Article Text

Download PDFPDF
Public attitudes about equitable COVID-19 vaccine allocation: a randomised experiment of race-based versus novel place-based frames
  1. Harald Schmidt1,2,
  2. Sonia Jawaid Shaikh3,
  3. Emily Sadecki4,
  4. Alison Buttenheim5,
  5. Sarah Gollust6
  1. 1 Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
  2. 2 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  3. 3 Amsterdam School of Communication of Research, University of Amsterdam, Amsterdam, The Netherlands
  4. 4 Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  5. 5 Department of Family and Community Health, Penn Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  6. 6 Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
  1. Correspondence to Dr Harald Schmidt, Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA; schmidth{at}


Equity was—and is—central in the US policy response to COVID-19, given its disproportionate impact on disadvantaged communities of colour. In an unprecedented turn, the majority of US states used place-based disadvantage indices to promote equity in vaccine allocation (eg, through larger vaccine shares for more disadvantaged areas and people of colour).

We conducted a nationally representative survey experiment (n=2003) in April 2021 (before all US residents had become vaccine eligible), that examined respondents’ perceptions of the acceptability of disadvantage indices relative to two ways of prioritising racial and ethnic groups more directly, and assessed the role of framing and expert anchors in shaping perceptions.

A majority of respondents supported the use of disadvantage indices, and one-fifth opposed any of the three equity-promoting plans. Differences in support and opposition were identified by respondents’ political party affiliation. Providing a numerical anchor (that indicated expert recommendations and states’ actual practices in reserving a proportion of allocations for prioritised groups) led respondents to prefer a lower distribution of reserved vaccine allocations compared with the randomised condition without this anchor, and the effect of the anchor differed across the frames.

Our findings support ongoing uses of disadvantage indices in vaccine allocation, and, by extension, in allocating tests, masks or treatments, especially when supply cannot meet demand. The findings can also inform US allocation frameworks in future pandemic planning, and could provide lessons on how to promote equity in clinical and public health outside of the pandemic setting.

  • COVID-19
  • ethics- medical
  • politics
  • public policy

Data availability statement

Data are available on reasonable request.

This article is made freely available for personal use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Data availability statement

Data are available on reasonable request.

View Full Text


  • HS and SJS contributed equally.

  • Contributors HS and SJS had the idea for the study and jointly designed the initial instrument, revised substantially after further input from SG, ES, AB. SJS led all data analyses, with assistance from ES and guidance from SG, AB, HS. HS wrote the first draft of the manuscript and led all subsequent revisions; all authors critically reviewed and revised the manuscript. Guarantors: HS, SJS.

  • Funding This study was supported by a Policy Accelerator Program grant of the Leonard Davis Institute of Health Economics at the University of Pennsylvania.

  • Disclaimer The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.