A Survival Analysis of Rural-Urban Disparities in COVID-19 Vaccination Uptake in the United States

• Published in: American journal of health promotion Vol. 39; no. 3; pp. 405 - 416
• Main Authors: Datta, Biplab Kumar, Jaremski, Jennifer E., Ansa, Benjamin E., Odhiambo, Lorriane, Clary, Catherine, Islam, K. M. Monirul, Johnson, J. Aaron
• Format: Journal Article
• Language: English
• Published: Los Angeles, CA SAGE Publications 01.03.2025; American Journal of Health Promotion
• Subjects: Adolescent; Adult; Adults; Age differences; Aged; Authorization; COVID-19; COVID-19 - prevention & control; COVID-19 vaccines; COVID-19 Vaccines - administration & dosage; COVID-19 Vaccines - therapeutic use; Ethnicity; Female; Healthcare Disparities - statistics & numerical data; Humans; Immunization; Male; Middle Aged; Race; Residence; Rural areas; Rural communities; Rural Population - statistics & numerical data; SARS-CoV-2; Socioeconomic Factors; Survival Analysis; United States - epidemiology; Uptake; Urban Population - statistics & numerical data; Vaccination Coverage - statistics & numerical data; Young Adult; United States; United States > US; COVID-19; rural populations; urban populations; socioeconomic disparities in health; vaccination
• ISSN: 0890-1171; 2168-6602; 2168-6602
• DOI: 10.1177/08901171241300136

Purpose 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.