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Explaining the U.S. rural disadvantage in COVID-19 case and death rates during the Delta-Omicron surge: The role of politics, vaccinations, population health, and social determinants

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  • Jones, Malia
  • Bhattar, Mahima
  • Henning, Emma
  • Monnat, Shannon M.

Abstract

The Delta-Omicron wave of the COVID-19 pandemic (Wave 4) in the United States occurred in Fall of 2021 through Spring of 2022. Although vaccinations were widely available, this was the deadliest period to date in the U.S., and the toll was especially high in rural areas, exacerbating an existing rural mortality penalty. This paper uses county-level multilevel regression models and publicly available data for 47 U.S. states and the District of Columbia. We describe differences in COVID-19 case and mortality rates across the rural-urban continuum during Wave 4 of the COVID-19 pandemic. Using a progressive modeling approach, we evaluate the relative contribution of a range of explanatory factors for the rural disadvantage we observe, including: pre-pandemic population health composition, vaccination rates, political partisanship, socioeconomic composition, access to broadband internet rate, and primary care physicians per capita. Results show that rural counties had higher observed burdens of cases and deaths in Wave 4 compared to more urban counties. The most remote rural counties had Wave 4 COVID-19 mortality rates 52% higher than the most urban counties. Older age composition, worse pre-pandemic population health, lower vaccination rates, higher share of votes cast for Donald Trump in the 2020 Presidential election, and lower socioeconomic composition completely explained the rural disadvantage in reported COVID-19 case rates in Wave 4, and accounting for these factors reversed the observed rural disadvantage in COVID-19 mortality. In models of mortality rate, Trump vote share had the largest effect size, followed by the percentage of the population age 50 or older, the poverty rate, the pre-pandemic mortality rate, the share of residents with a 4-year college degree, and the vaccination rate. These findings add to a growing literature describing the disproportionate toll of the COVID-19 pandemic on rural America, highlighting the combined effect of multiple sources of rural disadvantage.

Suggested Citation

  • Jones, Malia & Bhattar, Mahima & Henning, Emma & Monnat, Shannon M., 2023. "Explaining the U.S. rural disadvantage in COVID-19 case and death rates during the Delta-Omicron surge: The role of politics, vaccinations, population health, and social determinants," Social Science & Medicine, Elsevier, vol. 335(C).
    • Handle: RePEc:eee:socmed:v:335:y:2023:i:c:s0277953623005373
    DOI: 10.1016/j.socscimed.2023.116180
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    References listed on IDEAS

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    1. Shana Kushner Gadarian & Sara Wallace Goodman & Thomas B Pepinsky, 2021. "Partisanship, health behavior, and policy attitudes in the early stages of the COVID-19 pandemic," PLOS ONE, Public Library of Science, vol. 16(4), pages 1-13, April.
    2. Cossman, J.S. & James, W.L. & Cosby, A.G. & Cossman, R.E., 2010. "Underlying causes of the emerging nonmetropolitan mortality penalty," American Journal of Public Health, American Public Health Association, vol. 100(8), pages 1417-1419.
    3. Theodore Samore & Daniel M T Fessler & Adam Maxwell Sparks & Colin Holbrook, 2021. "Of pathogens and party lines: Social conservatism positively associates with COVID-19 precautions among U.S. Democrats but not Republicans," PLOS ONE, Public Library of Science, vol. 16(6), pages 1-26, June.
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    1. A. Jerrod Anzalone & Michael T. Vest & Makayla E. Schissel & Bradley Price & William B. Hillegass & Ronald Horswell & San Chu & Clifford J. Rosen & Lucio Miele & Susan L. Santangelo & Gordon S. Smith , 2025. "Higher mortality following SARS-CoV-2 infection in rural versus urban dwellers persists for two years post-infection," Nature Communications, Nature, vol. 16(1), pages 1-18, December.
    2. Xiaowei Zhuang & Van Vo & Michael A. Moshi & Ketan Dhede & Nabih Ghani & Shahraiz Akbar & Ching-Lan Chang & Angelia K. Young & Erin Buttery & William Bendik & Hong Zhang & Salman Afzal & Duane Moser &, 2025. "Early detection of emerging SARS-CoV-2 Variants from wastewater through genome sequencing and machine learning," Nature Communications, Nature, vol. 16(1), pages 1-12, December.
    3. Ash, Ramsey W. & Carpenter-Song, Elizabeth & Sosin, Anne N. & Moen, Erika L. & Gunn, Christine, 2025. "The role of place-based consciousness in COVID-19 vaccine hesitancy: A survey analysis across rural and urban subgroups in the U.S," Social Science & Medicine, Elsevier, vol. 373(C).

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