Date of Award

Fall 2023

Document Type

Open Access Dissertation


Health Services and Policy Management

First Advisor

Peiyin Hung


Background Vaccination remains a cornerstone of public health, significantly contributing to the prevention and control of infectious diseases. During the COVID-19 pandemic, vaccine development was critical to prevent new SARS-Cov-2 infections. However, COVID-19 vaccination uptake among racial and ethnic minority populations and rural residents in the United States (US) lags behind their urban non-Hispanic White counterparts. Underlying causes of these disparities are unclear, but vaccine hesitancy, access to care barriers, and structural racism may be to blame. Such barriers may vary by residential urbanicity, leading to different racial/ethnic disparities in rural and urban America. Understanding the variations in vaccine uptake and the reasons for non-vaccination across diverse racial, ethnic, and rural populations is essential to inform the development of tailored interventions to address potential gaps in population immunity and infection risks for future pandemics. Methods This research was conducted in two parts; the first being a nationally representative cross-sectional study using data derived from the Understanding America Study collected between Dec 2020-Jan 2021 (Wave 21) and Nov 2022 – Jan 2023 (Wave 33). A total of 9,589 participants from the 50 US states and Washington, DC responded to at least one of these surveys, and of them, 7,540 participants responded to Wave 33. Differences in vaccination initiation by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other-race) and geographic location (urban, suburban, rural) were examined using weighted multivariable logit model with two-way interactions of race/ethnicity and residential urbanicity, controlling for age, gender, marital status, education, employment status, income, health insurance, number of household residents, history of COVID-19 diagnosis, and state of residence. The second section was a longitudinal study and analyzed data from the Understanding America Study collected between Feb-Mar 2021 (wave 25), and Nov 2022-Jan 2023 (wave 33). A total of 3,913 national participants remained in the study consistently across waves 25-33, of which 2,610 had not been vaccinated for COVID-19 at the baseline (Feb 2021, wave 25). Survey respondents reported on reasons for non-vaccination (e.g., personal preference, vaccine shortage, transportation barriers). We categorized the reasons under WHO’s 3C Vaccine Hesitancy model with constructs of Complacency, Confidence, and Convenience to identify patterns of reporting constructs over time and by race/ethnicity, and residential urbanicity. Three phases of analyses were conducted using descriptive and Chi-square tests with Bonferroni multiple comparison corrections: 1) baseline (Feb-Mar 2021, wave 25) comparisons for non-vaccination reasons between those eventually getting vaccinated and those remaining unvaccinated between waves 25 and 29; 2) temporal changes in reasons among the unvaccinated between waves 25 and 29; 3) differences of changes in reasons for non-vaccination by race/ethnicity [non-Hispanic White, non-Hispanic Black, Hispanic, other-race] and residential urbanicity [urban, suburban, rural] among those remaining unvaccinated. All analyses incorporated complex survey weights to represent the national population. Findings As of Jan 2023, of the 7,540 participants (62.05% non-Hispanic White, 11.90% non-Hispanic Black, 17.04% Hispanic, and 8.82% others; 13.60% rural, 50.73% suburban, and 36.78% urban), 1,407 (23.48%) remained unvaccinated, with substantial variations in vaccination initiation by rural/urban status and race/ethnicity. Compared to the non-Hispanic White group, in rural areas, the non-Hispanic Black group was more likely to initiate vaccination (predicted probability = 62.25%, 95% CI = 58.16% and 66.35% vs. 86.53%, 95% CI = 74.96% to 98.10%), whereas in urban areas, vaccination initiation rates between non-Hispanic Whites and non-Hispanic Blacks were similar. The Hispanic group in suburban and urban areas was more likely to initiate vaccination than the non-Hispanic White group (predicted probability = 78.98, 95% CI = 75.23% to 82.74% vs. 72.98%, 95% CI = 70.68% to 75.28% and predicted probability = 86.68%, 95% CI = 82.78% to 90.58% vs. 82.34%, 95% CI = 79.98% to 84.70% respectively) but the vaccination rates of Hispanic and non-Hispanic white groups in rural areas were similar. Of the 2,610 participants without COVID-19 vaccination in Feb 2021, a total of 1,651 (59.53%) initiated vaccination between Feb – Jul 2021, while 959 (40.47%) never got vaccinated. Reasons for those never vaccinated were very different from those who became vaccinated eventually. Despite the increased vaccination uptake over time, the vaccination uptake increased mostly among those that did not experience confidence or complacency as barriers to vaccination in previous waves. Complacency levels increased considerably in the urban non-Hispanic White group between Feb-Mar 2021 and Jun-Jul 2021 (59.52% to 63.04%) and suburban Hispanic group (50.84% to 64.24%). On the other hand, reporting of complacency reduced in the urban non-Hispanic Black and Hispanic groups (66.46% vs. 49.83% and 79.52% vs. 60.97%). Initially, vaccine access was a barrier to uptake especially for the non-Hispanic other (41.69%) and suburban (26.16%) groups but, overtime became negligible as access improved. While a majority of the groups exhibited increased confidence in the vaccines available, some groups including the rural and suburban Hispanic groups, and the urban non-Hispanic White group were increasingly concerned about the vaccines over time (rural Hispanic group [0% vs. 11.23%], suburban Hispanic group [28.30% vs. 35.88%], urban non-Hispanic White group [20.26% vs. 34.88%]. Conclusions Racial disparities in COVID-19 vaccination initiation differ by residential location and reasons for non-vaccination differ among individuals who eventually got vaccinated and those who never were vaccinated during the study period, as well as by race/ethnicity and rural-urban status, highlighting the need to tailor educational campaigns and outreach efforts to address specific concerns of different subgroups. While access to vaccines has improved over time, belief systems and safety and effectiveness concerns continue to remain barriers to vaccination uptake. Further research is needed to identify strategies to dispel doubts on the safety and effectiveness of the COVID-19 vaccine.


© 2024, Shiba Simon Bailey

Available for download on Wednesday, December 31, 2025

Included in

Public Health Commons