The Role of Community-Level Factors on Disparities in COVID-19 Infection Among American Indian/Alaska Native Veterans.

American Indian and Alaska Native (AI/AN) communities have been disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic. This study examines whether neighborhood characteristics mediate AI/AN versus White-non-Hispanic Veteran COVID-19 infection disparities, and whether mediation differs based on proximity to reservations. Using Veteran Health Administration’s (VHA) national database of VHA users evaluated for COVID-19 infection (3/1/2020–8/25/2020), we examined whether census tract neighborhood characteristics (percent households overcrowded, without complete plumbing, without kitchen plumbing, and neighborhood socioeconomic status [n-SES]) mediated racial disparities in COVID-19 infection, using inverse odds-weighted logistic models controlling for individual-level characteristics. Using moderated mediation analyses, we assessed whether neighborhood mediating effects on disparities differed for those residing in counties containing/near federally recognized tribal lands (i.e., Contract Health Service Delivery Area [CHSDA] counties) versus not. The percent of households without complete plumbing, percent without kitchen plumbing, and n-SES partially mediated AI/AN-White-non-Hispanic COVID-19 infection disparities (accounting for 17–35% of disparity) to a similar extent in CHSDA and non-CHSDA counties. The percent of households without kitchen plumbing had stronger mediating effects for CHSDA than non-CHSDA residents. Neighborhood-level social determinants of health may contribute to the disproportionate COVID-19 infection burden on AI/ANs; differences are exacerbated among AI/ANs living near reservations.