With the COVID-19 pandemic raging in the United States, rural Americans find themselves trapped in a whirlwind of misinformation and distrust as they seek answers for questions like the following:
“Is the pandemic really as bad as the media portrays?”
“Why should I wear a mask when I spend most of my time working away from other people?”
“How can I know this vaccine is safe when it was developed in such a short period of time?”
As a result, people living in rural America are some of the most vaccine-hesitant and mask-resistant populations, and are more likely to believe the severity of the pandemic is exaggerated. If policymakers and public health leaders wish to sway rural residents towards COVID-19 vaccination, they’ll need to start locally by engaging with primary care providers and other community leaders.
Focus on trust
In times of inconsistent, disparately deployed relief from state and federal programs, rural Americans are increasingly relying on their local community leaders to meet their respective population health and economic needs.
Despite the higher rates of vaccine hesitancy, an overwhelming majority (86%) of people living in rural areas still place a high level of trust in their healthcare providers to give them reliable, evidence-based information. This trend appears to hold in both rural and urban settings and across racial/ethnic groups, even for the most vaccine-hesitant individuals.
This trust in healthcare providers may be attributed to the tight-knit culture within many rural regions. A major misconception about rural communities is that low population density results in social isolation, though in reality, it’s often the opposite. For instance, rural residents are often found enjoying a long chat with their community pharmacist while picking up prescriptions or catching up with their primary care physician on medical and non-medical topics after bumping into each other at the grocery store. Rural providers are deeply rooted in their local communities, and they often invest more time volunteering in the community compared to their urban counterparts.
The importance of trust cannot be overemphasized, particularly for individuals who trust their providers to deliver evidence-based COVID-19 information but are otherwise vaccine-hesitant. This is an important area where rural providers can sway patients towards vaccination, bridging necessary gaps to ultimately reach herd immunity.
Trust is also a key factor for predominately Black, Latinx, and Indigenous communities, many of whom are wary of the COVID-19 vaccine due to their histories of being exploited and oppressed by government and medical entities, and also due to their being disproportionately impacted by COVID-19. Rural America today is characterized by a growing percentage of BIPOC (Black, Indigenous, and People of Color), emphasizing the importance of understanding the intersectionality of factors that play into distrust of medical and governmental institutions.
Success story: West Virginia
The state of West Virginia serves as an important example of the “start local” approach for COVID-19 vaccination in rural regions. With West Virginia’s largely rural population, state governmental leaders felt that contracting with large pharmacy chains (as many other states have been doing) would not be as successful logistically or politically for vaccination campaigns.
Instead, West Virginian governmental leaders collaborated with independent community pharmacists throughout the state who’d already established good rapport and relationships with local residents. This collaboration accelerated the process of scheduling appointments and successfully vaccinating an increasing majority of the state’s population, including residents living in long-term care facilities. As a result, West Virginia currently has one of the highest vaccination rates in the country.
Community-based participatory model: the pathway forward
West Virginia marks an excellent example of investing resources in established community entities, utilizing this local trust to improve vaccination outcomes. To replicate this model, government entities must initiate such partnerships and also open lines of communication for continual assessment and operational review.
Community-based participatory research (CBPR) has emerged as a research framework that foregrounds collaboration of community members, healthcare workers, researchers, and community organizations to improve outcomes and reduce health disparities. Similarly, engaging local residents and organizations throughout the vaccine planning and distribution processes may help to better tailor efforts to address the unique challenges within rural populations, including geographic distance, medical distrust, linguistic barriers, and more.
It’s critical to recognize the diverse community leadership that may also contribute to this endeavor, including faith-based leaders, local business owners, educators, county commissioners, and other trusted community members. Such community leaders will propose innovative ideas to address the unique needs of the community, assist with mobilizing and financing the resources needed for vaccination efforts, and provide the necessary social capital to get people to vaccination sites.
As we seek to address vaccine hesitancy and increase vaccination rates in rural America, we must start local, as we strive for health equity in our rural communities.
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Taylor Zabel is an MD candidate at Harvard Medical School, where he serves as the Junior Lead for the Family Medicine Interest Group. He's also involved with the Student Leadership Committee at the Harvard Center for Primary Care and serves on the Board of Directors for the Kansas Rural Health Association. Taylor previously worked as a Truman-Albright Fellow for the Federal Office of Rural Health Policy and the National Advisory Committee on Rural Health & Human Services.
Tarika Srinivasan is an MD candidate at Harvard Medical School, where she serves on the leadership teams for the Bioethics Interest Group and Global Surgery Student Alliance. At the University of Texas at Austin, she completed a cross-continental charity bike ride with Texas 4000 for Cancer for rural cancer advocacy and worked with grassroots organizations in Central Texas and India to increase uptake of palliative care services and advanced care planning. Tarika was previously a Biomedical Ethics Research Fellow at the Mayo Clinic, where she researched equitable implementation of genomic screening in primary care.
Lily Mirfakhraie is an MD candidate at Harvard Medical School, where she serves as President of the History of Medicine Interest Group and a member of Future Doctors in Politics. She graduated from Yale University in 2019, where she was a founding member of the Rural Students Association and conducted research on healthcare systems in Appalachia.