Health, Well-Being, and Health-Related Quality of Life Following COVID-19

Abstract

Coronavirus disease 2019 (COVID-19 may have serious effects on health, well-being, and quality of life (QoL). This study explores the perceptions of health, well-being, and QoL in those who contracted the COVID-19 virus compared with those who did not. A convergent mixed-methods design with convenience sampling (n = 41) was conducted between December 2020 and January 2021. The outcome measures included the Short Form–36 and the Pizzi Health and Wellness Assessment. There were no statistically significant differences in perceived health, well-being, and QoL. However, qualitative analysis revealed mental, physical, social, and family health impacts across both groups, with the COVID-19 survivors reporting greater feelings of isolation and fear, resulting in decreased social and family participation. The results indicate that all persons who have experienced the COVID-19 pandemic have experienced negative health-related impacts, but those who actually contracted the virus experienced greater impacts on QoL in areas related to occupational health and participation.

Introduction

Coronavirus disease 2019 (COVID-19) is an illness caused by the severe acute respiratory syndrome coronavirus 2. COVID-19 causes fever, dry cough, shortness of breath, fatigue, body aches, and other flu-like symptoms that range in severity from mild to fatal. Some severe symptoms include pneumonia or kidney failure. Research has found that COVID-19 survivors experienced both physical and mental health changes as a result of contracting the virus (Kemp et al., 2020). Mao et al. (2020) found that mechanical ventilation secondary to COVID-19 led to central nervous system symptoms, such as dizziness, headaches, impaired consciousness, acute cerebrovascular disease, ataxia, and seizures. Li et al. (2020) found that about 88% of COVID-19 survivors experienced neurologic manifestations, acute cerebrovascular diseases, and impaired consciousness, and that those who had the virus were at a higher risk of developing acute respiratory distress syndrome, fibrosis, wheezing, shortness of breath, or asthma. Other common physical impairments of COVID-19 survivors include low functional tolerance, immobility, muscle atrophy, joint-related pain, and contractures (Kemp et al., 2020).

Persons who did not contract the virus may also be at risk for mental health challenges due to the social isolation and fear experienced during the pandemic. A recent study examining the effects of the COVID-19 pandemic in China found that 35% of the general population suffered from psychological distress (Qui et al., 2020). Research in the United States indicates that there were higher incidences of anxiety, depression, and suicidal ideation across the population in 2020 as compared with 2019 (Czeisler, 2020).

Although previous literature has focused on the immediate and short-term physical effects of COVID-19, the effects on well-being and quality of life (QoL) continue to be mostly neglected (Eghigian, 2020; Zhang & Feei Ma, 2020). This study sought to examine the health-related QoL impacts of COVID-19 on survivors and the pandemic-related impacts on those who did not contract COVID-19. Based on gaps in existing literature, the following research question was posed:

• Research Question: Is there a difference in the perceived health, well-being, and health-related QoL of COVID-19 survivors as compared with those who did not contract the virus?

Method

A convergent mixed-methods design was used to identify the health impacts of the COVID-19 pandemic between persons who contracted the virus (COVID+; n = 20) and those who did not (COVID–; n = 21). Institutional review board (IRB) approval was obtained prior to data collection. Eligibility required participants to be between the ages of 18 and 70 years. Participants were recruited through convenience sampling by phone or email, comprising friends, family, or personal contacts of the authors of this study, to create a COVID+ and COVID– group. Participation in the COVID+ group required participants to have reported a positive polymerase chain reaction (PCR) or rapid antigen test between March 2020 and January 2021. Participants who were believed to have contracted COVID-19 but did not receive a positive test or were below the age of 18 years were excluded from the study.

Participants ranged in age from 22 to 70 years, with a mean age of 35.8 years. The total sample size was 41. Of the 41 participants recruited, 27 were female and 14 were male. All participants were residents of the New York metropolitan tristate area. Each participant received and returned an informed consent form through email. Following consent, each participant completed a demographic questionnaire, the Short Form–36 (SF-36; Stewart & Ware, 1992), and the Pizzi Health and Wellness Assessment (PHWA; Pizzi, 2015).

The PHWA and SF-36 were used to measure health, wellness, and health-related QoL among participants. The PHWA is a clinical self-assessment tool for anyone above the age of 18 years. It measures the relationship between occupational performance and participation and several areas of health, well-being, and QoL (Pizzi, 2001). This assessment includes quantitative questions on a 0 to 10 rating scale (0 being the lowest; 10 being the highest). The questions target six aspects of health, namely, social, physical, family, occupational, mental/emotional, and spiritual health. The assessment also consists of open-ended qualitative questions that ask participants to reflect on their quantitative responses for each aspect of health. The PHWA demonstrates good reliability in each dimension of health and wellness (r = .69–.75; Serwe et al., 2019).

The SF-36 is a self-report assessment of perceived health-related QoL across six domains, namely, physical functioning, role limitations due to physical or emotional problems, energy/fatigue, emotional well-being, social functioning, and general health perceptions (Stewart & Ware, 1992). It includes 36 questions ranked using a Likert-type scale as well as “yes” or “no” questions about how one’s health impacts their daily functioning. The SF-36 has demonstrated good reliability (.73–.96; Brazier et al., 1992).

Statistical analysis for quantitative data was done using SPSS Version 27. Descriptive statistics were conducted for demographic variables. Between-group differences in gender analyzed using a chi-square test, and age using a t test, were not significant. Primary statistical analysis was conducted using a two-tailed Mann–Whitney U test to examine differences in scores on the PHWA and SF-36 between groups. Due to the small sample size and observational nature of this study, the present authors used an alpha of .05 without a correction for multiple tests to decrease the probability of committing a Type II error. The concern for committing a type I error is negligible as there was no statistical significance found in any of the statistical calculations.

The qualitative responses of participants on the PHWA were coded and themed as described in Creswell and Poth (2018). After digitally organizing the data, the researchers began the process of memoing to gain a general sense of the data and begin synthesizing the information. Next, researchers began independently coding the data prior to meeting for a group debriefing session where similar codes were categorized. Each author created a codebook and presented these findings at the debriefing group session where a new codebook was created to reflect the final merged codes. The researchers came together to analyze the relationship between the codes and categories that had emerged and sorted them into themes. Thus, the authors participated in peer debriefing of the codes, categories, and themes as a group. In addition to peer debriefing, member checking was also completed to enhance credibility of the findings.

Results

Demographics

The mean age of the COVID+ group was 39.05 years. This group comprised 12 females and eight males. The mean age of the COVID– group was 32.90 years and comprised 15 females and six males. There were no statistical differences found between groups in age (t = –1.3; p = .19) or gender (p = .382).

Quantitative

The results from the Mann–Whitney U test analysis of the responses between groups on the PHWA found no significant differences between groups across all categories with the exception of the Physical Health Level of Interest category (Tables 1 and 2). The results of the Mann–Whitney U test analysis of the SF-36 assessment (Table 3) between groups yielded similar nonsignificant results.

Table 1.

PHWA Perceived Health Comparison.

Category	COVID+ M (SD)	COVID– M (SD)	U statistic (p)	Cohen’s d
Social health	7.4 (2.3)	8.27 (1.1)	0.487 (.4)	.48
Physical health	7.05 (2.3)	7.5 (1.6)	0.228 (.7)	.23
Family health	7.75 (2.5)	7.77 (2.0)	0.009 (.64)	.01
Occupational health	7.7 (1.9)	8.09 (1.3)	0.240 (.67)	.24
Mental/emotional health	7.45 (2.6)	7.36 (2.2)	0.038 (.64)	.04
Spiritual health	7.5 (2.0)	7.27 (1.8)	0.118 (.54)	.12

Note. COVID+ refers to COVID-19 survivors and COVID– refers to those who did not contract COVID-19. U refers to the Mann–Whitney U test. PHWA = Pizzi Health and Wellness Assessment.

Table 2.

PHWA Desire to Improve Health Comparison.

Category	COVID+ M (SD)	COVID– M (SD)	U statistic (p)	Cohen’s d
Social health day-to-day	8.18 (1.7)	8.19 (1.0)	0.007 (.69)	.01
Social health level of interest	6.21 (3.0)	6.31 (2.2)	0.038 (.94)	.04
Physical health day-to-day	7.35 (2.1)	8.10 (1.4)	0.424 (.31)	.47
Physical health level of interest	8.35 (2.0)	6.81 (2.9)	0.616 (.06)	.62
Family health day-to-day	8.32 (1.6)	7.71 (1.7)	0.369 (.3)	.37
Family health level of interest	6.63 (3.4)	7.25 (3.1)	0.191 (.69)	.19
Occupational health day-to-day	7.89 (1.7)	7.76 (1.0)	0.094 (.75)	.09
Occupational health level of interest	7.64 (2.8)	6.52 (3.1)	0.378 (.22)	.38
Mental and emotional health day-to-day	8.12 (1.9)	7.74 (1.7)	0.211 (.32)	.21
Mental and emotional health level of interest	8.42 (2.7)	7.87 (2.6)	0.208 (.22)	.21
Spiritual health day-to-day	8.07 (1.9)	7.75 (1.4)	0.36 (.193)	.19
Spiritual health level of interest	7.85 (2.6)	8 (2.5)	0.97 (.07)	.06

Note. COVID+ refers to COVID-19 survivors and COVID– refers to those who did not contract COVID-19. U refers to the Mann–Whitney U test. PHWA = Pizzi Health and Wellness Assessment.

Table 3.

SF-36 Comparison.

Category	COVID+ M (SD)	COVID– M (SD)	U statistic (p)	Cohen’s d
Physical functioning	86.01 (18.8)	92.7 (10.8)	1.124 (.26)	.44
Role limitations due to physical health	82.89 (36.5)	93.18 (22.1)	1.37 (.17)	.34
Role limitations due to emotional health	75.58 (36.7)	69.69 (42.3)	0.521 (.6)	.15
Energy and fatigue	52.13 (25.3)	61.36 (17.0)	1.263 (.21)	.43
Emotional well-being	67.05 (25.0)	72.91 (17.5)	0.241 (.81)	.27
Social functioning	73 (26.3)	80.45 (21.0)	0.794 (.43)	.31
Pain	74.13 (21.0)	82.16 (18.5)	1.397 (.16)	.41
General health	69.5 (22.6)	69.45 (17.8)	0.076 (.94)	.01

Note. COVID+ refers to COVID-19 survivors and COVID– refers to those who did not contract COVID-19. U refers to the Mann–Whitney U Test. SF-36 = Short Form–36.

Qualitative

Eight main themes emerged across both the COVID+ and COVID– groups from the participants’ responses on the open-ended questions on the PWHA. These themes included anxiety, depression, job stress, fatigue, physical impairment, exercise, social participation, and family participation. The themes that emerged from the responses of the COVID+ group only are physical impairment due to COVID-19, changes in exercise, and changes in social and family participation. Textual data from participants illustrating these themes can be found in Table 4.

Table 4.

Selected Quotes Collected From Participants.

Themes	COVID+ sample quotes	COVID– sample quotes
Mental health
Increased anxiety	“Social isolation has led to increased feelings of stress and anxiety which greatly impacts my work performance, my desire to engage in leisure pursuits and my interpersonal relationships”	“In the past few months I have felt more anxious and exhausted . . . There’s not much going on to look forward to and I am worried about getting COVID.” “I’m generally a very optimistic person but it’s more difficult during COVID.”
Increased depression	“I haven’t been taking care of myself physically and I have not been eating the best due to lack of motivation and possible depression. I am much more tired than I would normally be and get tired much faster.”	“Adjusting to the pandemic, it caused a little emotional distress and anxiety.” “This is a difficult time as we have to adjust to a pandemic. Trying to stay safe, healthy, has changed a lot in our lives. I find myself feeling a little sad.”
Increased job stress	“I found my work treating COVID-19 patients to be quite traumatic as I experienced prolonged exposure to the trauma and death of others. I felt overwhelmed with feelings of pressure, worry, uncertainty, fear, grief, depression and anxiety.” “My overall occupational health greatly declined during this time as I worked directly with COVID-19 patients in a health care setting. Much of this was due to a lack of leadership and instruction on how to best handle and treat COVID-19 patients, fear around coming into contact with the disease and a scarcity of personal protective equipment . . .”	“Working at home full-time with no office is stressful . . . It sometimes leaves me feeling very weary at the end of the day and week”
Physical health
Physical Impairment due to COVID-19	“Post COVID, I have started to feel asthmatic symptoms and have needed my inhaler more.” “Still working on gaining muscle back from being sick with COVID in September.”
Exercise	“I’m just tired all day, every day. I’ve also gained weight since the beginning of the pandemic and have no motivation to take it off . . . The fact that the gyms are closed also adds to my disinterest in exercising.”	“I feel very motivated during COVID-19 to workout because it is exciting for me. It is something to look forward to each day when I don’t have as much going on.”
Increased fatigue	“During this time, I feel my life has become much more sedentary. My current physical health largely affects my day-to-day activities. Not only does my reduced physical health contribute to feelings of low energy and fatigue but also reduces my ability to effectively manage daily stresses and anxiety.”	“I am lazier lately from gaining weight.”
Social health
Social participation	“I feel my social health suffered during this time as my normal social interactions were severely limited both because of the impossibility of physically attending social gatherings as well as my dwindling emotional and mental health . . .”	“I have to schedule and make time for social interactions today mostly via zoom or facetime” “I check in with people more often.” “Since I am not able to hang out in a normal capacity with some of my friends it has taken a toll on me.”
Family participation	“I just look forward to going home and spending time with my immediate family every day.” “I rated myself in family health much lower than I would have before the COVID-19 pandemic because I feel my communication and time spent with them was drastically reduced.”	“It’s nice spending extra time with my family during COVID. I enjoy being home and doing things together like playing games and watching movies.” “My family and I do not communicate as well as we could.”

Mental health

Increased anxiety

Participants in both groups reported that changes in work demands, increased social isolation, and trying to keep family members healthy and safe from COVID-19 caused a significant increase in their anxiety.

Increased depression

Both groups reported increased feelings of depression. The COVID+ group stated that they had less motivation and increased fatigue after recovery, which led to neglecting personal self-care and an overall negative impact on their mood, whereas the COVID– group reported negative mood changes due to the pandemic and related restrictions and social isolation.

Increased job stress

Both groups indicated that they suffered from increased job stress due to the transition to working from home, which caused social isolation and increased demands. Health care workers in both groups indicated that the precautions, fear of contracting COVID-19, scarcity of personal protective equipment, and increased job demands led to a significant increase in job stress.

Physical health

Physical impairment due to COVID-19

The COVID+ group reported residual physical symptoms since recovering from the acute virus, including asthmatic symptoms and loss of muscle mass. Those who did not contract COVID-19 reported weight gain and decreased activity level, which they felt negatively impacts their overall health.

Exercise

The COVID+ group indicated that they do not exercise as much as they would like secondary to weight gain, lack of motivation, and gym closures early on. The COVID– group, on the contrary, reported that they felt very motivated to start new workout routines, and that exercise was something to look forward to.

Increased fatigue

Both groups indicated increased levels of fatigue and decreased motivation.

Social health

Social participation

Although both groups reported difficulties with social interaction, the COVID+ group described greater feelings of isolation and poor socialization. Many survivors reported being afraid of giving COVID-19 to loved ones and staying away from their friends and families even after recovery. The COVID– group reported having some difficulty navigating distancing requirements at first but adapting through the use of technology as a means of social interaction.

Family health

Family participation

Some participants from both groups expressed that they enjoyed being home to spend time with their families, while others expressed that there was too much time at home with their families. However, the COVID+ group expressed poorer family health due to the fact that they feared giving COVID-19 to family members and thus isolated themselves even after the they no longer had the virus.

Discussion

The combined quantitative and qualitative findings of this study indicate that the health, well-being, and health-related QoL of all individuals have been affected by the COVID-19 pandemic. However, qualitatively, COVID-19 survivors reported greater feelings of isolation and fear, resulting in decreased social and family participation as well as more challenges with physical health and participation. These findings are important to occupational therapy practitioners as they highlight the effects of COVID-19 on occupational health and participation.

Mental Health

The negative mental health impacts of the COVID-19 pandemic are widespread and far-reaching in our communities and not limited to only those who contracted the virus. Both the COVID+ and COVID– groups reported increased anxiety, depression, and job stress, which negatively impacted their mental health. Factors that may be contributing to this are social isolation, high rates of unemployment, increased/changing job demands, fear of contracting the virus, fear of the long-term implications of catching the virus, and death of loved ones (Qui et al., 2020).

Physical Health

The results of this study indicate that the population as a whole may be struggling with symptoms of fatigue since the beginning of the pandemic, indicating that this may be a pandemic-specific effect and not due to COVID-19 virus itself. This is consistent with research indicating that the COVID-19 pandemic may have led to increased fatigue in entire populations, not just those who contracted the virus (Morgul et al., 2021). The reasons for this include the emotional and psychological stress brought on by the pandemic, leading to increased anxiety and depression, which can result in increased fatigue. However, the qualitative findings of this study indicate that persons who contracted the virus reported greater perceived physical health challenges, especially regarding exercise and activity level. This may be due to lingering physical impacts of COVID-19, such as shortness of breath and muscular weakness (Kemp et al., 2020).

Social and Family Health

Both groups reported a decrease in social health since the beginning of the pandemic. However, qualitatively, the COVID+ group reported higher levels of perceived challenges in social and family health compared with the COVID– group. Survivors of COVID-19 feared transmitting COVID-19 to friends and family members, thus leading to self/social isolation. Furthermore, friends and family members may have been reluctant to interact with those who tested positive for COVID-19 even after they recovered, leading to further isolation. The COVID– group reported perceived negative social health due to social distancing requirements and shutdowns; however, unlike the COVID+ group, they indicated adapting to virtual means of communication and interaction with friends and family more so than did the COVID+ group.

Limitations and Future Research

Limitations to this study include limited external validity due to the small sample size of 41 participants. In addition, participants were recruited through convenience sampling, increasing the chance of selection bias. Variability in reliability of the COVID-19 tests at the time poses another limitation. Sensitivity and specificity of the tests were not addressed in this article due to the evolving nature of those tests. Another limitation is the fact that the COVID-19 survivors in the sample were in different stages of recovery from the virus and their perceived health-related QoL may have been affected by this difference.

Future studies should include larger sample sizes to detect perceived differences in health, well-being, and QoL in COVID-19 survivors and those who did not contract the virus, with greater accuracy. Research should be conducted once COVID-19 is no longer classified as a pandemic as the lived experiences of the current pandemic may be influencing perceived health, well-being, and QoL of all persons, thus confounding the results.

Conclusion

The COVID-19 pandemic has resulted in perceived mental, physical, social, and family health challenges for all individuals, not only for those who contracted COVID-19. However, those who contracted the virus reported greater health-related QoL impacts than those who did not, specifically in areas related to occupational health and participation (spending time with friends and family, and participation in an exercise routine). These participation-related challenges are important findings that speak to the role of occupational therapy practitioners in supporting COVID-19 survivors to reintegrate into their roles within their families and communities as well as to promote health recovery and support the community health and wellness of all individuals.