By: Randall Simpson, Public Health Analyst III
Since the global COVID-19 pandemic reached the United States in January 2020, its impact on our rural communities reveal long-held public health challenges. The first few months of the initial U.S. coronavirus spread focused on large metropolitan areas. We saw higher rates of infection in large cities, like New York City and Boston, compared to areas of low population density in rural regions. By the summer of 2020, though, the increasing prevalence of the virus shifted – 18 of the top 25 COVID-19 hotspots were in non-metropolitan counties and Florida surpassed New York’s daily record of cases in a single day. While 1 in 5 Americans reside in rural counties, the rural population has disproportionate rates of exposure, infection, hospitalization, and mortality related to COVID-19. Several unique features of rural communities increase the risk of coronavirus-related mortality and other long-term health effects.
Older age
Two-thirds of small non-metropolitan counties in the U.S. are categorized as “older-age” counties – counties in which more than 20 percent of the population is age 65 or older. The Centers for Disease Control and Prevention reports that adults ages 65 and older comprise the highest proportion of intensive care admissions and deaths related to COVID-19.
Underlying Medical Conditions
Seventy-five percent of those hospitalized with COVID-19 (regardless of age) have an underlying medical condition. Nearly two-thirds are attributed to just four conditions: obesity, diabetes, hypertension and heart failure. Rural residents are more likely to have a serious chronic health condition that exacerbates the effects of COVID-19, including heart disease, diabetes and obesity, compared to urban counterparts.
Socioeconomic Challenges
Rural residents are more likely to face challenges related to poverty, food insecurity, lack of health insurance, compared to their urban counterparts. These socioeconomic challenges increase the likelihood of COVID-19 infection and hospitalization. For people of color and indigenous people living in rural areas, the likelihood of facing these challenges is even higher. Highly diverse rural communities (in which at least 33 percent of the population are people of color) have had more COVID-19 deaths per capita than less diverse rural communities and are at a greater risk of financial insecurity, poor health literacy and transportation needs than other rural communities. These risk factors dramatically impact the road to recovery for this historically disenfranchised population.
Access to Critical Care Resources
Financial pressures have led to the closure of over 130 rural hospitals in the U.S. since 2010, with 15 of those closing since March 2020. This highlights the struggles rural healthcare has faced in recent years in providing care with limited availability of medical personnel, resources and services. Barriers to COVID-19 testing, treatment and vaccination are compounded not only by service barriers, but by environmental and socioeconomic factors including travel and transportation costs, care coordination, and un- or under-insurance.
Low Confidence in Public Health Efforts
Rural communities have higher rates of vaccine hesitancy than their urban or suburban counterparts. Rural residents are twice as likely to say they will “definitely not” be vaccinated against COVID-19 and are more likely to see getting vaccinated as a “personal choice,” according to survey data from the Kaiser Family Foundation (KFF). Quickly-spread misinformation and unproven claims concerning the COVID-19 virus and the vaccines have fueled skepticism about the seriousness of the pandemic and the efficacy of the vaccines.
Understanding the key factors that contribute to the disproportionate impact of COVID-19 may also give greater insight into confronting these challenges. To address vaccine hesitancy and misinformation, collaborative partnerships with community stakeholders and trusted messengers in the community could contribute to an increase in vaccine confidence and uptake. For example, a majority (86 percent) of rural Americans from the KFF survey place a high level of trust in their own doctor or health care providers to provide reliable, evidence-based information. Effective, tailored messaging delivered by trusted stakeholders can increase patient confidence. The use of telehealth and digital resources, for example, bridge the gap in healthcare access based on geographic location. Providing rural stakeholder support with local and community partnerships ensures access to high-quality care with evidence-based guidance.
The factors that contribute to the COVID-19 impact in rural communities existed well before the pandemic. However, the current situation has really put a spotlight on rural health disparities. Addressing these factors could have key implications for long-term outcomes for the pandemic and beyond.