The relationship between SDOH disparities and COVID-19 test positivity: A retrospective cohort study of United States veterans Público

Thompson, Brianna (Fall 2023)

Permanent URL:


Introduction: Social determinants of health disparities (SDOH) with COVID-19 test positivity within high-risk populations is a focus in post-pandemic era. One of the largest integrated health care systems is housed by the United States Department of Veteran Affairs. The Veteran Health Administration (VHA) holds one of the largest populations that consist of electronic health records of available data across 1,293 VA facilities in the United States. The overall goal of this study is to understand the association between SDOH disparities with COVID-19 test positivity. Specific aims include: 1) to identify individual SDOH exposures while adjusting for demographics and all other SDOH exposures that impact the risk of testing positive for COVID-19; and 2) to examine the potential impact of geographic location (urban versus rural) in the relationship between SDOH disparities and COVID-19 test positivity. Results from this study can aid in developing public health policies and tailor interventions in high-risk areas to prevent the spread of disease.


Methods: This is a cross-sectional study of veterans seeking COVID-19 inpatient and outpatient care at the VHA. Eligible participants included all veterans who had a record of COVID-19 testing and were defined as a veteran patient who received inpatient or outpatient testing for COVID-19 from the VA between January 1, 2019 through September 30, 2020. Social determinants of health exposures education, marital status, household size, number of children, household income, and rural-urban commuting area (RUCA) were collected from the USVETS database. Demographic variables age, gender, and race/ethnicity were used for descriptive analysis and as confounding covariates. A bivariate analysis was conducted to examine individual SDOH exposures and demographics with the outcome of testing positive for COVID-19. A multivariable regression analysis was conducted to identify SDOH exposures associated with testing positive for COVID-19 after adjusting for demographics and all other SDOH exposures. Rural/urban are defined as residential location and were used in a final analysis exploring effect modification in the relationship between SDOH disparities and COVID-19 test positivity.


Results: Of the veterans who received inpatient and outpatient care for COVID-19, 89% were male, 67% were non-Hispanic white, and 23% were non-Hispanic Black. The overall average age was 61 years. After adjusting for confounders age, gender, and race/ethnicity and all other SDOH covariates, there was a higher test positivity among veterans that had a household income less than or equal to $39,999 compared to those that earn more than or equal to $75,000 (OR 1.07, 95% CI: 1.06, 1.09), completed high school compared to those who completed graduated school (OR 1.07, 95% CI: 1.06, 1.09), had four or more persons living in the household compared to those living alone (OR 1.22, 95% CI: 1.20, 1.24), had three or more children compared to those with no children (OR 1.14, 95% CI: 1.11, 1.18), and lived in rural areas compared to those living in urban areas (OR 1.17, 95% CI: 1.16, 1.18). There were no differences between rural versus urban in the relationship between SDOH variables and COVID-19 test positivity.


Discussion: Findings of this study demonstrated that certain SDOH exposures, including income, education level, household size, and the presence of children in the household, are associated with an increased risk of veterans t4esting positive for COVID-19. This suggests that veterans facing these disparities are more vulnerable to the disease. There were no significant differences after stratifying on urban/rural in the relationship between SDOH disparities and COVID-19 test positivity. Future research should examine access to care in vulnerable populations where risk of testing positive was higher to improve data collection and testing in rural communities. The results of this study emphasize the importance of raising awareness about these disparities and their impact on veterans’ health outcomes and can inform public health policies and initiatives aimed at reducing COVID-19 risk among veterans. Policymakers should consider the social factors highlighted in this study when designing and implementing interventions. This study contributes to our understanding of the impact of SDOH on COVID-19 risk among veterans and underscores the importance of addressing these disparities through targeted interventions. This knowledge can help improve the health and well-being of veterans living in vulnerable populations in the United States.

Table of Contents

Table of Contents

I.                 Introduction 1

II.                Methods 6

A.   Study Design 6

B.    Study Population 7

C.    Data Sources 7

D.   Data Measures 7

E.    Analysis 9

III.             Results 10

IV.             Discussion 12

V.               References 17

Figure 1 20

Figure 2 21

Table 1 22

Table 2 24

Table 3 25

Table 4 26

About this Master's Thesis

Rights statement
  • Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.
Subfield / Discipline
  • English
Research Field
Committee Chair / Thesis Advisor
Última modificação

Primary PDF

Supplemental Files