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Adverse childhood experiences and COVID-19 vaccination uptake: Examining the intersection of sex and urban-rural residence

Karyn Fu,Dylan B. Jackson,Alexander Testa

Published 2025 in PLoS ONE

ABSTRACT

Background Adverse childhood experiences (ACEs) have been linked to negative health outcomes and behaviors in adulthood. Despite widespread research on ACEs, their relationship with COVID-19 vaccination uptake, particularly heterogeneity across demographic groups, remains underexplored. This study examined the association between ACEs and COVID-19 vaccination status, with a focus on how this relationship varies by sex and urban-rural residence. Methods Data were obtained from the 2022 Behavioral Risk Factor Surveillance System (BRFSS), including respondents who participated in the ACEs and COVID-19 vaccination optional state modules (N = 12,085 adults). COVID-19 vaccination status (yes/no) served as the dependent variable, while ACEs were categorized into four levels: 0, 1, 2–3, and 4 + ACEs. Multivariable logistic regression analyses, stratified by sex and urban-rural residence, were conducted to assess the association between ACEs and vaccination status. Results Among the sample, 76.2% reported receiving at least one dose of the COVID-19 vaccine. Multivariable analysis revealed no statistically significant association between ACEs and vaccination status for the full sample. Stratified analyses indicated that male respondents living in rural counties with 4 + ACEs had significantly lower odds of vaccination (adjusted odds ratio [aOR] = 0.57, 95% CI = 0.34–0.96). No significant associations were observed for other demographic groups (e.g., females in urban or rural areas; males in urban areas). Conclusions The findings suggest that males in rural areas with high ACE exposure may be vulnerable to low COVID-19 vaccination uptake. Targeted trauma-informed public health interventions warrant consideration to address vaccination uptake among this population.

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