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Nebraska's gap between urban and rural vaccination is widest in nation

Nebraska's gap between urban and rural vaccination is widest in nation

The billboards put up on rural highways in Nebraska’s Panhandle make a direct vaccination pitch to the region’s ranchers.

“You wouldn’t skip vaccinating your cattle,” say the signs featuring two head of black Angus. “Don’t skip getting vaccinated for COVID-19.”

Talk about herd immunity.

But despite such targeted messaging, Nebraska’s rural communities have a long way to go to reach the levels of vaccination needed to end the COVID-19 pandemic.

Vaccination rates in rural Nebraska badly lag those in urban parts of the state. In fact, Nebraska’s rural rates are among the lowest in the region, according to a World-Herald analysis of county vaccination data.

Roughly 40% of Nebraska adults living in rural areas are fully vaccinated, compared with more than 60% of those living in the state’s metro areas.

What’s more, the county-level data submitted to the U.S. Centers for Disease Control and Prevention suggest that Nebraska’s rural-urban vaccination divide is the widest in the nation. And Nebraska’s rural vaccination gap among the vulnerable 65-and-over age group also appears to be the nation’s biggest.

Public health officials say Nebraska’s lagging rural rates are concerning, especially with a more contagious strain of the virus on the rise and fast becoming dominant nationally. The variant first identified in India has already been detected in Omaha and some parts of rural Nebraska.

“Communities that have chosen to not have a higher rate of vaccination are unfortunately setting themselves up to be preyed upon by some of these more transmissible variants,” said Dr. Mark Rupp, an infectious disease expert at the University of Nebraska Medical Center.

Nebraska can take a lesson from neighboring Missouri, whose rural vaccination rates are even lower.

The Delta variant has now rushed into that gap, leaving the Show-Me State with the nation’s highest current case rate and inundating rural hospital wards with COVID-19 patients, all at a time the pandemic is supposed to be ending.

Most of the counties with Nebraska’s lowest vaccination rates can be found in the Panhandle and the Sand Hills — sprawling, sparse grasslands where cattle are plentiful and conservatism and general distrust of government are high. In one Sand Hills county, figures suggest that only 11% of adults have been vaccinated.

“People just do not want to vaccinate overall,” said Meghan Trevino, coordinated services director of the North Platte-based West Central District Health Department. CDC data shows that about 27% of adults in her county are fully vaccinated, a figure that ranks 80th among the state’s 93 counties.

The administration of Gov. Pete Ricketts said in a statement that the governor has consistently recommended that Nebraskans get vaccinated.

“In Nebraska, we believe in personal responsibility,” spokesman Taylor Gage said. “We’re asking Nebraskans to take responsibility for their own health care, and to visit with their doctor about the vaccine and whether it’s right for them.”

The administration detailed efforts that state and local health officials have taken to make shots widely available across the state and to encourage people to get them — including initiatives targeting rural residents.

But some public health officials say the big divide revealed by the analysis shows that there’s room to do more.

Dr. Bob Rauner of Partnership for a Healthy Lincoln, and a Panhandle native, said that given rural Nebraska’s conservative bent, it would help for residents to hear more messages from Republican elected officials as well as trusted local voices like doctors, nurses and clergy.

“Geography is not destiny,” Rauner said.

It’s now been more than six months since the U.S. launched its COVID-19 vaccination campaign, creating hopes of finally ending the deadly pandemic that has claimed more than 2,200 lives in Nebraska and over 600,000 nationally.

Nebraska as a whole has ranked well in getting shots into arms. It’s in the top half of states and better than the U.S. average. It’s also among the best states at vaccinating those 65 and over.

But the statewide rates mask a growing urban-rural divide.

The state’s most populous counties tend to have the highest vaccination rates. Lancaster County has 63% of its 18-and-over population fully vaccinated, followed by Douglas at 62% and Sarpy at 58%.

On the flip side, 11 rural counties have rates under 25%, including McPherson at 11%, Grant and Logan at 16% and Arthur at 17%.

One notable rural exception is Thurston County, home to the state’s Winnebago and Omaha Indian Reservations. It leads the state with its vaccination rate, with almost 67% fully vaccinated.

Grouping counties that are located within metro areas and outside metro areas reveals the wide 60%-40% urban-rural divide on vaccinations. The disparity is even wider among those 65 and older, with 84% of that vulnerable demographic vaccinated in urban counties but only 60% in rural ones.

Of the 873,000 Nebraska adults who were fully vaccinated as of Thursday, county-of-residence data has been collected for about 89% of them. So rates in a number of counties are likely higher than what’s reported.

Because of differences in the degree to which states have collected county-of-residence information, it’s difficult to compare rural and urban rates among all states. Nebraska’s lack of such data is among the highest in the CDC database.

But Nebraska’s rural-urban vaccination gap appears to be the nation’s largest, a product of both above-average urban vaccination rates and lagging rural ones.

Nebraska’s metro area vaccination rate ranks in the top third of the country, exceeding even California’s. But its rural rates are in the bottom third, trailing most neighboring states. Most of the lowest-ranking states are in the South.

Nebraska’s 20-point gap between rural and urban rates is the largest in CDC data, followed by Florida and Missouri.

Iowa has a much smaller rural-urban gap, with a 60% urban vaccination rate and 53% rural. Nationally, the urban-rural gap is 56% to 44%.

The Nebraska Department of Health and Human Services says its vaccination database has a higher level of county-of-origin information than the CDC’s and a urban-rural gap that’s closer to 10%. But the department declined to provide the county-level numbers to support that figure, saying to do so would violate federal medical confidentiality laws.

Regardless, a significant urban-rural divide persists.

A recent survey conducted by UNMC and the state HHS offered insight into the reluctance of some Nebraskans to take the vaccines. In the online survey, respondents were asked whether they intended to get the shots when given the chance.

Safety concerns, potential side effects and lack of trust were the top reasons given by those who were hesitant, said Dejun Su, director of a UNMC center dedicated to reducing health disparities.

The survey likewise showed a rural-urban gap, with rural respondents twice as likely to say they do not intend to get vaccinated as urban ones.

The survey also found higher reluctance based on political affiliation. Thirteen percent of those identifying as Republicans said they did not intend to get vaccinated, compared with just 2% of Democrats.

“We did find a big difference between Republicans and Democrats,” Su said.

The same party disparity is evident in Nebraska’s county vaccination figures.

The percentage of residents in a county who haven’t taken the vaccine tends to hew closely to the county’s percentage of registered voters who are Republicans. Among the state’s 93 counties, the five with the highest percentage of registered Republicans rank 92nd, 93rd, 90th, 88th and 89th in vaccination rate.

It’s difficult to say for sure whether those differences are a reflection of partisan politics or the fact that Republicans just generally tend to be more conservative. But there’s no question that the pandemic, from masks to vaccines, has long been highly politicized.

“Unfortunately, I think it largely breaks down around political viewpoints,” UNMC’s Rupp said of vaccine hesitancy. “One of the saddest things about this whole pandemic has been how polarized and politicized medical and public health issues have become.”

State HHS officials say they used the UNMC survey results to tailor vaccine communications strategies for both rural Nebraska and underserved communities.

Outreach to rural areas has included radio, online and billboard advertising, town hall events and work with partners like the Nebraska Farm Bureau, the Center for Rural Affairs, chambers of commerce and local health departments, spokesperson Olga Dack said.

Online ads in rural Nebraska touted vaccines as “how we get normal life and our freedom back.” The federal government has provided funding to states for such rural vaccination outreach.

Local health departments say they’ve also worked to get accurate information to the people in their area.

The Panhandle Public Health District held a Facebook Live event featuring Dr. James Lawler, a director of UNMC’s Global Center for Health Security, seeking to dispel misinformation on vaccines.

Director Kim Engel said the agency has also encouraged people to talk to their doctors or to friends and loved ones who have taken the vaccine.

Months into the vaccination campaign, access to vaccines is certainly no longer an issue.

“People are as close to vaccines as they are to groceries,” Engel said.

But as the old rural saying goes, you can lead a horse to water ...

“It’s a personal choice at this point, I think,” Engel said. “We’re just trying to be positive and be there when they want it.”

Myra Stoney, director of the Southwest Nebraska Public Health Department, is familiar with all the arguments for not getting vaccinated, including people who deny that there was a pandemic.

“All of the common answers that you hear across the nation, that’s what we hear out here,” she said.

But she and other public health officials say they have not given up on convincing those hesitant to take the shots.

Jeremy Eschliman, director of the Kearney-based Two Rivers Public Health Department, said minds can be changed, but it’s hard work. His agency has focused on people who say the vaccines have not been studied enough, figuring that they can be convinced if given the right information.

“There’s never been an issue that’s been quite so divisive,” said Eschliman, who’s been in public health for 22 years.

Rupp noted that people in rural America are more conservative and individualistic, which has likely played into the lag. But he said they are also very patriotic and take pride in their country, state and community. More messaging playing to that pride could help make rural communities safer for everyone, he said.

Rauner, of Partnership for a Healthy Lincoln, said the strong vaccination rates seen in a handful of rural counties suggest that the reluctant can be convinced if they hear from the right people.

He pointed to Boone County, which has a 52% vaccination rate despite being surrounded by counties with rates as low as 27%. Rauner said he knows Boone County to be home to strong and respected family health care practitioners, as evidenced by its traditionally high rate for preventive cancer screenings.

“That’s a trusted voice they’re going to listen to,” he said. “They’re not going to listen to Bob Rauner.”

The billboards encouraging ranchers to get vaccinated originated with a local health care provider.

Sandy Montague-Roes, director of a community health organization that’s part of the Chadron hospital, said she and a co-worker were inspired by a rancher who came in for his vaccination.

The rancher recounted a conversation he had over coffee with a neighbor who was opposed to getting the vaccine. The rancher had noted to the neighbor they would do anything they can to protect the investment they make in their cattle herd.

“Why are we any different?” the rancher asked.

The billboards have received a lot of attention. Some people have stopped along the road to take selfies with them. The signs have generated some negative comments, too.

But at least, Montague-Roes said, they are sparking conversations in the community about the benefits of getting vaccinated.

Omaha World-Herald: Live Well

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Reporter - Metro News

Henry is a general assignment reporter, but his specialty is deep dives into state issues and public policy. He's also into the numbers behind a story, yet to meet a spreadsheet he didn't like. Follow him on Twitter @HenryCordes. Phone: 402-444-1130.

Julie Anderson is a medical reporter for The World-Herald. She covers health care and health care trends and developments, including hospitals, research and treatments. Follow her on Twitter @JulieAnderson41. Phone: 402-444-1066.

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