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

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.