Receipt of Influenza and Pneumonia Vaccinations: The Dual Disparity of Rural Minorities

Background: The CDC recommends that older adults receive influenza and pneumococcal polysaccharide (PPV) vaccinations. Research has found disparities between white and minority racial/ethnic populations. Prior studies, however, have not focused upon the combined effects of race/ethnicity and rural residence, which may create a dual hazard. The purpose of our research was to examine the receipt of influenza and PPV using a nationally representative sample of US adults, with particular attention to rural minority persons.

Methods: We used information from the 2005 Behavioral Risk Factor Surveillance System (BRFSS), restricted to persons aged 50 and over for annual influenza vaccinations, and to persons aged 65 and older for lifetime PPV. The 2005 BRFSS data set contained information from respondents in very small counties, not available in more recent releases. The independent variables of interest were residence, coded at the county level as Urban, Micropolitan Rural, Small Adjacent Rural, and Remote Rural, and self-reported race (white, black, and other). Multivariable analysis controlled for personal and county-level characteristics.

Results: Overall, 42.0% of the sample reported an influenza vaccination; this rate was higher for whites (43.6%) and rural residents (43.9%). Within rural residents, only 31.1% of black adults, versus 44.9% of whites, reported an influenza vaccination. Total urban and rural receipt of PPV were similar (64.7% and 64.0%, respectively). However, only 41.1% of rural black adults, versus 65.8% of whites, reported a PPV. Multivariate analysis documented a significant interaction between race and rurality. Compared to urban whites, white rural residents were more likely to report a flu shot, while rural black adults were much less likely to do so (ORs from 0.65 to 0.66, depending on level of rurality). Rural black adults were particularly disadvantaged in receipt of PPV, with ORs ranging from 0.43 in large rural counties to 0.21 in small counties adjacent to larger areas. Physician supply at the county level was positively associated with vaccination.

Conclusions: Our study confirms race-based differences in receipt of immunizations and extends current knowledge by documenting an interactive effect of race/ethnicity in rural populations. The results also indicated the importance of provider availability to service delivery. Programs that have been effective at increasing immunization rates among urban minority populations should be examined for possible applicability to small rural communities. Given the difficulty inherent in attracting providers to rural areas, alternative delivery methods (such as vaccinations administered by a pharmacist) may be an effective solution.