Rural-urban and within-rural differences in COVID-19 vaccination rates

Abstract

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.

Keywords: COVID-19; rural-urban continuum; vaccination; vaccine.

FIGURE 1

COVID‐19 vaccination rates by rural‐urban continuum code (RUCC) (Panel A) and average county‐level vaccination rates by RUCC (Panel B) for adults ages 18+ 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