Staff at one of Maine's largest vaccination sites celebrate their 100,000th vaccination. The clinic at the Cross Insurance Center in Bangor was part of a statewide effort. (Photo submitted)

Although rural areas tend to have lower vaccination rates than metropolitan ones, two states with very high vaccination rates are also the most rural.

Maine and Vermont are the first and second most rural states based on the percentage of population that lives in rural areas. The two states rank third and sixth nationally in the percentage of their population that is vaccinated. Statewide, seven out of every 10 residents in Maine and Vermont are completely vaccinated against the Covid-19, according to the Daily Yonder’s most recent analysis.

Why have these states achieved such high vaccination levels, despite the challenges of having a dispersed population that tends to be older and have less access to healthcare? Part of the answer is that residents in Vermont and Maine are less hesitant than other parts of the U.S. to get vaccinated, according to polling by the Covid Collaborative. But on its own, that doesn’t get shots into people’s arms.

A major factor in vaccine uptake is vaccine hesitancy, a measurement of whether residents are reluctant to take a Covid-19 vaccine. New England, including the states of Vermont and Maine (see inset below), have some of the nation’s lowest vaccine hesitancy rates. The map shows the percent of population that says they will probably or definitely not get the vaccine. Blue counties have fewer residents who are vaccine hesitant. Yellow and red counties have more. Visit an interactive version of the map for methodology and more information. (IMHE/Covid Collaborative)

Vermont has used a variety of strategies to promote and deliver vaccines, according to the deputy commissioner of the Vermont Health Department, Kelly Dougherty, MSW, MPH. First and foremost has been consistency.

Vermont has no local or county health departments. Instead, it has a statewide network of local health offices that are part of the state health department. “That allowed us to have a consistent statewide approach with staff in our local offices doing outreach and conducting vaccination clinics,” Dougherty said.

Vermont also closely monitored each of its regions and “targeted areas with lower levels of uptake … essentially making it difficult to not run into a vaccination clinic in one’s community,” Dougherty said.

CDC records show about half of Vermont’s 400,000 rural residents are completely vaccinated. That’s about 10% higher than the national rural vaccination rate. The actual number of vaccinated rural residents is higher because a quarter of Vermont’s 450,000 completed vaccinations are not allocated to specific counties.

Vermont has also paid special attention to its vulnerable communities, particularly Black, indigenous, and people of color (BIPOC) Vermonters, who initially didn’t appear to be taking the vaccine as readily as other groups. One strategy has been to host clinics where trusted community partners are present and relevant materials and videos are available in multiple languages. “Community organizations also did outreach directly with their constituents and registered them for vaccine appointments,” Dougherty said.

This kind of nuanced cooperation worked in Maine, too, according to a health official.

“Ensuring access to Covid-19 vaccines takes coordination between many organizations, municipalities, and the state of Maine,” said James Jarvis, MD, FAAFP. Jarvis is physician leader with the Covid-19 Incident Command for Northern Light Health, a statewide healthcare system.

In early February, Maine opened its first mass vaccination clinic in Bangor with many other sites from Portland to Presque Isle soon to follow. “Through the efficiency and ease of these sites, we vaccinated more than 70% of the nearly 1.3 million Mainers,” Jarvis said.

About two thirds of Maine's rural residents are completely vaccinated. That's nearly 50% higher than the national rural vaccination rate of about 45%.

Like Vermont, Maine does not have a network of county health departments. Instead the state relied heavily on collaboration between its two primary health systems, Northeast Light Health and MaineHealth. Combined, these systems operate nearly 20 community hospitals, many of which are in rural areas. They’re also responsible for a network of primary care practices and home health agencies. Since vaccinations began, the two organizations have administered a significant percentage of the total doses statewide.

For reference, by the end of October, Northern Light Health had administered 260,000 doses at established clinics, pharmacies, and vaccination sites, and an additional 52,000 doses at schools, pop-up clinics, community and long-term care facilities, and people’s homes through their homecare agency, Northern Light Home Care & Hospice.“Access to healthcare services has always been a challenge in Maine’s most remote communities, especially for those with limited transportation options or the ability to leave work to receive necessary care,” Jarvis said. Some may even travel hours for higher-level care.

“Northern Light Home Care & Hospice was critical in making sure we reached these hardest-to-reach rural areas,” Jarvis said. By leveraging their home-care and hospice teams based in five locations across Maine, Northern Light was able to vaccinate many who were homebound or would have had particular difficulty getting to a vaccination site. Similar to Vermont, Maine also invested in reaching populations that were vulnerable, working specifically with leaders in immigrant communities to coordinate vaccine access for new Mainers.

In addition to the spaces, places, and delivery, there has also been the task of addressing vaccine hesitancy. Vermont’s Health Department has leaned into social media plus its traditional partnerships with local press and community organizations.

In Maine, many towns, universities, and the state developed campaigns to build awareness around the safety and efficacy of the Covid-19 vaccine. As Jarvis put it, “A successful vaccination strategy takes teamwork.” From holding town-hall-style meetings to providing one-on-one engagement with community members, the focus has been on respectfully addressing people’s concerns.

Northern Light Home Care & Hospice even held pop-up clinics during town fairs and seasonal events to accommodate individuals who may have had a more difficult time scheduling a vaccine. “If community members couldn’t come to us, then we made every effort to meet them where they were at,” Jarvis said.

Looking ahead, Jarvis said, “We are seeing a promising number of people who meet booster (and third dose) criteria wanting to receive an additional dose.” Recent statistics showed that more than 100,000 Mainers had already received a third dose. However, he emphasized the focus remains on making sure as many residents as possible are vaccinated with the initial series. “This is the best defense in the fight against Covid-19,” he said.

Dougherty said that when it comes to boosters in Vermont, “We have not had quite the response we had hoped.”  As of late October, the state had given 63,000 doses, which was fewer than anticipated.

Both states have recently launched efforts to vaccinate children ages 5 to 11. Vermont began offering doses the first week of November, with Maine quickly following suit. Both states plan to use community-based clinics, schools, pediatrician offices, and pharmacies.

This aligns with Dougherty’s emphasis on ensuring that “vaccine opportunities are many and varied and that distance is not a barrier.” The path to success is not a secret.

“While there is no magic recipe, education and teamwork across the board are certainly key components,” Jarvis said.