key: cord-0998857-ahz6w4hr
authors: Sun, Yue; Monnat, Shannon M.
title: Rural‐urban and within‐rural differences in COVID‐19 vaccination rates
date: 2021-09-23
journal: J Rural Health
DOI: 10.1111/jrh.12625
sha: 4d628e1d38f45db0e6aa98106d3b42b16ede04e0
doc_id: 998857
cord_uid: ahz6w4hr

PURPOSE: COVID‐19 mortality rates are higher in rural versus urban areas in the United States, threatening to exacerbate the existing rural mortality penalty. To save lives and facilitate economic recovery, we must achieve widespread vaccination coverage. This study compared adult COVID‐19 vaccination rates across the US rural‐urban continuum and across different types of rural counties. METHODS: We retrieved vaccination rates as of August 11, 2021, for adults aged 18+ for the 2,869 counties for which data were available from the CDC. We merged these with county‐level data on demographic and socioeconomic composition, health care infrastructure, 2020 Trump vote share, and USDA labor market type. We then used regression models to examine predictors of COVID‐19 vaccination rates across the USDA's 9‐category rural‐urban continuum codes and separately within rural counties by labor market type. FINDINGS: As of August 11, 45.8% of adults in rural counties had been fully vaccinated, compared to 59.8% in urban counties. In unadjusted regression models, average rates declined monotonically with increasing rurality. Lower rural rates are explained by a combination of lower educational attainment and higher Trump vote share. Within rural counties, rates are lowest in farming and mining‐dependent counties and highest in recreation‐dependent counties, with differences explained by a combination of educational attainment, health care infrastructure, and Trump vote share. CONCLUSION: Lower vaccination rates in rural areas is concerning given higher rural COVID‐19 mortality rates and recent surges in cases. At this point, mandates may be the most effective strategy for increasing vaccination rates.

or describe differences between different types of rural areas. In this brief report, we expand on the existing evidence base by using county vaccination rates from the CDC to describe rural-urban continuum and within-rural differences in rates and identify the major contributors to this variation.

There are several potential explanations for lower vaccination rates in rural areas. Lower vaccination rates are not a new phenomenon for rural areas. Coverage rates are lower in some rural subpopulations for flu, pneumococcal, and human papillomavirus. [7] [8] [9] [10] [11] [12] In terms of COVID-19, more limited vaccine information and availability may have mattered early on, but vaccines are now widely available across most of the United States. However, availability does not equate to access. Counties comprising more vulnerable populations, including larger shares of racial/ethnic minorities and higher rates of poverty and uninsured populations, have been found to have lower vaccination rates. 13 Rural residents are on average poorer, have lower rates of insurance coverage, have less robust health care infrastructure, and must travel further distances to venues where vaccines are administered. 14, 15 Accordingly, while availability is unlikely to be the main explanation for differences in vaccination rates, access factors may play some role.

Vaccine resistance and hesitancy have been identified as the primary contributors to lower rural vaccination rates. 16 The KFF's vaccine monitor shows that 21% of rural adults reported that they would definitely not get vaccinated compared to 14% of suburban and 12% of urban residents. 6 Vaccine resistance and hesitancy are complex and driven by multiple factors. Lower levels of educational attainment 17 and more conservative political ideologies in rural areas may play important roles. Those with a college degree have a higher selfreported vaccination rate than those without, and Democrats have a higher self-reported rate than Republicans. 6 Rural counties had much higher vote shares for Trump in the 2020 Presidential election, and county Trump vote share is associated with lower vaccination rates. 18 Differences in perceptions of risk and virus severity and differences in attitudes about personal choice versus collective responsibility may also be related. Consistent with this explanation, rural residents have been less likely to adopt COVID-19 prevention behaviors, such as physical distancing, avoiding dining out, and wearing face masks. [19] [20] [21] Smaller shares of rural residents report being worried about getting sick, and larger shares say that the severity is exaggerated, getting vaccinated is a personal choice, and believe in at least one myth about the vaccine. 16 However, rural areas are not homogenous. Just as COVID-19 mortality rates and health behaviors and outcomes in general vary across different types of rural communities, 1,2,22,23 vaccination rates are likely to vary within rural America. Accordingly, the factors described above may also contribute to within-rural differences in vaccination rates. In addition, labor markets may play an important role. Rural counties vary drastically in their labor market contexts. Rural counties dominated by mining and farming have historically been more politically and religiously conservative, [24] [25] [26] potentially driving lower vaccination rates in these types of communities. Conversely, residents of recreation-dependent rural coun-ties tend to be more politically liberal, 24 due in large part to recent "creative class" urban migration to these areas. 27 Recreation counties also attract older and wealthier retirees, 24 which may portend higher vaccination rates in these counties. Although these potential explanations are not exhaustive, they are a starting point for thinking about why vaccination rates may vary across different types of rural areas.

We retrieved county-level COVID-19 vaccination rates as of August 11, 2021, for adults ages 18+ from the CDC. 5 Table A1 shows mean values for all predictors for the United States overall and by RUCC. There were no concerns with multicollinearity.

We then subset our analysis to rural counties (N = 1,789) to examine within-rural variation in vaccination rates. In addition to the predictors above, we added the USDA ERS economic dependence typology to examine differences across different types of rural labor markets:

farming, mining, manufacturing, government, recreation, and nonspecialized (reference group). 32 The first set of regression results show coefficients for each predictor unadjusted for the other predictors. We then present fully adjusted models predicting vaccination rates within rural counties. All models control for state fixed effects to account for the clustering of counties within states and unobserved state-level 

As of August 11, 2021, 45.8% of adults in rural counties had been fully vaccinated compared to 59.8% in urban counties. Figure 1 Rates are also significantly lower in counties in the highest quartile of

Note: N=2,869 US counties. Rates are unadjusted. Vaccination rates are current as of August 11, 2021. Panel A represents the percentage of adults ages 18+ who are vaccinated within that RUCC category. Panel B represents the mean vaccination rate for each RUCC category. Error bars represent 95% confidence intervals. RUCCs: (1) large urban: counties in metro areas of 1 million population or more; (2) medium urban: counties in metro areas of 250,000-1 million population; (3) small urban: counties in metro areas of fewer than 250,000 population; (4) large rural adjacent to metro: nonmetro county with an urban population of 20,000 or more, adjacent to a metro area; (5) large rural remote: nonmetro county with an urban population of 20,000 or more, not adjacent to a metro area; (6) medium rural adjacent to metro: nonmetro county with an urban population of 2,500-19,999, adjacent to a metro area; (7) medium rural remote: nonmetro county with an urban population of 2,500-19,999, not adjacent to a metro area; (8) small rural adjacent to metro: nonmetro county with an urban population of less than 2,500, adjacent to a metro area; and (9) small rural remote: nonmetro county with an urban population of less than 2,500, not adjacent to a metro area percent Black (β = -4.18, P < .001) and significantly higher in counties with higher median household income and more physicians per capita.

Collectively, the variables in the full model explain 69% of the variation in vaccination rates across US counties.

Vaccination rates also vary across different types of rural counties. Vaccination rates by economic dependence are shown in online Appendix Figure A2 . Unadjusted regression coefficients for each predictor are presented in the first column of Rates are significantly higher in rural counties with larger shares of Hispanics, residents age 65+, higher median household income, and more physicians per capita.

Stepwise models (shown in online Appendix Table A3) 

Using county-level data from the CDC, we found that COVID-19

vaccination rates are significantly lower in rural than in urban counties as of August 11, 2021. These findings conform with those based on self-reported survey data. 6 However, we expand on the existing evidence base by comparing rates along the 9-category rural-urban continuum and across different types of rural counties. We found that vaccination rates decline monotonically with of a recent KFF sample indicated that their current vaccination intention is "wait and see," combatting misinformation will not be enough. 6 Vaccine mandates will likely be the most effective strategy for increasing coverage rates to a sufficient level to reduce coronavirus spread.

Findings should be considered in light of some limitations. Analyses are ecological, and findings cannot be applied at the individual level.

We were unable to examine geographic variation in race-specific vaccination rates given that data are not available at the county level.

Rural vaccination rates may be lower among racial/ethnic minorities than among Whites, although some American Indian communities have achieved high vaccination rates, 35 and we show higher vaccination rates in counties with the largest shares of Hispanics.

COVID-19 will have profound long-term implications for US population health. Higher rural COVID-19 mortality rates 1 threaten to exacerbate the already large and growing rural mortality penalty. 2, 3 Widespread vaccination has the potential to reduce vulnerability to variants that could lead to new surges and a new wave of COVID-19

deaths. Federal, state, and local governments must reduce misinformation and resistance across the U.S. In rural areas, working more closely with PCPs and faith leaders, who enjoy high levels of trust with rural residents, may be an especially promising strategy, but we may be at the point where vaccine mandates will be the most effective strategy for increasing rates enough to meaningfully reduce spread and save lives.

Rural-urban and within-rural differences in COVID-19 mortality trends

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The authors acknowledge support from 2 research networks funded by the National Institute on Aging (R24 AG065159 and 2R24 AG045061),