Trajectories and patterns of US counties' policy responses to the COVID-19 pandemic: A sequence analysis approach.

Background: It is increasingly recognized that policies played a role in mitigating or exacerbating health inequities during the COVID-19 pandemic. While US counties were particularly active in policymaking, limited work has characterized geographic and temporal variation in pandemic-era policymaking at the local level, a prerequisite for later studies examining the health effects of these policies. This paper fills this gap by characterizing county-level COVID-19-related policy trajectories over time using a novel national policy database and innovative methods. Methods: Data came from the US COVID-19 County Policy (UCCP) Database, including 309 counties in 50 states plus Washington DC during January 2020 to December 2021. We examined measures of overall policy comprehensiveness, as well as three domains including containment and closure, economic response, and public health. We applied sequence analysis to characterize county-level trajectories overall and within each policy domain, and cluster analysis to group similar trajectories. Results: There was wide variation in policymaking, with nearly half of counties demonstrating consistently comprehensive policymaking, about 15-20% with consistently low comprehensiveness, and the remainder exhibiting intermittent comprehensiveness. Economic policies were less comprehensive than containment/closure and public health policies. There was also substantial variation within and across states, and associations with county characteristics. Conclusion: This study is among the first to document substantial geographic and temporal variation in a variety of US county-level COVID-19-related policies, which likely contributed to health disparities during and after the pandemic. Future work should evaluate how these different policy trajectories differentially affected health and social outcomes.