strategies they developed to address these challenges.

• Research aim: determine what challenges rural public health officials encountered during the pandemic while performing their duties and what strategies they enacted to combat these challenges and promote the COVID vaccines and mitigation guidelines.
• Research questions: using results from interviews with public health officials, this qualitative study answers the following research questions:
  • What strategies did public health officials use to promote COVID safety guidelines and the COVID vaccine in rural Wisconsin?
  • How did public health officials tailor COVID mitigation strategies to account for the unique characteristics of their rural communities?

We present this article in accordance with the SRQR reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-21/rc).

Methods

Preliminary data

A preliminary study was conducted identifying Wisconsin counties with high and low COVID mortality rates. The preliminary study findings determined which counties to contact public health officials. Mortality rates and vaccination rates referenced in this study were established in the preliminary study. Findings from the preliminary study identified areas to further investigate to better understand the challenges public health officials faced while enacting COVID mitigation strategies and promoting the COVID vaccine. Wisconsin county populations and vaccination rates per county for both the primary COVID vaccine series and the 2022–2023 COVID bivalent booster were accessed through the WDHS and Wisconsin Immunization Registry (WIR) databases. COVID mortality rates were accessed using county COVID data through March 2023 from Johns Hopkins Coronavirus Research Center databases (JHUCRC). Rural counties with the highest COVID mortality rates (HMRCs) and the rural counties with the lowest COVID mortality rates (LMRCs) were determined to be the counties of interest for this study. Rural counties were defined as counties under 75,000 in population and having no metropolitan area with over 50,000 residents for this study, using definitions from the USDA and the Rural Health Information Hub (16).

Recruitment

Based upon the 72 rural counties of Wisconsin, defined using this study’s parameters for rurality, a homogenous sample of public health officials operating in similarly rural populated Wisconsin counties was obtained with a total of 14 interviews. The technique of purposeful sampling was used to ensure information-rich cases were obtained in as few interviews as possible while still allowing for the ability to compare similarities and differences among the interview results (17).

County public health office contact information was searched using Wisconsin state registries and websites. Google, Facebook, and other forms of social media were searched as well to obtain contact information for public health officials. After the interview, participating public health officials were asked for the contact information of multiple potential community leaders in their community to obtain potential interview participants for a future study.

Ethical considerations

Upon contact for recruitment, interview participants were assured that their contact information, names, and other identifying information would stay confidential and not be included in the resulting reports, presentations, and manuscripts. A disclosure statement was included in the interview guide, noting the confidentiality of personal identifying information, and only responses to interview questions would be included in the research outputs and manuscripts. The survey guide was emailed to confirmed interview participants at least a week before the scheduled interview. The interview guide included the IRB-approved informed consent form, so that it was provided before the start of the interview. The consent form ensured data confidentiality, and steps were taken to reduce risks to participants, such as not including any identifying information or county information in the research outputs. All survey information was securely stored within secure drives and folders on a password-protected computer. Certain information regarding a participant’s years of experience and their role was obtained ahead of the interview as part of a survey attached to the interview guide, which was sent before the interview took place. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This project was approved by the Medical College of Wisconsin Institutional Review Board #5. All participants adhered to informed consent upon agreeing to participate in this study.

Interview procedure

Interviews typically took place within a month of contacting the participant. Participants were interviewed for approximately one hour using the interview guide included in Appendix 1. Qualitative data from interviews with public health professionals were collected through virtual, recorded interviews using Zoom Meeting videotelephony software. All participant interviews were computer-mediated interviews. Interview responses were transcribed verbatim using Zoom transcription software, deidentified for analysis. Transcribed interviews were saved to a document folder and read thoroughly to understand and synthesize the responses.

The interview protocol and interview questions were constructed using information from a robust literature review and an understanding of presumptive challenges rural public health officials faced (see Appendix 1). Interview participants were provided a $50 Visa gift card for their time and contribution to the study. Interviews asked questions about COVID prevalence trends, vaccine trends, factors health officials noticed contributing to vaccine acceptance in their communities, vaccine promotion ideas, and strategies they used to develop effective public health messaging, and interventions that they conducted to increase vaccinations among at risk and hesitant populations from the onset of the pandemic in 2020 through 2023. Public health officials were also asked what factors they believe created challenges for pandemic preparedness and overall public health operations. Transcribed interviews were read multiple times to understand the information. Thematic analysis was used to analyze and understand the qualitative data. Recurring themes were identified and discussed in detail. The analytical approach for this study is described in more detail to follow.

Qualitative data analyses

The qualitative data analysis process began with the familiarization of participants’ responses to the interview questions. The responses were expected to reveal new ideas and concepts on a topic that has not been thoroughly researched yet, namely COVID mitigation and pandemic preparedness in Wisconsin’s rural healthcare system. Data saturation was achieved as participants gave similar responses, leading to consistent and categorizable data. Purposeful sampling facilitated reaching saturation because counties with low COVID mortality rates were expected to share similarities, contrasting with those with high COVID mortality rates. Themes were developed through abstraction, using recurring coded concepts and quotes from interviewees. For analyzing the interview transcripts, an inductive, thematic approach was used, involving open coding, category creation, and abstraction (18). A coding tree was created to identify specific terms or phrases through inductive coding, with codes generated as transcripts were reviewed. “Qualitative codes”, such as vaccine promotion, community support, healthcare accessibility, and political polarization, were assigned to relevant segments of text within responses. These segments were coded with key terms that best summarized the message conveyed. Recurring challenges, strategies, and ideas were identified for categorization. Categories were formed after all data segments were thoroughly reviewed and coded. MAXQDA software facilitated coding and report generation, with coded segments and quotes utilized in the analysis. Themes emerged by contextualizing coded segments and categories.

The primary researcher conducted all interviews and performed all coding, providing an in-depth understanding of the data from which themes were identified. As a public health researcher, the primary researcher minimized potential bias by maintaining consistent questions across interviews and ensuring that personal public health and policy beliefs did not influence the process. Themes were further refined through abstraction, using recurring codes and quotes from participants. These themes and their quotes were reviewed by experienced qualitative researchers, manuscript coauthors, to verify accuracy and validity. The thematic analysis involved interpreting the meaning of various coded segments and quotes to construct overarching themes. Direct quotes from public health officials were analyzed for deeper meaning and incorporated into the results, supporting the validity of the themes.

Results

Fourteen public health officials from twelve different rural counties across Wisconsin were interviewed for this study. In total, participants represented six counties among the ten highest COVD mortality rate counties and six counties among the ten lowest COVID mortality rate counties. All of which were counties with populations under 75,000 residents. Participants had a range of public health experience, from five to 32 years of public health experience and one to 32 years in their position at the health department. Participant roles included: public health nurses, health officers, public health directors, supervisors, officers, and strategists (see Table 1). All health officials lived within the counties they worked in. Forty-eight potential participants and/or health departments from 24 different counties were contacted via email or phone to participate. Over 20 individuals responded; however, multiple health departments reported not having the time and were too busy or chose not to participate, citing they would like to put the struggles of the pandemic behind them. Fourteen public health officials agreed to participate and followed through with interviews.

Using thematic analysis, the following core themes were identified from public health interviews: (I) rural public health officials encountered numerous challenges for COVID mitigation further complicated by long-standing inadequacies in the rural health system; (II) effective strategies for mitigating COVID engaged community members, quickly adapted to changes, and effectively navigated misinformation and political polarization of COVID; and (III) public health officials made do with the resources they had and relied on community strengths to best mitigate the impact of COVID. Content supporting the creation of the core themes was identified in all public health official interviews. Challenges and corresponding effective strategies used by health officials are displayed in Table 2. Themes, definitions of themes, and supporting quotes for subthemes are displayed in Table 3.

Rural public health officials encountered numerous challenges for COVID mitigation, further complicated by long-standing inadequacies in the rural health system

Participating public health officials all referenced challenges with COVID mitigation stemming from adverse rural characteristics and long-standing resource inadequacies. Limited resources complicated COVID mitigation, and limited health treatment services led to more severe outcomes for residents contracting COVID. The challenges faced by resource inadequacies were not new to public health departments, but the level of response needed during the pandemic was further complicated due to the resource inadequacies.

Subtheme: chronic resource and finance inadequacies for proper preparedness

When public health officials were asked to describe the challenges they faced early on in the pandemic, almost all referenced resource inadequacies contributing to improper preparedness for a pandemic. Of the health officials who discussed resource inadequacies, many explained how resource inadequacies continued to be a major problem throughout the pandemic, even with emergency funds. Inadequacies could not be counteracted with funds alone in a short amount of time. Several public health officials detailed the complications they had with resource inadequacies, describing how these inadequacies complicated COVID mitigation. One participant described their county as “not resource-rich” when discussing how community members typically travel long distances, often up to an hour, to other, more urban counties within Wisconsin. Another health official discussed how they viewed their county as very remote and having limited resources, stating:

We’re quite isolated. We have 2 very part-time health clinics. We do have a public health department. It’s just a 3-person staff, so very small. (P1C1).

One health officer from a remote northern county discussed how limited they were on multiple modern resources:

Some areas don’t have service for Internet. Or it’s very slow. Food, mental health, and medical technology, we lack accessibility in all those areas. (P7C7).

This health official went on to mention their county had no hospital, treatment center, substance abuse centers, or critical access centers. If someone within the county needed immediate health services, they would have to travel at least 30 minutes from almost any part of the county to receive the aid they needed. The 3-person public health staff was the smallest of all county public health offices participating in the study. Public health officials had to serve many different roles during the pandemic with such a small staff.

Another health official described their county as sparsely populated, with only three towns, a few villages, and only one grocery store within the whole county. This means some folks drive up to 45 minutes just for groceries. Two other grocery stores within the county closed post-pandemic. The public health official went on to describe their county’s unique and changing network of healthcare facilities:

We have one hospital in our county, and then we have one private clinic. We do have another clinic that’s attached to the hospital that’s in the western part of our county. But it’s the same system, accessibility is not great… the high level of care is just not there. (P14C12).

Rural communities not only struggle with adequate funds to support public health departments, but also treatment centers and hospitals. The alarming number of hospitals that have closed in Wisconsin over the past years is a cause of great concern for some health officials. One health official had the following to say on the topic of the decline of hospitals in rural Wisconsin:

I have massive concerns about the closing of hospitals throughout rural Wisconsin. From everyday just people giving birth, and people getting in car accidents to pandemic preparedness. I am very concerned about rural access to healthcare. (P5C5).

Public health officials from counties without hospitals and a limited number of clinics shared a common view. Many rural community members have to travel outside of their county of residence for health services. Many residents travel over an hour, or even two hours for those living in select north central counties.

Public health financing was discussed with every public health official. Views on adequate funding during the pandemic ranged for participants as many believed the state and federal aid was adequate. ARPA grants and COVID relief funds aided their ability to enact COVID mitigation plans. However, most health officials stressed how inadequate public health funding was leading up to the pandemic and how non-COVID initiatives are yet to be properly funded. Outside of COVID relief grants and COVID-centered funding, public health financing continues to be viewed as inadequate. One public health official described their struggle with funding:

We don’t get many dollars from the state or federal government. It’s local dollars. If we could get more from federal and state resources. That would help us to be able to provide more for those services. But we really rely on local tax levy dollars, and we just don’t have the funding in our county to support what needs to be done (P3C3).

Another public health official expressed their frustrations with the delayed timeliness of pandemic relief funds:

We got our 1st case on March 9th of 2020, and we did not receive any assistance from the Federal Government until June of that year. Funds were not deployed very rapidly in the beginning, which was frustrating. (P5C5).

The same health officer later detailed why public health funding needs to be improved beyond COVID relief funds:

We need long-term, sustained, flexible funding for health departments to respond to community needs. We get no money from the State dedicated to mental health prevention. We had a really tragic series of suicides at our local university last year. It was devastating and highly unusual for our community. We didn’t have any financial resources to respond to that. (P5C5).

Participants expressed why improvements need to be made to public health infrastructure and pandemic preparedness to improve their county’s health system. These are not improvements they can make on their own. Additional funding and large-scale change is needed to improve rural health systems.

Subtheme: challenges with tracking cases and vaccinations

Tourism

People traveling in and out of rural counties pose issues for COVID tracking. Multiple public health officials noted how travelers would contract COVID in the urban areas and travel to their counties. Some of these travelers had second homes in the rural counties; however, others were there for only a short time. Tracking COVID cases and quarantines for these travelers was challenging. These travelers did not want to quarantine because they had to be while in the city, and they did not expect to have to in rural Wisconsin. Public health officials presumed that if a traveler had COVID, they likely were not going to quarantine thus possibly spreading COVID to rural residents.

Five different county health officials mentioned that their counties see high volumes of tourism. While multiple other counties mentioned urban residents traveled to their county just for the seclusion and to get away from COVID in the cities. For some counties, the tourism is people visiting the county for what it provides, “we have a lot of lakes and national forest land. We see a lot of tourism, which increases our population definitely in the summertime.” (P13C11).

For a couple of counties, tourism revolved around major events such as music concerts or fairs. One county health official noted how their county canceled a major concert that brought enough people to nearly double the whole county population. The decision to cancel the concert was not made lightly, as it made some businesses concerned about losses in revenue, but others supported the decision. One particular county noted they still had their massive event, which increases their county’s population by 50,000 people annually. When asked if they recall a spike in COVID cases after the major county event, this public health official responded:

Yeah, because the whole town, nobody had masks on here. A minority of people had masked up. There were people from all over the country here. (P7C7).

Commuters

Multiple public health officials discussed how several community members traveled to other counties, and for some northern and western counties, into other states for work. These health officials noted it was challenging to keep track of who got vaccinated and where, especially if some community members were being vaccinated by their out-of-county or state employers.

Religious groups

With a few of Wisconsin’s rural communities having Plain Communities, and other communities that do not seek out public health services, it is challenging to track COVID cases within the Plain Community. One public health official explained the relationship:

Our Plain Community wanted to know everything. We drove around every week to every one of their bishops with packets of paper, with all the guidelines and the updates, because they wanted that. The very 1st time that one of the doctors vaccinated them, they told us to stop coming. Simply because they don’t believe in it. We’re like, we are not pushing this on you… But they decided they didn’t want anything from us. We had their trust, and then we lost it. We had a lot of pushback on the vaccine. (P14C12).

Undocumented workers

A couple of public health officials brought up complications with tracking COVID cases and vaccinations among undocumented immigrant workers within their counties. One county had a unique challenge with tracking COVID cases among a large population of migrant farmhands. Once the vaccine was available, the county health department faced similar challenges with tracking the vaccines they gave to the migrant workers. The public health official representing this county provided great detail on this situation:

Farm owners made all of their staff get vaccinated, which was a whole gamble. When they came, because they’re not legal, and today’s world of ice issues we have going on, they wouldn’t give us their real names. They wouldn’t give us their real birthdays. Trying to get a two-dose series into these people when you can’t match up names was an absolute disaster. And of course, there’s a language barrier, because almost all of them speak Spanish, and we don’t. (P14C12).

The challenges arising from tracking COVID cases and vaccines among undocumented people were not limited to just farms and their migrant workers. Other counties also pointed out how they had undocumented people in their county’s homeless shelters and working in manufacturing and agricultural factories. The undocumented and uninsured created several challenges for our public health officials, especially those from counties with strong agricultural economies. The strategies the health officials enacted to promote communication with undocumented workers are detailed within the next subtheme.

Subtheme: public health employee burnout and turnover

All participating public health officials reported having at least one position turnover during the COVID pandemic, with 10 participants reporting more than one instance of someone within the department leaving their position. For some county health departments, this was maybe 3 out of 4 positions or 5 vacated positions out of 6 throughout the pandemic, with the only member of the health department remaining with the health department, the interview participant. Reasons ranged from retirement, early retirement, and switching to a higher-paying job. Many people left public health altogether, seeing burnout as a major factor in their decision. Multiple health officials also noted that competitive wages for traveling nurses were the main reason their nurses left their positions at the health department. The nurse could make substantially more money elsewhere.

One public health official shared their internal dilemma regarding their continued role within public health during the pandemic. While already suffering from burnout, they also received backlash from community members and harsh messages on social media. This health official shared:

Those are the things that fatigued me and contributed to people leaving. I don’t want to dismiss how challenging it was. It was the most challenging thing I’ve ever done in my career, by far. It had incredible effects on me professionally, and the decisions and stress that I was under it had profound effects on my family. I had school-aged children getting harassed because they have this mother, who is a health official, making them wear a mask to school. It was profoundly challenging. (P2C2).

This health official stayed on at their public health office and was moved into a director role near the start of the pandemic. Their decision to stay with their public health department through a challenging time is commendable.

Subtheme: COVID fatigue

As the pandemic waned on for multiple years, Americans began feeling the phenomenon referred to as “COVID fatigue”. Public health officials reported how several community members grew tired of the continued COVID restrictions, mandates, guideline updates, isolation, masking, and vaccines. Multiple public health officials reported having community members who began to oppose mitigation guidelines because they were fatigued and wanted to return to normalcy. Low COVID booster vaccine rates were believed to contribute to COVID fatigue, with one health official reporting:

Seeing that our long-term care facilities are still managed under strict COVID guidance. And then there’s the rest of our population, where it’s just your recommendation is the same with any upper respiratory infection. Stay home when you’re sick. Just managing all of that, we’re COVID-fatigued. But we try to accommodate those who want the booster. We stay up to date and be able to refer them or provide it. (P10C8).

Effective strategies for mitigating COVID engaged community members, quickly adapted to changes, and effectively navigated misinformation and political polarization of COVID

Public health officials involved in the study detailed numerous strategies and tactics they enacted to mitigate the spread of COVID. Of all the enacted strategies, tactics, interventions, and plans discussed by our rural public health officials, the most effective were those that focused on engaging the community and keeping the community members involved as much as possible. This theme first presents the recurring barriers and challenges public health officials faced in promoting the COVID vaccine, followed by the strategies they enacted to combat those barriers and challenges.

Subtheme: perceived and unperceived barriers to community vaccine acceptance

The public health officials involved in this study had much to say on the topic of vaccine acceptance within their community. Every public health professional involved in the study stated they supported the initial roll-out of the vaccine, with many stating they were “excited” or “relieved” to receive the vaccine. None of the involved health officials reported not receiving the COVID primary series vaccine once it was made available to them. As for community views on the COVID vaccine, the reaction to the roll-out and acceptance to vaccinate was very mixed across communities and within communities. Rural residents essentially were in three groups: (I) those who were eager to receive the vaccine; (II) those who were hesitant and unsure about the vaccine but willing to receive it; and (III) those who were either anti-vax or opposed to receiving the vaccine for various reasons.

All the participating public health officials stated how many community members were anxiously awaiting the vaccine and were ready to receive it once it was available, especially elderly people and those with preexisting health conditions, the most at-risk groups for having severe complications from contracting COVID. Those who were the most vulnerable to severe complications were the people public health officials wanted to make sure got the vaccine as soon as it became available. One official commented:

I think if anything early on, there was just an incredible eagerness, and people valued and acknowledged what an important tool the vaccine was. (P2C2).

However, some community members considered the safety of the vaccine and how fast it was produced. The same health official went on to say:

As the pandemic went on, though yes, there was angst about the speed. Was it safe? We’re not going to take it now. (P2C2).

Another public health official noted the varying excitement, yet anxiety regarding the vaccine among the second group of community members, the vaccine-hesitant group:

We were still hearing that in the later months of 2020, there was such eagerness or anxiety for the vaccine to become available. There was great excitement, then it shifted to anxiety... (P1C1).

The third group of community members described by public health officials, those who did not want to receive the vaccine or even opposed the vaccine, had many different reasons for going unvaccinated. This complex group had an array of reasons for not receiving the COVID vaccine, reasons ranging from health and safety concerns to religious and cultural reasons, and overall opposition to the vaccine due to personal beliefs.

Health and safety concerns

The COVID vaccine was developed and disseminated in record time, rushing through many steps. The rush caused concerns for many Americans. The number of potential vaccines and different companies offering the vaccines made it difficult to keep track of all the vaccine information. In turn, hesitancies arose among community members. One health official stated:

They did have different rules for different vaccines because you got Moderna and Pfizer. Then, later on, the Johnson and Johnson came out, but you only got one of them, and then it was you could get this and you could get that. People didn’t trust that because they didn’t think they had enough time to test the safety of the vaccine. (P8C7).

For some people, it is not specifically the COIVD vaccine that they have concerns about, but all vaccines. One health official noted several community members in their county oppose vaccines, not because of religion or culture, but because of the belief that all vaccines are unsafe. Stating how some members of the county believe they “can fix everything with essential oil and vaccines cause autism.” (P14C12).

Health and safety concerns are valid reasons for the low acceptance rate in communities. Public health officials were asked if they believed more people would vaccinate if the COVID vaccine were deemed 100% safe and effective. Responses varied, with most officials saying they believed vaccination rates would increase slightly. However, all public health officials stated they believed some residents would still not vaccinate as the health and safety of the vaccine was not their concern.

Religion and culture

Multiple rural Wisconsin counties have unique cultural groups comprising their county’s population. Five public health officials interviewed mentioned they have “Plaine Communities” living within the county. One health official explained:

We have a giant population of plain community, whether that’s Mennonite or Amish, or both. Mostly in the western part of our county. But that accounts for a lot of our numbers being so low, too, because they have their own way of doing things, and they have their own way of health care that does not usually involve a vaccine…. (P14C12).

Personal beliefs

When asked about potential reasons as to why some residents have low vaccine acceptance, one county health official pointed out how residents had “mistrust in government, mistrust in pharmaceutical companies”. This same health official noted other community members had some religious and personal convictions for not vaccinating, but mistrust was a leading reason, noting “We’ve seen it grow and spread like wildfire on social media.” (P14C11), referring to the growing mistrust in the government, pharmaceutical companies, and the vaccine.

One public health official had the following to say about the negative personal beliefs on the vaccine complicated their mitigation steps:

The same vocal people about the masking. We’re vocal about the vaccines. It wasn’t a large contingent, but a small contingent can make a lot of noise seem a lot bigger. Those concerns have grown over time as the myths and social media things have spread. (P4C4).

This same public health official went on to describe how there is now a decreased demand for COVID vaccine boosters:

Initially, people were desperate to get it. Your elderly population is eager to get it, and you’re very proactive, middle-aged people. We aren’t even providing the vaccine at the health department anymore, because the demand is so small. One of the biggest barriers for us is that we are not set up for billing. Once the vaccine stopped being free. We had to charge people that full $200 a dose. (P4C4).

Concerns about vaccine safety, effectiveness were not new to the COVID vaccine. Even mistrust of the government has been a long-standing concern for many people regarding vaccines. The COVID vaccine and even COVID mitigation efforts, however, did see complications stemming from the timing of the pandemic, the timing of the vaccine’s release, and the changing culture around vaccines.

Subtheme: misinformation and political polarization of COVID

As the pandemic waned on into an election year in the US, misinformation started being pushed with political ambitions. The COVID vaccine was rolled out near the end of 2020, during the conclusion of an election year in the US, sparking a great debate as to vaccinate or not. This division led to health departments receiving backlash and negativity as it became a hot topic in the political forum, with continued lower acceptance by the Republican party versus the Democratic party (Bentzen and Smith, 2020). Nearly every public health official mentioned their county was primarily “red” or conservative and made the association that conservative community members were less likely to support COVID mitigation guidelines and vaccinate, compared to more liberal community members. The combination of misinformation and political division regarding pandemic mitigation guidelines and the vaccine became a major challenge for public health officials. One health official explained the political polarization situation as:

I will say people with a more liberal point of view seem to follow those rules better than people with a conservative point of view. Conservative people tended to be more like, “You’re not telling me what to do, that’s my right”. Where liberal people would be more like, “Get your mask on”. For sure, that was a trend here. During that time, all the political issues, along with COVID, put people at odds. Some people support the health department, and then some people were nasty with the use of social media or the newspapers, and just slamming the health department… (P7C7).

Several health officials brought forth the relationship without being asked if they felt that COVID had become politically charged. While referring to the vaccine, one health official noted:

I think, being such a conservative community, we have a large percentage of our population who would not get it, regardless of whether it was a hundred percent safe and effective. (P13C11).

Another public health official discussed how conservative beliefs opposing the COVID vaccine were shared by multiple members of their county board, which created a lack of support for public health actions:

I think we’ve seen, very recently, a shift in vaccine support. I remember 3 years ago, when I was starting my current position, our director was on vacation, and I was in my position for 2 weeks. I was called on the county board floor to talk about COVID vaccine and vaccinating children, because we had 2 individuals on the county board who didn’t believe we should be giving COVID vaccine to kids at all. And we shouldn’t be advertising to them. We shouldn’t be using any funding to advertise to them. (P13C11).

When describing how politically conservative members of the community spread information about the health department and vaccinations, one participant stated:

We got told at 1 point that we were making $70,000 for every 10 people that we got to take the vaccine personally, not even through the department, like we got a check. (P14C12).

Misinformation eventually gave way to conspiracy theories among community members. Theories, such as “there are microchips in the vaccines” and that the vaccines are more likely to kill than COVID, circulated with great speed. Misinformation in the schools circulated as well, often about masking. One health official involved with COVID mitigation at the local schools noted they heard community members saying, “masking made them sick”. “Them” being kids in school. When asked if they believed community members with low vaccine acceptance would be more likely to vaccinate if vaccine safety concerns were reduced, they stated:

I don’t think there’s any scientific evidence that could ever convince a lot of these people. Conspiracy theories and all. They are so 100 percent certain of the conspiracy theory stuff and the truth behind it. It’s not about science. It’s not about evidence at this point. (P4C4).

COVID mitigation and vaccine promotion were opposed in many communities, creating challenges for our public health officials when doing their duties. At times, the opposition became very severe and even struck fear in some public health officials. They felt no support from anywhere at times as described in the next subtheme.

Subtheme: lack of support: the fear of being chastised or reprimanded

Community leadership support lacked for some public health officials which created great challenges for them while performing their duties. Low community support of the public health department and their decision-making not only harmed COVID response processes but also took a toll on public health officials. These were their fellow community members who no longer supported or trusted them. Political leaders seemed to point seemed to point the finger at public health at times, not supporting public health decision-making, and disrespecting the expertise of public health officials. One public health professional had the following to say on the topic:

The biggest problem I think we had locally was. We were all in silos, and I don’t know if we could have changed that. But public health was the lead. With no support from anywhere. (P12C10).

In some counties, there was a lack of support from fellow county workers. One health official stated:

Our sheriff’s department refused to enforce any type of mask mandate. They refused to enforce any kind of business closure. We were told from our county board from the beginning that even though they were, even though the chair was supported, that they wouldn’t put any kind of mandate into place at all in our community. (P13C11).

Castigation and aggressive community opposition grew concerning for our public health officials. One participant detailed a story about a time they were confronted at a vaccine clinic:

We only got stormed once. But we never ran a vaccine clinic without law enforcement on site. A woman came in with papers about how we were the devil, and screaming at everyone who was waiting there. Saying, “I can’t believe you would let them poison you like this.” (P14C12).

Another health official noted how they encountered a cyber-attack:

One of our business Zoom Meetings was taken over by some outside people had to shut down the meeting, you know, people took control of the Zoom Meeting and started writing on all the slides and writing, swear words, and swearing. We did get cyber-attacked. (P1C1).

One health official noted how politics and media were negatively influential at times, which created further challenges for public health officials.

The health department was being vilified in some circles. On social media. We know how influential that could be. (P2C2).

Throughout the pandemic public health officials were doing their best they could, protecting their community, yet somehow, they lost the trust of the community. One health official described how their situation has drastically improved since the height of the pandemic:

The build-back that we’ve done has been tremendous. We’ve spent the last 2 years really trying to gain that trust back that we are not just COVID. Communicable disease has been here forever. This is something we’ve always done. It just got blown up by the pandemic. Now it’s just re-educating people to say we do so much more than just make you stay home. We are slowly gaining that trust back. We’re doing a lot in the community now. (P14C12).

Other participants shared similar stories about losing trust with community members, even though they were making their best efforts to serve their community while receiving no extra benefits.

COVID vaccine promotion was challenging for many public health officials, as was COVID case, or contact tracing, and vaccination tracking when attempting to make sure people followed up with their second dose.

The most effective strategies for mitigating COVID described by the study participants could fit either of the following comprehensive mitigation strategies: (I) community-engaged health communication strategies; and (II) community-focused vaccine promotion. Public health officials also noted having to navigate a unique, unanticipated set of barriers when developing strategies and interventions for mitigating COVID and disseminating the COVID vaccine. This unanticipated challenge was the political polarization of the pandemic and, in turn, anti-COVID mitigation agendas circulating within the community. Our health officials had to quickly develop new strategies to help navigate the political polarization of the pandemic and the harsh backlash that would follow. For public health officials wanting to stay ahead of the curve, they had to integrate a third comprehensive set of strategies; (III) navigating political polarization and anti-COVID agendas.

Subtheme: community-engaged health communication strategies

Guidelines and informative resources passed down from state and federal government organizations were perceived by public health officials as useful, but not all that applicable to their communities. On the other hand, false information, or misinformation, also circulated in the community. Public health officials needed to get out ahead of the pandemic, communicate with the community, and set up strategic lines of communication for the dissemination of accurate information.

We had to put other things in place in terms of public, you know, communications. We set up a series of meetings with local businesses. We sent out invites to over 300 businesses so that we could update them on safe at-home practices or safe business practices. (P1C1).

Contacting businesses, both large and small, allowed this county’s small public health department to create an information network across the county. Information was relayed to the various businesses during occasional meetings. The business owners could then relay the information to other community members. This system was deemed a highly effective way to communicate all new COVID safety guidelines and restrictions. Most business owners were on board with the idea and were able to meet virtually when new information needed to be disseminated to the community. The public health official from this county even mentioned that the businesses were able to open back up after the state closure mandate was lifted, and none had to close again for lack of following COVID safety guidelines. Eventually, the COVID vaccine was developed, and community concerns and questions grew. Multiple county departments established dedicated phone lines for community members’ questions. One county official described how and why they went about establishing the phone line:

We set up a dedicated phone number for taking all those community calls about the vaccine. “I’m 65. When am I going to get it...” We had so many questions flooding our department that we hired one of the staff here in the county and repurposed them to just handle all these calls. (P1C1).

While our public health officials reported engaging with the community when enacting COVID mitigation strategies, they also reported calling upon the community to serve. The pandemic caused public health offices across America to overhaul and scale up. Departments hired more staff and tried to quickly replace staff who left their positions. Some of the smaller public health departments involved in this study had to double, even triple, their staff to keep up with COVID mitigation guidelines, primarily contact tracing, disseminating information, setting up testing and vaccine clinics, and administering vaccines.

At one time, I had 25 staff total, and normally I have 12. We doubled our staff with our contact tracers and our COVID people. (P12C10).

Volunteerism became a major benefit for some counties. A supervisor noted:

Our saving grace was that we had a system for volunteers, and we ended up having a lot of people reach out to us during the pandemic who volunteered. We had a lot of nurses, a lot of just community citizens in general, retired physicians who were happy to help in any way possible during our mass clinics. Whether that was sitting in the parking lot, directing cars, or handing out pagers to use like a pager system. We had nurses who refiled for their nursing licenses, even though they were retired, so that they could help vaccinate. (P13C11).

Many effective vaccine promotion strategies utilized community input and feedback to determine strategic places for vaccine clinics and dissemination strategies. It was important public health officials listen to their community members to avoid greater push-back as well.

Subtheme: community-focused vaccine promotion

Restricting personal autonomy and one’s right to decide on whether to vaccinate proved to be very controversial across America. In rural landscapes where people felt they may be protected by secluded living; the vaccine mandates were poorly received by many residents who were hesitant about vaccine safety or simply anti-vaccine.

Our focus was just more on giving it to those who wanted it? It was the people who were desperately trying to get in that 1st group of people who got the first 200 doses that we got into the county and set up those mass vaccine clinics for. And so many people were very much wanting that initially. You heard more of the pushback as the mandates came. (P4C4).

Undocumented and uninsured populations created challenges for public health officials when tracking cases and vaccinating. Effective strategies to provide vaccines to these people involved county public health departments focusing their efforts on reaching these people, as they knew they were unlikely to go to clinics for vaccinations.

We do outreach to uninsured adults to make sure that they know that we have the COVID booster vaccine. We do a lot of outreach to our large farms, who sometimes have large numbers of employees who are migrant workers, to make sure that they know that they can get their flu and COVID shots from us. (P5C5).

As previously mentioned within this core theme, misinformation and political polarization created challenges for public health officials when enacting COVID mitigation strategies and promoting the vaccine. The strategies enacted by public health officials to combat these challenges are described in the next subtheme.

Subtheme: navigating political polarization, misinformation, and anti-COVID agendas

The political polarization of COVID and actions taken to mitigate COVID created great challenges for our public health officials when performing their duties. Strategies had to be developed to combat the circulating misinformation and disruptive agendas. Public health officials reported numerous different tactics to educate people and combat misinformation without getting dragged into political arguments. One public health official had a powerful message that they tried to convey to community members when promoting and enforcing COVID mitigation steps.

If your mission is to keep people from getting diseases, then you want to use vaccines that are effective and don’t have bad side effects. I think things should be evidence-based. We should use science and research. Let’s be careful. That’s not a political thing. When people politicize things that are not political, and say, “Oh, let’s not talk politics.” I call foul. I don’t care if you’re Republican or Democrat. Are you going to provide a public health response that protects people from disease and public health threats? The virus doesn’t vote. (P1C1).

Another public health official explained how they felt a more democratic board provided them with greater support to perform their duties.

Because we had good financial support and because politically, we had a Democratic board that was supportive. We were in really good shape as a county for our response to the pandemic. (P12C10).

Public health officials had to adapt quickly to new politically polarizing agendas and misinformation aimed at COVID mitigation and the COVID vaccine. Through developing effective messages tailored to their target community, engaging the community, not infringing upon the rights of people, and disseminating accurate information across multiple forms of media, public health officials could effectively adapt.

Public health officials made do with the resources they had and relied on community strengths to best mitigate the impact of COVID

Since rural communities often lack quality health services and resources, they must deal with these shortcomings. It is important to consider the rurality of a community, the health resources available to them, and how accessible these resources are. When developing and implementing COVID mitigation and vaccine promotion strategies, it became clear to public health officials that they needed to account for rurality by leveraging their community strengths. Rural communities across Wisconsin share many similarities and differences. For example, the pandemic timeline was quite different for rural areas, with some experiencing their first COVID cases months after other counties in Wisconsin. Rural communities may have benefited more from delayed closures rather than immediate ones.

We closed with everyone else, but beginning in the fall, we went back to full-time in person, and we never went back to virtual ever. We never closed schools back down to virtual. We implemented mandatory masks, or they implemented mandatory masks for all students and staff for that full 1st year of 2020. When the vaccine came out, we were very specific on making sure the school staff also got vaccinated and were prioritized. The school never went back to virtual. When you hear some of the rural communities having to close down their school. We didn’t. We were in school. (P9C8).

When discussing a strength, they had that assisted their county with responding to the emergency of the pandemic, one health official mentioned:

I think the key strength in our county is that we’re small. We don’t have very many resources ever. Our community organizations are used to working together and kind of coming together to figure out problems. We are already used to working like that. So then, in an emergency or a pandemic, we just came together again and divvied up what needed to be done. (P3C3).

Another health officer stated:

Our small community came together in a lot of different ways. Being a small community, we knew we worked well with our emergency personnel. (P9C8).

Rural communities had to band together and be resilient when navigating the challenges of the COVID pandemic. Public health officials had to call upon their community for support in many ways.

One strength we have in our county is that a lot of the people who work up here, whether it’s in healthcare or law enforcement. They’re here because they have a strong passion for rural health. They’re not doing it for a paycheck. They cared about the clients that they were seeing and cared about the community that they were serving. (P13C11).

This same public health official also mentioned their department’s assistant director at was not a nurse and could not administer vaccines, so the assistant director focused on pulling numbers and configuring COVID data to display to community members. This assistant director had little experience in working with data, but they learned how to create a data dashboard on their own to display the COVID data and made it accessible to the community. The resiliency displayed by rural public health officials as they served many different roles is highly commendable.

Discussion

The thematic analysis of qualitative data collected through interviews with 14 rural public health officials provided the information needed to determine what strategies public health officials use to promote COVID safety guidelines and the COVID vaccine in rural Wisconsin, and how did public health officials tailor COVID mitigation strategies to account for the unique characteristics of their rural communities. Hearing the perspectives of county public health officials allowed for a better understanding of how the pandemic affected the health of their county and the responsibilities of their position. The following discussion entails the challenges and barriers to effective COVID mitigation, allowing for an in-depth understanding of the strategies public health officials had to develop and enact to combat the challenges they faced. The discussion continues by examining the identified themes and strategies shared by public health officials to answer the first research question.

Barriers to effectively mitigating the spread of COVID

This study investigated how rural county public health officials navigated barriers to effective COVID mitigation and challenges that arose throughout the pandemic. Barriers identified by public health officials could be linked to long-standing, chronic inadequacies with Wisconsin’s rural health system and challenges associated with rurality, and not specific to COVID. Limited health resources, challenges with accessibility, and outdated emergency preparedness protocols further complicated mitigation response during the pandemic (19). The remaining barriers identified by public health officials were more COVID-specific, such as barriers to vaccination and high rates of circulating misinformation, stemming from how novel and controversial the pandemic was aligning with existing research on COVID vaccine hesitancies and opposition (9,10,20).

Rural resource inadequacies

The pandemic revealed issues with resource shortages in rural communities and their healthcare systems. Rural health resources, providers, and treatment centers could not fulfill the needs of their service areas due to ongoing shortages (21,22). Several public health officials mentioned that their counties had no hospital or treatment facility. A few counties even lacked an active health clinic for basic health services. In counties with hospitals, these hospitals were often lacking. One county reported having three hospitals; however, one lacked an intensive care unit (ICU), and another only had 7 ICU beds. Public health officials noted that their rural hospitals were understaffed and had an insufficient number of beds, which forced them to divert patients to other hospitals, often located in more urban areas hours away. Moving patients to distant hospitals was difficult not only for the patients but also for their families, who had to travel to visit them during their care.

Effective COVID mitigation and vaccine promotion strategies

Multi-pronged evidence-based strategies constructed by the CDC included strategies: universal face mask use, physical distancing, avoiding nonessential indoor spaces, increasing testing, prompt quarantine of exposed persons, safeguarding those at increased risk for severe illness or death, protecting essential workers, postponing travel, enhancing ventilation and hand hygiene (23). While the strategies recommended by the CDC were proven to be effective, they were broad and challenging to enact with different populations. Rural public health officials reported that they used information passed down from larger organizations, such as the CDC, but some strategies were simply ineffective in their community. Health officials noted numerous different strategies for mitigating COVID that were categorized based on their collective aims. Table 2 contains the categorized strategies with supporting quotes from interviewed public health officials. Accounting for rurality, identifying potential barriers, vaccine promotion, vaccine dissemination, health communication, establishing partnerships, community engagement, data sharing, navigating misinformation and political polarization, and relying on community strengths are all strategies identified within this study as effective strategies for COVID mitigation used by rural Wisconsin public health officials. The effective strategies presented in this study align with existing research (15).

The third theme revolved around how public health officials made do with the resources they had and relied on community strengths to best mitigate the impact of COVID, supported by public health officials sharing the attributes and strengths of their county’s health system or the community itself. Health officials often noted the benefits of having a close-knit community where everyone knows everyone and can communicate effectively across different community groups. Additionally, health officials shared stories on the camaraderie and resiliency of rural communities, stating how resourceful and giving community members were either through adapting to new rules, developing new skills, learning new strategies, or volunteering. Improving emergency planning and partnering with other rural health organizations for emergency response could alleviate some resource inadequacies as resources could be more effectively shared.

Participants reported how rural community members value their decision-making, personal beliefs, and autonomy. Mandates did more harm than good for several counties. Multiple health officials detailed how ineffective mask and quarantine mandates were in their communities. When trying to enforce mask mandates, especially in schools, they were met with intense community push-back as parents felt masks were not good for their children. Health officials noted that even community members without children in school were against masks. The same goes for quarantine orders. After a couple of weeks of isolation, rural community members were no longer interested in staying home. Many rural community members already have limited social activities available to them due to remote residence, and for some folks, lack of virtual socializing capabilities. Long-term quarantine was likely to anger people if heavily enforced, thus multiple health officials, not wanting to lose the community’s trust, chose not to enforce mandates.

Like quarantine and mask mandates, vaccine mandates caused numerous issues in rural communities. Research suggests vaccine acceptance can be increased and uncertainty reduced more effectively through vaccine interventions, whereas removing the choice through a mandate may negatively impact vaccine acceptance (24). One public health official noted that when the hospital in their county mandated the COVID vaccine for all workers, several nurses threatened to quit if they were forced to receive the vaccine. This was reported from a county with one of the highest mortality rates, the same county that reported having a portion of the community believing “vaccines cause autism and everything can be healed with essential oils”.

Two public health officials reported that in each of their counties, they were able to enact and enforce mask and social distancing mandates effectively. These public health officials explained how they knew they had the power to make the decision, and they knew it would benefit the community as a whole. Interestingly, both these public health officials reported that their county, while predominantly conservative, likely had a higher proportion of liberal residents compared to other rural counties. Both these counties were among the highest vaccinated counties and had among the lowest mortality rates according to JHUCRC data (25).

All interview participants noted that vaccine promotion during the pandemic faced significant challenges at multiple levels, and some degree of resistance persists today. Participants stressed the importance of ensuring vaccine access for those who seek it and described efforts such as organizing vaccination clinics, conducting at-home visits, and implementing community outreach initiatives to increase vaccine uptake. However, vaccine acceptance varied across communities, and as vaccine availability expanded, COVID vaccination rates declined, especially in the most rural counties and in areas with the highest mortality rates. Political polarization and the rapid spread of misinformation in rural areas appeared to play a substantial role in shaping vaccine attitudes (26).

Navigating misinformation and political polarization was essential for public health officials attempting to educate their community on COVID safety guidelines and promote the vaccine. Health officials involved in this study discussed how they had politically charged members and groups within their community who spread misinformation and actively opposed their recommendations. These disruptors challenged public health actions in many different ways from cyber-attacks to spreading misinformation on social media and even physically causing disruptions at vaccine clinics. Our public health officials had to combat the misinformation they encountered by deflecting the misinformation and providing accurate information in the form of education and open communication via social media, newspapers, radio, town halls, phone banks, and meetings with community members and organizations. Some health officials noted they had people monitoring their social media to provide information on posts that asked questions or posted misinformation on their department’s social media page. Similarly, phone banks were used by several health departments so that concerned residents could call in with any COVID-related questions. Multiple participants also noted developing data dashboards or positing weekly data updates on their department’s webpage and social media page so that the community could be keep up to date on COVID case counts.

Participants consistently identified politics, government distrust, and misinformation as key factors contributing to the evolving vaccine culture, a finding that aligns with existing literature on vaccine hesitancy (15,27). Research has shown that political affiliation significantly influences vaccine acceptance, with Republican voters demonstrating higher levels of hesitancy than their Democratic counterparts (28). Moreover, Republican-led states were slower to implement COVID prevention measures, which contributed to delayed responses and increased mortality rates, particularly among racial minorities (29).

Wisconsin is one of the most politically divided states in the US, with rural areas in Wisconsin leaning heavily conservative, as evidenced by recent election outcomes (30,31). Study participants spoke about how they believed conservative leaders are more likely to oppose COVID mitigation efforts and express skepticism about vaccines broadly. Some participants voiced concerns about political efforts aimed at undermining public confidence in vaccines, not only for COVID but also for other preventable diseases. This concern is underscored by legislative developments in neighboring Iowa, where conservative lawmakers have introduced a bill that would ban the administration of mRNA vaccines (32). These developments signal an uncertain future for vaccination efforts in the United States. The findings of this study underscore the urgent need for continued advocacy and research to support vaccine promotion and address growing resistance.

Perceived community member beliefs factoring into vaccine acceptance and vaccine hesitancies were explored in-depth through this study. Aligning with previous research, this study did find that rural vaccine acceptance is influenced in large part by concerns about vaccine safety, mistrust in health leaders and government, misinformation, and the decreasing severity of the COVID virus (33). However, findings from this study also found that community political ideology and political polarization of the pandemic and the vaccine to contribute significantly to vaccine acceptance and decision-making.

Tailoring COVID mitigation strategies and plans to account for rural community variance

Knowing the rural community that one engages with is essential to building trust, effective partnerships, and disseminating information. Participating public health officials had, on average, over 10 years of experience in public health in their county, and all lived within their county. The background and expertise these public health officials had aided their ability to connect with community members and form partnerships in critical times. Successful public health department campaigns accounted for the diverse characteristics of their rural community, tailoring messaging for target audiences within the community. Existing communication networks established before the pandemic proved beneficial when needing to contact groups and organizations regarding COVID updates promptly. Using the qualitative data collected through public health official interviews and thematic analysis, multiple recommendations for developing effective community-tailored COVID mitigation strategies were constructed and included in Figure 1.

Figure 1 Recommendations for tailoring COVID mitigation and vaccine promotion in rural communities. COVID, coronavirus disease.

Lessons learned

Improvements to be made

Conversations with public health officials yielded numerous areas for improvement in Wisconsin’s rural health system. Multiple health officials reported on being a part of emergency response organizations, such as the Western Wisconsin Readiness Coalition. The coalition assisted the counties with emergency planning and response. Strengthening emergency management plans and partnerships would help rural counties and their health departments better prepare for future disease outbreaks. Having coordination in planning and response strategies across Wisconsin will help all counties stay up to date on protocols, data, resource sharing, and communication with other counties. Enhancing data capabilities, both in the quality of data systems and public health employee data skills would allow public health departments to develop useful data dashboards and track disease cases within their own health department. Data could assist in determining which groups are most vulnerable to contracting, transmitting, and experiencing severe complications from COVID. Additionally, vaccination promotion and monitoring of unvaccinated populations could assist with improving vaccine rates. Vaccine acceptance and disease mitigation guidelines within communities should be improved by establishing trust with community members and extending public health reach throughout the county.

Limitations

This study operated under the assumption that public health departments were essentially the primary organization for promoting COVID vaccinations. While vaccine education is a key role of public health departments, promoting and providing vaccines is not always a primary focus. Public health departments perform many duties other the COVID response. Additionally, the promotion and provision of vaccines can be done by many other organizations, e.g., hospitals, clinics, pharmacies, and even private businesses. Public health officials perform many tasks to serve their community, other than the promotion of vaccines; thus for a better understanding of vaccine beliefs within communities, it could benefit the research to include additional participants from additional organizations. The study was not completely void of potential interviewer bias in the interpretation of qualitative responses. The primary researcher conducted, reviewed, and analyzed all interviews, which allowed for a thorough understanding of the data, but the interpretation was that of one researcher.

Future implications

This study has useful findings for public health officials, health professionals, and emergency planners, primarily those working in rural communities, as well as researchers interested in rural pandemic outcomes. The effective strategies for mitigating COVID can be used by rural public health officials across Wisconsin and in similar rural states of America in the event of future public health emergencies. Findings on pandemic challenges faced by rural public health officials can be used as evidence and advocacy for increasing government funding of rural public health initiatives, improving rural health systems, and increasing the number of health resources and entities. This research also provides evidence on the lack of support public health officials encountered from community members and leaders in some cases. Public health officials encountered an extreme lack of support from their community during the pandemic. This lack of support, accompanied by increasing burnout and even hostility from the community, has increased the need for public health security and protection, mental health support, public awareness, and political/institutional support (34). Actions should be taken to better support our public health officials as they are required to serve many roles in times of public health emergencies, making them essential to rural health systems. Findings from this study also support the use and effectiveness of rural community-tailored public health campaigns. Public health officials developed effective messaging for the different, unique communities within their county. The tailored messaging and communication practices were better received by the different communities, meanwhile broad and general messaging was less effective. The financial support public health departments received during the pandemic aided their ability to develop precise messaging and communication strategies. This research validates how COVID relief funds were used effectively and supports the need for sustainable funding of rural public health departments so that they have the resources they need to develop community-tailored public health campaigns for other public health initiatives, other than COVID.

Interview participants echoed concerns shared by local health officials nationwide as the current federal administration reduces public health funding and terminates jobs as funding from the COVID Relief Bill and the American Rescue Plan Act expires (35). Rural public health officials collectively noted that the only time they had sufficient public health funding was when they received emergency relief and COVID research-related funds. At the time this study concluded, the federal administration announced plans to reduce $11.4 billion in COVID-related funding allocated to state and local health departments, resulting in the loss of numerous employment opportunities and public health initiatives (36). These COVID relief funds contributed to the expansion of public health infrastructure, the enhancement of emergency preparedness, the improvement of wastewater treatment, and the management of infectious diseases (35,36). The diminution of these essential public health systems, which demonstrated their significance during the pandemic, is without precedent. Interviews with public health officials highlighted the need to increase mental health services in their communities post-pandemic. Participants planned to use COVID funds for mental health education and promotion. They pointed out that mental health issues in rural areas existed well before the pandemic, but the effects of social isolation have worsened the situation. Many officials expressed a desire to allocate COVID relief funds to address growing mental health concerns locally. The findings align with existing research on mental health disparities, which shows that rural communities experience higher suicide rates and are less likely to seek help for mental health conditions due to severe inequities in services and providers (37,38). The availability of COVID-related relief funds enabled public health departments to improve their capabilities and infrastructure, supporting their communities in multiple ways. The discontinuation of these funds hampers ongoing public health initiatives and may cause some departments to revert to previous operational models. The ongoing mental health crisis, especially in rural areas, remains a significant concern. Since local health departments often serve as the primary healthcare providers in many rural counties across America, they are likely to be most impacted by the end of relief funds. The results of this study advocate for the redistribution or reallocation of government relief funds to sustain and enhance public health infrastructure and services.

Vaccine hesitancy research like this study is essential for understanding low vaccine acceptance in communities and developing strategies to reduce those hesitancies. Current conditions in the US may disagree with the need for vaccine hesitancy research as there has been a push to reduce vaccines and vaccine-related research. The federal government is currently defunding research on vaccine hesitancy by slashing major funding opportunities allocated to vaccine research (39). The vaccine climate in America comes at an alarming time, shortly after the country has returned to normalcy post-pandemic. Meanwhile, a measles outbreak has grown in Texas to a magnitude unseen in decades. Even in rural Wisconsin, public health officials are already worried. Multiple public health officials noted their concerns about vaccine acceptance in the future. Some health officials even noted how members of their new county board were so opposed to vaccines that they felt the health department should not even offer vaccines, of all kinds, to anyone. The removal of vaccines from US healthcare could be monumentally jarring and incorrigible. The US experienced just how taxing a virus strain can be without a useful vaccine during the pandemic. Research like this study is essential for advancing vaccine uptake, acceptance, promotion, and dissemination. Using findings from this study, the next steps will be to investigate perceived COVID challenges faced by non-public health personnel within rural communities. Further research on how effective COVID mitigation strategies were by comparing and contrasting how COVID impacted rural communities using COVID data, such as county mortality rates, would allow for a more in-depth analysis of the strategies used by public health officials. The comparison of rural county characteristics could also identify what should not be done to mitigate the spread of disease during an outbreak. Additionally, further investigation of long-standing financial barriers to quality health services in rural communities would benefit rural communities as findings could be used to develop health advocacy documentation to improve funding for rural health systems and public health interventions.

Conclusions

When the COVID pandemic caused numerous challenges for the American health system, rural communities encountered extreme disadvantages due to limited health resources, limited treatment center accessibility, and suboptimal community vaccination rates. For many rural counties with little to no hospitals or clinics, public health became the primary resource for health information and provisions, and was the frontline response to COVID mitigation for rural communities. This study found public health identified three core themes from public health interviews: (I) rural public health officials encountered numerous challenges for COVID mitigation further complicated by long-standing inadequacies in the rural health system; (II) effective strategies for mitigating COVID engaged community members, quickly adapted to changes, and effectively navigated misinformation and political polarization of COVID; and (III) public health officials made do with the resources they had and relied on community strengths to best mitigate the impact of COVID. Rural public health officials performed their duties the best they could while having to navigate perceived challenges stemming from long-standing inadequacies in the rural health system and unperceived challenges, i.e., the rapid circulation of misinformation and political polarization of COVID. The most effective strategies for mitigating COVID focused on vaccine promotion and education on mitigation guidelines through community engagement, extending public health reach throughout the county, and relying on community strengths. Increasing rural public health funds so that public health departments can scale up, employ more staff, and provide more services to residents would improve rural health system conditions. Additionally, hospital and health treatment center accessibility, capabilities, and staffing need to increase to better serve rural residents. This study serves as a guide of lessons learned for rural public health officials in the event of future public health crises. This study also serves as evidence and advocacy for the improvement of Wisconsin’s rural health system.

Acknowledgments

The authors extend many thanks to MCW researchers and faculty for supporting this project, to anonymous reviewers for useful recommendations, and to participating interviewees from rural Wisconsin county public health departments for important comments.

Footnote

Reporting Checklist: The authors have completed the SRQR reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-21/rc

Data Sharing Statement: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-21/dss

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-21/prf

Funding: This study received research support for gift cards came from the Medical College of Wisconsin, Institute for Health and Humanity, Administrative funds (No. 3305816).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-21/coif). The authors reported they were employed by the Medical College of Wisconsin at the time this study was conducted and research support for gift cards came from the Medical College of Wisconsin, Institute for Health and Humanity, Administrative funds (funding source 3305816). J.M. was MCW Professor, mentored the first author G.B., and was Co-PI of an NCATS supplemental award for COVID epidemiology research. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This project was approved by the Medical College of Wisconsin Institutional Review Board #5. All participants adhered to informed consent upon agreeing to participate in this study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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