[Skip to Content]
[Skip to Content Landing]

Association of Social and Behavioral Risk Factors With Mortality Among US Veterans With COVID-19

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Are social and behavioral risk factors associated with mortality in US veterans with COVID-19?

Findings  In this cohort study of 27 640 veterans who received a positive test result for COVID-19, risk factors such as housing problems, financial hardship, alcohol use, tobacco use, and substance use were not associated with higher mortality.

Meaning  This study found no association between social and behavioral risk factors and death from COVID-19 in an integrated VA health system; such a system is known to transcend social vulnerabilities and has the potential to be a model of support services for households and at-risk populations in the US.


Importance  The US Department of Veterans Affairs (VA) offers programs that reduce barriers to care for veterans and those with housing instability, poverty, and substance use disorder. In this setting, however, the role that social and behavioral risk factors play in COVID-19 outcomes is unclear.

Objective  To examine whether social and behavioral risk factors were associated with mortality among US veterans with COVID-19 and whether this association might be modified by race/ethnicity.

Design, Setting, and Participants  This cohort study obtained data from the VA Corporate Data Warehouse to form a cohort of veterans who received a positive COVID-19 test result between March 2 and September 30, 2020, in a VA health care facility. All veterans who met the inclusion criteria were eligible to participate in the study, and participants were followed up for 30 days after the first SARS-CoV-2 or COVID-19 diagnosis. The final follow-up date was October 31, 2020.

Exposures  Social risk factors included housing problems and financial hardship. Behavioral risk factors included current tobacco use, alcohol use, and substance use.

Main Outcomes and Measures  The primary outcome was all-cause mortality in the 30-day period after the SARS-CoV-2 or COVID-19 diagnosis date. Multivariable logistic regression was used to estimate odds ratios, clustering for health care facilities and adjusting for age, sex, race, ethnicity, marital status, clinical factors, and month of COVID-19 diagnosis.

Results  Among 27 640 veterans with COVID-19 who were included in the analysis, 24 496 were men (88.6%) and the mean (SD) age was 57.2 (16.6) years. A total of 3090 veterans (11.2%) had housing problems, 4450 (16.1%) had financial hardship, 5358 (19.4%) used alcohol, and 3569 (12.9%) reported substance use. Hospitalization occurred in 7663 veterans (27.7%), and 1230 veterans (4.5%) died. Housing problems (adjusted odds ratio [AOR], 0.96; 95% CI, 0.77-1.19; P = .70), financial hardship (AOR, 1.13; 95% CI, 0.97-1.31; P = .11), alcohol use (AOR, 0.82; 95% CI, 0.68-1.01; P = .06), current tobacco use (AOR, 0.85; 95% CI, 0.68-1.06; P = .14), and substance use (AOR, 0.90; 95% CI, 0.71-1.15; P = .41) were not associated with higher mortality. Interaction analyses by race/ethnicity did not find associations between mortality and social and behavioral risk factors.

Conclusions and Relevance  Results of this study showed that, in an integrated health system such as the VA, social and behavioral risk factors were not associated with mortality from COVID-19. Further research is needed to substantiate the potential of an integrated health system to be a model of support services for households with COVID-19 and populations who are at risk for the disease.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: April 13, 2021.

Published: June 9, 2021. doi:10.1001/jamanetworkopen.2021.13031

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Kelly JD et al. JAMA Network Open.

Corresponding Author: J. Daniel Kelly, MD, MPH, Department of Epidemiology and Biostatistics, University of California, San Francisco, 550 16th St, San Francisco, CA 94143 (dan.kelly@ucsf.edu).

Author Contributions: Mr Leonard and Dr Keyhani had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kelly, Wray, Myers, Keyhani.

Acquisition, analysis, or interpretation of data: Kelly, Bravata, Bent, Leonard, Boscardin, Keyhani.

Drafting of the manuscript: Kelly, Leonard.

Critical revision of the manuscript for important intellectual content: Kelly, Bravata, Bent, Wray, Boscardin, Myers, Keyhani.

Statistical analysis: Kelly, Leonard, Boscardin.

Obtained funding: Keyhani.

Administrative, technical, or material support: Kelly, Bravata, Bent, Wray, Leonard, Myers.

Supervision: Kelly, Keyhani.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by grant 1IP1HX001994 from the US Department of Veterans Affairs. Dr Kelly was supported by K23 grant AI135037 from the National Institute of Allergy and Infectious Diseases.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the US veterans for their contributions to this research and ultimately ending the COVID-19 pandemic.

Centers for Disease Control and Prevention. Risk for COVID-19 infection, hospitalization, and death by race/ethnicity. Accessed April 29, 2021. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html
Worobey  M , Pekar  J , Larsen  BB ,  et al.  The emergence of SARS-CoV-2 in Europe and the US.   bioRxiv. Preprint posted online May 2020. doi:10.1101/2020.05.21.109322 Google Scholar
Solis  J , Franco-Paredes  C , Henao-Martínez  AF , Krsak  M , Zimmer  SM .  Structural vulnerability in the U.S. revealed in three waves of COVID-19.   Am J Trop Med Hyg. 2020;103(1):25-27. doi:10.4269/ajtmh.20-0391 PubMedGoogle ScholarCrossref
Villarosa  L . 'A terrible price': the deadly racial disparities of Covid-19 in America. The New York Times. April 29, 2020. Accessed April 29, 2021. https://www.nytimes.com/2020/04/29/magazine/racial-disparities-covid-19.html
Dyer  O .  Covid-19: Black people and other minorities are hardest hit in US.   BMJ. 2020;369:m1483. doi:10.1136/bmj.m1483 PubMedGoogle ScholarCrossref
Rogers  TN , Rogers  CR , VanSant-Webb  E , Gu  LY , Yan  B , Qeadan  F .  Racial disparities in COVID-19 mortality among essential workers in the United States.   World Med Health Policy. August 5, 2020. doi:10.1002/wmh3.358 PubMedGoogle Scholar
Mayfield  CA , Sparling  A , Hardeman  G ,  et al.  Development, implementation, and results from a COVID-19 messaging campaign to promote health care seeking behaviors among community clinic patients.   J Community Health. October 30, 2020. doi:10.1007/s10900-020-00939-0 PubMedGoogle Scholar
Izzy  S , Tahir  Z , Cote  DJ ,  et al.  Characteristics and outcomes of Latinx patients with COVID-19 in comparison with other ethnic and racial groups.   Open Forum Infect Dis. 2020;7(10):a401. doi:10.1093/ofid/ofaa401 PubMedGoogle ScholarCrossref
Page  KR , Venkataramani  M , Beyrer  C , Polk  S .  Undocumented U.S. immigrants and Covid-19.   N Engl J Med. 2020;382(21):e62. doi:10.1056/NEJMp2005953 PubMedGoogle Scholar
Oppel  RA , Gebeloff  R , Rebecca Lai  KK , Wright  W , Smith  M . The fullest look yet at the racial inequity of coronavirus. The New York Times. July 5, 2020. Accessed April 29, 2021. https://www.nytimes.com/interactive/2020/07/05/us/coronavirus-latinos-african-americans-cdc-data.html
Maroko  AR , Nash  D , Pavilonis  BT .  COVID-19 and inequity: a comparative spatial analysis of New York City and Chicago hot spots.   J Urban Health. 2020;97(4):461-470. doi:10.1007/s11524-020-00468-0 PubMedGoogle ScholarCrossref
Nayak  A , Islam  SJ , Mehta  A ,  et al.  Impact of social vulnerability on COVID-19 incidence and outcomes in the United States.   medRxiv. Preprint posted online April 17, 2020. doi:10.1101/2020.04.10.20060962Google Scholar
Karaye  IM , Horney  JA .  The impact of social vulnerability on COVID-19 in the U.S.: an analysis of spatially varying relationships.   Am J Prev Med. 2020;59(3):317-325. doi:10.1016/j.amepre.2020.06.006 PubMedGoogle ScholarCrossref
Freese  KE , Vega  A , Lawrence  JJ , Documet  PI .  Social vulnerability is associated with risk of COVID-19 related mortality in U.S. counties with confirmed cases.   J Health Care Poor Underserved. 2021;32(1):245-257. doi:10.1353/hpu.2021.0022 PubMedGoogle ScholarCrossref
Farhoudian  A , Baldacchino  A , Clark  N ,  et al.  COVID-19 and substance use disorders: recommendations to a comprehensive healthcare response. An International Society of Addiction Medicine Practice and Policy Interest Group position paper.   Basic Clin Neurosci. 2020;11(2):133-150. doi:10.32598/bcn.11.covid19.1PubMedGoogle Scholar
Wong  MS , Steers  WN , Hoggatt  KJ , Ziaeian  B , Washington  DL .  Relationship of neighborhood social determinants of health on racial/ethnic mortality disparities in US veterans—mediation and moderating effects.   Health Serv Res. 2020;55(suppl 2):851-862. doi:10.1111/1475-6773.13547 PubMedGoogle ScholarCrossref
Griffin  CL  Jr , Stein  MA .  Self-perception of disability and prospects for employment among U.S. veterans.   Work. 2015;50(1):49-58. doi:10.3233/WOR-141929 PubMedGoogle ScholarCrossref
Rentsch  CT , Kidwai-Khan  F , Tate  JP ,  et al.  Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: a nationwide cohort study.   PLoS Med. 2020;17(9):e1003379. doi:10.1371/journal.pmed.1003379 PubMedGoogle Scholar
Ioannou  GN , Locke  E , Green  P ,  et al.  Risk factors for hospitalization, mechanical ventilation, or death among 10 131 US veterans with SARS-CoV-2 infection.   JAMA Netw Open. 2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310 PubMedGoogle Scholar
McCreight  MS , Gilmartin  HM , Leonard  CA ,  et al.  Practical use of process mapping to guide implementation of a care coordination program for rural veterans.   J Gen Intern Med. 2019;34(suppl 1):67-74. doi:10.1007/s11606-019-04968-x PubMedGoogle ScholarCrossref
Leonard  C , Gilmartin  H , McCreight  M ,  et al.  Operationalizing an implementation framework to disseminate a care coordination program for rural veterans.   J Gen Intern Med. 2019;34(suppl 1):58-66. doi:10.1007/s11606-019-04964-1 PubMedGoogle ScholarCrossref
Montgomery  AE , Rahman  AKMF , Chhabra  M , Cusack  MC , True  JG .  The importance of context: linking veteran outpatients screening positive for housing instability with responsive interventions.   Adm Policy Ment Health. 2021;48(1):23-35. doi:10.1007/s10488-020-01028-z PubMedGoogle ScholarCrossref
Bell  MD , Muppala  B , Weinstein  AJ ,  et al.  Randomized clinical trial of cognitive remediation therapy with work therapy in the early phase of substance use disorder recovery for older veterans: 12-month follow-up.   J Subst Abuse Treat. 2020;112:17-22. doi:10.1016/j.jsat.2020.01.018 PubMedGoogle ScholarCrossref
Peterson  K , Anderson  J , Boundy  E , Ferguson  L , McCleery  E , Waldrip  K .  Mortality disparities in racial/ethnic minority groups in the Veterans Health Administration: an evidence review and map.   Am J Public Health. 2018;108(3):e1-e11. doi:10.2105/AJPH.2017.304246 PubMedGoogle ScholarCrossref
Wong  MS , Hoggatt  KJ , Steers  WN ,  et al.  Racial/ethnic disparities in mortality across the Veterans Health Administration.   Health Equity. 2019;3(1):99-108. doi:10.1089/heq.2018.0086 PubMedGoogle ScholarCrossref
Kondo  K , Low  A , Everson  T ,  et al.  Prevalence of and Interventions to Reduce Health Disparities in Vulnerable Veteran Populations: A Map of the Evidence. Department of Veterans Affairs; 2017.
US Department of Veterans Affairs. Office of Health Equity. Accessed April 29, 2021. https://www.va.gov/healthequity/
DuVall  S , Scehnet  J . Introduction to the VA COVID-19 Shared Data Resource and its use for research. VA Informatics and Computing Infrastructure webinar. April 22, 2020. Accessed April 29, 2021. https://www.hsrd.research.va.gov/cyberseminars/catalog-upcoming-session.cfm?UID=3810
US Department of Veterans Affairs, Health Services Research & Development. Corporate Data Warehouse. Accessed April 29, 2021. https://www.hsrd.research.va.gov/for_researchers/vinci/cdw.cfm
US Department of Veterans Affairs. VA priority groups. Accessed April 29, 2021. https://www.va.gov/health-care/eligibility/priority-groups/
Barnett  PG , Chow  A , Flores  NE . Using tobacco health factors data for VA Health Services Research. Technical Report 28. VA Palo Alto Health Economics Resource Center; 2014. Accessed April 29, 2021. https://www.herc.research.va.gov/files/RPRT_768.pdf
Bush  K , Kivlahan  DR , McDonell  MB , Fihn  SD , Bradley  KA .  The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking: Ambulatory Care Quality Improvement Project (ACQUIP)—alcohol use disorders identification test.   Arch Intern Med. 1998;158(16):1789-1795. doi:10.1001/archinte.158.16.1789 PubMedGoogle ScholarCrossref
Sohn  MW , Arnold  N , Maynard  C , Hynes  DM .  Accuracy and completeness of mortality data in the Department of Veterans Affairs.   Popul Health Metr. 2006;4:2. doi:10.1186/1478-7954-4-2 PubMedGoogle ScholarCrossref
Mor M. Assessing race and ethnicity in VA data. VIReC Database and Methods Seminar. April 5, 2021. Accessed April 29, 2021. https://www.hsrd.research.va.gov/cyberseminars/catalog-upcoming-session.cfm?UID=3965
Reaven  PD , Emanuele  NV , Wiitala  WL ,  et al; VADT Investigators.  Intensive glucose control in patients with type 2 diabetes—15-year follow-up.   N Engl J Med. 2019;380(23):2215-2224. doi:10.1056/NEJMoa1806802 PubMedGoogle ScholarCrossref
US Census Bureau. Income, poverty and health insurance coverage in the United States: 2019. September 15, 2020. Accessed April 29, 2021. https://www.census.gov/newsroom/press-releases/2020/income-poverty.html
Ahmad  K , Erqou  S , Shah  N ,  et al.  Association of poor housing conditions with COVID-19 incidence and mortality across US counties.   PLoS One. 2020;15(11):e0241327. doi:10.1371/journal.pone.0241327 PubMedGoogle Scholar
Siu  JY .  Health inequality experienced by the socially disadvantaged populations during the outbreak of COVID-19 in Hong Kong: an interaction with social inequality.   Health Soc Care Community. October 2020. doi:10.1111/hsc.13214 PubMedGoogle Scholar
Dasgupta  S , Bowen  VB , Leidner  A ,  et al.  Association between social vulnerability and a county’s risk for becoming a COVID-19 hotspot—United States, June 1-July 25, 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(42):1535-1541. doi:10.15585/mmwr.mm6942a3 PubMedGoogle ScholarCrossref
Gabrielian  S , Yuan  AH , Andersen  RM , Rubenstein  LV , Gelberg  L .  VA health service utilization for homeless and low-income veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles.   Med Care. 2014;52(5):454-461. doi:10.1097/MLR.0000000000000112 PubMedGoogle ScholarCrossref
Edelman  EJ , Maisto  SA , Hansen  NB ,  et al.  The Starting Treatment for Ethanol in Primary Care Trials (STEP Trials): protocol for three parallel multi-site stepped care effectiveness studies for unhealthy alcohol use in HIV-positive patients.   Contemp Clin Trials. 2017;52:80-90. doi:10.1016/j.cct.2016.11.008 PubMedGoogle ScholarCrossref
US Department of Veterans Affairs. Veterans experiencing homelessness. U.S. Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) program. Accessed April 29, 2021. https://www.va.gov/homeless/hud-vash.asp
O’Mahen  PN , Petersen  LA .  Effects of state-level Medicaid expansion on Veterans Health Administration dual enrollment and utilization: potential implications for future coverage expansions.   Med Care. 2020;58(6):526-533. doi:10.1097/MLR.0000000000001327 PubMedGoogle ScholarCrossref
Tsai  J , Link  B , Rosenheck  RA , Pietrzak  RH .  Homelessness among a nationally representative sample of US veterans: prevalence, service utilization, and correlates.   Soc Psychiatry Psychiatr Epidemiol. 2016;51(6):907-916. doi:10.1007/s00127-016-1210-y PubMedGoogle ScholarCrossref
Ruggles  KV , Fang  Y , Tate  J ,  et al.  What are the patterns between depression, smoking, unhealthy alcohol use, and other substance use among individuals receiving medical care? a longitudinal study of 5479 participants.   AIDS Behav. 2017;21(7):2014-2022. doi:10.1007/s10461-016-1492-9 PubMedGoogle ScholarCrossref
O’Connell  MJ , Kasprow  WJ , Rosenheck  RA .  Differential impact of supported housing on selected subgroups of homeless veterans with substance abuse histories.   Psychiatr Serv. 2012;63(12):1195-1205. doi:10.1176/appi.ps.201000229 PubMedGoogle ScholarCrossref
Ogilvie  RP , MacLehose  RF , Alonso  A ,  et al.  Diagnosed sleep apnea and cardiovascular disease in atrial fibrillation patients: the role of measurement error from administrative data.   Epidemiology. 2019;30(6):885-892. doi:10.1097/EDE.0000000000001049 PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity


My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.