Vaccine Uptake and Hesitancy in Rural America in the Wake of the COVID-19 Pandemic

Since the onset of the COVID-19 pandemic, persistent disparities in the burden of disease have been seen between rural and urban areas of the United States. Despite lacking the population density in which we would expect COVID-19 to propagate most easily, rural areas have consistently had a higher incidence of COVID-19 relative to population size than urban areas.^1–3 With rural Americans more likely than their urban counterparts to be older and sicker and to hold more chronic conditions associated with poor COVID-19 outcomes, this high case incidence has had devastating consequences for many rural communities throughout the United States.⁴ Rural mortality rates for COVID-19 have consistently surpassed urban mortality rates since the fall of 2020, with little reason to expect a reversal in that trend.^5,6

While the older age and comorbidity status of rural communities do place them at higher risk for negative COVID-19 outcomes, scholars have pointed to two additional factors to explain the higher burden of COVID-19 in rural communities: limitations in health care access and lower levels of adoption of preventive health behaviors. In the area of access, almost 66% of health professional shortage areas nationwide are located in rural areas, and more than 140 rural hospitals have closed since 2010 (https://unc.live/3zaXFJC; https://bit.ly/40GzRsR). When paired with the higher travel burden that rural Americans face in accessing care, rural Americans are placed at a considerable disadvantage for positive outcomes when they become sick with COVID-19.⁷

Simultaneously, other research has pointed to differences in the adoption of preventive health behaviors across rural and urban communities in explaining differences in COVID-19 outcomes. For example, my past work suggests that rural Americans have been less likely to wear face masks than urban Americans,⁸ and other research points to rural Americans also being less likely to vaccinate.⁹ Combined, these behavioral differences place rural Americans at a higher risk for contracting COVID-19 and facing its severe consequences.

Despite the importance of this existing work on COVID-19 in rural America, critical questions remain. Most notably, more work is needed in the area of vaccination to understand the extent to which lower vaccine uptake in rural communities is the result of higher levels of hesitancy in rural communities or the result of the many challenges that rural Americans face in accessing primary and preventive care including vaccination.

RURAL VACCINE UPTAKE, HESITANCY, AND ACCESS

In this issue of AJPH, Soorapanth et al. (p. 680) begin to answer this question with one of the most comprehensive studies to date on rural versus urban vaccine uptake and hesitancy. Relying on survey data from the COVID-19 Trends and Impact Survey (CTIS) collected over Facebook from May 2021 to April 2022 and rurality information derived from zip codes and Rural‒Urban Commuting Area codes, Soorapanth et al. explored the nuanced relationship between vaccination rates, vaccination hesitancy, and vaccination refusal in rural and urban communities.

In line with past research, Soorapanth et al. found that, across most states, rural areas had lower levels of COVID-19 vaccination during their period of analysis. Simultaneously, however, they found that hesitancy—which they defined as the proportion of the public who are unvaccinated but who state they probably will or will not get vaccinated—was only different between rural and urban areas in 12% of states examined. Similarly, the vaccine refusal rate—which the researchers defined as individuals who are unvaccinated and state that they definitely will not vaccinate—was only different between rural and urban areas in 21% of states examined.

The study by Soorapanth et al. adds important nuance to the literature on vaccination in rural areas that was previously missing. While vaccination rates are consistently lower in rural areas, the difference in uptake appears to be infrequently attributable to differences in future intention to vaccinate among the unvaccinated. The major strength of the study by Soorapanth et al. is the scope of the sample they relied on. The CTIS surveyed upward of 40 000 respondents per day, over the course of the year, providing a massive sample of respondents in both rural and urban communities to study. The research also presents an intriguing idea in its discussion, suggesting that instead of hesitancy explaining the discrepancy between vaccine uptake and intentions between rural and urban communities, access issues could instead explain this difference.

With that said, there are several limitations of the study by Soorapanth et al. that should be acknowledged as well. Critically, while the authors suspected that access could explain the discrepancy between uptake and hesitancy, they provided no evidence that access explained the difference observed. It certainly could be the case that limited access to vaccines in rural communities has led to lower levels of uptake, but more research would be needed to support that conclusion. Three years into the COVID-19 pandemic, I find access to be a less convincing argument. While pockets of vulnerable individuals in rural America may not yet have had access to vaccination, the majority of rural Americans have had the chance to vaccinate. Exploring the potential role of access in explaining the discrepancy between uptake and hesitancy is a vital next step for the literature.

Equally important, the study did not include several covariates that could alternatively help to explain both vaccine uptake and hesitancy. The lack of a measure of partisanship is particularly glaring. The COVID-19 pandemic has seen lower levels of vaccine uptake and higher hesitancy among conservatives, driven in part by the concerted effort of antivax advocacy groups, influencers, and key Republican politicians.¹⁰ With rural areas across the country tending to be conservative, the article by Soorapanth et al. could be missing a key determinant of vaccine uptake or hesitancy. Similarly, future rural vaccination research would benefit from the inclusion of measures of rural identity.¹¹ The extent to which rural Americans feel a sense of closeness with rural life and other rural Americans could shape willingness to adopt prosocial health behaviors like vaccination and also help to explain the researchers’ finding that rural Americans were more likely to trust health information from friends and family.

THE FUTURE OF RURAL VACCINE HESITANCY RESEARCH

Ultimately, Soorapanth’s article presents a useful jumping-off point for additional research on vaccine uptake and hesitancy in rural America in the wake of the COVID-19 pandemic. Additional research is clearly needed to untangle the discrepancy between lower uptake in rural America but not higher levels of hesitancy. Investigations of access should feature prominently into these studies, but so should investigations of political beliefs and rural identity. Just as important, additional research using other (non-CTIS) platforms provides the opportunity to innovate in survey design. Efforts should be made to capture vaccine hesitancy as the spectrum that it is instead of using a single survey item. Relatedly, capturing the full diversity and gradations of rurality instead of relying on single rural-versus-urban items would be a useful advance. Finally, moving beyond cross-sectional research to focus on changing uptake and hesitancy within individuals over time would be valuable.

Regardless of whether it is driven by access challenges, political circumstances, hesitancy, or any other factor, additional interventions are clearly needed to address the lower levels of vaccine uptake in rural communities. Without targeted efforts, rural‒urban disparities in health outcomes will continue to be exacerbated by COVID-19, placing unnecessary additional burden on an already strained rural health care system.