{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T13:09:41Z","timestamp":1788786581341,"version":"build-2803163510"},"reference-count":49,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,9,5]],"date-time":"2026-09-05T00:00:00Z","timestamp":1788566400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100012781","name":"Merck Sharp & Dohme LLC","doi-asserted-by":"publisher","award":["100878"],"award-info":[{"award-number":["100878"]}],"id":[{"id":"10.13039\/100012781","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Vaccines"],"abstract":"<jats:p>Background\/Objectives: Rural populations in the United States experienced consistently lower COVID-19 vaccination rates than urban populations during the pandemic. While barriers to vaccination have been well documented, less is known about facilitators of uptake in rural settings. This study aimed to identify facilitators of COVID-19 vaccination in rural communities from the perspectives of Washington State University (WSU) Extension personnel and to examine these factors using the Consolidated Framework for Implementation Research (CFIR) Outer Setting domain. Methods: A qualitative descriptive study was conducted using semi-structured key informant interviews with WSU Extension personnel. Twenty-one participants representing 34 of 40 Extension offices across Washington State were interviewed in Fall 2023. Interviews were transcribed, de-identified, and analyzed using deductive thematic analysis. Findings were organized into the seven CFIR Outer Setting constructs: critical incidents, local attitudes, local conditions, partnerships and connections, policies and laws, financing, and external pressures. Results: Perceived facilitators of COVID-19 vaccination were identified across all CFIR Outer Setting constructs. Trust emerged as a central theme, with participants reporting that vaccine acceptance was higher when information was delivered by trusted local sources, including Extension personnel, healthcare providers, community leaders, and informal networks. Participants described leveraging partnerships with public health agencies, schools, faith-based organizations, and community groups as enhancing outreach and information dissemination. Additional facilitators identified by participants included no-cost vaccine and personal protective equipment availability, accessible community-based vaccination sites, culturally appropriate educational materials, and coordinated communication systems. Conclusions: Rural vaccination efforts were supported by trust, strong community partnerships, and locally tailored strategies. These findings may inform future public health emergency responses in rural communities.<\/jats:p>","DOI":"10.3390\/vaccines14090776","type":"journal-article","created":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T12:12:25Z","timestamp":1788783145000},"page":"776","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Utilizing the CFIR to Evaluate Rural COVID-19 Vaccine Uptake: Extension Personnel Perspectives"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9415-2520","authenticated-orcid":false,"given":"Megan","family":"Undeberg","sequence":"first","affiliation":[{"name":"College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA 99202, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ghazal","family":"Meratnia","sequence":"additional","affiliation":[{"name":"College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA 99202, USA"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Skylar","family":"Zelenko","sequence":"additional","affiliation":[{"name":"College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA 99202, USA"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1039-1311","authenticated-orcid":false,"given":"Kimberly","family":"McKeirnan","sequence":"additional","affiliation":[{"name":"College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA 99202, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,5]]},"reference":[{"key":"ref_1","unstructured":"United States Census Bureau (2026, June 29). What Is Rural America?, Available online: https:\/\/www.census.gov\/library\/stories\/2017\/08\/rural-america.html."},{"key":"ref_2","unstructured":"United States Census Bureau (2026, June 29). Nation\u2019s Urban and Rural Populations Shift Following 2020 Census, Available online: https:\/\/www.census.gov\/newsroom\/press-releases\/2022\/urban-rural-populations.html."},{"key":"ref_3","unstructured":"Nicholson, A. (2026, June 29). Chapter 2, Rural America in Context, Population Health in Rural America in 2020: Proceedings of a Workshop, Available online: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK575082\/."},{"key":"ref_4","unstructured":"Health Resources & Services Administration (2026, June 29). Medically Underserved Areas\/Populations, Available online: https:\/\/data.hrsa.gov\/topics\/health-workforce\/shortage-areas\/map-gallery-mua."},{"key":"ref_5","unstructured":"Health Resources & Services Administration (2026, June 26). Scoring Shortage Designations, Available online: https:\/\/bhw.hrsa.gov\/workforce-shortage-areas\/shortage-designation\/scoring."},{"key":"ref_6","unstructured":"Centers for Disease Control and Prevention (2026, June 29). About Rural Health, Available online: https:\/\/www.cdc.gov\/rural-health\/php\/about\/index.html."},{"key":"ref_7","unstructured":"(2026, June 29). Medically Underserved Area: Criteria and Federal Programs. Available online: https:\/\/legalclarity.org\/medically-underserved-area-criteria-and-federal-programs\/."},{"key":"ref_8","unstructured":"Community Health Association of Mountain Plains States (2026, June 29). Understanding HPSAs and MUAs. Available online: https:\/\/champsonline.org\/resources\/rrresources\/understanding-hpsas-and-muas."},{"key":"ref_9","unstructured":"United States Department of Agriculture (2026, July 30). Rural Classifications, Available online: https:\/\/www.ers.usda.gov\/topics\/rural-economy-population\/rural-classifications."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"761","DOI":"10.1016\/j.amjmed.2025.01.008","article-title":"Bridging the Health Care Gap in Rural Populations: Challenges, Innovations, and Solutions","volume":"138","author":"Javed","year":"2025","journal-title":"Am. J. Med."},{"key":"ref_11","unstructured":"National Institute for Health Care Management (2026, June 29). Rural Health: Addressing Barriers to Care. Available online: https:\/\/nihcm.org\/publications\/rural-health-addressing-barriers-to-care."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"465","DOI":"10.1016\/j.amepre.2021.03.023","article-title":"Racial\/Ethnic and Socioeconomic Disparities in Adult Vaccination Coverage","volume":"61","author":"Kawai","year":"2021","journal-title":"Am. J. Prev. Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"335","DOI":"10.15585\/mmwr.mm7109a2","article-title":"Disparities in COVID-19 Vaccination Coverage Between Urban and Rural Counties\u2014United States, 14 December 2020\u201331 January 2022","volume":"71","author":"Saelee","year":"2022","journal-title":"Morb. Mortal. Wkly. Rep."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"916","DOI":"10.1111\/jrh.12625","article-title":"Rural-urban and within-rural differences in COVID-19 vaccination rates","volume":"38","author":"Sun","year":"2022","journal-title":"J. Rural Health"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"818","DOI":"10.15585\/mmwr.mm7022e1","article-title":"Patterns in COVID-19 Vaccination Coverage, by Social Vulnerability and Urbanicity\u2014United States, December 14, 2020-May 1, 2021","volume":"70","author":"Barry","year":"2021","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"68","DOI":"10.1016\/j.vaccine.2022.11.015","article-title":"COVID-19 vaccine coverage disparities in rural and farm children","volume":"41","author":"VanWormer","year":"2023","journal-title":"Vaccine"},{"key":"ref_17","unstructured":"Kaiser Family Foundation (2026, June 29). KFF COVID-19 Vaccine Monitor\u2014Rural America: April 2021. Available online: https:\/\/www.kff.org\/covid-19\/kff-covid-19-vaccine-monitor-rural-america\/."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"405","DOI":"10.1177\/08901171241300136","article-title":"A Survival Analysis of Rural-Urban Disparities in COVID-19 Vaccination Uptake in the United States","volume":"39","author":"Biplab","year":"2025","journal-title":"Am. J. Health Prom."},{"key":"ref_19","first-page":"100409","article-title":"Impact of healthcare capacity disparities on the COVID-19 vaccination coverage in the United States: A cross-sectional study","volume":"18","author":"Cuadros","year":"2023","journal-title":"Lancet Reg. Health Am."},{"key":"ref_20","unstructured":"Washington State Department of Health (2026, July 30). Respiratory Immunization Data, Available online: https:\/\/doh.wa.gov\/data-statistical-reports\/health-behaviors\/immunization\/respiratory-immunization-data."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"McKeirnan, K.C., Undeberg, M.R., Zelenko, S., and Meratnia, G. (2024). A Qualitative Analysis of Rural Community Vaccination Barriers During the COVID-19 Pandemic. Vaccines, 12.","DOI":"10.3390\/vaccines12121442"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"125897","DOI":"10.1016\/j.vaccine.2024.04.043","article-title":"programmatic update on COVID-19 vaccination in rural communities in the United States","volume":"42","author":"Alexandra","year":"2024","journal-title":"Vaccine"},{"key":"ref_23","unstructured":"NORC at the University of Chicago (2026, June 26). COVID-19 Vaccination Success Stories in Rural Communities. Available online: https:\/\/www.norc.org\/research\/projects\/covid-19-vaccination-success-stories-in-rural-communities.html."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"125628","DOI":"10.1016\/j.vaccine.2024.01.053","article-title":"The U.S. COVID-19 vaccination program: A look back and future directions","volume":"42","author":"Hall","year":"2024","journal-title":"Vaccine"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"50","DOI":"10.1186\/1748-5908-4-50","article-title":"Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science","volume":"4","author":"Damschroder","year":"2009","journal-title":"Implement. Sci."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1186\/s13012-022-01245-0","article-title":"The updated Consolidated Framework for Implementation Research based on user feedback","volume":"17","author":"Damschroder","year":"2022","journal-title":"Implement. Sci."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1186\/s13012-017-0628-2","article-title":"Assessing citation networks for dissemination and implementation research frameworks","volume":"12","author":"Skolarus","year":"2017","journal-title":"Implement. Sci."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1186\/s13012-025-01450-7","article-title":"The Consolidated Framework for Implementation Research (CFIR) User Guide: A five-step guide for conducting implementation research using the framework","volume":"20","author":"Reardon","year":"2025","journal-title":"Implement. Sci."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"72","DOI":"10.1186\/s13012-016-0437-z","article-title":"A systematic review of the use of the Consolidated Framework for Implementation Research","volume":"11","author":"Kirk","year":"2015","journal-title":"Implement. Sci."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Shafie, A.A., Moreira, E.D., Vidal, G., Di Pasquale, A., Green, A., Tai, R., and Yoong, J. (2024). Sustainable Dengue Prevention and Management: Integrating Dengue Vaccination Strategies with Population Perspectives. Vaccines, 12.","DOI":"10.3390\/vaccines12020184"},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Adamu, A.A., Jalo, R.I., Ndwandwe, D., and Wiysonge, C.S. (2024). Assessing the Implementation Determinants of Pilot Malaria Vaccination Programs in Ghana, Kenya, and Malawi through a Complexity Lens: A Rapid Review Using a Consolidated Framework for Implementation Research. Vaccines, 12.","DOI":"10.3390\/vaccines12020111"},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Lubeya, M.K., Chibwesha, C.J., Mwanahamuntu, M., Mukosha, M., Vwalika, B., and Kawonga, M. (2024). Determinants of the Implementation of Human Papillomavirus Vaccination in Zambia: Application of the Consolidated Framework for Implementation Research. Vaccines, 12.","DOI":"10.3390\/vaccines12050542"},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Adamu, A.A., Ndwandwe, D., Ndoutabe, M., Adamu, U.S., Jalo, R.I., Abubakar, K., Ticha, J.M., Ainan, S.A., Shibeshi, M., and Nomhwange, T. (2025). Exploring the Contextual Factors That Influence Polio Supplementary Immunisation Activities in the WHO African Region: A Rapid Review. Vaccines, 13.","DOI":"10.3390\/vaccines13080870"},{"key":"ref_34","unstructured":"Tolley, E.E., Ulin, P.R., Mack, N., Robinson, E.T., and Succop, S.M. (2016). Qualitative Methods in Public Health: A Field Guide for Applied Research, Jossey-Bass Public Health. [2nd ed.]."},{"key":"ref_35","unstructured":"UCLA Center for Health Policy Research (2026, July 07). Key Informant Interviews. Available online: https:\/\/healthpolicy.ucla.edu\/programs\/health-data\/trainings\/Documents\/tw_cba23.pdf."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1093\/intqhc\/mzm042","article-title":"Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups","volume":"19","author":"Tong","year":"2007","journal-title":"Int. J. Qual. Health Care"},{"key":"ref_37","unstructured":"National Archives (2026, May 30). Morrill Act, Available online: https:\/\/www.archives.gov\/milestone-documents\/morrill-act."},{"key":"ref_38","unstructured":"U.S. Department of Agriculture (2026, May 30). History, Available online: https:\/\/www.nifa.usda.gov\/about-nifa\/who-we-are\/history."},{"key":"ref_39","unstructured":"Western Extension Director Association (WEDA) (2026, May 30). History of Extension. Available online: https:\/\/weda.extension.org\/professional-development\/extension-employee-onboarding-modules\/history-of-extension\/."},{"key":"ref_40","unstructured":"National Institute of Food and Agriculture (2026, May 30). Cooperative Extension System, Available online: https:\/\/www.nifa.usda.gov\/about-nifa\/what-we-do\/extension."},{"key":"ref_41","unstructured":"Washington State University (2026, May 30). WSU Extension. Available online: www.extension.wsu.edu."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1758","DOI":"10.1111\/j.1475-6773.2006.00684.x","article-title":"Qualitative data analysis for health services research: Developing taxonomy, themes, and theory","volume":"42","author":"Bradley","year":"2007","journal-title":"Health Serv. Res."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1893","DOI":"10.1007\/s11135-017-0574-8","article-title":"Saturation in qualitative research: Exploring its conceptualization and operationalization","volume":"52","author":"Saunders","year":"2018","journal-title":"Qual. Quant."},{"key":"ref_44","unstructured":"(2026, July 30). City-Data.com. Ferry County, Washington. Available online: https:\/\/www.city-data.com\/county\/Ferry_County-WA.html."},{"key":"ref_45","unstructured":"(2026, July 30). City-Data.com. King County, Washington. Available online: https:\/\/www.city-data.com\/county\/King_County-WA.html."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Washburn, L., Norman-Burgdolf, H., Jones, N., Kennedy, L.E., and Jarvandi, S. (2022). Exploring Extension Agent Capacity and Readiness to Adopt Policy, Systems and Environmental Change Approaches. Front. Public Health, 10.","DOI":"10.3389\/fpubh.2022.856788"},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Vincenzo, J.L., Spear, M.J., Moore, R., Purvis, R.S., Patton, S.K., Callaghan-Koru, J., McElfish, P.A., and Curran, G.M. (2023). Reaching late adopters: Factors influencing COVID-19 vaccination of Marshallese and Hispanic adults. BMC Public Health, 23.","DOI":"10.1186\/s12889-023-15468-3"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"104241","DOI":"10.1016\/j.ijnurstu.2022.104241","article-title":"Addressing vaccine hesitancy and resistance for COVID-19 vaccines","volume":"131","author":"Peters","year":"2022","journal-title":"Int. J. Nurs. Stud."},{"key":"ref_49","doi-asserted-by":"crossref","unstructured":"Poole, H., Lona, A., Barroga, T.R.M., Ghrist, M., and Mulcahy, E.R. (2024). Understanding the Role of Extension Professionals in Public Health and One Health in Kansas. Int. J. Environ. Res. Public Health, 21.","DOI":"10.3390\/ijerph21060747"}],"container-title":["Vaccines"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-393X\/14\/9\/776\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T12:34:54Z","timestamp":1788784494000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-393X\/14\/9\/776"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,5]]},"references-count":49,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["vaccines14090776"],"URL":"https:\/\/doi.org\/10.3390\/vaccines14090776","relation":{},"ISSN":["2076-393X"],"issn-type":[{"value":"2076-393X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,5]]}}}