Quality of life post-COVID recovery: A prospective observational study, North India

Materials & Methods

This prospective observational study was conducted by the department of Community Medicine, Maulana Azad Medical College, New Delhi, India. This study was conducted in line with the principles of the Declaration of Helsinki after obtaining the ethical approval from the Institutional Ethics Committee. Written informed consent was obtained from all the participants enrolled.

The study employed a prospective observational design and spanned a 15-month period, from May 2022 to July 2023. Throughout this period, we extended our research purview across all 11 districts of Delhi, ensuring a broad representation. The participants, included in the study, were aged above 18 years, with a COVID-19 diagnostic report available for the first time at least 14 days prior and within the past six months from the date of enrolment. Certain groups, however, were purposefully excluded from this study, namely pregnant women, those with a subsequent re-infection of COVID-19 post-initial recovery, and those in the terminal stages of any disease. Considering a prevalence of 22 per cent of post-COVID symptoms, a confidence level of 95 per cent, a relative precision of 4.4 per cent, and an allowable error of 20 per cent, the estimated sample size was 351. However, we recruited 369 participants in this study. Figure 1 depicts a map showing the distribution of study participants across various districts of Delhi.

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Fig. 1.

Map showing distribution of study participants across various districts of Delhi (n=369). Source: Map was generated using Tableau software for Geographic Information Systems (GIS).

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Data collection procedure

The list of participants infected with COVID-19 was obtained on a daily basis from the Directorate General of Health Service, Delhi (DGHS). The eligible participants were then selected using a random sampling method from the Excel sheet provided by DGHS. Approximately 10 participants were enrolled daily until the desired sample was achieved. Subsequently, those participants who fulfilled the inclusion criteria were contacted through phone calls, and later, through field visits at their households. Following the acquisition of written informed consent, they were enrolled in the study for follow-up at baseline and prospectively at six months after recovery. Enrolment ceased once the required number of study participants was entered in the study. The study flow has been depicted in figure 2.

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Fig. 2.

Study flow diagram.

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During the baseline evaluation, socio-demographic characteristics of the participants were recorded using a structured interview schedule. These included age, education level, socio-economic status, sex, baseline details on comorbidities, and their treatment profile. The WHOQOL-BREF Scale was utilized in this study to assess the QOL among the participants at the baseline and at six months post-enrolment. This instrument, developed by the WHO, serves as a shortened version of the original WHOQOL-100. It comprises 26 items that measure four primary domains: physical health, psychological well-being, social relationships, and environment. The variables evaluated against the WHOQOL-BREF SCORE included age, sex, educational background, vaccination status, and comorbidities. Each item is rated on a 5-point Likert scale, with the aggregate scores converted to a scale ranging from 0 to 100, where higher scores indicate a better QOL. The WHOQOL-BREF has been widely recognized for its cross-cultural validity and is specifically designed to be comprehensive in its assessment of the multidimensional facets of QOL across diverse settings and populations. After collecting baseline data, participants were revisited for a follow up at the 6^th month.

Recovery among hospitalised patients was defined as discharge from the hospital following the completion of treatment, whereas recovery among non-hospitalized patients was defined as 14 days from the onset of symptoms after confirmed diagnosis through RT-PCR or antigen testing¹³. Post-COVID syndrome (PCoVS) was defined by symptoms that emerged during or after the COVID-19 infection and continued beyond 12 wk¹⁴.

Data was collated in MS Excel and analysed using IBM SPSS Version 25 (IBM Corp., Armonk, NY, USA). Data was summarised using descriptive statistics. Results were presented as frequencies for the categorical variables. Continuous data, if non-normal, was described using the median (IQR), specifically for QOL SCORE. The mean (± Standard Deviation; SD) was employed when the data were continuous and exhibited a normal distribution. Mann-Whitney U test and Kruskal-Wallis test were applied to find the relationship between median scores of different WHO BREF QOL domains and various sociodemographic parameters. The Wilcoxon signed-rank test was used to compare WHO BREF QOL scores at baseline and at six months; P< 0.05 was considered to be statistically significant.

Results

Data from 369 participants was included for analysis, among which males comprised 50.1 per cent (n=185) and females 49.9 per cent (n=184). PCoVS was reported more among females (84.2%) than males (75.1%), a statistically significant difference (P=0.03). The overall mean age was 42 ± 14.9 yr; those with the syndrome averaged 43.2 yr, while those without averaged 37.6 yr. The prevalence of PCoVS was found to be increasing with age (P=0.028). The proportion of PCoVS was higher among illiterate participants, followed by those who had primary and middle school education. In terms of treatment during their initial COVID-19 diagnosis, 35.1 per cent (n=130) were managed at home or via telemedicine, and of these, 81.5 per cent reported PCoVS. Regarding the vaccination status of the participants, 85.7 per cent of unvaccinated and 79.4 per cent of the vaccinated group reported post-COVID symptoms as depicted in table I.

Table II shows that at the baseline, both groups exhibited no significant difference in their QoL scores across all domains (physical, psychological, social associations, and environmental health). However, by the 6^th month, participants without PCoVS consistently reported superior QoL scores in all domains. Specifically, their physical health was significantly better (P=0.004), they exhibited enhanced psychological well-being (P<0.001), enjoyed better social relationships (P=0.002), and had a more positive perception of their environmental health (P=0.003).

In the ‘physical health domain,’ a significant majority, 228 participants, demonstrated improvements, while 122 participants experienced a decline; a statistically significant difference (P<0.001). Similarly, in the ‘psychological health aspect,’ 205 participants exhibited enhanced scores, contrasting with 138 participants who noted a dip (P<0.001). In the ‘social health domain’, 186 participants witnessed a reduction, while 133 noticed an uptick, with the difference bearing a P≤0.01. Lastly, the ‘environmental health scores,’ akin to the ‘social health,’ revealed 186 participants with lowered scores over the half-year period, whereas 133 participants marked an improvement (P<0.001) as described in table III.

Table IV depicts that in the physical domain, for the group with PCoVS, males and females had significantly different scores (79 and 75, respectively; P<0.001), age groups, particularly 18-30 years, as well as participants with no comorbidity, differed significantly (P=0.001). In the psychological domain, significant differences were noted based on sex (P<0.001) and age (P=0.001) within the PCoVS group. The Social Domain showed significant differences in the PCoVS group based on sex (P<0.001), age (P=0.001), and level of education (P=0.002), while in the participants without PCoVS, age was a significantly associated factor (P=0.03). In the environmental domain, the PCoVS group showed significant differences based on sex (P<0.001), age (P<0.001), and education (P<0.001), and the non-PCoVS group displayed differences based on sex (P=0.03) and morbidity profile (P=0.005).

Discussion

The long-term consequences of COVID-19 continue to pose significant public health challenges even after the end of the acute phase. Persistent symptoms, generally referred to as post-COVID condition or long COVID, have been documented to impact patients’ physical, psychological, social, and occupational functioning months after recovery, contributing to increased healthcare utilization, reduced work productivity, and impaired QoL. Furthermore, the WHO recognizes post-COVID condition as a major health concern requiring long-term surveillance and rehabilitation strategies. This study investigated the QoL among post-COVID-19 recovered individuals in North India using the WHO-QoL BREF scale, providing prospective, domain-specific QoL data. The findings reveal a significant disparity in QoL between those experiencing PCoVS and those who did not, especially over a six-month follow up period.

Out of 369 study participants in our study, 79.6 per cent were found to have post-COVID-19 syndrome. In a similar study conducted by Jacobs et al¹⁵, 72.7 ^{per cent of} participants experienced persistence of symptoms after 35 days of recovery. No significant differences were depicted in baseline QoL scores between PCoVS and non-PCoVS groups across all domains. However, after six months of follow up, significantly lower scores of QoLs across all domains were evident among participants with post-COVID syndrome than those without. Participants without PCoVS reported better physical health (median score: 79 vs. 75, P=0.004), psychological health (median score: 83 vs. 75, P<0.001), social relationships (median score: 75 vs. 67, P=0.002), and environmental health (median score: 81 vs. 78, P=0.003) after six months. In a meta-analysis conducted by Malik et al¹⁶, it was concluded that PCoVS was associated with poor QOL and persistence of symptoms assessed using EQ-VAS (59%; 95% CI: 42%–75%) and EuroQoL 5-dimensional-5 levels (EQ-5D-5L) questionnaire (P<0.05). A statistically significant drop in QoL at six months was also observed in a study conducted by Taboada et al¹⁷ in Spain using the EQ-5D-3L questionnaire (P<0.001). A systematic review by Nandasena¹⁸, which included 4,408 patients, reported similar findings, indicating that the QoL of post-COVID-19 patients was significantly impacted¹⁸. Additionally, an online survey in Pakistan using the SF-12 questionnaire concluded that despite presumed ‘recovery’ from COVID-19 disease, patients continued to experience a wide range of persistent symptoms months after the initial infection, leading to a decline in QoL¹⁹. This highlights the difficulties faced by patients due to the persistence of symptoms after recovery from acute illness. Among all four domains, the social domain exhibits the lowest scores among participants, which is due to social disruption during the pandemic and the stigma associated with the COVID-19 infection.

The median WHOQOL-BREF score in all four domains was significantly higher among males compared to that of females (P<0.01), as also observed in a similar study conducted by Sarda et al²⁰ and Hawlader et al²¹ (P<0.05). Females had lower SF-36 scores in the domains of bodily pain (BP), mental health(MH), vitality (VT), and general health (GH) as compared to males (P<0.01) in a study conducted by Chen et al²². This might be due to inappropriate coping mechanisms and a tendency to develop anxiety related to the disease.

Individuals aged over 61 yr had significantly lower scores in the physical health domain than those in the 18-30 yr age group (55 vs. 82, P=0.001). A study by Hossein Khorani also indicated that age was negatively correlated with QoL in patients recovered from COVID-19²³. This could be due to the risk of multiple health disorders with advancing age²⁴. There was a significant difference in physical domain QoL scores in illiterate and graduate participants (66 vs. 79, P=0.05) as well as participants with at least one comorbidity as compared to no comorbidity (71 vs. 79, P=0.001). This was consistent in the studies conducted by Algahtani et al²⁵ in Saudi Arabia and Arab-Zozani et al²⁶ in Iran.

The psychological domain showed significant variations with age and morbidity profile, with younger individuals (18-30 yr) scoring higher compared to those over 61 (81 vs. 75, P=0.001), and individuals without comorbidities scoring better (75 vs. 71, P=0.02). Younger individuals may score higher in the psychological domain due to better mental health, greater social interactions, and more optimistic outlooks about life. They often have fewer responsibilities and stressors compared to older adults. Individuals without comorbidities likely had less anxiety and depression, leading to better psychological well-being, as they possibly experienced fewer health-related worries and limitations.

Our study reported that QoL scores among the post-COVID patients decreased significantly with age, with the lowest scores observed among participants aged 46-60 yr in psychological, social, and environmental domains. Additionally, higher scores were observed in the social domain among participants with a higher level of education (P=0.009). This finding is consistent with the study by Skevington et al²⁷, who evaluated the relationship between QoL and education across 13 countries in both ill and healthy populations. They derived that a higher level of education was associated with improved job opportunities and higher income, which positively impacted QOL. A similar positive association was identified by Hawlader et al²¹.

The environmental domain scores were significantly different by sex and morbidity profile, with males scoring higher (78 vs. 75, P=0.03) and those without comorbidities scoring better (78 vs. 75, P=0.005). Males scored higher in the environmental domain, possibly due to greater access to resources and social support, and less chronic stress. Those without comorbidities scored better, probably because they faced fewer physical and mental health challenges and associated financial burdens.

The key strength of our study was its prospective and comprehensive nature, which allowed the determination of change in QoL among patients affected with PCoVS over a period of time. However, the study had several limitations. The study was limited by a small sample size and excluded individuals under 18 yr of age as well as populations from regions outside Delhi, which restricted the generalizability of its findings to those groups. The observational design limited the ability to establish causality between PCoVS and QoL outcomes. Dependence on self-reported data might have introduced bias into the results, as participants could have either underreported or exaggerated their symptoms and perceived QOL. There was no comparison in the present study with the QOL of participants before COVID-19 infection. Additionally, there was no comparison with the QOL of the general population. However, due to widespread community transmission and potential recall bias, identifying a comparable uninfected population was challenging. The data collection period coincided with the emergence of the Omicron variant of SARS-CoV-2 (the causative virus of COVID-19) and its sub-lineages in the country. The long COVID effects observed may vary depending on the circulating variant. Additionally, undetected COVID-19 reinfections may have occurred within the study population, as testing rates declined during the latter part of the pandemic. This might have influenced the study findings.

Our study provides valuable insights into the impact of post-COVID condition on QoL after six months of follow-up. Early rehabilitative measures should be taken to enhance the QOL, reduce mental stress, and social burden on patients who have recovered from COVID-19 disease. Females as well as people with co-morbidities are the concerned group in patients with PCoVS and should be given a longer duration for rehabilitation. Future studies should adopt a longitudinal design with larger and more diverse populations to gain deeper insights into the long-term effects of COVID-19 on QoL. Additionally, incorporating objective measures of health and well-being could complement self-reported data, providing a more robust assessment of the pandemic’s long-term effects. Our findings are suitable to inform the policymakers in developing patient-centred management strategies with multidisciplinary post-COVID care clinics for faster recovery and enhanced QOL.