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Healthcare Essentials

May 6, 2022

Vaccine Hesitancy and the Growing Divide

By Cara N. Ludwig, Kyla Wonder

New data published by the Centers for Disease Control and Prevention (“CDC”) indicates that the divide between rural and urban areas in COVID-19 primary vaccination coverage has more than doubled in under a year. In April 2021, urban areas had 46% primary vaccination coverage among people aged 5 years and older who received a dose of a COVID-19 vaccine during the time period from December 14, 2020 through January 31, 2022, while rural areas hovered around 39%.[1] By January 2022, primary vaccination coverage in urban areas and rural areas increased to approximately 75% and 59%, respectively.[2] In other words, the urban/rural COVID-19 vaccination gap more than doubled in less than a year.

Adults in rural areas were nearly three times as likely as their urban counterparts to report that they “definitely won’t” receive a COVID-19 vaccine, and rural parents were approximately twice as likely to report that their child will “definitely not” receive one.[3] The CDC discussed several possible barriers to COVID-19 vaccination[4] in rural areas that may be driving the gap further apart, including historically low levels of vaccine confidence in rural areas for other routinely recommended vaccines.[5]

For instance, vaccine confidence appears to be linked with trust in the vaccine,[6] and vaccine trust is associated with vaccine uptake.[7] Vaccine trust may have multiple dimensions,[8] including trust in the healthcare system and individual healthcare providers.[9] A survey of factors influencing an individual’s willingness to receive a vaccination found that a recommendation from the individual’s healthcare provider mattered to more participants (73%) in making a vaccination decision than the participants’ age (60%) or the opinions of a participant’s family and friends (38%).[10] The CDC’s new data seem to confirm this, with nearly 76% of parents in rural areas stating their children’s healthcare provider was their trusted source for vaccination information.[11] Interestingly, nearly 40% of rural parents also reported that their child’s pediatrician did not recommend a COVID-19 vaccine, compared to 8% of urban parents.[12] If rural areas historically have low levels of confidence in vaccines and their trusted source of vaccination information is not actively recommending vaccination or building trust in the vaccine, rural areas could continue falling behind in vaccination.

The CDC has launched several programs that can assist with building trust and vaccine confidence in rural areas and other disproportionately affected populations. Two of these programs are Partnering for Vaccine Equity and Vaccinate with Confidence. Partnering for Vaccine Equity offers federal funding to state, tribal, territorial,and local immunization programs and health departments to support adult vaccination.[13] It recommends that medical offices in socially vulnerable communities receive larger percentages of vaccine doses to increase vaccine access in communities facing transportation challenges and low socioeconomic status, noting that primary care providers are an important influence on an individual’s vaccination decisions.[14]

Vaccinate with Confidence, another ongoing joint effort by the CDC, local and state health departments, and other local partners, is designed to enhance trust and confidence in COVID-19 vaccines in areas with low vaccination rates.[15] Vaccinate with Confidence focuses on building trust[16] by working with local community leaders as well as educating and supporting local healthcare providers.[17] Both programs are intended to reduce disparity in COVID-19 vaccination coverage by facilitating access to vaccines as well as supporting rural healthcare providers in encouraging vaccination, both generally and for COVID-19 specifically. Such programs are another step towards closing the vaccination gap between urban and rural populations as well as a potential resource for rural healthcare providers.

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[1] See Ryan Saelee, PhD, Elizabeth Zell, MStat, et al., Disparities in COVID-19 Vaccination Coverage Between Urban and Rural Counties — United States, December 14, 2020–January 31, 2022, 71 Morbidity and Mortality Weekly Report 335 (March 4, 2022), https://www.cdc.gov/mmwr/volumes/71/wr/mm7109a2.htm.

[2] These disparities in vaccination coverage rates vary by state; for example, the vaccination coverage rate for North Carolinians in urban and rural areas was 91.3% and 68.7% respectively. See Id.

[3] See Id.

[4] See Id.

[5] See Id. See also Holly A. Hill, MD, PhD, Laurie D. Elam-Evans, PhD et al., Vaccination Coverage Among Children Aged 19–35 Months — United States, 2017, 67 Morbidity and Mortality Weekly Report 1123, (October 12, 2018), https://www.cdc.gov/mmwr/volumes/67/wr/mm6740a4.htm.

[6] National Vaccine Advisory Committee, Assessing the State of Vaccine Confidence in the United States: Recommendations from the National Vaccine Advisory Committee, 130 Pub. Health Reports 573 (2015) as cited in Carl A. Latkin, Lauren Dayton et al., Trust in a COVID-19 vaccine in the U.S.: A socio-ecological perspective, 270 Social Science and Medicine 113684, Section 1 (2021), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7834519/ (defining vaccine confidence as “the trust that parents or health-care providers have (1) in the recommended immunizations, (2) in the provider(s) who administers vaccines, and (3) in the process that leads to vaccine licensure and the recommended vaccination schedule”).

[7] See Latkin, supra note 5 (citing Sandra Quinn, Amelia Jamison, et al., Exploring the Continuum of Vaccine Hesitancy Between African American and White Adults: Results of a Qualitative Study, PLOS Currents (2016)).

[8] See Id.

[9] See Latkin supra note 5, at Section 1 (citing Paul L. Reiter, Michael L. Pennell, Mira L. Katz, Acceptability of a COVID-19 vaccine among adults in the United States: how many people would get vaccinated, 42 Vaccine 6500, (2020), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7440153/). See also Heidi J. Larson, Richard M. Clarke et al., Measuring trust in vaccination: A systematic review, 14 Hum. Vaccines and Immunotherapeutics 1599 (2018) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6067893/)(examining the relationship between vaccine acceptance and trust, including trust in the vaccine’s safety and efficacy, in individuals advising on or administering vaccines, and in the wider health system).

[10] See Reiter, supra note 8, at Section 3.3.

[11] See Saelee, supra note 1 (citing Grace Sparks, Liz Hamel, et al., KFF COVID-19 vaccine monitor: differences in vaccine attitudes between rural, suburban, and urban areas. Kaiser Fam. Found; (2021). https://www.cdc.gov/mmwr/volumes/71/wr/mm7109a2.htm).

[12] See Id.

[13] Equity of Adult Vaccination, Vaccines & Immunizations, https://www.cdc.gov/vaccines/health-equity/index.html (last visited April 21, 2022).

[14] Centers for Disease Control & Prevention, Expanding COVID-19 Vaccine Distribution to Primary Care Providers to Address Disparities in Immunization Guide for Jurisdictions, 2 (2021), https://www.cdc.gov/vaccines/covid-19/downloads/Guide-for-Jurisdictions-on-PCP-COVID-19-Vaccination.pdf.

[15] See Saelee, supra note 1. See also Trends in COVID-19 Vaccine Confidence in the US, COVID Data Tracker, https://covid.cdc.gov/covid-data-tracker/#vaccine-confidence (analyzing variances in vaccination status and intent among adults and children in urban, suburban, and rural areas).

[16] Vaccinate with Confidence COVID-19 Vaccines Strategy for Adults, Vaccines & Immunizations,  https://www.cdc.gov/vaccines/covid-19/vaccinate-with-confidence/strategy.html (last visited April 21, 2022).

[17] Id.



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