Using Disadvantage Indices to Address Structural Racism and Discrimination in Pandemic Vaccine Allocation and Beyond: Defining the Shape of a Novel Paradigm to Promote Health Equity

COVID-19暴露了有色人种不公平的医疗保健服务和不同的健康结果， 由于结构性种族主义和歧视（SRD）-但在一个前所未有的转折，决策者也部署了 一个主要的新工具，以解决SRD内，并可能以外的流行。快速和广泛地采用 美国国家科学、工程和医学院（NASEM）的提议， （n=34）通过在疫苗分配计划中纳入劣势指数（DI）来解决SRD。地方是地方-- 基于贫困或脆弱性的统计措施，整合了人口普查数据，如收入、教育、 或住房质量，来对小到社区的地理区域进行排名。因为后果之一就是 SRD的一个重要原因是，有色人种面临经济和住房机会减少， 在贫困社区，DI同时捕捉SRD的影响，并提供缓解工具。为 例如，在严重短缺的情况下，DI用于增加贫困地区的疫苗份额， 延伸，更多的有色人种。因此，DI减轻了传统分配框架导致的风险， SRD，即使是无意的。尽管如此，快速的采用和广泛的用途仍然不清楚最佳用途是什么 的DI是在卫生紧急情况之内和之外。我们的目标是确定 DI在应对Covid-19、未来流行病、公共卫生和临床护理中的SRD。 作为 混合方法 DIs 弱势 与 入射角， 差中差 对 与 弱点 SRD 的 医院 将 弱势 一个高度跨学科的团队与社区咨询委员会合作，我们提出了一个观察 学习有两个目标。首先，我们将确定使用 在COVID-19疫苗分配中，以解决SRD和改善医疗保健可及性以及 有色人种社区：我们将评估3种最常用的DI的影响 新推出的CDC/HHS指数（少数民族健康社会脆弱性指数） 使用预测模型，按种族和族裔分列的住院、死亡和疫苗接种率， 分析各州实际疫苗推广情况。我们还将进行定性面试 在32个CDC辖区内，疫苗分配和健康公平领导者是DI的促进者和障碍 占弱势群体的最大份额。其次，我们将确定可能的优势， 在紧急情况之外的公共卫生和临床护理中使用DI， 并改善有色人种弱势群体的医疗服务和结果：我们将使用 德尔菲法，以确定卫生部门的公平工作队的领导人，并在最大的公平领导人 在相同的32个CDC管辖区的系统，排名DI的具体用途，从文献中确定。我们 通过两项具有全国代表性的创新性调查实验补充专家意见， 社区在有影响力的获奖团体审议（CHoosing All Together-CHAT） Q L .

Covid-19 exposed inequitable healthcare access and disparate health outcomes of people of color, that are due to structural racism and discrimination (SRD)—but in an unprecedented turn, policymakers also deployed a major novel tool to address SRD within, and likely outside of the pandemic. Rapidly and widely adopting a proposal by the National Academies of Science, Engineering and Medicine's (NASEM), a majority of US states (n=34) addressed SRD by including disadvantage indices (DIs) in vaccine allocation plans. DIs are place- based statistical measures of deprivation or vulnerability that integrate Census data such as income, education or quality of housing, to rank geographic areas as small as neighborhoods. Because one of the consequences of SRD is that people of color face reduced economic and housing opportunities and account for larger shares of disadvantaged communities, DIs simultaneously capture SRD impact, and offer tools for mitigation. For example, under severe scarcity, DIs were used to increase vaccine shares for disadvantaged areas, and, by extension, more people of color. DIs hence mitigated the risk that traditional allocation frameworks result in SRD, even if unintended. Still, the rapid adoption and wide rangeof uses leave unclear what the optimal uses of DIs are within and outside of health emergencies. Our goal is to determine the strengths and weaknesses of DIs in addressing SRD in Covid-19, future pandemics, public health and clinical care. As mixed-methods s DIs disadvantaged alongside incidence, difference-in-difference on with weaknesses SRD the hospital will disadvantaged a highly interdisciplinary team collaborating with a community advisory board, we propose an observational tudy with 2 aims. First, we will identify the impact, strengths, and weaknesses of using in Covid-19 vaccine allocation to address SRD and improve healthcare access and outcomes of communities of color : We will evaluate t he impact of the 3 most frequently used DIs a newly launched CDC/HHS index (the Minority Health Social Vulnerability Index ) on Covid-19 hospitalizations, deaths and vaccination rates by race and ethnicity, using predictive modeling and analyses of states' actual vaccine-roll-out. We will also conduct ualitative interviews facilitators and barriers of DIs with vaccine allocation and health equity leaders in the 32 CDC jurisdictions the largest shares of disadvantaged communities. Second, we wil identify the possible strengths and of using DIs in public health and clinical care outside of emergency settings to address and improve healthcare access and outcomes of disadvantaged communities of color: We will use Delphi method to identify how health department equity taskforce leaders, and equity leaders in the largest systems in the same 32 CDC jurisdictions, rank concrete uses of DIs, identified from the literature. We complement expert views with two innovative nationally representative survey-experiments, and engaging communities in impactful award-winning group deliberation (CHoosing All Together-CHAT) q l .