COVID-19 Vaccination Field Guide Addendum: 

Rural Considerations for Vaccine Confidence 

and Uptake Strategies

U.S. Department of 

Health and Human Services

Centers for Disease 

Control and Prevention
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The original COVID-19 Vaccination Field Guide: 12 Strategies for 

Your Community presents evidence-based strategies being applied 

in communities across the country to increase COVID-19 vaccine 

confidence and uptake. 

To help rural communities apply these strategies, this addendum 

includes rural considerations and examples for the 12 strategies 

based on successes in the field and input from health departments 

and rural health organizations. 

State and local health departments, community- and faith-based 

organizations, and local nonprofits are encouraged to try a 

combination of these strategies to increase vaccination rates.

Vaccine Confidence is the trust 

that people have in recommended 

vaccines and how they are 

administered and developed. 

Without some level of confidence, 

people will not move toward 

receiving a vaccine.

Vaccine Uptake refers to the 

proportion of the population 

that has received a vaccine.
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Strategy 1

Vaccine Ambassadors

Vaccine ambassadors train community members to disseminate important health information in their communities. They are 

most effective when they are trusted community members and share similar beliefs and characteristics with their peers.

Rural Consideration

Recruiting vaccine ambassadors may be more challenging in rural areas because communities tend to be very small – everybody 

knows each other. This can make it riskier for people to actively promote vaccination if they worry about being shunned by their 

peers, friends, or family. When recruiting ambassadors, it can be helpful to identify people who have already spoken up in support 

of other issues in their community, even if the issues were not related to health. Consider identifying ambassadors representing 

different racial/ethnic groups and occupations that are common in the community.

A “snowball” approach can be used, whereby local influencers are asked to identify potential ambassadors, and those people are in 

turn asked to identify others as well. 

Example: The North Carolina Farm Bureau filmed its President getting vaccinated and shared the video on Facebook.

Strategy 2

Medical Provider 

Vaccine Standardization

Offering vaccination as a default option during patient visits and integrating vaccination into medical practice procedures. 

Rural Consideration

It may be more difficult for rural residents to access routine medical care in general, due to provider shortages in rural areas and 

long driving distances. Therefore, there may be fewer opportunities for rural residents to access COVID-19 vaccines through 

routine medical care than for urban or suburban residents. In rural areas, vaccination and/or vaccine counseling can happen 

during home visits, mobile units, or telemedicine.

Example: The Health Wagon, a free clinic operating in a six-county area of Southwest Virginia, provides care to people through 

four mobile units, outreach events, and stationary clinics to provide COVID-19 vaccines.
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Strategy 3

Medical Reminders

Messages sent to patients to remind them of recommended or upcoming appointments. Messages can be sent by autodialed 

phone calls, text messages, or post-cards, for example. 

Rural Consideration

In rural communities, where cell phone service or broadband internet may be limited, reminders via text message or email may 

not be feasible. Using more traditional methods, such as landline phone calls or sending postcards through the mail, can be 

effective. 

Example: Support and Services at Home (SASH) staff used a newsletter and prerecorded phone calls to reach older 

adults in affordable housing buildings in rural Vermont, and then helped them schedule appointments and any needed 

transportation.

Strategy 4

Motivational Interviewing

Patient-centered conversations designed to increase patient motivation and likelihood of health behavior uptake.

Rural Consideration

As rural residents face challenges accessing in-person healthcare, motivational interviewing may need to be employed more often 

outside of in-person clinical settings. Offering opportunities to talk to a healthcare provider at community events like county fairs, 

during pharmacy visits, or through telehealth visits, will allow people to ask questions and get their personal concerns addressed 

at their own convenience. Many rural residents call health departments directly, so it can also be helpful to train public health 

nurses in how to use motivational interviewing techniques over the phone.

Limited language services can also be a barrier for groups like refugees and migrant farmworkers, so it can be helpful to 

collaborate with organizations serving these groups to help provide interpretation during vaccine conversations.

Example: In Trousdale County, Tennessee, a private telepharmacy company, AdhereRx, uses motivational interviewing to 

overcome barriers to COVID-19 vaccinations. 
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Strategy 5

Financial Incentives

Financial incentives aim to motivate people to participate in a health behavior by providing a tangible reward, or a chance at a 

tangible reward, for completion of the behavior.

Rural Consideration

Incentives may be less effective in rural communities that have high levels of government mistrust, and they need to be 

considered carefully so they do not appear coercive. Smaller incentives may work better than bigger incentives. One size does not 

fit all, and it’s important to tailor incentives to the needs of each community. Some examples of rural-focused incentives include 

free fishing/hunting licenses, state fair tickets, park passes, or gas gift cards.

Example: The Governor of Minnesota implemented a vaccination rewards program including free fishing licenses, state fair 

tickets, baseball tickets, and national park passes.

Strategy 6

School-Located Vaccination Programs

School-located vaccination programs are events held at a school campus to remove logistical barriers and increase vaccine 

uptake. These can be open to students only, or offered to faculty, families, and the greater community. 

Rural Consideration

In rural communities, schools can be a particularly important access point to increase access to COVID-19 vaccination for staff, 

students, their families, and the wider community. School nurses may be especially trusted by rural families if they do not regularly 

see other primary healthcare providers.

Example: The Eatonville School District in rural Washington State partnered with a local pharmacy to vaccinate students 12-

15 years old at the local middle school. 
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Strategy 7

Home-Delivered Vaccinations

Home-delivered vaccination efforts reach populations where they are; traditionally used when barriers to transportation and 

access exist.

Rural Consideration

To meet the challenges that many people in rural areas face in accessing health services, it can be helpful to offer home-delivered 

vaccination, especially for older adults, people with disabilities, or those who lack transportation. If rural residents don’t want their 

neighbors to know that they are getting vaccinated, it can be helpful to pair home-delivered vaccination with other health service 

offerings.

Example: A husband and wife physician team travels hours to deliver vaccines to rural residents in East Texas. They pair 

vaccines with other internal medicine services. 

Strategy 8

Workplace Vaccinations

A vaccination event held on-site at a workplace to remove logistical barriers and create norms. This can be open to employees 

only or extended to family members or the greater community.

Rural Consideration

Workplace vaccinations help address barriers to accessing COVID-19 vaccination at health services. There are many factories, 

and food processing plants in rural areas, which are ideal locations for worksite vaccination programs. It is also possible to bring 

vaccinations out to agricultural fields to vaccinate farmworkers.

Some workers may not wish to make their vaccination status known, so workplace vaccination events may require adjustments 

to protect privacy. For example, larger employers could offer vaccines at the occupational health clinic instead of in a more 

visible location in the facility. Smaller employers can help workers to get appointments at local pharmacies and help facilitate 

transportation. Regardless of employer size, it is important to consider whether language needs or immigration status of workers 

might make workers hesitant to attend workplace vaccination events.

Example: Regence Health Plans partnered with Medical Teams International to bring COVID-19 vaccines to migrant 

farmworkers in rural Oregon. 
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Strategy 9

Vaccination Requirements

Vaccination requirements are policies that require employees, students, or patrons to be vaccinated and provide proof of 

vaccination to comply.

Rural Consideration

Many rural residents place a high value on personal freedom, so there may be strong resistance to vaccination requirements. 

Employers, schools, public events, and restaurants that will be putting requirements in place should plan for regular discussions to 

answer questions and educate people prior to the implementation of any requirements. 

Example: Tyson Foods, which operates many plants in rural areas, required its entire U.S. workforce to be vaccinated by 

November 1, 2021. They implemented a comprehensive education, engagement, and incentive program during the months 

leading up to the requirement. In addition, Tyson received positive feedback from staff who say the mandate makes them feel 

safer.

Strategy 10

Effective Messages Delivered 

by Trusted Messengers

Effective messages are messages that have undergone testing with the intended population and were shown to produce 

the desired outcome. Trusted messengers are people seen as credible sources of information by specific populations. Trusted 

messengers can be trained to be vaccine ambassadors and may include experts. 

Rural Consideration

Effective messages used in rural areas can incorporate rural values (e.g., resilience, personal freedom, neighborliness, family) 

and be tailored to address the reasons for low vaccine confidence in the community. Using images that reflect diverse rural 

experiences can increase the acceptability of materials. Messages should be written at the appropriate reading level (e.g., 6th 

grade or lower) and in preferred languages.

In some rural areas, trusted messengers like healthcare providers and faith leaders may be reluctant to promote vaccination. 

In this case, it may be necessary to think creatively about recruiting other types of messengers. Examples could include school 

staff, pharmacists, veterinarians, agricultural extension agents, community-based organizations, Farm Board leaders, or 4-H 

club members. Rural librarians can also serve as trusted messengers, in addition to helping rural residents to access vaccine 

information and internet services. 

Example: In Panola, Alabama, a trusted resident and the county commissioner went door-to-door to persuade other 

residents to get vaccinated, approaching conversations with kindness and compassion and addressing personal fears and 

concerns, resulting in 94% of adults getting vaccinated. 
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Strategy 11

Provider Recommendations

Provider recommendation refers to healthcare professionals suggesting that a patient receive a COVID-19 vaccination. 

Rural Consideration

Providers in rural areas often serve a smaller population than those in metropolitan areas. Therefore, recommending the vaccine 

may make them feel like a lone voice if their communities strongly oppose vaccination. Working with community-based partners 

who interface with patients can help ensure cohesive messaging in communities. Community health workers can serve as an 

effective bridge between providers and rural residents.

Example: A network of community partners employed community health workers to promote COVID-19 vaccination in 32 

rural counties in Kentucky and West Virginia. 

Strategy 12

Combating Misinformation

Tactics used to address and dismantle misinformation and disinformation. Misinformation refers to the sharing of false 

information and disinformation refers to information that is deliberately misleading and intended to manipulate a narrative.

Rural Consideration

In rural areas, misinformation may circulate more via word of mouth than on the internet. Identifying the various sources of 

misinformation can be an important step to addressing misinformation. 

To address misinformation circulating via word of mouth, rural vaccine ambassadors can work with trusted messengers, training 

them to have one-on-one conversations as necessary. Local health departments can work with their County Extension office for 

highly localized information and expert advice and can partner with local newspapers and radio to ensure accurate information is 

being disseminated by local, trusted sources. 

Example: In response to COVID numbers going up in Walker County, Texas, a local doctor and a radio station teamed up 

against misinformation about COVID-19 vaccine.