Though urban-rural disparities in COVID-19 vaccination coverage was documented at a point of time, little is known on the evolution of vaccination uptake over time. This study, using individual level time-to-event data, intend to assess the differences in monthly progression of vaccination uptake among U.S. adults by urban/rural residence.
Design
Survival analysis.
Setting
Urban and rural areas in 29 U.S. states.
Subjects
135,969 adults aged 18+ years.
Measures
Time (in months) to receive the first dose of COVID-19 vaccine since the U.S. Food and Drug Administration (FDA) Emergency Use Authorization of Pfizer-BioNTech- and Moderna- COVID-19 Vaccine in December 2020.
Analysis
Kaplan-Meier survivor functions and stratified Cox proportional hazard models were estimated for the event of being vaccinated by urban/rural residence for 25 months starting from December 2020. Monthly survival probabilities for urban- and rural- adults were further assessed within certain demographic and socioeconomic groups.
Results
We found a gradual divergence of COVID-19 vaccination uptake in favor of urban adults, which was robust across sex, age groups, race and ethnicity, education, and income levels. In April 2021, after vaccine eligibility was expanded, 42.2% adults in urban and 53.3% adults in rural areas were unvaccinated. While only 19.3% urban adults remained unvaccinated in December 2022, this rate was 32.5% among rural adults. Compared to their urban counterparts, rural adults were 0.77 (95% CI: 0.76 - 0.79) times as likely to receive the first dose of COVID-19 vaccine.
Conclusions
Time-to-event analysis of vaccination against COVID-19 indicated a lower uptake among rural adults, which was persistent across different demographic and socioeconomic groups.
AnzaloneAJHorswellRHendricksBM, et al.Higher hospitalization and mortality rates among SARS-CoV-2-infected persons in rural America. J Rural Health. 2023;39(1):39-54. doi:10.1111/jrh.12689
2.
GromeHNRamanRKatzBD, et al.Disparities in COVID-19 mortality rates: implications for rural health policy and preparedness. J Public Health Manag Pract. 2022;28(5):478-485. doi:10.1097/PHH.0000000000001507
3.
BarryVDasguptaSWellerDL, et al.Patterns in COVID-19 vaccination coverage, by social vulnerability and urbanicity - United States, December 14, 2020-May 1, 2021. MMWR Morb Mortal Wkly Rep. 2021;70(22):818-824. doi:10.15585/mmwr.mm7022e1
4.
MurthyBPSterrettNWellerD, et al.Disparities in COVID-19 vaccination coverage between urban and rural counties - United States, December 14, 2020-April 10, 2021. MMWR Morb Mortal Wkly Rep. 2021;70(20):759-764. doi:10.15585/mmwr.mm7020e3
5.
QiaoSLiZZhangJSunXGarrettCLiX. Social capital, urbanization level, and COVID-19 vaccination uptake in the United States: a national level analysis. Vaccines (Basel). 2022;10(4):625. doi:10.3390/vaccines10040625
6.
HuangQCutterSL. Spatial-temporal differences of COVID-19 vaccinations in the U.S. Urban Inf. 2022;1(1):19. doi:10.1007/s44212-022-00019-9
7.
SunYMonnatSM. Rural-urban and within-rural differences in COVID-19 vaccination rates. J Rural Health. 2022;38(4):916-922. doi:10.1111/jrh.12625
8.
SaeleeRZellEMurthyBP, et al.Disparities in COVID-19 vaccination coverage between urban and rural counties - United States, December 14, 2020-January 31, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(9):335-340. doi:10.15585/mmwr.mm7109a2
9.
BennettKJPumkamCProbstJC. Rural-urban differences in the location of influenza vaccine administration. Vaccine. 2011;29(35):5970-5977. doi:10.1016/j.vaccine.2011.06.038
10.
JainBPaguioJAYaoJS, et al.Rural-urban differences in influenza vaccination among adults in the United States, 2018-2019. Am J Public Health. 2022;112(2):304-307. doi:10.2105/AJPH.2021.306575
11.
VlahovDBondKTJonesKCOmpadDC. Factors associated with differential uptake of seasonal influenza immunizations among underserved communities during the 2009-2010 influenza season. J Community Health. 2012;37(2):282-287. doi:10.1007/s10900-011-9443-x
12.
GarzaNLeibenspergerMBonnevieE. The association between receiving the flu and COVID-19 vaccines and related factors, data from the StopFlu campaign in eight states and the District of Columbia, 2022. J Community Health. 2023;48(4):731-739. doi:10.1007/s10900-023-01213-9
13.
DavisTCVanchiereJASewellMRDavisABWolfMSArnoldCL. Influenza and COVID-19 vaccine concerns and uptake among patients cared for in a safety-net health system. J Prim Care Community Health. 2022;13:21501319221136361. doi:10.1177/21501319221136361
HestR. Four methods for calculating income as a percent of the federal poverty guideline (FPG) in the behavioral risk factor surveillance system (BRFSS). State Health Access Data Assistance Center. 2019. https://collections.nlm.nih.gov/catalog/nlm:nlmuid-101753745-pdf. Accessed October 3, 2023.
MollaloATatarM. Spatial modeling of COVID-19 vaccine hesitancy in the United States. Int J Environ Res Public Health. 2021;18(18):9488. doi:10.3390/ijerph18189488
18.
ChandakANayarPLinG. Rural‐urban disparities in access to breast cancer screening: a spatial clustering analysis. J Rural Health. 2019;35(2):229-235. doi:10.1111/jrh.12308
19.
LoftusJAllenEMCallKTEverson-RoseSA. Rural-urban differences in access to preventive health care among publicly insured minnesotans. J Rural Health. 2018;34(Suppl 1):s48-s55. doi:10.1111/jrh.12235
20.
HarrisJKBeattyKLeiderJPKnudsonAAndersonBLMeitM. The double disparity facing rural local health departments. Annu Rev Public Health. 2016;37(1):167-184. doi:10.1146/annurev-publhealth-031914-122755
21.
GuoJDicksonSBerenbrokL, et al.Racial disparities in access to potential COVID ‐19 vaccine administration facilities across US states: a geographic information systems analysis. Health Serv Res. 2021;56(S2):87-88. doi:10.1111/1475-6773.13852
22.
NguyenKHYankeyDLuPJ, et al.Report of health care provider recommendation for COVID-19 vaccination among adults, by recipient COVID-19 vaccination status and attitudes — United States, April-September 2021. MMWR Morb Mortal Wkly Rep. 2021;70(50):1723-1730. doi:10.15585/mmwr.mm7050a1
23.
ZhangDSonHShenY, et al.Assessment of changes in rural and urban primary care workforce in the United States from 2009 to 2017. JAMA Netw Open. 2020;3(10):e2022914. doi:10.1001/jamanetworkopen.2020.22914
24.
United States Department of Agriculture. The COVID-19 pandemic and rural America. Published online January 18, 2023. https://www.ers.usda.gov/covid-19/rural-america/. Accessed January 16, 2024.
25.
LakhaniHVPillaiSSZehraMSharmaISodhiK. Systematic review of clinical insights into novel coronavirus (CoVID-19) pandemic: persisting challenges in U.S. Rural population. Int J Environ Res Public Health. 2020;17(12):4279. doi:10.3390/ijerph17124279
SunYChengKJMonnatSM. Rural-urban and within-rural differences in COVID-19 mortality rates. J of Rural Soc Sciences. 2022;37(2):3.
28.
HardcastleVGZhangXHoT. COVID-19 vaccine hesitancy and the rural-urban divide: a preliminary analysis. Academia Letters. 2021. doi:10.20935/AL330. Published online April 5.
29.
RobinsonRNguyenEWrightM, et al.Factors contributing to vaccine hesitancy and reduced vaccine confidence in rural underserved populations. Humanit Soc Sci Commun. 2022;9(1):416. doi:10.1057/s41599-022-01439-3
30.
KoskanAMLoCocoIEDanielCLTeeterBS. Rural Americans’ COVID-19 vaccine perceptions and willingness to vaccinate against COVID-19 with their community pharmacists: an exploratory study. Vaccines. 2023;11(1):171. doi:10.3390/vaccines11010171
31.
LatkinCADaytonLYiGKonstantopoulosABoodramB. Trust in a COVID-19 vaccine in the U.S.: a social-ecological perspective. Soc Sci Med. 2021;270:113684. doi:10.1016/j.socscimed.2021.113684
32.
SoorapanthSCheungRZhangXMokdadAHMensahGA. Rural-urban differences in vaccination and hesitancy rates and trust: US COVID-19 trends and impact survey on a social media platform, May 2021-April 2022. Am J Public Health. 2023;113(6):680-688. doi:10.2105/AJPH.2023.307274
33.
ReillyM. Health disparities and access to healthcare in rural vs. Urban areas. TIA. 2021;14(2):6-27. doi:10.3798/tia.1937-0237.2109
YuHKlompasMKofnerAHorvitz-LennonMZhangFMcKernanS. COVID-19 vaccination: concerning trends in primary care health professional shortage areas. Am J Prev Med. 2022;63(1):e31-e33. doi:10.1016/j.amepre.2021.12.024
36.
KhubchandaniJSharmaSPriceJHWiblishauserMJSharmaMWebbFJ. COVID-19 vaccination hesitancy in the United States: a rapid national assessment. J Community Health. 2021;46(2):270-277. doi:10.1007/s10900-020-00958-x
37.
GatwoodJMcKnightMFiscusMHohmeierKCChisholm-BurnsM. Factors influencing likelihood of COVID-19 vaccination: a survey of Tennessee adults. Am J Health Syst Pharm. 2021;78(10):879-889. doi:10.1093/ajhp/zxab099
38.
ThierKWangYAdebamowoCNtiriSOQuinnSCNanX. Understanding the psychological antecedents of COVID-19 vaccine acceptance among Black Americans: implications for vaccine communication. J Commun Healthc. 2023;16(1):62-74. doi:10.1080/17538068.2022.2117528
39.
LennonRPSmallMLSmithRA, et al.Unique predictors of intended uptake of a COVID-19 vaccine in adults living in a rural college town in the United States. Am J Health Promot. 2022;36(1):180-184. doi:10.1177/08901171211026132
40.
YangSTaoRBhattarM, et al.Designing and testing social media campaign messages to promote COVID-19 vaccine confidence among rural adults: a community-engaged approach featuring rural community leader and clinician testimonials. Prev Med Rep. 2023;36:102508. doi:10.1016/j.pmedr.2023.102508
41.
PetersMDJ. Addressing vaccine hesitancy and resistance for COVID-19 vaccines. Int J Nurs Stud. 2022;131:104241. doi:10.1016/j.ijnurstu.2022.104241
42.
StrullyKWHarrisonTMPardoTACarleo-EvangelistJ. Strategies to address COVID-19 vaccine hesitancy and mitigate health disparities in minority populations. Front Public Health. 2021;9:645268. doi:10.3389/fpubh.2021.645268
43.
CallaghanT. Vaccine uptake and hesitancy in rural America in the wake of the COVID-19 pandemic. Am J Public Health. 2023;113(6):615-617. doi:10.2105/AJPH.2023.307305
44.
AfifiRAParkerEADinoGHallDMUlinB. Reimagining rural: shifting paradigms about health and well-being in the rural United States. Annu Rev Public Health. 2022;43:135-154. doi:10.1146/annurev-publhealth-052020-123413
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