KFF COVID-19 Vaccine Monitor: Differences in Vaccine Attitudes Between Rural, Suburban, and Urban Areas

Key Findings

• Throughout the past year, the KFF COVID-19 Vaccine Monitor has provided a look into how the coronavirus pandemic has impacted people living in different areas of the U.S., including analyses of the vaccine intentions of rural residents. This latest report draws on two surveys conducted in November (before news of the omicron variant) – one of adults and one of parents – and shows that those living in different types of communities hold very different views of COVID-19 vaccines, particularly when it comes to children. In addition, parents living in different community types report getting different levels of information regarding COVID-19 vaccines from their children’s schools and pediatricians.
• Rural and suburban adults continue to lag somewhat behind those living in urban areas in terms of vaccine uptake. As of November, eight in ten urban residents (79%) say they have gotten at least one dose of a COVID-19 vaccine compared to seven in ten suburban adults and 67% of rural adults. One in five (21%) of those living in rural areas and one in six (16%) of those living in suburban areas say they will “definitely not” get a COVID-19 vaccine, at least twice the share of urban residents who say the same (8%).
• The rural-urban gap in vaccination intention is even larger when it comes to children. About half of rural parents say they will definitely not get their 12-17 year-old children or their 5-11 year-old children vaccinated for COVID-19. A quarter of rural parents (26%) say they have vaccinated their 12-17 year-old, compared to nearly two-thirds of parents in urban areas (64%) and about half of those living in suburban areas (47%) areas. One in ten rural parents and a similar share of suburban parents (14%) report that their 5-11 year-old child is vaccinated, compared to about a quarter (23%) of urban parents who say the same.
• Four in ten parents overall say they have spoken to their child’s pediatrician about the COVID-19 vaccine. Yet, those living in rural areas are more likely than those living in suburban or urban areas to report their child’s pediatrician did not recommend the vaccine for their child. More than one-third of rural parents say they had a conversation with their child’s health care provider and the provider did not recommended they get their child vaccinated (compared to around one in ten urban and one in seven suburban parents).
• Around half of all parents say their child’s school has provided them with information on how to get a COVID-19 vaccine for their child, but smaller shares of rural than urban parents say their child’s school has encouraged parents to get their child vaccinated (36%) compared to parents in suburban (44%) and urban (50%) areas.

• Views on COVID-19 vaccine mandates also differ across communities. A majority of urban residents support the federal government requiring large employers to either have their employees be vaccinated or get tested weekly, while rural and suburban residents are more divided on this Biden administration guideline. In addition, most workers living in urban areas say their employer already requires employees to be vaccinated for COVID-19 or that they support such a requirement, while six in ten rural workers and half of suburban workers do not want their employer to issue a vaccine mandate. Opposition to schools requiring eligible students to be vaccinated for COVID-19 is also higher among rural and suburban parents compared to urban parents.
• While differing partisanship and demographics may contribute to differences in vaccine attitudes between people living in urban, suburban, and rural communities, multivariate analysis suggests that there is a relationship between community type and COVID-19 vaccine uptake that exists even when controlling for party identification and demographics. Using a statistical technique called logistic regression, we find that rural and suburban adults are less likely than urban adults to report being vaccinated for COVID-19, even after controlling for age, race, ethnicity, education, income, party identification, and ideology.

Rural and Suburban Residents Lag Behind Urban Residents In COVID-19 Vaccination

Since around May 2021, adults living in rural areas (and to a lesser extent, those living in suburban areas) have lagged behind those living in urban areas in terms of self-reported COVID-19 vaccine uptake. As of November 2021 (before news of the omicron variant), eight in ten urban residents (79%) say they have gotten at least one dose of a COVID-19 vaccine compared to seven in ten suburban adults and 67% of rural adults.

At the same time, rural adults have consistently been among the groups most likely to express strong resistance to getting a COVID-19 vaccine. As of November, one in five of those living in rural areas (21%) and one in six suburban residents (16%) say they will “definitely not” get a COVID-19 vaccine, at least twice the share of urban residents who say the same (8%).

Rural and suburban residents also view vaccine safety slightly differently than their urban counterparts. While majorities across these three groups are confident the COVID-19 vaccines are safe for adults, smaller shares of rural residents (65%) and suburban residents (70%) believe this compared to urban residents (79%).

At least some of the differences in vaccination intention and uptake by community type may be due to underlying demographic and political differences between people living in different communities. Adults living in rural areas are more likely than those living in urban to identify as Republicans (33% vs. 16%), which might partially explain the differing vaccination intentions given that Republicans have been slower to embrace COVID-19 vaccines than Democrats. However, rural residents are also older on average than urban residents (33% vs. 17% are ages 65 and older), which would suggest potentially higher uptake in rural areas since older adults report getting vaccinated at higher rates than younger adults.

Multivariate analysis suggests that despite these differences between communities, there is a relationship between community type and COVID-19 vaccine uptake that exists even when controlling for partisanship and demographics. Using a statistical technique called logistic regression, we find that rural and suburban adults are less likely than urban adults to report being vaccinated for COVID-19, even after controlling for age, race, ethnicity, education, income, party identification, and ideology.

Booster Intentions

Despite significant differences in initial COVID-19 vaccination uptake between community types, there was no significant difference in uptake or intention for booster shots as of November, prior to news of the omicron variant. As recommendations for all adults to get boosted initially got made, fully vaccinated rural and suburban residents acted like their urban counterparts in terms of booster uptake, with 14% of all rural adults, 14% of all suburban adults, and 18% of all urban adults reporting having received a booster shot after being fully vaccinated, according to the November COVID-19 Vaccine Monitor.

Half of rural and suburban adults say they are vaccinated and either already have received a booster dose or plan to get one, compared to about six in ten (57%) of those living in urban areas.

Rural Parents Report Lower COVID-19 Vaccine Uptake Among Their Children Compared To Urban And Suburban Parents

Rural parents report lower intent to vaccinate both children 12-17 years old, who have been eligible for vaccinations for the past several months, as well as 5-11 year-olds who just became eligible last month, with about half of rural parents saying they will definitely not vaccinate their child in either age group, before news of the Omicron variant became widespread.

A quarter of rural parents (26%) say they have gotten their 12-17 year-old vaccinated, compared to nearly two-thirds of parents in urban areas (64%) and about half of those living in suburban areas (47%). About half of rural parents (53%) say they definitely won’t get their 12-17 year-old vaccinated, compared to 29% of suburban parents and 20% of urban parents.

For children ages 5-11, one in ten rural parents and a similar share of suburban parents (14%) say their child has received at least one dose of a COVID-19 vaccine, compared to about a quarter (23%) of urban parents of children ages 5-11. An additional 12% of suburban parents say they will get their child 5-11 vaccinated right away, while about a third say they want to wait and see before they make that decision (36%). On the other hand, half (49%) of rural parents say they definitely won’t get their 5-11 year-old vaccinated compared to 22% of urban parents and 27% of suburban parents.

It is notable that these differing intentions to vaccinate children for COVID-19 do not appear to reflect broader differences in attitudes towards vaccines generally between parents living in different types of communities. Nine in ten parents across community types (88% of urban parents, 90% of suburban parents, and 92% of rural parents) say they normally keep their children up to date with recommended childhood vaccines such as the MMR vaccine, while about one in ten in each type of community say they have ever delayed or skipped some childhood vaccines for their children.

There are not major differences in parents’ level of concern about their child getting sick from COVID-19 based on the type of community in which they live. Less than half of rural parents (44%) and suburban parents (46%) say they’re worried their child will get seriously sick from the coronavirus, as do 55% of urban parents.

Concerns ABOUT covid-19 vaccine SAFETY for children

Compared to their urban and suburban counterparts, rural parents are less likely to say they are confident that the COVID-19 vaccines are safe for children, which may be one driver of why they are more likely to say they won’t get their children vaccinated. About one-third (35%) of rural parents say they are very or somewhat confident the vaccines are safe for children ages 12-17, compared to 50% of suburban parents and 62% of urban parents. Around three in ten rural parents (29%) are confident that vaccines are safe for children between the ages of 5-11, compared to 43% of suburban and 50% of urban parents who say the same.

Rural parents also appear to be more concerned about the vaccine than the virus itself when it comes to their children. Six in ten rural parents think that getting vaccinated would be a bigger risk to their 12-17 year old teen’s health than getting COVID, even though scientific bodies have concluded the opposite is the case. Majorities of suburban and urban parents say they believe becoming infected poses a bigger risk to their 12-17 year-old. Similarly, about half (53%) of rural parents think the vaccine is a bigger risk to their 5-11 year-olds’ health than getting infected with COVID, compared to about half of suburban parents (52%) and nearly seven in ten urban parents (69%) who believe the virus poses a greater risk to their younger children than the vaccine.

While vaccine safety concerns are higher among rural parents compared to urban parents, the opposite is true when it comes to some concerns that might indicate an access barrier to getting their children vaccinated. Among parents of unvaccinated children, urban parents are more likely than rural parents to say they are concerned about needing to take time off work to get their child vaccinated (38% vs. 21%). Three in ten suburban parents are concerned about taking time off work to get their child vaccinated for COVID-19. Some parents across community types are also concerned about other access issues including not being able to get their child vaccinated from a place they trust (15% rural, 23% suburban, 24% urban) and having difficulty traveling to a place to get their child vaccinated (14% rural, 17% suburban, 21% urban).

the role of pediatricians

Pediatricians are the top trusted source for information about the COVID-19 vaccines for children among parents across community types, with around three-quarters of each group saying they trust their child’s pediatricians a great deal or a fair amount. While majorities of urban and suburban parents also trust their local health department and the CDC, rural parents are somewhat less trusting of some of these sources (50% trust their local public health department and 45% trust the CDC). Fewer parents say they trust their child’s school or daycare or other parents they know for reliable information on the COVID-19 vaccine for children.

Similar shares of parents across community types say they have spoken to their child’s pediatrician about the COVID-19 vaccine, with more than half of parents saying they had not yet talked to a health care provider about the vaccine for their child as of mid-November. However, there are big divides between community types in terms of whether parents say their child’s pediatrician recommended their child get vaccinated or not. More than one-third of rural parents of both teens and younger children say their child’s health care provider did not recommend they get their child vaccinated.

Among rural parents of teenagers, 37% say they talked to their child’s health care provider about the vaccine and the provider did not recommend the vaccine for their teen, compared to 14% of suburban parents and 8% of urban parents who said the same. Similarly, 35% of rural parents of children ages 5-11 say they spoke to their child’s health care provider, and the health care provider did not recommend the vaccine for their younger child (compared to 13% suburban parents and 8% urban parents). By contrast, a larger share of parents living in urban areas compared to rural areas say their child’s health care provider recommended vaccination for both their 12-17 year-old (33% vs. 18%) and their 5-11 year-old (25% vs. 12%).

What is unclear from the survey data is whether parents who say their pediatrician did not recommend that their child get vaccinated for COVID-19 felt the provider was providing an active recommendation against vaccinating their child, or whether they did not provide a recommendation one way or the other. Either way, this differential communication from providers may be one contributing factor to the fact that rural parents appear less willing to get their child vaccinated than those living in urban and suburban settings.

Survey findings also indicate that rural parents are more likely than urban or suburban parents to report having conversations with health care providers that made them less willing to vaccinate their child for COVID-19. Among rural parents of children ages 5-17, about equal shares report having conversations with their child’s health care provider that make them more willing (12%) and less willing (14%) to get their child vaccinated. For urban and suburban parents, conversations with their pediatricians were more like to make them more willing (14% suburban, 17% urban) than less willing (1% suburban, 2% urban) to get their child vaccinated. As of November, about one in five in each group say their conversation with a health care provider did not have an impact on their decision about vaccinating their child, while at least half say they did have not talked to their child’s pediatrician about the vaccine yet.

THE ROLE OF SCHOOLS

Around half of all parents across community types say their child’s school has provided them with information on how to get a COVID-19 vaccine for their child. However, smaller shares of rural parents say their child’s school has encouraged them to get their child vaccinated (36%) compared to parents in urban areas (50%). This difference may play an important role in vaccine uptake for children across communities, as we have previously reported that parents whose children’s schools encouraged vaccination are more likely than those whose schools did not encourage vaccination to say their child was vaccinated for COVID-19.

Views Of Vaccine Mandates Across Communities

In addition to different attitudes towards the COVID-19 vaccines themselves, rural, suburban, and urban residents have different views on vaccine mandates in workplaces and in schools. A majority of urban residents support the federal government requiring large employers to either have their employees be vaccinated or get tested weekly, while rural and suburban communities are more divided on this Biden administration guideline. Six in ten urban residents (62%) say they support the requirement, while suburban and rural residents are split with about half supporting the requirement (47% and 46%, respectively) and opposing the requirement (51%, respectively).

While the federal mandate for large employers is stalled due to court challenges, many private businesses have already begun requiring their workers to get vaccinated. About a quarter of workers in rural areas and suburban areas say their employer has required them to get vaccinated for COVID-19, compared to one-third of urban workers (35%). Rural workers are the most likely to oppose their own employer instituting a mandate with 61% saying they do not want their employer to require them to get vaccinated, similar to the share of suburban workers (50%) and larger than the share of urban (41%) workers who say the same.

In addition to differing views on vaccine workplace mandates, rural, suburban, and urban parents have differing views on whether schools should require all eligible students to be vaccinated for COVID-19. While majorities of parents of school aged children (ages 5-17) across community types say schools should not require all eligible students to be vaccinated for COVID-19, opposition is much stronger among parents living in rural areas (82%) and suburban areas (69%) compared to urban areas (57%).