Social Determinants of Health and Risk for Long COVID in the U.S. RECOVER-Adult Cohort, 2025, Feldman et al.

[SNT Gatchaman]

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

Spoiler: Authors

Candace H Feldman; Leah Santacroce; Ingrid V Bassett; Tanayott Thaweethai; Radica Alicic; Rachel Atchley-Challenner; Alicia Chung; Mark P Goldberg; Carol R Horowitz; Karen B Jacobson; J Daniel Kelly; Stacey Knight; Karen Lutrick; Praveen Mudumbi; Sairam Parthasarathy; Heather Prendergast; Yuri Quintana; Nasser Sharareh; Judd Shellito; Zaki A Sherif; Brittany D Taylor; Emily Taylor; Joel Tsevat; Zanthia Wiley; Natasha J Williams; Lynn Yee; Lisa Aponte-Soto; Jhony Baissary; Jasmine Berry; Alexander W Charney; Maged M Costantine; Alexandria M Duven; Nathaniel Erdmann; Kacey C Ernst; Elen M Feuerriegel; Valerie J Flaherman; Minjoung Go; Kellie Hawkins; Vanessa Jacoby; Janice John; Sara Kelly; Elijah Kindred; Adeyinka Laiyemo; Emily B Levitan; Bruce D Levy; Jennifer K Logue; Jai G Marathe; Jeffrey N Martin; Grace A McComsey; Torri D Metz; Tony Minor; Aoyjai P Montgomery; Janet M Mullington; Igho Ofotokun; Megumi J Okumura; Michael J Peluso; Kristen Pogreba-Brown; Hengameh Raissy; Johana M Rosas; Upinder Singh; Timothy VanWagoner; Cheryl R Clark; Elizabeth W Karlson

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.

Web | PDF | Annals of Internal Medicine | Paywall

 

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Risk of long COVID increases with social and economic hardship

In a new analysis of the RECOVER-Adult cohort, Mass General Brigham researchers found a two- to three-times higher risk of long COVID in those with social risk factors, including financial hardship, food insecurity, experiences of medical discrimination, and skipped medical care due to cost...

www.eurekalert.org

News Release 28-Jul-2025

Risk of long COVID increases with social and economic hardship​

Mass General Brigham investigators led a nationwide study that found that financial hardship, food insecurity, lack of healthcare access, and other social risk factors are linked to higher risks of long COVID

Peer-Reviewed Publication
Brigham and Women's Hospital


Mass General Brigham investigators led a nationwide study that found that financial hardship, food insecurity, lack of healthcare access, and other social risk factors are linked to higher risks of long COVID

Long COVID includes a wide range of symptoms that present or persist three or more months after SARS-CoV-2 infection. Although in recent years researchers have gained greater insight into the prevalence, symptoms and effects of long COVID through the longitudinal Researching COVID to Enhance Recovery (RECOVER) Initiative, social risk factors for developing long COVID remain incompletely understood. In a new analysis of the RECOVER-Adult cohort, Mass General Brigham researchers found a two- to three-times higher risk of long COVID in those with social risk factors, including financial hardship, food insecurity, experiences of medical discrimination, and skipped medical care due to cost. Findings are published in Annals of Internal Medicine.

“During the pandemic, we saw the overwhelming role that social risk factors played in determining who was infected with COVID-19 and what the severity and mortality from disease was,” said lead author Candace Feldman, MD, MPH, ScD, of the Division of Rheumatology, Inflammation and Immunity at Brigham and Women’s Hospital (BWH), a founding member of the Mass General Brigham healthcare system. “We wanted to understand whether those risk factors also play a significant role in the longer-term, chronic symptoms that can affect people months and even years after SARS-CoV-2 infection.”

In this study, the researchers analyzed 3,700 participants from the RECOVER-Adult cohort, who had a SARS-CoV-2 infection during the Omicron variant outbreak, completed a baseline survey about social and economic factors at the time of infection, and completed a six-month follow-up survey assessing long COVID symptoms. The RECOVER-Adult participants were from 33 states, Washington, D.C., and Puerto Rico, and joined the study between October 2021 and November 2023.

In the baseline survey, the researchers assessed four major individual-level social risk factors: economic instability, education and language access barriers, health care access and quality challenges, and lack of social and community support using a series of questions and previously validated surveys. They also used ZIP code data to study area-level measures of risk, like household crowding.

After adjusting for variables including hospitalization for SARS-CoV-2 infection (as a marker of disease severity), vaccination history, pregnancy status, age, sex, race and ethnicity, the researchers found significant associations between nearly all the individual-level social risk factors studied and increased risk of developing long COVID. Furthermore, a greater number of social risk factors conferred a higher risk of long COVID. Living in areas with more household crowding was also associated with a greater risk of long COVID.

There was a significantly higher burden of social risk factors among racially or ethnically minoritized groups. However, the researchers found that social risk factors appeared to affect white, Black and Hispanic people’s risks of long COVID similarly.

Going forward, RECOVER Initiative researchers hope to determine whether these findings extend to children with long COVID and whether certain long COVID symptoms may be linked to specific social risk factors. They also hope to study symptoms of COVID-19 lasting a year or longer to better understand how social factors might contribute to these symptoms’ persistence.

“While rates of COVID-19 have decreased, long COVID is a chronic disease that many people still suffer from,” said senior author Elizabeth Karlson, MD, MS, of the Division of Rheumatology, Inflammation and Immunity at BWH. “As with other chronic diseases, many different parts of people's social environment influence long COVID risk. Future interventions must address these factors to effectively reduce adverse outcomes among people with high burden of social risk factors.”

Authorship: In addition to Feldman and Karlson, Mass General Brigham authors include Leah Santacroce, Ingrid V. Bassett, Tanayott Thaweethai, Yuri Quintana, Bruce D. Levy, and Cheryl R. Clark.

Additional authors include Radica Alicic, Rachel Atchley-Challenner, Alicia Chung, Mark P. Goldberg, Carol R. Horowitz, Karen B. Jacobson, J. Daniel Kelly, Stacey Knight, Karen Lutrick, Praveen Mudumbi, Sairam Parthasarathy, Heather Prendergast, Nasser Sharareh, Judd Shellito, Zaki A. Sherif, Brittany D. Taylor, Emily Taylor, Joel Tsevat, Zanthia Wiley, Natasha J. Williams, Lynn Yee, Lisa Aponte-Soto, Jhony Baissary, Jasmine Berry, Alexander W. Charney, Maged M. Costantine, Alexandria M. Duven, Nathaniel Erdmann, Kacey C. Ernst, Elen M. Feuerriegel, Valerie J. Flaherman, Minjoung Go, Kellie Hawkins, Vanessa Jacoby, Janice John, Sara Kelly, Elijah Kindred, Adeyinka Laiyemo, Emily B. Levitan, Jennifer K. Logue, Jai G. Marathe, Jeffrey N. Martin, Grace A. McComsey, Torri D. Metz, Tony Minor, Aoyjai P. Montgomery, Janet M. Mullington, Igho Ofotukun, Megumi J. Okumura, Michael J. Peluso, Kristen Pogreba-Brown, Hengameh Raissy, Johana M. Rosas, Upinder Singh, Timothy VanWagoner.

Disclosures: Feldman receives grant support to her institution for health equity research and consults for several organizations on unrelated content. Knight receives research funding from Janssen. Alicic, Parthasarathy, Aponte-Soto, Singh, Levitan, and Mullington receive NIH or other research funding or consulting support unrelated to this manuscript.

Funding: This study was funded in part by the National Institutes of Health (OTA OT2HL161841, OTA OT2HL161847, and OTA OT2HL156812).

Paper cited: Feldman CH et al. “Social Determinants of Health and Risk of Long COVID in the U.S. RECOVER-Adult Cohort” Annals of Internal Medicine DOI: 10.7326/ANNALS-24-01971

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About Mass General Brigham

Mass General Brigham is an integrated academic health care system, uniting great minds to solve the hardest problems in medicine for our communities and the world. Mass General Brigham connects a full continuum of care across a system of academic medical centers, community and specialty hospitals, a health insurance plan, physician networks, community health centers, home care, and long-term care services. Mass General Brigham is a nonprofit organization committed to patient care, research, teaching, and service to the community. In addition, Mass General Brigham is one of the nation’s leading biomedical research organizations with several Harvard Medical School teaching hospitals. For more information, please visit massgeneralbrigham.org.

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Journal​

Annals of Internal Medicine

DOI​

10.7326/ANNALS-24-01971

Method of Research​

Survey

Subject of Research​

People

Article Title​

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

Article Publication Date​

28-Jul-2025

COI Statement​

Feldman receives grant support to her institution for health equity research and consults for several organizations on unrelated content. Knight receives research funding from Janssen. Alicic, Parthasarathy, Aponte-Soto, Singh, Levitan, and Mullington receive NIH or other research funding or consulting support unrelated to this manuscript.

 

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Economically disadvantaged patients at greater risk for long COVID

A prospective observational cohort study determined the associations between social determinants of health (SDoH) at the time of SARS-CoV-2 infection and subsequent risk for long COVID.

www.eurekalert.org

News Release 28-Jul-2025

Economically disadvantaged patients at greater risk for long COVID​

Peer-Reviewed Publication
American College of Physicians


Embargoed for release until 5:00 p.m. ET on Monday 28 July 2025

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Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.

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1. Economically disadvantaged patients at greater risk for long COVID

Abstract:

https://www.acpjournals.org/doi/10.7326/ANNALS-24-01971

URL goes live when the embargo lifts

A prospective observational cohort study determined the associations between social determinants of health (SDoH) at the time of SARS-CoV-2 infection and subsequent risk for long COVID. The study found that people with social risk factors including economic instability and food insecurity at the time of COVID-19 infection were at greater risk for long COVID. The results suggest policy efforts are essential to dismantle the systemic drivers of social risk factors and address the disparities exacerbated by the COVID-19 pandemic. The study is published in Annals of Internal Medicine.



Researchers from Brigham and Women’s Hospital, Harvard Medical School, and colleagues studied data from 3,787 adults enrolled in the RECOVER-Adult study between October 2021 and November 2023 who had acute SARS-CoV-2 infection with the Omicron variant. Participants completed comorbidity and SDoH surveys at baseline and long COVID symptom surveys at six-month follow-up. The researchers used the Healthy People 2030 categorizations for SDoH to consider four domains of individual-level social risk factors (economic instability, education and language access barriers, health care access and quality challenges, and lack of social or community support) and two area-level measures from ZIP code data (neighborhood poverty and household crowding). The outcome measured was meeting the criteria for likely long COVID from the 2024 update of the RECOVER-Adult Long COVID Research Index (LCRI) based on the 6-month patient-reported symptom survey. The researchers found that persons with financial hardship, food insecurity, less than a college education, and health care access challenges were at higher risk for developing long COVID. Living in a ZIP code with higher household crowding was also associated with greater risk of long COVID. Secondary analyses found that a greater number of social risk factors within most domains conferred higher risk for long COVID. The findings show the lasting contribution of social risk factors to the disparities exacerbated by the COVID-19 pandemic.