The Influence of County-Level Contextual Characteristics on COVID-19 Pandemic Vaccination Coverage in the United States, December 14, 2020–March 31, 2021 Open Access

James, Hanleigh (Spring 2021)

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Background: Deaths attributed to COVID-19 have disproportionately occurred in US counties with larger socioeconomically vulnerable communities. There is concern that vaccination coverage across US counties has not been commensurate with population vulnerability. This study estimated the associations between county-level contextual factors and vaccination coverage.


Methods: We focused on area-level characteristics acting as facilitators or barriers to vaccination uptake. The county was the unit of analysis. The study outcome was the percentage of county residents who have had at least one dose of the vaccine as of December 14, 2020, obtained from the CDC’s COVID Data Tracker. For analysis, counties were divided into tertiles based on vaccination coverage. We merged county vaccination coverage with the 2018 AHRQ’s database on Social Determinants of Health (SDOH). Five domains of SDOH factors were examined: demographic composition, economic factors, educational attainment, physical infrastructure, and healthcare context. A logistic regression model was estimated to determine the association between county SDOH and low vaccination coverage, defined as the lowest tertile of county vaccination coverage.


Results: Unadjusted and adjusted odds ratios were largely similar. The percentage of population who are not U.S citizens (OR=1.156, 95% CI=1.086,1.231) and average household size (OR=27.629, 95% CI=17.523,43.563) were positively associated with low vaccination coverage. The percentage of households with limited English speaking (OR=0.799, 95% CI=0.735,0.870), percentage of the population with some post-high school education (OR=0.962 , 95% CI=0.950,0.974), median household income (OR=0.985, 95% CI=0.975,0.995), shortage of primary care physicians (OR=0.890, 95% CI=0.796,0.996), and number of facilities (OR=0.983, 95% CI=0.971,0.996) were inversely associated with low vaccination coverage.


Discussion: We identified several correlates of county-level COVID-19 vaccination coverage during the first phase of the vaccine roll-out. This information may be used to identify and address barriers and facilitators for vaccination uptake to ultimately improve coverage of the vaccine in vulnerable communities to reduce inequities in disease burden.

Table of Contents

Introduction 1

Methods 4

Study Outcome 4

Study Exposures 4

Statistical Analysis 5

Results 7

Discussion 12

Conclusion 19

References 21

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