Targeting COVID Vaccine Hesitancy in Rural Communities in Tennessee: Implications for Extending the COVID-19 Pandemic in the South

Approximately 40% of Tennesseans are vaccinated fully, due mainly to higher vaccination levels within urban counties. Significantly lower rates are observed in rural counties. Surveys suggest COVID-19 vaccine hesitancy is entrenched mostly among individuals identifying as white, rural, Republican, and evangelical Christian. Rural counties represent 70 of the total 95 counties in Tennessee, and vaccine hesitancy signifies an immediate public health crisis likely to extend the COVID-19 pandemic. Tennessee is a microcosm of the pandemic's condition in the Southern U.S. Unvaccinated communities are the greatest contributors of new COVID-19 infections, hospitalizations, and deaths. Rural Tennesseans have a long history of cultural conservatism, poor health literacy, and distrust of government and medical establishments and are more susceptible to misinformation and conspiracy theories. Development of novel strategies to increase vaccine acceptance is essential. Here, I examine the basis of COVID-19 following SARS-CoV-2 infection and summarize the pandemic's extent in the South, current vaccination rates and efforts across Tennessee, and underlying factors contributing to vaccine hesitancy. Finally, I discuss specific strategies to combat COVID-19 vaccine hesitancy. We must develop novel strategies that go beyond financial incentives, proven ineffective toward vaccinations. Successful strategies for vaccine acceptance of rural Tennesseans could increase acceptance among unvaccinated rural U.S. populations.