Observational Study

. 2025 Sep;178(9):1287-1297.

doi: 10.7326/ANNALS-24-01971. Epub 2025 Jul 29.

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

Candace H Feldman¹, Leah Santacroce², Ingrid V Bassett³, Tanayott Thaweethai⁴, Radica Alicic⁵, Rachel Atchley-Challenner⁶, Alicia Chung⁷, Mark P Goldberg⁸, Carol R Horowitz⁹, Karen B Jacobson¹⁰, J Daniel Kelly¹¹, Stacey Knight¹², Karen Lutrick¹³, Praveen Mudumbi¹⁴, Sairam Parthasarathy¹⁵, Heather Prendergast¹⁶, Yuri Quintana¹⁷, Nasser Sharareh¹⁸, Judd Shellito¹⁹, Zaki A Sherif²⁰, Brittany D Taylor²¹, Emily Taylor²², Joel Tsevat²³, Zanthia Wiley²⁴, Natasha J Williams²⁵, Lynn Yee²⁶, Lisa Aponte-Soto²⁷, Jhony Baissary²⁸, Jasmine Berry²⁴, Alexander W Charney²⁹, Maged M Costantine³⁰, Alexandria M Duven³¹, Nathaniel Erdmann³², Kacey C Ernst³³, Elen M Feuerriegel³⁴, Valerie J Flaherman³⁵, Minjoung Go³⁶, Kellie Hawkins³⁷, Vanessa Jacoby³⁸, Janice John³⁹, Sara Kelly⁴⁰, Elijah Kindred⁴¹, Adeyinka Laiyemo⁴², Emily B Levitan⁴³, Bruce D Levy⁴⁴, Jennifer K Logue⁴⁵, Jai G Marathe⁴⁶, Jeffrey N Martin⁴⁷, Grace A McComsey²⁸, Torri D Metz⁴⁸, Tony Minor⁴⁹, Aoyjai P Montgomery⁵⁰, Janet M Mullington⁵¹, Igho Ofotokun²⁴, Megumi J Okumura⁵², Michael J Peluso⁵³, Kristen Pogreba-Brown³³, Hengameh Raissy⁵⁴, Johana M Rosas⁵⁵, Upinder Singh⁵⁶, Timothy VanWagoner⁵⁷, Cheryl R Clark⁵⁸, Elizabeth W Karlson¹

Affiliations

¹ 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.).
² Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (L.S.).
³ Harvard Medical School, and Infectious Diseases Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts (I.V.B.).
⁴ Harvard Medical School, and Biostatistics, Massachusetts General Hospital, Boston, Massachusetts (T.T.).
⁵ Department of Medicine, University of Washington, Spokane, Washington (R.A.).
⁶ Biostatistics, Massachusetts General Hospital, Boston, Massachusetts (R.A.-C.).
⁷ Health and Behavior, Department of Population Health, New York University Grossman School of Medicine, New York, New York (A.C.).
⁸ Neurology, UT Health San Antonio, San Antonio, Texas (M.P.G.).
⁹ Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York (C.R.H.).
¹⁰ 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.).
¹¹ 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.).
¹² Cardiovascular Research, Cardiology, Intermountain Health, and Division of Epidemiology, Department of Medicine, University of Utah, Salt Lake City, Utah (S.Knight).
¹³ Family & Community Medicine, University of Arizona, Tucson, Arizona (K.L.).
¹⁴ Department of Population Health, New York University Grossman School of Medicine, New York, New York (P.M.).
¹⁵ Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona, Tucson, Arizona (S.P.).
¹⁶ Illinois Research Network (ILLInet), and Emergency Medicine, University of Chicago, Chicago, Illinois (H.P.).
¹⁷ Harvard Medical School, and Division of Clinical Informatics, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Y.Q.).
¹⁸ Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah (N.S.).
¹⁹ Division of Pulmonary, Critical Care, Allergy and Immunology, LSU Health Services Center, New Orleans, Louisiana (J.S.).
²⁰ Department of Biochemistry & Molecular Biology, Department of Medicine, Howard University College of Medicine, Washington, DC (Z.A.S.).
²¹ Division of Health Strategies, Community Impact, American Heart Association, Atlanta, Georgia (B.D.T.).
²² Solve M.E., Los Angeles, California (E.T.).
²³ 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.).
²⁴ Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia (Z.W., J.Berry, I.O.).
²⁵ Institute for Excellence in Health Equity, Department of Population Health, New York University Grossman School of Medicine, New York, New York (N.J.W.).
²⁶ Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois (L.Y.).
²⁷ Illinois Research Network (ILLInet) and Illinois Unidos, Chicago, Illinois (L.A.-S.).
²⁸ Case Western Reserve University School of Medicine, Cleveland, Ohio (J.Baissary, G.A.M.).
²⁹ Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York (A.W.C.).
³⁰ Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Ohio State University, Columbus, Ohio (M.M.C.).
³¹ Medical & Surgical Specialties Research, Providence Swedish Medical Center, Seattle, Washington (A.M.D.).
³² Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama (N.E.).
³³ Epidemiology, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona (K.C.E., K.P.-B.).
³⁴ Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado (E.M.F.).
³⁵ Departments of Pediatrics and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California (V.J.F.).
³⁶ Hospital Medicine, Stanford University, Stanford, California (M.G.).
³⁷ Division of Infectious Disease, Department of Medicine, Public Health Institute at Denver Health, Denver, Colorado, and Division of Infectious Disease, University of Colorado, Aurora, California (K.H.).
³⁸ Department of Obstetrics and Gynecology, University of California, San Francisco, San Francisco, California (V.J.).
³⁹ Primary Care, Family Medicine, Cambridge Health Alliance, Boston, Massachusetts (J.J.).
⁴⁰ Illinois Research Network (ILLInet), Chicago, Illinois, and Research Services, University of Illinois College of Medicine, Peoria, Illinois (S.Kelly).
⁴¹ Illinois Research Network (ILLInet) and Bright Star Community Outreach, Chicago, Illinois (E.K.).
⁴² Division of Gastroenterology, Department of Medicine, Howard University, Washington, DC (A.L.).
⁴³ School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama (E.B.L.).
⁴⁴ Harvard Medical School, and Division of Pulmonology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (B.D.L.).
⁴⁵ Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington (J.K.L.).
⁴⁶ Division of Infectious Diseases, Boston University/Boston Medical Center, Boston, Massachusetts (J.G.M.).
⁴⁷ Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California (J.N.M.).
⁴⁸ Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah (T.D.M.).
⁴⁹ Faith Communities Outreach, Metro Health System, Cleveland, Ohio (T.M.).
⁵⁰ Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama (A.P.M.).
⁵¹ Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts (J.M.M.).
⁵² Departments of Pediatrics and Internal Medicine, University of California, San Francisco, San Francisco, California (M.J.O.).
⁵³ Division of Infectious Diseases, HIV and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California (M.J.P.).
⁵⁴ Division of Pulmonary, Department of Pediatrics, University of New Mexico, Health Sciences Center, Albuquerque, New Mexico (H.R.).
⁵⁵ Population Health, Department of Medicine, NYU Langone Health, New York, New York (J.M.R.).
⁵⁶ Division of Infectious Diseases, Department of Medicine, Stanford University, Stanford, California (U.S.).
⁵⁷ Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma (T.V.).
⁵⁸ Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (C.R.C.).

PMID: 40720834
PMCID: PMC12352746 (available on 2026-01-29)
DOI: 10.7326/ANNALS-24-01971

Observational Study

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

Candace H Feldman et al. Ann Intern Med. 2025 Sep.

. 2025 Sep;178(9):1287-1297.

doi: 10.7326/ANNALS-24-01971. Epub 2025 Jul 29.

Authors

Affiliations

¹ 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.).
² Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (L.S.).
³ Harvard Medical School, and Infectious Diseases Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts (I.V.B.).
⁴ Harvard Medical School, and Biostatistics, Massachusetts General Hospital, Boston, Massachusetts (T.T.).
⁵ Department of Medicine, University of Washington, Spokane, Washington (R.A.).
⁶ Biostatistics, Massachusetts General Hospital, Boston, Massachusetts (R.A.-C.).
⁷ Health and Behavior, Department of Population Health, New York University Grossman School of Medicine, New York, New York (A.C.).
⁸ Neurology, UT Health San Antonio, San Antonio, Texas (M.P.G.).
⁹ Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York (C.R.H.).
¹⁰ 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.).
¹¹ 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.).
¹² Cardiovascular Research, Cardiology, Intermountain Health, and Division of Epidemiology, Department of Medicine, University of Utah, Salt Lake City, Utah (S.Knight).
¹³ Family & Community Medicine, University of Arizona, Tucson, Arizona (K.L.).
¹⁴ Department of Population Health, New York University Grossman School of Medicine, New York, New York (P.M.).
¹⁵ Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Arizona, Tucson, Arizona (S.P.).
¹⁶ Illinois Research Network (ILLInet), and Emergency Medicine, University of Chicago, Chicago, Illinois (H.P.).
¹⁷ Harvard Medical School, and Division of Clinical Informatics, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Y.Q.).
¹⁸ Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah (N.S.).
¹⁹ Division of Pulmonary, Critical Care, Allergy and Immunology, LSU Health Services Center, New Orleans, Louisiana (J.S.).
²⁰ Department of Biochemistry & Molecular Biology, Department of Medicine, Howard University College of Medicine, Washington, DC (Z.A.S.).
²¹ Division of Health Strategies, Community Impact, American Heart Association, Atlanta, Georgia (B.D.T.).
²² Solve M.E., Los Angeles, California (E.T.).
²³ 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.).
²⁴ Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia (Z.W., J.Berry, I.O.).
²⁵ Institute for Excellence in Health Equity, Department of Population Health, New York University Grossman School of Medicine, New York, New York (N.J.W.).
²⁶ Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois (L.Y.).
²⁷ Illinois Research Network (ILLInet) and Illinois Unidos, Chicago, Illinois (L.A.-S.).
²⁸ Case Western Reserve University School of Medicine, Cleveland, Ohio (J.Baissary, G.A.M.).
²⁹ Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York (A.W.C.).
³⁰ Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Ohio State University, Columbus, Ohio (M.M.C.).
³¹ Medical & Surgical Specialties Research, Providence Swedish Medical Center, Seattle, Washington (A.M.D.).
³² Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama (N.E.).
³³ Epidemiology, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona (K.C.E., K.P.-B.).
³⁴ Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado (E.M.F.).
³⁵ Departments of Pediatrics and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California (V.J.F.).
³⁶ Hospital Medicine, Stanford University, Stanford, California (M.G.).
³⁷ Division of Infectious Disease, Department of Medicine, Public Health Institute at Denver Health, Denver, Colorado, and Division of Infectious Disease, University of Colorado, Aurora, California (K.H.).
³⁸ Department of Obstetrics and Gynecology, University of California, San Francisco, San Francisco, California (V.J.).
³⁹ Primary Care, Family Medicine, Cambridge Health Alliance, Boston, Massachusetts (J.J.).
⁴⁰ Illinois Research Network (ILLInet), Chicago, Illinois, and Research Services, University of Illinois College of Medicine, Peoria, Illinois (S.Kelly).
⁴¹ Illinois Research Network (ILLInet) and Bright Star Community Outreach, Chicago, Illinois (E.K.).
⁴² Division of Gastroenterology, Department of Medicine, Howard University, Washington, DC (A.L.).
⁴³ School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama (E.B.L.).
⁴⁴ Harvard Medical School, and Division of Pulmonology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (B.D.L.).
⁴⁵ Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington (J.K.L.).
⁴⁶ Division of Infectious Diseases, Boston University/Boston Medical Center, Boston, Massachusetts (J.G.M.).
⁴⁷ Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California (J.N.M.).
⁴⁸ Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah (T.D.M.).
⁴⁹ Faith Communities Outreach, Metro Health System, Cleveland, Ohio (T.M.).
⁵⁰ Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama (A.P.M.).
⁵¹ Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts (J.M.M.).
⁵² Departments of Pediatrics and Internal Medicine, University of California, San Francisco, San Francisco, California (M.J.O.).
⁵³ Division of Infectious Diseases, HIV and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California (M.J.P.).
⁵⁴ Division of Pulmonary, Department of Pediatrics, University of New Mexico, Health Sciences Center, Albuquerque, New Mexico (H.R.).
⁵⁵ Population Health, Department of Medicine, NYU Langone Health, New York, New York (J.M.R.).
⁵⁶ Division of Infectious Diseases, Department of Medicine, Stanford University, Stanford, California (U.S.).
⁵⁷ Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma (T.V.).
⁵⁸ Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (C.R.C.).

PMID: 40720834
PMCID: PMC12352746 (available on 2026-01-29)
DOI: 10.7326/ANNALS-24-01971

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 Disclaimer

Conflict of interest statement

Disclosures: Disclosure forms are available with the article online.

References

1. World Health Organization. Social Determinants of Health. Accessed at https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1 on 28 February 2024.
1. Office of Disease Prevention and Health Promotion. Social Determinants of Health. Accessed at https://odphp.health.gov/healthypeople/priority-areas/social-determinant... on 25 June 2025.
1. Alderwick H, Gottlieb LM. Meanings and misunderstandings: a social determinants of health lexicon for health care systems. Milbank Q. 2019;97:407–419. doi: 10.1111/1468-0009.12390 - DOI - PMC - PubMed
1. Bailey ZD, Krieger N, Agénor M, et al. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389:1453–1463. doi: 10.1016/S0140-6736(17)30569-X - DOI - PubMed
1. Egede LE, Walker RJ. Structural racism, social risk factors, and Covid-19 - a dangerous convergence for Black Americans. N Engl J Med. 2020;383:e77. doi: 10.1056/NEJMp2023616 - DOI - PMC - PubMed

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

Affiliations

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

Authors

Affiliations

Abstract

Conflict of interest statement

References

Publication types

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Medical

Miscellaneous