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Rural communities outside American cities continue to fall behind in the race to get vaccinated against COVID-19 as President Joe Biden’s July 4th goal of reaching 70% of American adults looms on the horizon.
Alaska is the only state that has recorded the average number of fully vaccinated people in rural areas since the 19th century. every state opened the shots to everyone 16 and older, according to the latest analysis of NPR vaccination records at the district level from the Centers for Disease Control and Prevention.
Everywhere else, rates in urban counties have exceeded those in rural counties.
Over a dozen states where Rural rates actually exceeded urban rates seven weeks ago turned around so that they are now chasing their urban counterparts. These include Oregon, where rural areas are now 9 percentage points behind cities, and Maine, where they are now 7 points behind.
Florida, Massachusetts, and Nebraska have the largest differences, with rural counties lagging 14 percentage points. For Florida and Nebraska, these gaps are roughly twice the size of mid-April.
While these gaps are strong, they can hide a more complex history of vaccination rates as the data shows that many rural counties are well above average and urban areas are dragging their feet.
“There are a lot of, let’s call it, rural community judgments and a lot of blame placed on them for masks and vaccinations,” said Mark Holmes, professor at the University of North Carolina’s Gillings School of Global Public Health. “There is an overall continuum and it is not that easy as all large areas are fine and all rural areas are not.”
Indeed, a CDC report from mid-May included a detail that surprised Holmes: The suburbs that surround his state’s largest cities, Charlotte and Raleigh, NC, had vaccination rates significantly lower than their urban cores.
Not only that, these suburbs were worse off than even rural counties scattered across the state. Counties around Minneapolis, Birmingham, Ala., Seattle, Denver, and Portland, Oregon repeated this pattern, with the suburbs lagging behind both urban and rural counties in their states, according to the CDC’s analysis.
Bags with lower vaccination rates are a problem for people everywhere, experts say. If COVID-19 flared up in an unvaccinated rural or suburban area, those outbreaks would likely spread to nearby cities, according to Keith Mueller, director of the University of Iowa’s Rural Policy Research Institute.
“If we have learned something from 18 months of this pandemic, we have learned that it can spread from any location to any location. We are a far too mobile society,” says Müller.
As COVID-19 restrictions wear off and the summer travel season heats up, more Americans are likely to venture into national parks and other outdoor destinations in rural areas.
“You stop to refuel and suddenly that’s your contact,” says Holmes. “It’s ineffective to look at our borders, whether it’s national, state, or county borders, and say that’s over there. It doesn’t come here.”
Socio-economically endangered counties are struggling more
A second CDC report from the beginning of June sheds light on the demographic and social factors associated with lower vaccination rates in all counties, whether rural or urban.
The CDC ranks over 3,000 counties nationwide Social Vulnerability Index This measures 15 factors such as poverty, poor transport links and cramped living conditions, which weaken a community’s ability to react to disasters.
The researchers divided the counties into four categories – large cities, suburbs, small to medium-sized towns, and rural areas – and looked for demographic profiles associated with lower vaccination rates. Across all of these categories, households with children, people with disabilities and single parents were more likely to have lower vaccination rates. And researchers say these gaps are particularly pronounced in suburban and rural counties.
Counties with a higher number of mobile home residents as well as those with higher poverty and lower education rates also lagged significantly behind other counties in their rural-urban category, according to the CDC report.
“Rural communities often have a higher proportion of residents over 65 who have no health insurance, live with underlying illnesses or disabilities, and have limited access to critical care facilities, which increases the likelihood of getting sick or dying of COVID-19” says Vaughn Barry, a CDC epidemiologist and a lead author on the report.
The fight against hesitation should be “hyperlocal”
In the CDC reports, vaccination hesitation is rated as the primary one Barrier to reach rural areas and urge public health leaders to do more to overcome them. One in five rural Americans said they were “definitely not getting” the vaccine, according to a Kaiser Family Foundation survey April published. It met with the greatest opposition from Republicans, white Evangelical Christians, key workers in non-healthcare sectors, and adults under the age of 50.
Strategies to overcome this hesitation will look different for the hundreds of rural counties across the country, says Marcella Nunez-Smith, White House Chairwoman of COVID-19 Health Equality Law, but they are likely to share one critical point.
“Working with trusted, local community leaders is a must,” Nunez-Smith said at a news conference in May. “Equity work is always hyper-local. Communities are the experts for what they need.”
Doctors from the Navajo Nation, once one of the hardest hit areas in the country, say constant communication with their tribal members about battling the “monster” of COVID-19 has helped this remote area get some of the highest vaccination rates in New Mexico to reach Arizona.
Like most Native American tribes, the Navajo Nation has dozens of paid health workers who work with the Indian health service to venture into rural areas and forge relationships.
“They know their field very well. They all speak the language,” says Dr. Loretta Christensen, Acting Chief Medical Officer of the Indian Health Service and a member of the Navajo Nation. “You can take the one-on-one with people who may be hesitant, and sometimes it’s because they’re afraid to leave their homes, but we went into the houses and gave those vaccinations.”
Friends and family can be among the most influential when it comes to convincing a reluctant person, adds Dr. Chris Percy of the Northern Navajo Medical Center in Shiprock, NM. added
Patients often tell him what made them show up at recent vaccination events: “They just volunteer that ‘my mother and sisters … were in my case to come in here,'” says Percy.
Christensen and Percy say they can’t hit someone over the head with data or get unwilling patients to take the vaccine, but what they can do is come across as kind and lower all barriers.
“Our systems that we set up on Navajo don’t have a pre-registration component, or you need to do these five things before you get an appointment,” says Percy. “If you come by on Tuesday, just come over. … When you have made up your mind and are ready, we will be here. “
Barry’s report echoes Percy, suggesting walk-in clinics with flexible evening and weekend hours to accommodate working hours and reach people in socially vulnerable communities. The CDC researchers also suggest that organizing vaccine clinics near childcare facilities and working with schools could improve the lower rates they have seen among single parents in suburbs and rural counties.