Document Type


Publication Date




Publication Title

Frontiers in Public Health




1042570 (1-10)


Equitable and effective vaccine uptake is a key issue in addressing COVID-19. To achieve this, we must comprehensively characterize the context-specific socio-behavioral and structural determinants of vaccine uptake. However, to quickly focus public health interventions, state agencies and planners often rely on already existing indexes of "vulnerability." Many such "vulnerability indexes" exist and become benchmarks for targeting interventions in wide ranging scenarios, but they vary considerably in the factors and themes that they cover. Some are even uncritical of the use of the word "vulnerable," which should take on different meanings in different contexts. The objective of this study is to compare four vulnerability indexes produced by private, federal, and state institutions to assess the application of these measures to the needs of the COVID-19 pandemic and other emergent crises. We focus on federal, state, and private industries' vulnerability indexes for the Commonwealth of Virginia. Qualitative comparison is done by considering each index's methodologies to see how and why they defined and measured "vulnerability." We also quantitatively compare them using percent agreement and illustrate the overlaps in localities identified as among the most vulnerable on a choropleth map. Finally, we provide a short case study that explores vaccine uptake in the six localities that were identified by at least three indexes as most vulnerable, and six localities with very low vaccine coverage that were identified by two or fewer indexes as highly vulnerable. By comparing the methodologies and index (dis)agreements, we discuss the appropriateness of using pre-existing vulnerability indexes as a public health decision-making tool for emergent crises, using COVID-19 vaccine uptake as a case study. The inconsistencies reflected by these indexes show both the need for context-specific and time-sensitive data collection in public health and policy response, and a critical critique of measured "vulnerability."


© 2023 Cleveland Sa and Frydenlund.

This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0).The use, distribution or reproduction in other forums is permitted, provided the original authors and the copyright owners are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

Original Publication Citation

Cleveland Sa, L., & Frydenlund, E. (2023). The shortfalls of vulnerability indexes for public health decision-making in the face of emergent crises: The case of COVID-19 vaccine uptake in Virginia. Frontiers in Public Health, 11, 1-10, Article 1042570.


0000-0001-6840-1546 (Cleveland Sa), 0000-0002-7694-7845 (Frydenlund)