Quantifying Disparities in COVID-19 Vaccination Rates by Rural and Urban Areas: Cross-Sectional Observational Study
Authors: Dong Wenyong , Miao Yudong , Shen Zhanlei , Zhang Wanliang , Bai Junwen , Zhu Dongfang , Ren Ruizhe , Zhang Jingbao , Wu Jian , Tarimo Clifford Silver , Ojangba Theodora , Li Yi 
Published: May 2024

Background
Vaccination plays an important role in preventing COVID-19 infection and reducing the severity of the disease. There are usually differences in vaccination rates between urban and rural areas. Measuring these differences can aid in developing more coordinated and sustainable solutions. This information also serves as a reference for the prevention and control of emerging infectious diseases in the future.

Objective
This study aims to assess the current coverage rate and influencing factors of COVID-19 (second booster) vaccination among Chinese residents, as well as the disparities between urban and rural areas in China.

Methods
This cross-sectional study used a stratified random sampling approach to select representative samples from 11 communities and 10 villages in eastern (Changzhou), central (Zhengzhou), western (Xining), and northeast (Mudanjiang) Mainland China from February 1 to February 18, 2023. The questionnaires were developed by experienced epidemiologists and contained the following: sociodemographic information, health conditions, vaccine-related information, information related to the Protective Motivation Theory (PMT), and the level of trust in the health care system. Vaccination rates among the participants were evaluated based on self-reported information provided. Binary logistic regression models were performed to explore influencing factors of vaccination among urban and rural participants. Urban-rural disparities in the vaccination rate were assessed using propensity score matching (PSM).

Results
A total of 5780 participants were included, with 53.04% (3066/5780) being female. The vaccination rate was 12.18% (704/5780; 95% CI 11.34-13.02) in the total sample, 13.76% (341/2478; 95% CI 12.40-15.12) among the rural participants, and 10.99% (363/3302; 95% CI 9.93-12.06) among the urban participants. For rural participants, self-reported health condition, self-efficacy, educational level, vaccine knowledge, susceptibility, benefits, and trust in the health care system were independent factors associated with vaccination (all P＜.05). For urban participants, chronic conditions, COVID-19 infection, subjective community level, vaccine knowledge, self-efficacy, and trust in the health care system were independent factors associated with vaccination (all P＜.05). PSM analysis uncovered a 3.42% difference in vaccination rates between urban and rural participants.

Conclusions
The fourth COVID-19 vaccination coverage rate (second booster) among the Chinese population was extremely low, significantly lower than the previous vaccine coverage rate. Given that COVID-19 infection is still prevalent at low levels, efforts should focus on enhancing self-efficacy to expand the vaccine coverage rate among the Chinese population. For rural residents, building awareness of the vaccine’s benefits and improving their overall health status should be prioritized. In urban areas, a larger proportion of people with COVID-19 and patients with chronic illness should be vaccinated.