While the U.S. COVID-19 response had room for improvement, it also saw unprecedented uptake of a novel way of promoting health equity: a group of measures known as disadvantage indices. Ultimately adopted by more than half of U.S. states, planners used these indices to inform their vaccine allocation plans. “Importantly, such measures have major potential to promote social and racial equity outside of a pandemic setting,” says Senior Fellow Harald Schmidt, PhD, MA.

Disadvantage indices are statistical, place-based measures that combine metrics such as income, education, housing quality, health status, and more, to enable ranking of residents based on their neighborhoods and communities—e.g., either on the state, county, or zip code level. Originally a tool used in poverty research and managing responses to disasters such as floods or earthquakes, disadvantage indices combine pertinent, sociodemographic data to determine who is worse off, which can then drive health and policy interventions to aid the corresponding groups.  

Disadvantage indices can play an invaluable role in helping policymakers understand and address unmet social needs, and may also provide a tool to ensure that people from all backgrounds receive equal opportunities and equitable access to resources. However, their use in guiding policies and interventions is not yet mainstream and would benefit from refinement.

Inspired by the lessons learned from the COVID-19 pandemic, LDI joined an international group of experts who convened at the Brocher Foundation in Switzerland from December 12 to 14, 2023, to discuss and evaluate disadvantage indices. Planned by LDI Senior Fellow Harald Schmidt and law professor Ruqaiijah Yearby, the workshop brought together experts from different disciplines—including the humanities, social sciences, philosophy, bioethics, public health, policy, medicine, and law—and institutions around the world—including the World Health Organization’s Ethics Unit, the University of Oxford’s Poverty and Human Development Initiative, the University of Pennsylvania’s Perelman School of Medicine, and the Ohio State University Moritz School of Law. The Penn delegation included LDI Associate Fellow Tuhina Srivastava, PhD, MPH,  Summer Undergraduate Mentored Research Program (SUMR) alumna Aditi Doiphode, and myself. (The full list of participants, their diverse backgrounds, and their research contributions appears here.)

Over the course of the 3-day workshop, participants forged international research connections and spurred cross-disciplinary discourse on the concept of disadvantage. They discussed how such indices have been used across the world to respond to infectious disease outbreaks, provide the routine delivery of public health interventions, and improve health care access. They also considered the variability among different indices and raised the possibility that the  disadvantage indices can be used to track and address the impacts of structural racism and discrimination.

Background on Disadvantage Indices

First used in the United Kingdom in the late 1990s, disadvantage indices now are employed throughout the United States in various contexts, including to direct interventions in education, government affairs, urban planning, as well as emergency response. Disadvantage indices also have gained prominence globally, as the ubiquity and intersectionality of disadvantage across the world has been formally recognized by the United Nations. Since 2010, the United Nations Development Programme (UNDP) and the Oxford Poverty and Human Development Initiative (OPHI) has annually reported the Global Multidimensional Poverty Index (MPI). Officials at the World Health Organization (WHO), UNDP, OPHI, and other partners are also currently using multidimensional poverty and vulnerability indices to equitably inform responses to health emergencies, and WHO is actively working on the construction of new tools for global monitoring of health inequality.

In the United States, common disadvantage indices include the Centers for Disease and Control and Prevention’s social vulnerability index (SVI), a metric to identify communities that require support on the onset of public emergencies; the University of Wisconsin’s area deprivation index (ADI) intended for urban planning; and the childhood opportunity index (COI) by diversitydatakids.org (a research organization oriented to issues of childhood wellbeing and equity) that measures unequal access to social opportunities for children. These three indices, and many more, capture disadvantage using U.S. Census data, which provides pertinent socioeconomic and demographic data.

International Experts Workshop: Uses for Disadvantage Indices Are Expanding and Evolving

During the workshop, the attendees not only addressed the varied uses of disadvantage indices, but also the different ways indices measure disadvantage and the wide-ranging contexts in which indices can be applied—especially after the stark health inequities for disadvantaged populations across the world revealed during the COVID-19 pandemic. 

The workshop discussions revealed a potential for the disadvantage indices to be more widely applied, from clinical settings like tracking the levels of disadvantage across different surgical outcomes for varying patient demographics to global health settings like mapping the comparative levels of disadvantage across different countries. Co-convenor Harald Schmidt presented ways in which vaccine allocation planners used indices for planning outreach and information campaigns, the location of dispensing sites, and even vaccine distribution that prioritized more disadvantaged groups. He also shared compiled area deprivation index data that quantified the overlap of disadvantage with race in the United States, showing that, although White individuals accounted for the majority of the population, more than twice the percentage of Black and American Indian and Alaska Native individuals fall in the most disadvantaged quartile compared to their White counterparts.

There was a consensus among the participants that the metrics used to construct such indices should capture a community’s needs and the multidimensional nature of disadvantage, allowing policymakers to adopt informed policy responses. They agreed that perspectives on structural racism and discrimination also should be included when constructing and using disadvantage indices. Because disadvantage can be embedded in the social, political, and economic structures of power in which people navigate their lives, indices provide the opportunity to track the impacts of these structures.

Disadvantage Indices Vary in Measurement

The workshop proceedings also highlighted the importance of recognizing that indices do not all measure the same thing and give the same results (i.e., indices are not interchangeable), especially outside the scope of their intended use—meaning that not all indices can be applied to any setting and for all purposes. For example, the area deprivation index (ADI) and social vulnerability index (SVI) are composed of many of the same variables, except ADI includes housing value and payment data, while SVI includes racial and ethnic minority status data. When ADI and SVI are applied to the same scenarios, the ranking outputs they produce have been different. The disagreement that is present across different disadvantage indices requires us to be critically deliberate when choosing which one to use—the choice depends on the goals and context of the project. To identify which index is right for which purpose, Schmidt said “there is a lot of work ahead,” and noted that the workshop had helped make clearer how to prioritize that work ahead.

There also is room for improvement in the construction of many available disadvantage indices. For example, workshop participant Kim Rollings, PhD, MS, an environmental psychologist and architect at the University of Michigan, and colleagues conducted research that uncovered areas of underperformance in ADI compared to SVI. Looking towards the future, more transparency in how disadvantage indices are constructed will be important for matters of justice. 

Among the workshop outcomes was a plan for the attendees to design a disadvantage index database that would provide contrasting information about available indices. This goal will broaden researchers’ and policymakers’ capacity to choose the right indices in their work.

Using Disadvantage Indices to Address Structural Problems

Workshop discussions revealed that disadvantage indices are helpful tools for promoting equity. Using the right index can draw attention to the social, economic, and clinical shortcomings of certain populations that would benefit from prioritized resource allocation. In doing so, they offer practical ways to equitably direct resources and measure the impacts of such policy changes and promote informed action and interventions that are responsive to the needs of different patients, communities, and populations.

Attendees of the workshop discussed the potential for using disadvantage indices to track and address forms of structural disadvantage and inequality—such as structural racism and discrimination. Disadvantage indices include parameters and variables that reflect people’s varying levels of access to social factors that limit their ability to be healthy—i.e., the social determinants of health (SDOH). For example, the SVI includes information about social and economic opportunity of individuals, showing who is most disadvantaged between and with racial and ethnic minority groups. Because disadvantage indices track and compile SDOH, they can capture the impacts of people’s experiences of structural racism and discrimination, such as residential segregation and lack of access to health care, which have been shown to limit individuals’ equal access to opportunities and resources, resulting in health inequities. Moreover, when the rankings produced through an index are mapped, they can offer policymakers insights for how and where to intervene to address structural racism and discrimination. Some officials even are beginning to recognize racism and discrimination as direct SDOH. 

To learn more, we spoke with co-convenor Ruqaiijah Yearby, JD, MPH, and asked her about the significance of using disadvantage indices to capture the impacts of structural racism and discrimination. See Yearby’s response below. 

Yearby: Disadvantage indices can show the harmful impacts that structural racism and discrimination have on those in poverty and racial and ethnic minority individuals. Specifically, they lack access to quality health facilities in their neighborhoods, and cannot afford transportation to quality facilities. This is in large part due to structural racism and discrimination that has allowed health institutions to concentrate facilities in wealthy and predominantly White neighborhoods, while closing down facilities in areas that are poor or filled with racial and ethnic minorities. Disadvantage indices quantify these place-based disparities and provide government officials with the opportunity to use their resources to eliminate these disparities by redirecting resources based on need. 

For example, during COVID-19, the Michigan Department of Health and Human Services used the SVI to not only identify factors, such as poverty and transportation, which limited communities’ ability to get Covid-19 testing, treatment, and vaccinations, but they also used the SVI to provide resources to these disadvantaged communities, such as vaccines. Moving forward, the workshop highlighted that we need to further refine the key components necessary to track structural racism and discrimination in the U.S. and globally.

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