CS000000-A | 9/25/23

Centers for Disease Control & Prevention, 

COVID-19 Response, Vaccine Task Force

Vaccine Confidence & Demand Team, Insights Unit

The findings and conclusions in this report are those 

of the author(s) and do not necessarily represent 

the official position of the Centers for Disease 

Control and Prevention (CDC).

CDC’s State of 

Vaccine Confidence 

Insights Report

Vaccination in Rural America Special Report 

September 25, 2023
Page: 2

State of Vaccine Confidence Insights Report | September 25, 2023

Report Summary 

This State of Vaccine Confidence Insights Report emphasizes major themes influencing general vaccine 

confidence and uptake among rural populations in the United States between 2017-2023, with a particular 

focus on COVID-19 vaccination.

Themes with the potential to impact vaccine confidence and demand:

 Theme 1: Residents in rural parts of the United States have concerns about vaccine safety, longterm side effects, effectiveness, and necessity.

 Theme 2: Differences exist in vaccine access and vaccine confidence between rural areas and 

suburban and urban areas. 

 Theme 3: Lack of government trust and the politicization of science may have contributed 

to lower vaccine uptake in rural areas. However, community outreach and utilizing trusted 

messengers can and has increased vaccine confidence in rural America. 

Ways public health and partners can take action to improve vaccine confidence and demand:

 Offer additional services at vaccination sites to increase comfort of individuals seeking 

vaccination, such as multilingual support, vaccine counseling, and family-friendly services.

 Provide opportunities for community members to ask questions and voice their concerns. Offer 

channels for direct communication, such as helplines, email, or in-person meetings, where 

trained professionals can provide personalized information and address specific worries.

 Share multilingual messages that present the benefits of youth vaccination against COVID-19, 

including protection from severe illness or hospitalization and the ability to safely participate in 

childcare, school, sports, and other group activities. When possible, provide safety information 

and ways to have questions answered as part of this messaging approach.

 Ensure all messaging acknowledges and recognizes the diversity of rural populations and does 

not falsely label rural populations as monolithic.

 Complete need-based assessments and rapid community assessments to identify and address 

specific barriers in rural communities.

 Create community-based networks to increase vaccine access, such as providing vaccine 

appointments after traditional work hours.

 To build trust with rural residents, engage with trusted community leaders, gather community 

input on questions and concerns, and work to prioritize and address them.

 Encourage state and local health departments, community pharmacists, and other local trusted 

messengers to promote vaccine messaging in communities where they are the preferred trusted 

messenger over federal agencies.

 Utilize nontraditional sites like school-based health centers and mobile clinics to bridge the 

vaccination access gap in rural areas. 

 Address inaccurate health information about vaccine safety and effectiveness by leveraging 

health care professionals, public health departments, libraries, and other local institutions to 

answer consumer questions and provide informative resources.

 Provide support and guidance on managing common side effects and reassure the community 

that any adverse events are being closely monitored and addressed.

 Continue to implement evidence-based vaccination-promoting interventions endorsed by the 

Community Preventive Services Task Force.
Page: 3

State of Vaccine Confidence Insights Report | September 25, 2023

Contents

3

Aims and Methods

5

Theme 1: Residents in rural parts of the United 

States have concerns about vaccine safety, 

long-term side effects, effectiveness, and 

necessity. 

5

Perceptions, concerns, and threats to vaccine 

confidence

6

Questions to consider

6

Ways to take action

7

Theme 2: Differences exist in vaccine access 

and vaccine confidence between rural areas 

and suburban and urban areas. 

7

Differences in vaccination uptake between 

rural and non-rural populations

9

Vaccine access as a barrier to vaccination

10

Questions to consider

10

Ways to take action

10

Theme 3: Lack of government trust and the 

politicization of science may have contributed 

to low vaccine uptake in rural areas. However, 

community outreach and utilizing trusted 

messengers can and has increased vaccine 

confidence in rural America. [moderate/stable]

11

Vaccine hesitancy in rural populations

11

Strategies that have worked to promote 

vaccine uptake in rural populations

12

Questions to consider

12

Ways to take action

13

Inaccurate health information themes

13

Resources

14

References

18

Appendix: Inputs and Sources
Page: 4

State of Vaccine Confidence Insights Report | September 25, 2023

Aims and Methods

By reviewing and analyzing numerous specific sources and inputs (see Appendix), this State of Vaccine 

Confidence Insights Report emphasizes major themes influencing general vaccine confidence and 

uptake among rural populations in the United States between 2017-2023, with a particular focus 

on COVID-19 vaccination. These themes are characterized by the level and type of threat to vaccine 

confidence, degree of spread, and directionality. In addition, by examining how consumers think 

and feel, social processes, and the practical issues around vaccination, this Insights Report seeks to 

identify emerging issues related to the spread of inaccurate health information to help identify where 

intervention efforts can improve vaccine confidence across the United States. 

The information in this report is only a snapshot, and specific populations may be underrepresented. 

Images and quotes are illustrative examples and are not meant to comprehensively cover all content 

related to the highlighted themes. 

How do you classify this theme/information? 

High risk Moderate risk Low risk Positive sentiment

 May lead to 

vaccine refusals 

and decreased 

uptake 

 Wide reach, 

pervasive  

 Potential to 

trigger hesitancy 

to vaccination

 Moderate 

reach, modest 

dissemination 

 Concerning, but 

low risk to vaccine 

confidence 

 Limited 

reach, limited 

dissemination 

 Could increase 

vaccine 

confidence, intent, 

or motivation

 Variable reach and 

dissemination

How has this theme/idea changed over time (since last report or over the course of multiple 

reports)? 

Increasing

Information spreading 

rapidly 

Stable

Information remaining 

constant at prior level 

Decreasing

Information is not gaining further traction and 

there has been no indication of additional activity 
Page: 5

State of Vaccine Confidence Insights Report | September 25, 2023

Theme 1: Residents in rural parts of the United States 

have concerns about vaccine safety, long-term side 

effects, effectiveness, and necessity. 

Rural communities in the U.S. have been uniquely impacted by the COVID-19 pandemic. Data from the 

Centers for Disease Control and Prevention (CDC) indicate that rural areas have experienced higher 

rates of COVID-19 infection and mortality, lower vaccination coverage, and higher vaccine hesitancy

compared to urban areas. Addressing these rural-urban disparities and improving vaccine confidence 

within rural communities requires that public health officials and their partners recognize and 

engage with the complex cultural, historical, structural, and political factors that contribute to vaccine 

hesitancy. As such, it is important to better understand specific concerns about vaccination that may 

be especially salient within rural communities. 

Perceptions, concerns, and threats to vaccine confidence 

 According to data collected by CDC’s National Immunization Survey-Adult COVID Module 

(NIS-ACM) between May 28–June 30, 2023, urban and rural areas differ in their perceptions of 

COVID-19 vaccine safety, concern about COVID-19, and the importance of vaccines in protecting 

against COVID-19. Roughly half of adults in rural areas (50.9%) reported feeling confident in the 

safety of COVID-19 vaccines compared to 61.7% of urban-dwelling adults. Similarly, a smaller 

percentage of rural residents (63.3%) felt that vaccines were somewhat or very important in 

protecting against COVID-19 compared to adults in urban areas (76.1%). Rural adults were also 

less inclined to report feeling concerned about COVID-19 than urban adults (25.7% vs. 30.8%, 

respectively).1

 Some rural consumers state the primary cause of their vaccine-related concerns is fear, 

stemming from the belief that the COVID-19 vaccines were created hastily and that potential 

long-term side effects remain unknown. Additionally, their decision-making process is 

influenced by a multifaceted interplay of beliefs regarding bodily autonomy, trust in science and 

authority, and a strong regional identity, characterized by a sense of self-reliance.2

 A study exploring barriers to COVID-19 vaccination within rural Latino communities in southwest 

Florida found fear as a barrier to vaccination, such as fear of COVID-19 vaccines and their side 

effects.3

 A study exploring vaccine hesitancy found rural communities in Tennessee are prone to fear and 

conspiracy theories and are concerned about COVID-19 vaccine side effects.4

 Concerns about potential adverse events following vaccination are a barrier to vaccine 

confidence in rural areas, according to an August 2022 survey of 1,000 rural adults conducted 

by the National Rural Health Association. Among “persuadable” unvaccinated adults (i.e., 

respondents who indicated they might be willing to receive a COVID-19 vaccine in the future), 

83% expressed concern about serious adverse effects of vaccines, although the majority (66%) 

reported that they did not actually know someone who had experienced a serious adverse 

event.

 A study measuring the effectiveness of an HPV vaccination intervention in a rural medical clinic 

found a personal fear of adverse and/or side effects and uncertainty about vaccine necessity 

increased following interventions.5
Page: 6

State of Vaccine Confidence Insights Report | September 25, 2023

 Some consumers have expressed on social media that the fear of COVID-19 vaccine side effects 

is increasing in rural parts of the United States.6,7,8,a

 Some social media users have shared positive experiences about the lack of side effects 

following COVID-19 vaccination.9,10,11

 A 2022 study examining COVID-19 vaccine hesitancy in rural Chemung County, New York found 

23% of participants voiced apprehension about vaccine safety, 18% expressed concerns about 

insufficient long-term safety data, 9% feared potential side effects, 32% disagreed with vaccine 

mandates, and 18% held the belief that the vaccine is ineffective.12

 Some posts on social media indicate that low vaccine confidence in rural America might be 

due to peer pressure, lack of government trust, and unanswered questions about COVID-19 

vaccines.13,14

 Some social media users are frustrated that adults living in rural areas are refusing to receive the 

COVID-19 vaccine.15,16,17

a

Social media posts referenced throughout this report can be found in this online document.

Questions to consider 

 Which specific side effects and adverse events (e.g., myocarditis) are individuals in rural America 

concerned about? his

 How can specific messaging about vaccine side effects be applied without causing message 

fatigue while also acknowledging the known but rare serious adverse events associated with 

COVID-19 vaccination?

 How does a lack of trust in the federal government contribute to the perception that COVID-19 

vaccines were hastily developed, and how might this concern be addressed?

 How can state and local health departments increase vaccine uptake without using excessive 

messaging which may result in worsening vaccine confidence?

Ways to take action

 Encourage health care staff to employ strategies such as distracting, comforting, and educating 

individuals to decrease stress or anxiety while getting vaccinated.18

 Offer additional services at vaccination sites to increase comfort of individuals seeking 

vaccination, such as multilingual support, vaccine counseling, and family-friendly services.

 Provide information on vaccine safety through informational brochures, flyers, or posters that 

explain the benefits of vaccination, address common concerns, and debunk myths surrounding 

vaccines.

 Provide opportunities for community members to ask questions and voice their concerns. Offer 

channels for direct communication, such as helplines, email, or in-person meetings, where 

trained professionals can provide personalized information and address specific worries.

 Provide support and guidance on managing common vaccine side effects and reassure the 

community that any adverse events are being closely monitored and addressed.

 Develop plain language messages in English and Spanish pulling from recent CDC data reports 

and Morbidity and Mortality Weekly Reports (MMWRs) to educate people on the safety of the 

vaccine for children and the risk of severe COVID-19 illness in children.
Page: 7

State of Vaccine Confidence Insights Report | September 25, 2023

 Share multilingual messages that present the benefits of youth vaccination against COVID-19, 

including protection from severe illness or hospitalization and the ability to safely participate in 

childcare, school, sports, and other group activities. When possible, provide safety information 

and ways to have questions answered as part of this messaging approach.

 Amplify messages in English and Spanish about the safety and effectiveness of COVID-19 

vaccines in preventing severe illness, hospitalization, and death.

Theme 2: Differences exist in vaccine access and 

vaccine confidence between rural areas and 

suburban and urban areas. 

Rural residents in the United States encounter various health inequalities in comparison to their urban 

counterparts. According to the U.S. Census Bureau, over 46 million Americans, constituting 15 percent 

of the population, reside in rural areas. Unique challenges necessitate increased focus and allocation 

of resources to improve health outcomes in rural America. The implementation of enhanced public 

health programs, promoting healthier behaviors and neighborhoods, along with improved access to 

healthcare services, could prove beneficial for rural areas.19

Differences in vaccination uptake between rural and non-rural populations 

 Adults in rural areas have lower COVID-19 vaccine primary series completion rates as 

well as lower rates of updated (bivalent) COVID-19 vaccination than those in urban areas. 

According to NIS-ACM data from May 28–June 30, 2023, 20.5% of adults in rural areas are 

completely unvaccinated against COVID-19 compared to 11% of adults in urban areas who 

remain unvaccinated.1 Furthermore, a smaller percentage of adults in rural areas (75.4%) have 

completed their COVID-19 primary series compared to adults in urban areas (85.1%). 

 Similarly, NIS-ACM data from May 28–June 30, 2023 indicate differences between rural and 

urban populations in terms of updated (bivalent) COVID-19 vaccine uptake and intention. 

Among adults who completed the primary series but had not yet received an updated 

COVID-19 vaccine, intent to receive an updated COVID-19 vaccine was lower in rural areas, 

with 31.3% of rural residents reporting that they probably or definitely will not get an updated 

COVID-19 vaccine compared to 25.8% of urban-dwelling adults. Rural adults lagged slightly 

behind urban residents in being considered “up to date” on their COVID-19 vaccines at 24.6% 

versus 29.3%, respectively. 

 Based on National Immunization Survey–Child COVID Module (NIS-CCM) data from May 28–

June 30, 2023, 55.9% of adolescents aged 12-17 in rural areas are completely unvaccinated 

against COVID-19 compared to 33% of adolescents in urban areas (as reported by the parent 

or guardian completing the NIS-CCM survey).20 Rural adolescents have lower rates of primary 

series completion than urban adolescents (39.9% vs. 62.3%) as well as lower rates of up-to-date 

coverage against COVID-19 (9.4% vs. 16.8%). Among adolescents who already completed the 

primary series, 32.4% of adolescents in rural areas will probably or definitely not get an updated 

(bivalent) COVID-19 vaccine versus 18.9% of adolescents in urban areas. 

 Additional analysis of vaccination coverage among rural and urban populations can be 

found in this February 2023 MMWR, which analyzes NIS-ACM and NIS-CCM data collected in 

November–December 2022. 
Page: 8

State of Vaccine Confidence Insights Report | September 25, 2023

 A MMWR study published in February 2023 found COVID-19 vaccination rates among children

aged 6 months to 4 years varied based on their rural or urban county of residence. Children 

in rural counties had lower vaccination coverage with ≥1 doses of COVID-19 vaccine (3.4%) 

compared to those in urban counties (10.5%).21

 Kaiser Family Foundation 

published a poll in April 2021 

that surveyed 1,001 adults 

living in rural America.22 The 

poll found that 39% of rural 

residents reported they had 

received at least one dose of 

the COVID-19 vaccine, whereas 

only 31% of both suburban 

and urban residents received 

one dose of a COVID-19 

vaccine. However, a smaller 

proportion of unvaccinated 

rural residents (16%) expressed their intention to get the vaccine as soon as possible compared 

to urban (35%) and suburban (28%) residents. This suggests that vaccine uptake in rural 

communities initially surpassed that of urban and suburban areas; however, as access to 

vaccines became more widespread in densely populated regions, rural areas started to lag in 

terms of vaccination rates.

 A study examining excess mortality during the first two years of the pandemic found that 

despite the availability of vaccines, “excess mortality moved substantially from large metros 

in the first year of the pandemic to nonmetro areas during the second year,” with the authors 

noting that “differences in vaccination rates across metro-nonmetro categories may be playing 

an increasingly important role in the rural mortality disadvantage observed in the second year of 

the pandemic.”23

 County and local estimates for vaccine hesitancy in the United States show that individuals in 

rural counties have the highest estimated levels of vaccine hesitancy or unsureness.24,25

 According to data from the 2019 National Health Interview Survey, self-reported rates of 

influenza vaccination were higher in urban areas compared to rural areas among adults of all 

age groups.26

 Data from the 2018 National Immunization Survey-Teen shows that HPV vaccine uptake among 

adolescents is 15 percentage points lower in rural areas than urban areas.27 The same survey 

shows uptake of the meningococcal conjugate vaccine is 20 percentage points lower in rural 

areas than urban areas. Additional analysis can be found in this MMWR study published in 

August 2019.28

 A MMWR study published in 

October 2018 indicates that children 

below the age of three residing in 

non-MSAs receive recommended 

vaccines at lower rates compared to 

children in principal cities of MSAs. 

The difference in vaccination rates 

ranges from 2.6 to 6.9 percentage 

points.29
Page: 9

State of Vaccine Confidence Insights Report | September 25, 2023

 The findings of one study suggest that influenza vaccination rates among children living in rural 

areas were consistently 5 to 13 percentage points lower compared to those residing in urban 

and suburban areas throughout eight influenza seasons (2011-2012 through 2018-2019).30

Vaccine access as a barrier to vaccination 

 Reports about the end of the COVID-19 Public Health Emergency discuss decreased access 

to COVID-19-related testing and vaccines. This is in addition to relaxing or removing previous 

surveillance benchmarks, potentially masking the ability to notice increases in COVID-19 cases 

in rural areas.31

 A study exploring barriers to COVID-19 vaccination within rural Latino communities in southwest 

Florida found lack of accessibility to be a prominent theme regarding COVID-19 vaccines, as well 

as a lack of time and resources.3

 A study exploring vaccine hesitancy of rural communities in Tennessee claims that access to 

testing and vaccination is not as large a barrier to COVID-19 vaccination as poor access to 

healthcare infrastructure.4

 Geographical factors can exacerbate 

disparities in access, particularly for 

rural clinics that encounter difficulties in 

delivering vaccinations to residents several 

miles away. Rural communities frequently 

face shortages of resources, such as 

adequate cold storage facilities for vaccines 

and a scarcity of healthcare workers and 

pharmacy locations to administer them.32

 A MMWR study published in March 2022 showed several factors can contribute to the growing 

disparities among rural and nonrural populations, such as access to healthcare. Even prior to 

the COVID-19 pandemic, individuals in rural areas frequently reported inadequate healthcare 

providers or hospitals available to serve their communities, posing access difficulties for rural 

Americans seeking COVID-19 vaccination.33

 In one study, the rural–urban difference in hesitancy rates among those still unvaccinated was 

much smaller than the rural–urban difference in vaccination rates, suggesting that access to 

vaccines may be another contributor to the lower vaccination rates in rural areas.34

 Some social media users claim vaccine uptake in rural parts of the United States is low due to 

lack of access,35,36 while other social media users disagree.37,38

 Food insecurity and decreased 

consumer purchasing power may 

impede the ability to access wellness 

visits in rural areas. Therefore, routine 

vaccination may not be a priority for 

rural residents.39
Page: 10

State of Vaccine Confidence Insights Report | September 25, 2023

Questions to consider 

b

CDC-INFO.

 Will residents in rural areas still have access to COVID-19 vaccines following the end of the Public 

Health Emergency? 

 How can state and local health departments increase access to all vaccinations without requiring 

lengthy drives?

 Is lack of access to vaccination affecting routine childhood vaccination rates in children?

 What are the various structural barriers preventing rural residents from accessing vaccines?

Ways to take action

 Use community-driven, feet-on-the-ground leaders to develop robust public health messaging 

to promote vaccine uptake that take access issues into consideration.

 Work with partners that have existing relationships with rural residents to promote vaccine 

uptake. 

 Ensure all messaging acknowledges and recognizes the diversity of rural populations and does 

not falsely label rural populations as monolithic.

 Complete need-based assessments and rapid community assessments to identify and address 

specific barriers in rural communities.

 Create community-based networks to increase vaccine access, such as providing vaccine 

appointments after traditional work hours.

 Work with community and community partners to offer incentives for vaccination.

 To build trust with rural residents, engage with trusted community leaders, gather community 

input on questions and concerns, and work to prioritize and address them.

Theme 3: Lack of government trust and the 

politicization of science may have contributed to 

lower vaccine uptake in rural areas. However, community 

outreach and utilizing trusted messengers can and has 

increased vaccine confidence in rural America. 

Access to vaccines and increasing vaccine education are the two major themes that were found to 

increase vaccine confidence in rural communities. Rural communities face unique barriers that require 

solutions which are able to address these needs.b By providing resources to support access to those 

in rural communities, identifying and addressing misinformation, and providing opportunities to 

answer questions about vaccine safety, public health officials can increase vaccine confidence and 

uptake.40,41,42
Page: 11

State of Vaccine Confidence Insights Report | September 25, 2023

Vaccine hesitancy in rural populations 

 A qualitative study exploring rural Americans’ COVID-19 vaccine perceptions found that vaccinehesitant adults were more likely to trust local sources of health information such as healthcare 

providers, pharmacists, and county government officials.43

 Vaccine uptake and confidence can be influenced by an individual or community’s values, 

beliefs, and sense of identity, including political affiliation.44,45,46,47 As such, it is important to 

engage with rural communities in a manner that recognizes and resonates with their cultural 

and social context. 

 More than 600 vaccine-related bills have been introduced so far in 2023, eclipsing the total 

number of bills introduced in 2022 according to the National Conference of State Legislatures.48

Many states are considering legislation that would prohibit or curtail COVID-19 vaccine 

requirements as well as routine vaccine requirements imposed by schools, employers, and other 

entities.49

Strategies that have worked to promote vaccine uptake in rural 

populations

 In New York, the University of Rochester formed the Finger Lakes Rural Immunization Initiative, 

a 16-month project funded by CDC to increase vaccine awareness, knowledge, and acceptance 

in rural areas by engaging trusted messengers. These efforts resulted in an interactive workshop, 

interventional toolkit, and stakeholder forum designed to empower trusted messengers and 

foster community collaboration. Among the trusted messengers who were surveyed following 

their workshop participation, 45% reported that their patients were more likely to get vaccinated 

and 29% believed that their patients became vaccinated as a result of the conversational 

strategies from the workshop.

 A study measuring the effectiveness of an HPV vaccination intervention in a rural medical 

clinic found healthcare team training, education materials, and technology-based vaccine 

appointment reminders resulted in fewer missed vaccination appointments.5

 Locations that were well-stocked, efficient, and offered easy access saw positive feedback and 

support from the rural communities where they were administering the vaccines.50,51

 Consumers in low socioeconomic rural communities were more supportive of clinics and vaccine 

drives that offered vaccines for free.40,52

 Homebound consumers in rural counties stated their willingness to receive vaccines if they had 

the option of at-home administration.b

 Rural communities in some 

areas provided mobile vaccine 

clinics and incentives to reach 

consumers who desired COVID-19 

and influenza vaccines but did not 

have access otherwise.53

 Trusted messengers and health care professionals were used to address questions about vaccine 

safety, effectiveness, and misinformation for rural consumers.54,a 

 Local health departments and other health care professionals posted vaccine facts, and vaccine 

clinic locations on social media to inform their communities about the vaccines’ safety, efficacy 

and availability.55,56
Page: 12

State of Vaccine Confidence Insights Report | September 25, 2023

 Research indicates that rural residents might trust community pharmacists for health 

information and vaccine administration due to a number of factors, such as convenience and 

connectedness to the communities they serve.43 Consumers also believe trusted messengers 

play a large role in encouraging adults in rural America to receive the COVID-19 vaccine.57

Questions to consider 

 Who are the influential community leaders in the rural population? How can they be involved in 

public health initiatives?

 What are the specific reasons for low government trust among rural populations? How can local 

health departments foster trust and credibility?

 How can local health departments leverage community networks?

 How can local health departments monitor and evaluate the impact of community leader 

involvement?

Ways to take action

 Encourage state and local health departments, community pharmacists, and other local trusted 

messengers (e.g., faith leaders, firefighters, etc.) to promote vaccine messaging in communities 

where they are the preferred trusted messenger over federal agencies.

 Using trusted and celebrity messengers while providing opportunities to increase health 

literacy can combat misinformation within rural communities.4 Consider adopting a hyperlocal approach in rural settings by using locally recognizable people and locations in media 

campaigns.

 Nontraditional sites for preventative health services can help bridge the vaccination access gap 

in rural areas. 

 School-based health centers (SBHCs) present an 

opportunity to offer various healthcare services on 

school premises, eliminating the need for lengthy or 

inconvenient trips to the doctor’s office. According 

to a study in the American Journal of Public Health, 

adolescents assigned to an SBHC had higher 

completion rates for vaccination series compared 

to those assigned to a community health center.58

In Oregon, a state with a robust SBHC program 

consisting of 78 certified centers, 35,252 patients 

were served in 2016-2017, with 30% of them receiving at least one immunization.59

 Mobile health clinics operating in alternative settings, as highlighted in a review published 

in the International Journal for Equity in Health, can enhance population health through 

preventative measures, including immunizations. These clinics, located in workplaces and 

public spaces, offer convenient access to healthcare interventions.60
Page: 13

State of Vaccine Confidence Insights Report | September 25, 2023

 In rural communities, healthcare providers and pharmacists can employ various strategies to 

enhance vaccination rates.

 Simplify the vaccine regimen and minimize return visits by offering coadministration of 

vaccines (multiple vaccines in a single visit).

 Enhance scheduling flexibility by providing same-day appointments or walk-in visits, and athome/door-to-door vaccination. 

 Streamline the process by implementing standing orders for registered nurses, physician 

assistants, pharmacists and pharmacy technicians, and medical assistants in accordance with 

state-specific scope of practice laws to reduce wait times and delays.

 Improve communication and ensure follow-up by utilizing parent reminders via text messages, 

phone calls, and emails for upcoming visits and recall notices.

 Prioritize capacity building/team training and educational materials for staff/retail pharmacy 

staff/urgent care. 

 Inaccurate health information about the safety and effectiveness of COVID-19 vaccines was 

frequently addressed by health care professionals, local public health departments, and even 

libraries. These institutions aimed to increase vaccine confidence by answering consumer 

questions and providing informative resources.61,62,a

 Continue to implement evidence-based vaccination-promoting interventions endorsed by the 

Community Preventive Services Task Force.63

Inaccurate health information themes 

 Some consumers believe there is aborted fetal tissue in the COVID-19 vaccines or that the U.S. 

government exaggerated the number of COVID-19 cases.2

 The belief that COVID-19 cases are rising in rural America due to unvaccinated immigrants has 

been mentioned on social media.64

 Some individuals particularly in rural America have taken ivermectin due to the belief it is a safer 

and more effective method to treat and prevent COVID-19 than vaccination.65,66,67

 Some people believe the COVID-19 vaccine was created to sterilize older or exterminate certain 

populations.3

Resources

 Rural Health Clinic COVID-19 Programs | HRSA

 COVID-19 Vaccine Confidence Communication Toolkit | National Rural Health Association

 COVID-19 Vaccine Resources | National Rural Health Association

 Vaccination in Rural Communities | CDC

 Predictors and Barriers to Achieving Immunization in Rural and Urban Areas | Rural Health 

Research Gateway

 Vaccines for All: Reaching and Serving Rural Americans | Atlantic Health Partners
Page: 14

State of Vaccine Confidence Insights Report | September 25, 2023

References

Note: omitted numbers are social media citations, which can be found in this online document.

1. Centers for Disease Control and Prevention. (2023, June 30). COVID-19 Vaccination Coverage 

and Vaccine Confidence Among Adults. U.S. Department of Health and Human Services. 

https://www.cdc.gov/vaccines/imz-managers/coverage/covidvaxview/interactive/adults.html

2. Hoffman, J., & Schaff, E. (2021, April 30). Faith, freedom, fear: Rural America’s COVID vaccine 

skeptics. The New York Times. https://www.nytimes.com/2021/04/30/health/covid-vaccine-hesitancy-white-republican.html

3. Buro, A. W., Roman Candelaria, K., Bailey, R., Luna, F., Albizu-Jacob, A., Stern, M., & Redwine, 

L. (2022). Exploration of multilevel barriers and strategies that affected early COVID-19 

vaccination and testing in rural Latino communities in southwest Florida. International 

Journal of Environmental Research and Public Health, 19(18), 11785. https://doi.org/10.3390/

ijerph191811785

4. Alcendor, D. J. (2021). Targeting COVID vaccine hesitancy in rural communities in Tennessee: 

Implications for extending the covid-19 pandemic in the south. Vaccines, 9(11), 1279. 

https://doi.org/10.3390/vaccines9111279

5. Kepka, D., Christini, K., McGough, E., Wagner, A., Del Fiol, G., Gibson, B., Ayres, S., Brandt, H. 

M., Mann, S., Petrik, A. F., & Coronado, G. D. (2021). Successful multi-level HPV vaccination 

intervention at a rural healthcare center in the era of COVID-19. Frontiers in Digital Health, 3. 

https://www.frontiersin.org/articles/10.3389/fdgth.2021.719138

12. Terry, R., Asrar, A., & Lavertue, S. (2022). Covid-19 vaccine hesitancy in a rural primary care setting. Cureus, 14(7). https://doi.org/10.7759/cureus.27196

18. California COVID-19 Vaccination Program. (2021, October 25). Tips to ease anxiety during vaccination. California Department of Public Health. https://eziz.org/assets/docs/COVID19/IMM1401.pdf

19. Centers for Disease Control and Prevention. (2023, May 9). About Rural Health. U.S. Department 

of Health and Human Services. https://www.cdc.gov/ruralhealth/about.html

20. Centers for Disease Control and Prevention. (2023, June 30). COVID-19 Vaccination Coverage 

and Vaccine Confidence Among Children. U.S. Department of Health and Human Services. 

https://www.cdc.gov/vaccines/imz-managers/coverage/covidvaxview/interactive/children.

html

21. Murthy, B. P., Fast, H. E., Zell, E., Murthy, N., Meng, L., Shaw, L., ... & Harris, L. Q. (2023). COVID-19 

Vaccination Coverage and Demographic Characteristics of Infants and Children Aged 6 

Months–4 Years—United States, June 20–December 31, 2022. Morbidity and Mortality 

Weekly Report, 72(7), 183. https://www.cdc.gov/mmwr/volumes/72/wr/mm7207a4.htm

22. Kirzinger, A., Sparks, G., & Brodie, M. (2021, April 9). KFF COVID-19 Vaccine Monitor – Rural America. KFF. https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-rural-america/
Page: 15

State of Vaccine Confidence Insights Report | September 25, 2023

23. Paglino, E., Lundberg, D. J., Zhou, Z., Wasserman, J. A., Raquib, R., Luck, A. N., ... & Stokes, A. C. 

(2023). Monthly excess mortality across counties in the United States during the COVID-19 

pandemic, March 2020 to February 2022. Science Advances, 9(25), eadf9742. https://doi.

org/10.1126/sciadv.adf9742

24. Centers for Disease Control and Prevention. (2021, June 17). COVID-19 County Hesitancy. 

U.S. Department of Health and Human Services. https://data.cdc.gov/Vaccinations/

COVID-19-County-Hesitancy/c4bi-8ytd

25. Health Resources & Services Administration. (2021, September 1). List of Rural Counties and 

Designated Eligible Census Tracts in Metropolitan Counties. U.S. Department of Health and 

Human Services. https://data.hrsa.gov/Content/Documents/tools/rural-health/forhpeligibleareas.pdf

26. Jain, B., Paguio, J. A., Yao, J. S., Jain, U., Dee, E. C., Celi, L. A., & Ojikutu, B. (2022). Rural–urban differences in influenza vaccination among adults in the United States, 2018–2019. American 

Journal of Public Health, 112(2), 304–307. https://doi.org/10.2105/AJPH.2021.306575

27. Centers for Disease Control and Prevention. (2022, March 23). Vaccination in Rural Communities. 

U.S. Department of Health and Human Services. https://www.cdc.gov/ruralhealth/vaccines/index.html

28. Walker, T. Y., Elam-Evans, L. D., Yankey, D., Markowitz, L. E., Williams, C. L., Fredua, B., ... & Stokley, 

S. (2019). National, regional, state, and selected local area vaccination coverage among 

adolescents aged 13–17 years—United States, 2018. Morbidity and Mortality Weekly Report, 68(33), 718. https://www.cdc.gov/mmwr/volumes/68/wr/mm6833a2.htm

29. Hill, H. A., Elam-Evans, L. D., Yankey, D., Singleton, J. A., & Kang, Y. (2018). Vaccination coverage 

among children aged 19–35 months—United States, 2017. Morbidity and Mortality Weekly 

Report, 67(40), 1123. https://www.cdc.gov/mmwr/volumes/67/wr/mm6740a4.htm

30. Zhai, Y., Santibanez, T. A., Kahn, K. E., Srivastav, A., Walker, T. Y., & Singleton, J. A. (2020). Rural, 

urban, and suburban differences in influenza vaccination coverage among children. Vaccine, 38(48), 7596–7602. https://doi.org/10.1016/j.vaccine.2020.10.030

31. Assistant Secretary for Public Affairs. (2023, May 9). Fact Sheet: End of the COVID-19 Public Health 

Emergency. U.S. Department of Health and Human Services. https://www.hhs.gov/about/

news/2023/05/09/fact-sheet-end-of-the-covid-19-public-health-emergency.html

32. Cuadros, D. F., Branscum, A. J., Mukandavire, Z., Miller, F. D., & MacKinnon, N. (2021). Dynamics 

of the COVID-19 epidemic in urban and rural areas in the United States. Annals of Epidemiology, 59, 16–20. https://doi.org/10.1016/j.annepidem.2021.04.007

33. Saelee, R., Zell, E., Murthy, B. P., Castro-Roman, P., Fast, H., Meng, L., ... & Murthy, N. (2022). 

Disparities in COVID-19 vaccination coverage between urban and rural counties—United 

States, December 14, 2020–January 31, 2022. Morbidity and Mortality Weekly Report, 71(9), 

335. https://www.cdc.gov/mmwr/volumes/71/wr/mm7109a2.htm
Page: 16

State of Vaccine Confidence Insights Report | September 25, 2023

34. Soorapanth, S., Cheung, R., Zhang, X., Mokdad, A. H., & Mensah, G. A. (2023). Rural–urban differences in vaccination and hesitancy rates and trust: US COVID-19 trends and impact survey 

on a social media platform, May 2021–April 2022. American Journal of Public Health, e1–

e9. https://doi.org/10.2105/AJPH.2023.307274

39. Mead, A. (2019, September 25). Effective Communication and Consistency in Increasing Rural Vaccination Rates. Rural Health Information Hub. https://www.ruralhealthinfo.org/rural-monitor/increasing-vaccination-rates/

43. Koskan, A. M., LoCoco, I. E., Daniel, C. L., & Teeter, B. S. (2023). Rural Americans’ COVID-19 vaccine 

perceptions and willingness to vaccinate against COVID-19 with their community pharmacists: 

An exploratory study. Vaccines, 11(1), 171. https://doi.org/10.3390/vaccines11010171

44. Kenen, J. (2021, March 8). Vaccine-skeptical Trump country poses challenge to immunization 

push. Politico. https://www.politico.com/news/2021/03/08/coronavirus-vaccine-rural-america-473940

45. Ivory, D., Leatherby, L., & Gebeloff, R. (2021, April 17). Least vaccinated U.S. counties have 

something in common: Trump voters. The New York Times. https://www.nytimes.com/interactive/2021/04/17/us/vaccine-hesitancy-politics.html

46. Sehgal, N. J., Yue, D., Pope, E., Wang, R. H., & Roby, D. H. (2022). The Association Between 

COVID-19 Mortality and The County-Level Partisan Divide In The United States: Study 

examines the association between COVID-19 mortality and county-level political party 

affiliation. Health Affairs, 41(6), 853-863. https://doi.org/10.1377/hlthaff.2022.00085

47. Wallace, J., Goldsmith-Pinkham, P., & Schwartz, J. L. (2023). Excess Death Rates for Republican 

and Democratic Registered Voters in Florida and Ohio During the COVID-19 Pandemic. JAMA Internal Medicine. doi:10.1001/jamainternmed.2023.1154 

48. National Conference of State Legislatures. (2023, May 30). State Public Health Legislation Database. https://www.ncsl.org/health/state-public-health-legislation-database

49. Joseph, B. (2023, February 16). States continue to roll back vaccine requirements. LexisNexis. https://www.lexisnexis.com/community/insights/legal/capitol-journal/b/state-net/

posts/states-continue-to-roll-back-vaccine-requirements

57. Carter, T. (2021, May 5). My red state is still arguing over masks. But it’s not about COVID 

anymore. Washington Post. https://www.washingtonpost.com/outlook/2021/05/05/

masks-red-state-coronavirus/

58. Federico, S. G., Abrams, L., Everhart, R. M., Melinkovich, P., & Hambidge, S. J. (2010). Addressing 

adolescent immunization disparities: A retrospective analysis of school-based health center 

immunization delivery. American Journal of Public Health, 100(9), 1630–1634. https://doi.

org/10.2105/AJPH.2009.176628

59. Oregon Public Health Division. Oregon School-Based Health Centers: Status Update 2018. Oregon 

Health Authority. https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/le8926.pdf
Page: 17

State of Vaccine Confidence Insights Report | September 25, 2023

60. Yu, S. W. Y., Hill, C., Ricks, M. L., Bennet, J., & Oriol, N. E. (2017). The scope and impact of mobile 

health clinics in the United States: A literature review. International Journal for Equity in 

Health, 16(1), 178. https://doi.org/10.1186/s12939-017-0671-2

61. American Library Association. (2022, September 8). How Small and Rural Libraries Combat Misinformation. https://programminglibrarian.org/articles/how-small-and-rural-libraries-combat-misinformation

63. The Community Guide. (2022, October 4). Vaccination. https://www.thecommunityguide.org/

topics/vaccination.html

65. Ogle, K. (2021, September 10). Patients overdosing on ivermectin backing up rural Oklahoma 

hospitals, ambulances. KFOR. https://kfor.com/news/local/patients-overdosing-on-ivermectin-backing-up-rural-oklahoma-hospitals-ambulances/
Page: 18

State of Vaccine Confidence Insights Report | September 25, 2023

Appendix: Inputs and Sources

Social Media Listening & Media Monitoring Data Sources

Input Cadence Sources Tactics for Utilization

Communication 

Surveillance Report

Daily on 

weekdays

Google news

Meltwater

CrowdTangle

Native platform 

searches

Share of voice topic analysis to 

identify themes

Emerging topics 

Meltwater Daily Facebook, Twitter, 

Instagram

Blogs

News media

Online forums

Share of voice topic analysis

Emerging theme topics

Identify high reach/velocity topics

OADC (Office of the 

Associate Director 

of Communication) 

Channel COVID-19 

Post metrics

Weekly Sprout Social

Native OADC (Office of 

the Associate Director 

of Communication) 

account analytics

Analyze # of posts, topics 

Success of messages, # of 

impressions, reach, # engagements

OADC Channel 

Comment Analysis

Daily on 

weekdays

Native platform 

searches

Sentiment analysis

Identify message gaps/voids

Direct Report Data Sources

Input Cadence Sources Tactics for Utilization

CDC-INFO Metrics Weekly CDC-INFO inquiry line 

list

Prepared response 

(PR) usage report

 Cross-compare PR usage with inquiry theme 

analysis

 Sentiment analysis

Identify information gaps/voids

VTF Media 

Requests

Weekly Media request line list  Leading indicator for news coverage

Identify information gaps/voids

Web Metrics Weekly Top pages

Google search queries

Top FAQs

Referring domains

Identify information gaps/voids,

Identify keywords/search terms, changes in web 

traffic
Page: 19

State of Vaccine Confidence Insights Report | September 25, 2023

Research and Literature Data Sources

Input Cadence Sources Tactics for Utilization

Poll Review Weekly Harris Poll, PEW 

research, Gallup Poll, 

KFF, Annenberg Public 

Policy Center 

New data related to 

vaccine hesitancy

Identify socio-behavior indicators 

related to motivation and intention 

to vaccinate 

Literature Review Weekly PubMed, LitCovid, 

ProQuest Central, 

Altmetric 

New data related to 

vaccine hesitancy

Identify current vaccination 

intention

Identify barriers to vaccination

Third Party Report Data Sources

Input Cadence Sources Tactics for Utilization

Tanaq Social 

Listening +Media 

Monitoring Report

Weekly Meltwater

Sprout Social

First Draft

Native platform 

searches

Trending topics

Demographic and geographic 

conversation monitoring

Washington St. 

Louis iHeard

Weekly Proprietary methods Survey results

Emerging threats and data deficits

Vaccine narratives

Project VCTR Weekly Proprietary methods National and regional trends 

in negative attitudes toward 

vaccination

Conversations around Legislation