A nurse from the University of Alabama vaccinates a patient at a Covid-19 site in Hoover, Alabama. As states race to get more people vaccinated, Alabama is among the states with the lowest vaccination rates in the country. (AP Photo/Jay Reeves, File)

This article was produced by Stateline, an initiative of The Pew Charitable Trusts.

At the beginning of the pandemic, LaShonda McKinney knew access to transportation would be a barrier for some people in the rural Mississippi Delta who needed a Covid-19 test. McKinney,a Bolivar County native, offered people free rides through the county’s council on aging, where she serves as executive director.

Once Covid-19 vaccinations became available, the agency offered free rides to vaccination sites, but as vaccine supply exceeded demand in Mississippi and vaccine hesitancy persisted, the calls for rides dropped.

“I don’t think transportation is the issue,” McKinney told Stateline. “I think it’s more of the fear of the unknown than them having access to transportation.”

Federal and state officials have made vaccines available at community health centers and pharmacies and added mobile units to expand access to the shots. But vaccination rates continue to lag in rural Southern states such as Arkansas, Alabama, Louisiana and Mississippi, which rank near the bottom in the country for vaccine uptake.

Thanks to distribution efforts and the overall increase in the supply of vaccines, access is no longer the main problem to boosting vaccination rates. Instead, people’s personal beliefs and economic circumstances are the primary impediments—and those are tougher for public health officials and community leaders to overcome.

Some people who continue to decline vaccinations cite erroneous information from social media or say they distrust medical providers. For some, it’s a matter of freedom of choice. Others prioritize pressing life challenges. Community groups and health experts say local leaders must educate people, develop equitable incentives and creatively market the vaccines to hesitant groups.

But such steps haven’t made a huge difference in Alabama, where only 39% of the adult population is fully vaccinated, the second lowest state rate after Mississippi.

Dr. Karen Landers, Alabama’s assistant state health officer, expressed frustration that no matter how much she’s reminded people about the devastating effects of Covid-19 or educated them about the science behind the vaccines, some people just refuse to get the shots.

“It’s just a real challenge,” Landers told Stateline.

Alabama public health officials have provided transportation, partnered with local health centers and leaders, opened vaccine sites for extended hours, and pushed fact-based information through local television, digital and print news outlets and social media. They have produced public service announcements featuring University of Alabama football coach Nick Saban and NBA Hall of Famer Charles Barkley, an Alabama native.

As an incentive to get vaccinated, they are offering people who get the shot a chance to drive their car or truck on the Talladega Superspeedway, and they are considering other sweeteners. They are also working with the American Academy of Pediatrics to get kids vaccinated.

“As a pediatrician, as a person involved in communicable disease for pretty much my whole career, I’m really distressed that we have such low numbers,” Landers said. “We’ve got plenty of vaccine. Now we just need people to take it.”

McKinney of Mississippi and Sarah Berthelot, the president of the Louisiana Association of United Ways, said that in their states, the vaccination barriers include internet illiteracy and fears of using public transportation. And for some people with low incomes, they said, food and housing insecurity simply take precedence over getting a vaccine.

“Louisiana faced a series of hurricanes in the fall, and we’ve had two flooding events since the beginning of 2021. We had an ice event, and we had the flooding event two or three weeks ago,” Berthelot said. “The Covid pandemic overlaid with the natural disasters—people find themselves in situations that they’ve never been in before.”

Dr. Kevin Schulman, a professor of medicine at Stanford University, said there has been a misconception that vaccine hesitancy is the only reason people are avoiding the shots. Vaccine apathy, or the need to prioritize other life challenges over getting vaccinated, is also a major factor, Schulman said.

A Missed Target

The Biden administration’s goal is for at least 70% of the U.S. adult population (ages 18 and up) to have had at least one dose by July Fourth. So far, nearly 55% of the adult U.S. population has been fully vaccinated, with about 65% receiving at least one dose as of June 16, according to the federal Centers for Disease Control and Prevention.

Dr. Jennifer Dillaha, medical director of immunizations at the Arkansas Department of Health, said she has “no doubt” the state will eventually reach 70%—but not by July Fourth. About 42% of Arkansas adults are fully vaccinated. Dillaha says the department’s efforts, such as hosting drive-thru clinics in neighborhoods, have focused on people who are Black, Latino or from the Marshall Islands. Those groups have lower vaccination rates than White residents.

“These are often people who don’t access health care frequently,” Dillaha said. “They don’t have an established relationship with a health care provider, so we are working to provide the vaccines in locations that they find trustworthy.”

Although progress is steady, vaccine hesitancy and disinterest remain high among all demographics. From December 14 to April 10, vaccinations were higher for people in urban areas than rural areas in 49 states and Washington, D.C., a May report by the CDC found. Disparities persisted across all age groups and sexes; however, race and ethnicity data were not included because it was missing for 40% of people.

‘Dysfunctional Relationship with Health’

Dr. Thomas Dobbs, the state health officer in Mississippi, said his state has done a good job of getting people 65 and older vaccinated, and it has narrowed the Black-White vaccination gap. However, only 37% of Mississippi adults have been fully vaccinated.

Although hospitalizations, cases and deaths have declined, Dobbs told reporters during a recent news conference that Mississippi has a “very dysfunctional relationship with health,” and acknowledged there is some complacency among residents.

“We don’t seek health care unless we’re sick. We don’t have a high rate of people doing preventive measures,” Dobbs said. “We have a real challenge with a real failure in health prevention … and it’s not a Covid thing. It’s not a Covid vaccine thing. It’s a Mississippi thing, and we need to think about it holistically.”

Dr. Obie McNair, a 36-year internal medicine and pulmonary medical specialist in central Mississippi, said he doesn’t completely agree with Dobbs’ perspective.

“I think it’s a lack of affordable … good quality, culturally sensitive medical care and that’s part of the problem,” McNair told Stateline. “I wouldn’t put it all on patients that don’t wanna do it, but I think the state of Mississippi could be more patient-friendly by expanding Medicaid and other things.” 

Misinformation and concerns around vaccine efficacy have created a lack of confidence in the vaccines, said Dr. Paul Byers, the state epidemiologist. Byers emphasized that “the data has shown that these vaccines have been safe and effective and are really our best way to prevent infection.” But education and science aren’t sufficient to convince many Mississippians.

Mississippi state Rep. Dan Eubanks, a Republican, who contracted Covid-19 last summer, said he is not against vaccines in general, but he believes people should have the freedom to choose whether to take them. Eubanks said he has not been vaccinated and doesn’t think he needs to be because he has antibodies from his bout with the virus. Experts say people who recovered from Covid-19 should still get vaccinated.

Eubanks said he has been dissuaded by contradictory information.

“A lot of folks in this state are so tired of every comment or post that has ‘Covid’ in it. In Mississippi, everyone who wants [a vaccine] got it,” Eubanks said. “I think the government needs to take a cue from that. If they believed in efficacy as much as they touted … they should be OK with people at risk of getting the virus.”

His peer, Republican state Rep. Brady Williamson, also said he is not opposed to vaccines, but he needs more time to see whether the Covid-19 vaccines are effective or not. Williamson told Stateline in April that he would not get vaccinated because he is healthy and needed more information. On Wednesday, Williamson said his views haven’t changed.

“I wasn’t one to get the flu vaccine … but I’ve never had the flu,” Williamson said. “I want my immune system to do what it is supposed to do granted by God.”

Aside from time and more information, Williamson, who is a U.S. Army veteran, said he would only get a vaccine if it were mandated by the military.

Public health experts say changing that narrative will require intense effort at the community level.

“Everyone’s goal, I hope, is that all of us are safe as possible,” said Dr. Zanthia Wiley, director of antimicrobial stewardship at Emory University Hospital in Atlanta. “So, if it takes extra work, more one-on-one conversations, boots-on-the-ground work to get the word out about Covid vaccinations, then that’s what we have to do—one person at a time.”