Social Determinants of Health and Risk for Long COVID in the U.S. RECOVER-Adult Cohort

Candace H. Feldman, Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (C.H.F., E.W.K.).
Leah Santacroce, Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (L.S.).
Ingrid V. Bassett, Harvard Medical School, and Infectious Diseases Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts (I.V.B.).
Tanayott Thaweethai, Harvard Medical School, and Biostatistics, Massachusetts General Hospital, Boston, Massachusetts (T.T.).
Radica Alicic, Department of Medicine, University of Washington, Spokane, Washington (R.A.).
Rachel Atchley-Challenner, Biostatistics, Massachusetts General Hospital, Boston, Massachusetts (R.A.-C.).
Alicia Chung, Health and Behavior, Department of Population Health, New York University Grossman School of Medicine, New York, New York (A.C.).
Mark P. Goldberg, Neurology, UT Health San Antonio, San Antonio, Texas (M.P.G.).
Carol R. Horowitz, Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York (C.R.H.).
Karen B. Jacobson, Division of Research, Vaccine Study Center, Kaiser Permanente Northern California, Oakland, California, and Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford School of Medicine, Stanford, California (K.B.J.).
J Daniel Kelly, Hospitalist Medicine, Department of Medicine, University of California, San Francisco, and F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California (J.D.K.).
Stacey Knight, Cardiovascular Research, Cardiology, Intermountain Health, and Division of Epidemiology, Department of Medicine, University of Utah, Salt Lake City, Utah (S.Knight).
Karen Lutrick, Family & Community Medicine, University of Arizona, Tucson, Arizona (K.L.).
Praveen Mudumbi, Department of Population Health, New York University Grossman School of Medicine, New York, New York (P.M.).
Sairam Parthasarathy, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona, Tucson, Arizona (S.P.).
Heather Prendergast, Illinois Research Network (ILLInet), and Emergency Medicine, University of Chicago, Chicago, Illinois (H.P.).
Yuri Quintana, Harvard Medical School, and Division of Clinical Informatics, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Y.Q.).
Nasser Sharareh, Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah (N.S.).
Judd Shellito, LSU Health Sciences Center - New OrleansFollow
Zaki A. Sherif, Department of Biochemistry & Molecular Biology, Department of Medicine, Howard University College of Medicine, Washington, DC (Z.A.S.).
Brittany D. Taylor, Division of Health Strategies, Community Impact, American Heart Association, Atlanta, Georgia (B.D.T.).
Emily Taylor, Solve M.E., Los Angeles, California (E.T.).
Joel Tsevat, Division of General Internal Medicine, ReACH Center and Department of Medicine, Division of General Internal Medicine, Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, and Departments of Population Health and Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, Texas (J.T.).
Zanthia Wiley, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia (Z.W., J.Berry, I.O.).
Natasha J. Williams, Institute for Excellence in Health Equity, Department of Population Health, New York University Grossman School of Medicine, New York, New York (N.J.W.).
Lynn Yee, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois (L.Y.).
Lisa Aponte-Soto, Illinois Research Network (ILLInet) and Illinois Unidos, Chicago, Illinois (L.A.-S.).
Jhony Baissary, Case Western Reserve University School of Medicine, Cleveland, Ohio (J.Baissary, G.A.M.).
Jasmine Berry, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia (Z.W., J.Berry, I.O.).
et al.

Document Type

Article

Publication Date

7-29-2025

Publication Title

Annals of internal medicine

Abstract

BACKGROUND: Social determinants of health (SDoH) contribute to disparities in SARS-CoV-2 infection, but their associations with long COVID are unknown. OBJECTIVE: To determine associations between SDoH at the time of SARS-CoV-2 infection and risk for long COVID. DESIGN: Prospective observational cohort study. SETTING: 33 states plus Washington, DC, and Puerto Rico. PARTICIPANTS: Adults (aged ≥18 years) enrolled in RECOVER-Adult (Researching COVID to Enhance Recovery) between October 2021 and November 2023 who were within 30 days of SARS-CoV-2 infection; completed baseline SDoH, comorbidity, and pregnancy questionnaires; and were followed prospectively. MEASUREMENTS: Social risk factors from SDoH baseline questionnaires, ZIP code poverty and household crowding measures, and a weighted score of 11 or higher on the Long COVID Research Index 6 months after infection. RESULTS: Among 3787 participants, 418 (11%) developed long COVID. After adjustment for demographic characteristics, pregnancy, disability, comorbidities, SARS-CoV-2 severity, and vaccinations, financial hardship (adjusted marginal risk ratio [ARR], 2.36 [95% CI, 1.97 to 2.91]), food insecurity (ARR, 2.36 [CI, 1.83 to 2.98]), less than a college education (ARR, 1.60 [CI, 1.30 to 1.97]), experiences of medical discrimination (ARR, 2.37 [CI, 1.94 to 2.83]), skipped medical care due to cost (ARR, 2.87 [CI, 2.22 to 3.70]), and lack of social support (ARR, 1.79 [CI, 1.50 to 2.17]) were associated with increased risk for long COVID. Living in ZIP codes with the highest (vs. lowest) household crowding was also associated with greater risk (ARR, 1.36 [CI, 1.05 to 1.71]). LIMITATION: Selection bias may influence observed associations and generalizability. CONCLUSION: Participants with social risk factors at the time of SARS-CoV-2 infection had greater risk for subsequent long COVID than those without. Future studies should determine whether social risk factor interventions mitigate long-term effects of SARS-CoV-2 infection. PRIMARY FUNDING SOURCE: National Institutes of Health.

PubMed ID

40720834

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