{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,19]],"date-time":"2026-10-19T14:43:02Z","timestamp":1792420982504,"version":"4.5.0"},"reference-count":25,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T00:00:00Z","timestamp":1790812800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"},{"start":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T00:00:00Z","timestamp":1790812800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["J Prim Care Community Health"],"published-print":{"date-parts":[[2026,10]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction\/Objectives<\/jats:title>\n                    <jats:p>The COVID-19 pandemic increased mortality across the United States, but its burden was uneven across communities. Rural populations may be vulnerable because of differences in age structure, health care access, preventive behaviors, and vaccination uptake. This study examined the association between rurality and excess mortality during the COVID-19 pandemic in Nebraska.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This ecological study used Nebraska death certificate data from 2015 through May 2023, COVID-19 laboratory, hospitalization, and vaccination data, and American Community Survey sociodemographic data. Monthly deaths from 2015 through 2019 were used to forecast expected deaths by zip code tabulation area from January 1, 2020, through May 31, 2023, using seasonal autoregressive integrated moving average models. Excess mortality was calculated as observed minus expected deaths. Secondary regression analysis using Poisson regression assessed associations between rurality and excess mortality, with inclusion of demographic, socioeconomic, COVID-19 infection, hospitalization, and vaccination measures as covariates.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Nebraska had 63,333 observed deaths and 57,865 expected deaths, corresponding to 5,468 excess deaths. Rurality was the strongest associated factor for excess mortality across pandemic phases, with the strongest association during the pre-vaccine phase. Vaccination was generally associated with reduced excess mortality.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Rurality was an important risk factor for excess mortality in Nebraska. Findings support targeted rural surveillance, outreach, primary care engagement, and emergency preparedness.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/21501319261498009","type":"journal-article","created":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T00:06:54Z","timestamp":1792109214000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Rurality as a Risk Factor for Excess Mortality in Nebraska During the COVID-19 Pandemic"],"prefix":"10.1177","volume":"17","author":[{"given":"Elena","family":"Einspahr","sequence":"first","affiliation":[{"name":"Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yi","family":"Du","sequence":"additional","affiliation":[{"name":"Division of Public Health, Nebraska Department of Health and Human Services"},{"name":"University of Nebraska Medical Center, Lincoln, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James","family":"Lawler","sequence":"additional","affiliation":[{"name":"Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"Donahue","sequence":"additional","affiliation":[{"name":"Iowa Department of Health and Human Services, Des Moines, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-5448-2983","authenticated-orcid":false,"given":"Sai","family":"Paritala","sequence":"additional","affiliation":[{"name":"Division of Public Health, Nebraska Department of Health and Human Services"},{"name":"University of Nebraska Medical Center, Lincoln, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patrick","family":"Maloney","sequence":"additional","affiliation":[{"name":"Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,10,15]]},"reference":[{"key":"e_1_3_8_2_2","doi-asserted-by":"publisher","DOI":"10.1111\/joim.13199"},{"key":"e_1_3_8_3_2","volume-title":"Locational Disparity in Rural Education","author":"Hedlund C","year":"2021","unstructured":"Hedlund C. Locational Disparity in Rural Education. Bethel University; 2021. https:\/\/spark.bethel.edu\/cgi\/viewcontent.cgi?article=1279&context=etd."},{"key":"e_1_3_8_4_2","doi-asserted-by":"publisher","unstructured":"Huang Q Jackson S Derakhshan S et al. Urban-rural differences in COVID-19 exposures and outcomes in the South: A preliminary analysis of South Carolina. In: Odoi A ed. 2021; 16(2):e0246548. doi:10.1371\/journal.pone.0246548.","DOI":"10.1371\/journal.pone.0246548"},{"key":"e_1_3_8_5_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.puhe.2015.04.001"},{"key":"e_1_3_8_6_2","unstructured":"American Hospital Association. Hospitals and Health Systems Continue to Face Unprecedented Financial Challenges Due to COVID-19. 2020. https:\/\/www.aha.org\/system\/files\/media\/file\/2020\/06\/aha-covid19-financial-impact-report.pdf. 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The Older Population in Rural America: 2012-2016. 2019. https:\/\/www.census.gov\/content\/dam\/Census\/library\/publications\/2019\/acs\/acs-41.pdf."},{"key":"e_1_3_8_10_2","doi-asserted-by":"publisher","DOI":"10.15585\/mmwr.mm7020e3"},{"key":"e_1_3_8_11_2","doi-asserted-by":"publisher","DOI":"10.1007\/s11673-020-10049-0"},{"key":"e_1_3_8_12_2","doi-asserted-by":"publisher","DOI":"10.1097\/PHH.0000000000001507"},{"key":"e_1_3_8_13_2","doi-asserted-by":"publisher","DOI":"10.15620\/cdc:121523"},{"key":"e_1_3_8_14_2","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2022.0984"},{"key":"e_1_3_8_15_2","doi-asserted-by":"publisher","DOI":"10.1186\/s12889-022-14743-z"},{"key":"e_1_3_8_16_2","doi-asserted-by":"publisher","DOI":"10.1101\/2022.04.23.22274192"},{"key":"e_1_3_8_17_2","doi-asserted-by":"publisher","DOI":"10.21203\/rs.3.rs-3467683\/v1"},{"key":"e_1_3_8_18_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.annepidem.2021.04.007"},{"key":"e_1_3_8_19_2","volume-title":"Commuting Area Codes","author":"USDA ERS - Rural-Urban","unstructured":"USDA ERS - Rural-Urban. Commuting Area Codes. https:\/\/www.ers.usda.gov\/data-products\/rural-urban-commuting-area-codes\/. Accessed February 8, 2024."},{"key":"e_1_3_8_20_2","volume-title":"US Census Bureau","unstructured":"US Census Bureau. American Community Survey. https:\/\/data.census.gov\/"},{"key":"e_1_3_8_21_2","doi-asserted-by":"publisher","DOI":"10.15585\/mmwr.mm7033a2"},{"key":"e_1_3_8_22_2","volume-title":"Nebraska Receives First Shipment Of COVID-19 Vaccine","author":"Nebraska DHHS","year":"2020","unstructured":"Nebraska DHHS. Nebraska Receives First Shipment Of COVID-19 Vaccine; 2020."},{"key":"e_1_3_8_23_2","unstructured":"Affairs (ASPA) AS for P. COVID-19 Vaccines. 2020. 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