Post-COVID-19 survivors’ strategies for improving occupational balance: A qualitative study

Abstract

Introduction:

Coronavirus disease 2019 (COVID-19) has caused some major changes in occupational patterns that form part of the individual’s occupational identity. Due to debilitating symptoms, post-COVID-19 survivors with limitations in the occupational performance areas may experience occupational imbalance. The objective of this study was to investigate the methods employed by patients to engage in their daily activities for regaining occupational balance.

Methods:

The study used an interpretive paradigm and conventional content analysis. An in-depth semi-structured interview was conducted with 11 patients who had been hospitalized due to COVID-19 in the past 6 months or less, along with their three primary caregivers residing in Tehran. The sampling method used was purposive and continued until conceptual saturation was reached. Participants with the most tremendous possible diversity in demographic variables were included. Data were analyzed using Corbin and Strauss’s recommended Constant Comparative Analysis.

Results:

The findings showed that patients used different strategies which included self-treatment based on others’ recommendations, compensatory, fatigue prevention and adaptive strategies to restore occupational balance.

Conclusion:

As occupational therapists, we must understand post-COVID-19 survivors’ perspectives on occupations and their preferred strategies. Also, findings confirm that occupational balance is a dynamic process that the adaptive capacities of the patients help to restore occupational balance.

Introduction

Occupational balance is fundamental to occupational therapy. Occupational balance can be described as an individual’s perception of achieving an appropriate level of engagement in occupations and maintaining a desirable variation between them. Three dimensions of occupational balance were identified: the balance between different occupational areas, the balance between occupations with diverse characteristics and the balance in terms of time allocation (Wagman et al., 2012). There is a belief that maintaining a balance between occupations has a positive correlation with personal health, happiness and overall well-being (Bejerholm, 2010; Law, 2017). On the other hand, an imbalance in occupations can lead to both physical ailments and a sense of unhappiness (Law, 2017). Occupational imbalance refers to the experience of stress or boredom resulting from an inadequate level of occupational engagement, either due to being over-occupied or under-occupied. Moreover, there exists a negative correlation between well-being and occupational imbalance (Anaby et al., 2010). Physiologically, having psychological stress due to experiencing occupational imbalance may have a detrimental effect on the immune system which is essential in coping with viruses like Severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) (Segerstrom and Miller, 2004). There are numerous studies examining the occupational balance in other conditions or population groups in general. Nevertheless, this important concept has not been studied in survivors of the new coronavirus disease, which is spreading worldwide and has so far been considered a global concern.

Furthermore, the studies conducted in the field of occupational balance have pointed to a knowledge gap in this field in non-western societies (Wagman et al., 2015); it has not been addressed enough in eastern societies such as Iran and in the context of the emerging disease of coronavirus disease 2019 (COVID-19). Despite the significant advancements in our understanding of COVID-19 and the availability of new treatments since the start of the pandemic, the long-term consequences of the illness can be incapacitating, even for individuals who are young, physically fit or have experienced mild manifestations of the disease (Carfì et al., 2020). According to the National Institute for Health and Care Excellence, post-COVID-19 syndrome or long-COVID is characterized by a continuum of enduring physical, cognitive and/or psychological symptoms that endure for more than 12 weeks, with no explanation provided by an alternative diagnosis. Noteworthy symptoms encompass profound fatigue, breathlessness, chest discomfort, difficulties with memory, palpitations, dizziness and joint pain (NHS, 2021).

It is anticipated that the array of these effects can contribute to an occupational imbalance among patients following occupational restrictions. A study revealed that hospitalized post-COVID-19 patients reported enduring fatigue and breathlessness even 1 year after the initial onset of symptoms. Furthermore, their quality of life remained below the normal level (O’Brien et al., 2022). Additionally, a study found that despite receiving early mobilization and physical therapy, individuals who survived COVID-19 continued to experience physical performance deficits, particularly in carrying out activities of daily living, upon being discharged home (Belli et al., 2020). Given the significance of daily occupations in the management of chronic diseases (AOTA, 2014), as well as the emphasis on occupation-based and client-centered interventions in occupational therapy, it is crucial to promptly identify the approaches employed by individuals to restore their occupational balance. The objective of this study was to investigate the occupational limitations experienced by patients and, more importantly, to explore the strategies they utilized to regain occupational balance, drawing from their personal experiences and perspectives.

Methods

Research design

Between March 2021 and September 2022, this study used an interpretive qualitative paradigm and an inductive content analysis method.

A total of 11 post-COVID-19 patients who had been hospitalized in general wards within the past 6 months or less, along with their three primary caregivers, were engaged in in-depth semi-structured interviews. All participants were adults aged 18 years and above. To enhance the transferability of the data, maximum diversity was sought in terms of demographic variables, encompassing age, gender, educational level and socio-economic status. The interviews were conducted without any preconceived hypotheses or theoretical notions, with the focus solely on capturing the participants’ experiences and perceptions. Following the interviews, the principal investigator transcribed the audio recordings and subsequently engaged in multiple readings to gain a comprehensive understanding. Noteworthy statements within the text were conceptually labeled as codes by the investigator.

Subsequently, the identified codes were organized and grouped into subcategories based on their similarities and differences. This process involved utilizing an inductive approach to explore and develop the codes, categories and subcategories. To ensure comprehensive analysis, the properties and dimensions of the categories and subcategories were conceptually determined and thoroughly examined using the Constant Comparative Analysis (CCA) method, as recommended by Corbin and Strauss (2014). Through this iterative process, the categories and subcategories reached a point of saturation, ensuring a comprehensive analysis of the data.

Data collection

Data for this study were gathered through in-depth semi-structured interviews. The principal investigator (A.M.) initiated contact with the patients, introduced himself and provided a brief overview of the study before extending an invitation to participate. Once patients expressed their willingness, interviews were scheduled at locations convenient for them, such as their homes or workplaces. At the beginning of each interview, the study’s objectives were explained, and a series of questions were posed, including inquiries about the impact of the disease on daily life, areas of life affected by the disease and strategies employed to adapt and cope with limitations. An interview guide, outlined in Table 1, was used to steer the conversation, focusing on the study’s main topics. The duration of the interviews ranged from 30 to 60 minutes. Immediately following each session, the researcher meticulously listened to the audio recordings, transcribed them verbatim and addressed any ambiguities or sought clarifications by contacting some participants over the phone. Prior to commencing the study, written informed consent was obtained from all participants. The interviews were exclusively conducted by the first author of the article, who possessed extensive training in qualitative research and interview techniques. Data collection, analysis and sample selection were continued until conceptual saturation was attained. After conducting 14 interviews, it was determined that no new concepts or data were emerging from the participants. The interview process was also assessed and guided by other authors who were experts in qualitative research.

Table 1.

Interview guide.

Participants	Main questions	Probing questions
Patients and caregivers	What happened after you were discharged from the hospital? What aspects of your life did the disease restrict? How did you cope and adjust to these limitations? What kind of help did you provide to the patient?	Can you please explain it to me more? What happened next?

Data analysis

The data were subjected to analysis using the CCA method (Corbin and Strauss, 2014). The researcher thoroughly reviewed the accurately transcribed interviews multiple times to gain a comprehensive understanding of the content. Meaningful units were extracted from the text and assigned corresponding codes. These codes were continuously compared to both the original data and other codes. Subsequently, the codes were compared to one another based on their similarities and differences, leading to the classification of codes into categories and subcategories. The identified concepts were independently assessed by other researchers to ensure accuracy and clarity. Any ambiguities or inaccuracies were addressed and corrected during this process. The MAXQDA software (VERBI Manufacturer) version 19 was employed to effectively organize the data throughout the analysis.

Rigor

To ensure trustworthiness, the study considered four aspects: credibility, transferability, dependability and conformability (Lincoln and Guba, 1985). Maintaining continuous contact with post-COVID-19 survivors allowed for data collection and validation by the research team, enhancing the validity of the collected data. Member checking was utilized during data collection to validate the accuracy and authenticity of the participants’ experiences, making adjustments when necessary. To enhance credibility, participant quotations were transcribed verbatim, enabling readers to form their own judgments based on the study results. The analysis results were reviewed by all members of the research team, who possess expertise in the field of study, to ensure the dependability and confirmability of the data. Additionally, an external check was conducted, involving two experienced occupational therapists who independently reviewed the data. The selection of samples aimed to achieve maximum diversity, further supporting the transferability of the findings.

Ethical consideration

Prior to each interview, written informed consent was procured from all participants, ensuring their voluntary participation. To safeguard anonymity, participants and their quotations were assigned unique codes. Participants were informed of their right to withdraw from the study at any stage without facing any negative consequences. Sound recordings were conducted only after obtaining explicit permission from the participants.

Results

Characteristics of study participants

A total of 11 post-COVID-19 survivors who met the inclusion criteria participated in the study. In addition to these individuals, their three primary caregivers were also interviewed, resulting in a total of 14 interviews from which data were obtained and analyzed. The participants had a mean age of 41 ± 6 years, with an age range of 29–62 years. The average duration between the onset of symptoms and the interviews was 15 ± 6 weeks, ranging from 3.5 to 25 weeks.

Demographic information can be found in Table 2. Drawing from the experiences and perceptions of the participants, various strategies were identified and employed by post-COVID-19 survivors to engage in daily occupations and restore their occupational balance. These strategies encompassed self-treatment based on others’ recommendations, compensatory approaches, prevention of fatigue and breathlessness and adaptive strategies.

Table 2.

Demographic data.

Participant	Age	Position	Education level	Job	Marital status	Sex	Interview form	Time lapsed from symptom to interview (weeks)
1	37	Patient	Master’s	Accountant	Married	Male	Face to face	3.5
2	62	Patient	B.H.S.D. 1	Driver	Married	Male	Face to face	19
3	38	Patient	B.H.S.D.	Grocery store	Married	Male	Face to face	4
4	46	Patient	H.SC.D. 2	Housewife	Married	Female	Face to face	4
5	44	Caregiver	H.SC.D.	Industrial worker	Married	Male	Face to face	-
6	30	Patient	B.H.S.D.	Farmer	Single	Male	Face to face	5
7	44	Patient	H.S.D.	Computer services	Married	Male	Face to face	25
8	51	Caregiver	B.H.S.D.	Farmer	Married	Male	Face to face	-
9	36	Patient	Bachelor’s	Dress shop	Married	Female	What’s up	21.5
10	29	Caregiver	H.S.D.	Housewife	Married	Female	Face to face	-
11	29	Patient	Master’s	Student	Married	Female	Face to face	21.5
12	35	Patient	Ph.D. student	Mechanical Engineer	Married	Male	What’s up	25
13	38	Patient	Master’s	Factory Manager	Married	Male	What’s up	21.5
14	57	Patient	H.S.D.	Sports coach	Married	Male	Face to face	21.5

¹Below High School Diploma.

²High School Diploma.

Self-treatment with other’s recommendation

COVID-19 and post-COVID-19 patients to alleviate their symptoms, started doing and consuming such things like the use of medications without a prescription, use of herbal medicines with the recommendation of the Atari (herbal store), doing inappropriate sports activities and reliance on religious factors.

Self-medication

During the initial phase of the COVID-19 outbreak, there was a dearth of information regarding the disease and its treatment. As the early symptoms of COVID-19 resembled those of the common cold and flu, a significant number of individuals resorted to purchasing and using various antibiotics and antipyretics.

Participant 6 stated, “I thought it was like a common cold, so I bought the usual antibiotics and used them.”

Participant 9 also said, “I took 4 or 5 suppositories a day, whenever I used to take suppositories, my fever would have subsided for a couple of hours, but I had a fever again.”

Use of herbal medicines

In Iranian culture it is historically prevalent to use herbal medicines in the symptomatic treatment of diseases. This has led to the emergence of a specialized field of traditional medicine even in the country’s universities of medical sciences.

However, in many cases, people obtain herbal or traditional remedies from herbal medication stores (Atari). There the storekeeper may or may not have a good knowledge of herbal medicines, their side effects, their prescribed dosage and the temperament of the disease and the person, so sometimes their prescription might be ineffective or even worsen the patient’s condition.

Participant 13 mentioned, “I used to drink a lot of these sorts of teas that they said, I am a fan of teas like Thyme.”

Participant 10 also stated:

I also got the medicine from Atari. The storekeeper said it is a combination of several herbs and is suitable for sore throat, fever and cough. Thus I took it home and brewed it a few times and gave it to the patient, however, the patient’s condition seemed to become worse. I don’t know if it was because of the remedy or not.

Narcotics use

Considering that most of the participants in this study were from eastern Iran and the use of opium is particularly prevalent in this region, some participants used it to treat the complications and long-lasting problems of the disease.

Certain individuals held a strong belief in the preventive and protective effects of consuming opium to avoid contracting COVID-19, while others believed that the severity of the disease would be reduced in affected individuals. However, it is important to note that medical professionals have already dismissed the notion that opium has any therapeutic effects in treating COVID-19.

Participant 3 stated, “I don’t want to advertise it at all, but the only thing that saved my life was opium residue.”

Participant 1 said, “I inhaled a few opium puffs. I also gave it to my daughter and my wife, who were mildly affected. Fortunately, the illness did not progress.”

Participant 5 mentioned, “After lunch, I made him have some puffs. This made her feel better, her cough stopped, her headache got better and her sore throat got better. I don’t know what has such an impact on patients.”

Doing inappropriate sports activities

Inexpedient sports activities were performed by the patient. It was based on the advice of others, who are typically non-specialists or authorized to prescribe exercise or physiotherapy. Not only could it have no benefit, but it could make the patient’s condition worse.

Participant 13 said, “Somebody counseled me as a doctor and told me to go outside and get some air. Going out made me feel even more terrible. I was sick all over. I didn’t walk more than 30 yards, but it screwed me up. That night, I saved an audio file and I made a will.”

Participant 6 also said:

When I had a cold, I used to run in a very early stage of the illness. Thus I was sweating a lot, and getting warm. The final outcome was the disappearance of the sickness. I did the same with Corona, I had no fever, but my cough got worse.

Recourse to religious factors

Due to the cultural and religious context of some participants and the difficulty of dealing with this life-threatening disease and impending death, some patients relied on spiritual and religious factors. Like praying and appealing to Imams (PBUT), reading the Holy Quran and vowing to go back to normal life and health.

Participant 13 said, “When I was there, I vowed if I got better and return home.”

Participant 14 also added, “I used my medication with a positive attitude and I resorted to 8th imam (PBUH ¹ ).”

Compensatory strategy

Due to fatigue, shortness of breath and concerns about potential reinfection with COVID-19, patients have resorted to employing alternative approaches to engage in their activities and fulfill their needs. Drawing from the participants’ experiences in this study, several compensatory strategies were identified, including the utilization of assistive technologies (mechanical and electrical devices), engaging in remote shopping through telephone or online platforms, adopting teleworking practices and seeking assistance from others.

Using assistive technologies

Examples of such cases include using a car instead of walking regularly or using the elevator instead of the stairs.

Participant 4 stated, “I didn’t go anywhere, my husband took us in the car to see the street and people then came back home.”

Participant 7 also said, “Can you walk up and down the stairs? No, not at all, I got on the elevator so far.”

Shopping online or by telephone

During the COVID-19 pandemic grocery and food purchases either by phone or online have been considered a safe option for everyone, especially for COVID-19 patients.

Participant 11 mentioned, “After I was discharged from the hospital, due to the intense fatigue, I could not cook for a week. Instead, we ordered food from the restaurant. They put food in the elevator and we took it upstairs.”

Teleworking

Teleworking has become a prevalent and secure choice for both employers and patients during the COVID-19 pandemic. It is regarded as a safe measure to prevent the spread and transmission of the disease, while also serving as a means to mitigate patient fatigue.

Participant 7 said, “My work did not require much physical activity. I used to fix computers. However, later I started a new venture related to cryptocurrency. So I could work with a phone for my customers.”

Participant 4 also stated, “I got sick when I went to a sewing factory, so now my family won’t let me go and I sew at home.”

Using other people’s assistance

The use of other people’s help is another way of compensating for occupational limitations caused by the disease. Participants benefited from assigning their tasks to others and splitting their tasks with others to compensate for their occupational limitations.

Participant 5 stated, “God bless her, my sister used to make our meals and I was going to pick them up from her house.”

He also added, “When we brought my wife home, our two daughters took on some of the housework and shared it. For example, one was washing the lunch dishes and the other was washing the dinner dishes.”

Preventive strategies for fatigue and shortness of breath

Participants used fatigue prevention methods to stop the onset or worsening of fatigue. This involved prioritizing different activities, changing home arrangements and taking regular breaks during activities.

Prioritizing activities

Due to fatigue and lack of energy, post-COVID-19 patients had to expend their energy on their necessary and important activities to restore occupational balance.

Participant 12 said, “For example, we didn’t use the stairs and we saved most of our energy to go out together in the evening.”

Modifying home arrangements

Because of early fatigue and the need to have more time to rest, patients after COVID-19 were accustomed to making changes to their home environment to facilitate their activities.

Participant 11 stated, “After leaving the hospital, the mattresses and beds were in the living room for approximately 10 days. We didn’t have the mood and weren’t able to move our bed into the bedroom.”

Participant 2 also mentioned, “They brought everything I needed in my room, like the television, my telephone charger, the tea flask, etc.”

Taking regular rest periods during activities

Post-COVID-19 patients learned through trial and error to be sensitive to the onset of fatigue symptoms and incorporated brief periods of rest during their activities before reaching debilitating fatigue.

Participant 6 stated, “As soon as I rest for five minutes, I could get back to work for an hour.”

Participant 4 also quoted, “Now when I vacuum some parts, I have to sit down and rest, then get back up and continue. I get tired very quickly.”

Adaptive strategies

As applied in occupational therapy interventions it involves modifying the methods of performing activities and/or the environment to enhance occupational performance (AOTA, 2014).

Through the experiences of the participants in this study, it was observed that adaptive strategies were employed to alter approaches to work, self-care, leisure activities, household tasks and social engagement.

Changing the way of working

Changes in the way of doing work could be noted as a temporary change in the patient’s job position and giving them more time to do the work.

Participant 3 said, “My father, as my employer, didn’t let me do any activities. I did not lift heavy loads. I did not go to the fruit market, I just received cash from customers.”

Participant 6 also mentioned, “Now I irrigate agricultural fields much better, it takes longer. Because I get tired quickly, but the irrigation being done better anyway.”

Changing the way of doing self-care activities

Changing the way of doing personal self-care activities was reported as changing the ways of eating, bathing, and toileting. These adaptive methods help patients to cope more easily with the limitations caused by the disease.

Participant 1 stated, “After that, I did not take a bath for eleven days. When I decided to wash my hair, I left the bathroom door open.”

Participant 3 also mentioned, “At night, I had a jar next to me, I would urinate in it. Later, I would empty it myself in the morning. I did not get up at night to go to the toilet.”

Participant 7 declared, “We had a long oxygen hose, long enough to reach for the bathroom and toilet.”

This participant also added, “My eating routine was with oxygen in such a way that I brought an oxygen mask under my chin and when chewing, I put on the oxygen mask, again.”

Changing the way of leisure activities

Changes in the way of doing leisure activities included watching movies and series, using virtual social networks and reading books that the activities were physically inactive.

Participant 1 stated, “I tried to entertain myself by watching movies and series.”

Participant 3 also said, “My only entertainment was watching funny hidden camera clips on my phone.”

Changing the way of doing household tasks

Changes in the way of doing housework have been reported in the forms of considering rest time while doing housework, changing the body position and assigning and dividing the housework task with the family members.

Participant 4 quoted, “Even for preparing a simple meal, I had to sit on a chair. Otherwise, I couldn’t.”

Participant 5 also mentioned, “Our daughters divided the task of washing the dishes. One was washing the lunch dishes and the other washing the dinner dishes. We helped her.”

Changing the way of socializing

Socializing had also been altered as our participants reported. For example, they met with relatives in open areas, wearing a mask and keeping a great social distance, making video calls via mobile applications and meeting each other from behind the windows or on the balcony.

Participant 4 mentioned, “Our relatives didn’t come to our house, but they asked me to come to Dad’s house and meet each other. Over there was uncovered and larger than ours.”

This participant quoted, “When my brother got COVID-19, I didn’t go to see him at all, I just called him, and when he came to my father’s house, we tried to distance ourselves from him and wore a mask all the time.”

Participant 13 said, “It was a very hard time. You couldn’t see your wife and children for 22 days. Either we made a video call or they would come to the street and see me from the balcony. Well, it wasn’t interesting anymore. We missed each other a lot.”

Discussion

Participants in our study reported experiencing difficulty in breathing, alongside other chronic symptoms such as fatigue, depression, pain, anxiety and sleep disorders. These symptoms significantly impacted their ability to engage in meaningful occupations, as depicted in Table 4. Due to these variations in symptoms, the patients experienced occupational imbalance following a reduction in their occupational performance.

Table 4.

The symptoms (persistent, fluctuating and new) reported by the participants.

Symptoms

Fatigue Breathlessness Chest pain Dry cough with phlegm Breathing disorder after light activity Weakness in the muscles of the lower limbs Hair loss (alopecia) Dizziness Sleep disorders (quality, duration) Anosmia dysgeusia Feeling depressed and anxious Recurrence of depression and bipolar disorders Pain in the previously operated knee Severe stomachache Cognitive difficulties like memory Increased blood sugar Hip joints arthritis

Consistent with our findings, two systematic reviews (Lopez-Leon et al., 2021; Nasserie et al., 2021) have highlighted that a significant proportion of COVID-19 patients (mostly those who had been hospitalized) continue to experience persistent long-term symptoms for several months after the initial infection. These symptoms commonly include fatigue, shortness of breath, muscle pain, joint pain, cognitive impairments, neurological disorders, anxiety and depression (Calvache-Mateo et al., 2023; Galal et al., 2021; Ghosn et al., 2021; Munblit et al., 2021; Pasin et al., 2023; Schiavi et al., 2022; Wahlgren et al., 2022), leading to limitations in daily activities (Galal et al., 2021).

Based on their experiences, the participants used four different strategies including; self-treatment based on others’ recommendations, compensatory, fatigue preventive and adaptive strategies Table 3.

Table 3.

The codes, categories and subcategories and theme of the study.

Theme	Category	Subcategory	Code	Significant statements
Self-management strategies	Self-treatment using others’ recommendation	Non-prescription use of medication	Arbitrary Use of Antibiotics	“I thought it was like a cold, I bought antibiotics and used them.” (P6)
			Arbitrary Use of Antipyretics	“I put 4 or 5 suppositories a day, whenever I used to put suppositories, my fever would subside for a couple of hours, but I had a fever again.” (P9)
		Use of herbal medicines with the recommendation of the Atari	Drinking teas	“I used to drink a lot of these teas that they said, I am a fan of teas like Thyme.” (P13)
			Multi-herb combination remedies
		Narcotics use	Use of opium smoke	“I don’t want to advertise at all, but the only thing that saved my life was opium juice.” (P3)
			Use of opium residue (Shire and Sukhte)
		Doing inappropriate sports activities	Long-distance walking after discharge	“Someone advised me like a doctor and told me to get some fresh air. When I went outside I felt worse.” (P13)
			Running to warm the body
		Reliance on religious factors	Prayer and appeal to imams (PBUT 1 )	“When I was there, we vowed to do this if I get better and so on.” (P13) “I was using my medications with a positive attitude and I resorted to imams (PBUT).” (P14)
			Vows and almsgiving
	Compensatory strategy	Use of assistive technologies	Using a car instead of walking	“I didn’t go anywhere, my husband took us in the car to see the street and people then came back home.” (P4)
			Using the elevator instead of the stairs
		Online shopping or using the phone for giving shopping orders	Ordering food from the restaurant	“Because I was very tired, I did not cook for a week and we ordered food from restaurant.” (P11)
			Shopping from the grocery store through phone
		Telework or working remotely	Working from home	“I was going to a tailor shop where I was infected, so now my family doesn’t let me go there and I do it at home.” (P4)
			Working through the phone
		Receiving help from others	Assigning routine tasks to others	“God gives her blesses, my sister used to prepare meals for us and I was going and taking them from her house.” (P5)
			Splitting routine tasks among others
	Strategies to prevent fatigue and breathlessness	Prioritizing activities	Priority to have fun	“For example, we did not use the stairs and saved most of our energy for getting out together in the evenings.” (P12)
			Priority to self-care activities
		Making changes in the physical environment of the house	Placing the beds in the living room	“After discharge, the mattresses and beds were in the living room for about ten days and we were unable to move them.” (P11)
			Placing the necessities in the hand range
		Take regular breaks during activities	Frequent breaks during work	“As soon as I rest for five minutes, I could get back to work.” (P6)
			Interruption of activities with the onset of fatigue symptoms
	Adaptive strategies	Changing the way of self-care activities	Start taking the shower with the door opened and oxygen capsule	“After that, I did not go to the bathroom for eleven days. When I decided to wash my hair, I left the door of the bathroom open, then I did it myself.” (P1) “We had provided a long oxygen tube to the bathroom and toilet.” (P7)
			Toileting with oxygen capsule, and by wheelchair.
			Eating with wearing an oxygen mask
		Changing the way of doing work	Temporary Changes in the patient’s job position	“My father as an employer didn’t let me do any activities, I was not lifting heavy loads. I was not going to fruit market I only received cash from customers.” (P3)
			Doing the job in a longer time
		Changing the way of doing leisure activities	Watching movies and TV series	“I tried to entertain myself by watching movies and series.” (P1)
			Listening to music and reading books
		Changing the way of doing household tasks	Frequent breaks in cleaning the house	“Now it’s like that, when I vacuum some parts, I have to sit and rest, get up again and vacuum the rest, and I get tired very quickly.” (P4)
			Cooking in a sitting position
		Changing the way of social participation	Meeting the people in the uncovered and wide spaces	“Our relatives didn’t come to our house, but they told me to come to Dad’s house to meet each other. Over there was uncovered and large.” (P4)
			Meeting with wearing a mask and a long social distance
			Making video calls through mobile applications
			Meeting from behind the windows or balcony of the house

¹Peace Be Upon Them.

Self-treatment using others’ recommendations

In our study, the participants used all sorts of self-treatment such as pharma or non-pharma materials to manage their symptoms. These medications were often recommended by others. Similar to our results, a study showed that 21% of their participants used antibiotics without prescription during the outbreak of COVID-19, of which 20% said that the outbreak of COVID-19 and quarantine prevented them from going to medical centers, so they were self-medicating (Heydargoy, 2020).

The existence of some misconceptions and false news about the protective effects of opium against COVID-19 led to a surge in opium use in Iranian society (Pirnia et al., 2020). In our study, at least 45% of participants reported using opium and its residues (Shire and Sukhte) to treat and prevent disease.

Spirituality has long been recognized for its ability to assist individuals in coping with significant life stressors, including the challenges presented by the COVID-19 pandemic (Del Castillo, 2021).

People’s responses to such situations can vary, viewing it either as a threat or an opportunity, largely influenced by their personal experiences. Resolving this internal conflict may involve exploring alternative perspectives on the sacred and establishing new connections, or alternatively, distancing oneself from spiritual beliefs altogether (Sandage et al., 2020). Our participants, who have experienced a difficult period of hospitalization and fighting with death, reported religious strategies such as reliance on prayers, reading Quran, making vows and appealing to imams.

Compensatory strategy

There are several strategies to compensate for the negative consequences of social isolation, such as using social media, being in touch with family and friends through digital technologies, participating in online classes and attending virtual workplaces (Galea et al., 2020).

During the study, participants shared a range of compensatory strategies they employed to manage fatigue and other symptoms. These strategies included utilizing assistive devices, both mechanical and electrical, engaging in online shopping, placing orders by phone and seeking assistance from others.

Another study reported similar behavior regarding the frequent usage of elevators and wheelchairs by the participants to facilitate their mobility. In a systematic review of stroke survivors, it was shown that mobility devices like powered wheelchairs improve users’ activity and participation and increase mobility (Salminen et al., 2009). Furthermore, in a separate study involving patients with thoracic outlet syndrome, similar compensatory strategies were identified to enhance occupational performance and overall life quality (Ghamari et al., 2018). Given the debilitating effects of both conditions, patients employed comparable approaches, such as utilizing assistive devices, to effectively manage their occupational limitations.

Additionally, a study showed that due to the cancellation of elective surgeries and fears of disease transmission, surgeons favored telemedicine as a strategy that was quickly accepted by patients, healthcare systems and third party payers (Romanelli et al., 2020).

In our study due to fatigue and fear of disease transmission, some patients benefit from compensatory strategies like teleshopping and telecommuting.

Fatigue preventive strategy

The prevalent long-term health concern among COVID-19 survivors is post-viral fatigue (Halpin et al., 2021). A paradigm shift is required to move from looking at conditions like fatigue through the standard medical model to a more holistic way of looking at a complex problem where the patient is at the center of management. Many interventions can be performed with the goal of improving rest quality and providing a basis for activities that conserve energy, promote relaxation, and do not worsen symptoms.

Similarly, in cancer and Multiple Sclerosis patients, strategies to deal with fatigue include energy conservation, distraction and stress management (Asano and Finlayson, 2014; Mock, 2001). Energy conservation methods include postponing unnecessary activities, planning to perform prioritized activities during the times of energy peak, and organizing daily routines to have rest and activity times, all of which were reported by our participants.

Adaptive strategy

Adaptive strategies have been used to return to normal life and reduce fatigue-related disease. Despite the persistent symptoms, post-COVID-19 survivors should be able to use various strategies to maintain their physical, mental and emotional health. The strategies for managing stress and challenges identified can be broadly categorized into the following groups: avoidance-focused (i.e., maladaptive avoidance of the situation), approach-focused (i.e., strategies aimed at directly dealing with the stressor), emotion-focused (e.g., reinterpreting, creating distance) and problem-focused (e.g., attempting to resolve the situation, addressing the underlying cause (Littleton et al., 2007; Thompson et al., 2018).

Post-COVID-19 patients were actively and creatively able to manage their daily lives to some extent despite their symptoms. The patients were aware of their physical conditions and had learned the most effective method of performance. For example, sometimes it could be a small adaptation such as using a comfortable position instead of the usual position in performing activities (sitting instead of standing for cooking), avoiding tiring and breathtaking activities such as performing important self-care activities in other ways (going to the toilet by wheelchair and with an oxygen capsule, bathing with the door opened, eating with an oxygen mask, etc.), continuing to communicate with loved ones in other ways (meetings in outdoor, doing video calls, etc.) and saving energy for important activities.

In general, patients used a combination of strategies that included maladaptive strategies, such as the use of narcotics, and adaptive strategies to cope with the limitations caused by the disease. Adaptive strategies need to be educated, and maladaptive strategies need to be challenged through public awareness.

Limitations and suggestions

Due to the high prevalence of COVID-19 in Iran during the study period, certain patients and their families declined to take part in the in-person interviews. It was due to their fear of re-infection, so the researcher had to conduct some interviews virtually via mobile applications.

A recommendation is proposed to carry out a similar study involving post-COVID-19 patients who have been hospitalized in the intensive care unit (ICU). Since these patients are anticipated to experience more significant functional impairments compared to those in the general ward, their perspectives could provide a deeper understanding of the topic.

Conclusion

Post-COVID-19 survivors used strategies for performing occupations and regaining occupational balance. In some cases, the strategies were maladaptive and in some cases adaptive. As occupational therapists, we need to be aware of the occupational strategies used for educational proposes and interventional practices. In addition, findings confirm that occupational balance is a dynamic process in that the adaptive capacities of the patients help to restore the balance between various occupations.

Key findings

• Post-COVID-19 patients experienced a negative impact on both their occupational performance and occupational balance.

• Post-COVID-19 survivors employed innovative occupational strategies to manage occupational limitations and regain a state of occupational balance.

What the study added

Post-COVID-19 survivors used four strategies in doing their daily occupations and to restore occupational balance: self-treatment with others’ recommendations, fatigue prevention and compensatory and adaptive strategies.