R3 Seminar Recap: Social determinants of health and Long COVID: Insights from the RECOVER observational studies

RECOVER adult study finds social and economic challenges increase risk for Long COVID

Dr. Feldman (Brigham and Women’s Hospital, Harvard Medical School) presented on the background, key findings, and importance of a RECOVER study that examined how social risk factors influence the risk of developing Long COVID. 

Previous studies have found that individuals living in neighborhoods with higher poverty, unemployment, air pollution levels, or limited access to healthy food are more likely to develop Long COVID. These patterns may be linked to barriers in accessing healthcare, harmful environmental exposures, or discrimination. However, few studies have tracked participants over a long period of time (prospectively) and at both individual and neighborhood levels to examine how these social risk factors directly affect Long COVID risk.

Social risk factors are the conditions in daily life that shape people’s health. According to the Office of Disease Prevention and Health Promotion's Healthy People 2030 initiative, these social risk factors can fall into 5 areas: financial hardships, challenges in accessing healthcare, limited education and language barriers, lack of social support, and living in neighborhoods with high rates of poverty or crowded households.

To fill this gap, RECOVER researchers followed 3,787 adults who joined the study within 30 days of a SARS-CoV-2 infection (the virus that causes COVID-19) between October 2021 and November 2023. Participants completed surveys about their experiences with social risk factors such as financial hardship, food insecurity, and difficulty accessing healthcare. Researchers then followed them for at least 6 months to understand who developed Long COVID. 

The study found strong associations between the presence of social risk factors and the risk of developing Long COVID. These associations were found to be true for factors such as:

• Skipping healthcare services due to cost (adjusted risk ratio [ARR] 2.87, meaning that people who skip healthcare services due to cost have a 2.87 times higher risk of developing Long COVID than those who do not skip these services)
• Medical discrimination (ARR 2.37)
• Financial hardship (ARR 2.36)
• Food insecurity (ARR 2.36)
• Lack of social support (ARR 1.79) 

The study also found that the relationship between social risk factors and Long COVID was dose dependent. This means that individuals with multiple social risk factors had an even greater risk of developing the condition than those with a single risk factor, and that risk of developing Long COVID increased with each added risk factor. 

The study also found that Black or African American, and Hispanic, Latino, or Spanish participants experienced a greater burden of nearly all social risk factors, highlighting inequities that may contribute to adverse Long COVID outcomes for people in these groups.

Pediatric researchers also examine social risk factors 

Dr. Rhee (University of California San Diego School of Medicine, Rady Children’s Hospital) presented a forthcoming study examining how social and economic factors may influence the risk of Long COVID in children and adolescents enrolled in the RECOVER pediatric observational study.

The study surveyed caregivers of children and adolescents aged 6 to 17 between March 2022 and August 2024. The survey was administered at least 90 days after their child’s SARS-CoV-2 infection to determine whether symptoms persisted long enough to meet the definition of Long COVID. Long COVID status was determined using the children’s Long COVID research index developed by RECOVER researchers. Researchers also analyzed patterns among study participants to better understand how the f5 social risk factor areas may affect the risk of developing Long COVID.

Early results show that, for children and adolescents, much like for adults, social risk factors such as medical discrimination, unmet medical needs, food insecurity, transportation and childcare difficulties, and reliance on government financial assistance were linked to a higher risk of developing Long COVID.

Drs. Feldman and Rhee emphasized that interventions are needed to address differences in social risk factors. “It is important to think about what to do with the findings that we have, and what I would argue is that at this point, interventions are needed to address disparities in social risk factors,” shared Dr. Feldman. “Improving access to care and the overall health of populations disproportionately affected [by social risk factors] likely has the potential to affect Long COVID, but also a number of other chronic conditions.” 

The researchers highlighted the important contribution of the RECOVER National Community Engagement Group (NCEG) and the social risk factors writing committee. These groups were deeply involved in shaping the study—from design and data analysis to interpretation and communication of the results.

RECOVER Representatives bring community voices into research

Ms. Taylor, coauthor of the adult social risk factors paper and RECOVER Community Representative, spoke about how community members from the NCEG helped shape the research from start to finish. The NCEG is a small working group of Patient, Caregiver, and Community Representatives within RECOVER. Its members ensure that research reflects lived experiences and that findings are communicated clearly to the public.

Ms. Taylor explained that the adult study was developed through meaningful community engagement. Researchers sought ongoing feedback from RECOVER Representatives and the writing group to better understand the perspectives of communities most affected by COVID-19 and Long COVID. Drs. Feldman and Karlson (Brigham and Women’s Hospital, Harvard Medical School) presented their findings to several groups—including the NCEG, RECOVER investigators, and RECOVER study sites in Boston—to gather feedback and ensure alignment across different communities. 

Learn more about how RECOVER Representatives inform Long COVID research through authorship.

“The community voice is so important,” said Ms. Taylor. “Especially with RECOVER—because when patients are tired, or when caregivers have too much on their plate, Community Representatives are able to step in and elevate the voices of those patients.”

Dr. Karlson, co-author of the adult study paper and multiple principal investigator of RECOVER’s Data Resource Core, shared that the data used in in the adult study is publicly available via NHLBI BioData Catalyst® Powered by PIC-SURE. Learn about how to use this tool to access RECOVER data.

To find recordings and transcripts of more R3 seminars, visit the RECOVER YouTube channel and the R3 Seminar page.