Assessment of health-related quality of life of COVID-19 patients during follow-up

The coronavirus disease 19 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) primarily transmitted through respiratory droplets and close contact.1 While some individuals remain asymptomatic, others experience symptoms of acute respiratory infection in the early stages of the disease.2 However, certain patients develop severe manifestations of the disease, such as acute respiratory distress syndrome, as well as life-threatening complications including cytokine storm, leading to death.3


INTRODUCTION
The coronavirus disease  is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) primarily transmitted through respiratory droplets and close contact. 1 While some individuals remain asymptomatic, others experience symptoms of acute respiratory infection in the early stages of the disease. 2 However, certain patients develop severe manifestations of the disease, such as acute respiratory distress syndrome, as well as life-threatening complications including cytokine storm, leading to death. 3 COVID-19 not only affects the respiratory system but also has reported implications on various other organ systems, including the nervous system, cardiovascular system, hematological system, and mental health. [4][5][6][7] Despite extensive research on COVID-19, there is limited information available on the impact of the disease on patients' quality of life, psychological health, and life expectancy. 8 Studies have shown that COVID-19-related pneumonia in adults can lead to a decline in activities of daily living (ADL) and the overall quality of life accompanied by reduced physical and mental function. 9 Moreover, the circulation of myths and misinformation about the epidemic, coupled with travel bans and executive orders for quarantine, can have a detrimental effect on people's psychological well-being, further influencing their health and quality of life. 10 In light of these factors, it is essential to investigate whether patients who have recovered from COVID-19 experience depression and have lower health-related quality of life (HRQOL). Therefore, the objective of this study was to assess the HRQOL in patients who have undergone follow-up after recovering from COVID-19.

Study design and participants
This cross-sectional study was done on COVID-

Assessment of health-related quality of life of COVID-19 patients during follow-up
Medical University (BSMMU) who did their first-month follow-up. Patients who reported at BSMMU between April and September 2021 were enrolled in the study. Research assistants and data collectors were medical personnel who received training from the investigators of this study.

Data collection tools
The Bangla version of the SF-36 (Short Form-36) used in this study was translated from the International

Data analysis
Categorical variables were summarized using frequency and percentage, while quantitative variables were described using mean and standard deviation. Independent t-test was done to determine the differences of HRQOL outcome score between sexes.
Multiple linear regression analysis was done to determine the influence of factors (background characteristics) on HRQOL outcome score (dependent variable). Logistic regression analysis was employed for assessing the relationship of the independent factors with PCS score <50 and MCS score <50. Alfa level of less than 0.05 was considered statistically significant.
All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) for windows, version 21.

Background and clinical characteristics
A total of 225 COVID-19 patients were enrolled in the study where 100 (44.4%) were women. The mean (standard deviation) age of the patients was 36.9 (14.2) years and more than half of them aged between 40 and 60 years. More than four-fifth of them were from urban areas, had higher secondary or above education and were non-smokers. Five out of ten patients had severe to critical condition health condition. The average length of hospital stay was 12.4 days (TABLE 1). Khan

Outcome of HRQOL
The mean score of physical function was 85.5, limitations due to physical health problems was 83.9, body pain was 85.8, general health was 76.9, vitality was 72.7, social functioning was 59.2, limitations due to emotional health problems was 87.9 and mental health was 81.3 (TABLE 1). The overall score of HRQOL was 79 out of maximum achievable score, 100. The physical function, limitations due to physical health problems and bodily pain subgroup showed significant statistical difference between men and women. For physical function and general health subgroups, sex and severity of disease; for social functioning, limitations due to physical health problems and mental health subgroups only sex was found to be associated in linear regression analysis (TABLE 2).

Risk factors for HRQOL
Patients were divided into two groups according to the PCS and MCS with a cutoff point of 50 and then we explored the relationship between the PCS, MCS with the factors. Analysis showed that older age, rural residence and moderate to severe disease condition were significantly associated with a poor PCS and MCS score (TABLE 3).

DISCUSSION
The study findings indicate that COVID-19 patients even after one month of discharge, experience physical and psychological disturbances that affect their overall well-being. Evidence suggested that the physical symptoms associated with COVID-19, such as headache, abdominal and chest pain, can persist for a significant period, potentially impacting the daily lives and functionality of the patients. 11 The lower scores in various dimensions of SF-36, including physical function, general health, social functioning, mental health, and role-physical, indicate the effects of COVID-19 on different aspects of HRQOL.
These findings are consistent with previous studies conducted in different populations, further supporting the notion that COVID-19 has a profound impact on the well-being of individuals. 12 We observed that female patients exhibited significantly lower scores in all dimensions of SF-36 compared to male patients, suggesting that impact on HRQOL may be related to gender. Similar finding was also observed in a study conducted by Qu et al. 13 Additionally, older age was identified as a risk factor for poor HRQOL aligning with previous research. 12 The psychological burden experienced by COVID-19 patients including feelings of isolation, fear, and uncertainty, was found to be a significant factor affecting their HRQOL. These findings emphasize the importance of addressing not only the physical Khan    Such efforts should consider the specific demographic factors and challenges associated with COVID-19 to optimize patient outcomes and facilitate long-term recovery.

Limitation and strength
The study has limitations, such as reliance on selfreported measures, and a short-term follow-up. The study's strengths lie in its comprehensive assessment and recommendations for early interventions which can guide future research and support strategies for improving the well-being of COVID-19 patients.

Conclusion
Our study highlights the HRQOL of COVID-19 patients in Bangladesh. The findings emphasized that the COVID-19 patients with older age, rural residence and having severe to critical disease conditions need to be addressed comprehensively as they have a higher chance of having poor HRQOL status after COVID-19 infection.