Abstract
Background:
Most studies on long COVID-19 symptoms (LCSs) are conducted in urban areas or hospital. To date, relevant evidence in LCS from community-based rural studies is lacking. Therefore, the present study aimed to investigate LCS and its determinants in a rural adult population of northern India.
Methods:
A cross-sectional study was conducted in a rural district, Jhajjar, Haryana in 2023. Forty clusters were covered from one randomly selected subdistrict. A semistructured questionnaire on the SurveyMonkey platform consisted of questions related to sociodemographic profile, health problems, pre-existing morbidity, LCS, and functional difficulties. The data regarding infection with COVID-19 were collected based on self-reported positive testing for SARS-CoV-2 on RT-PCR.
Results:
Out of the 3700 enumerated, 2954 (79.8%) were surveyed. The self-reported infection rate was 6.2% (183/2954, 95% CI: 5.3–7.1). Further, 23% (42/183, 95% CI: 17.01-29.7) of infected cases have LCS, whereas 1.4% (42/2954) of the study population have LCS. The prevalence of LCS was higher in females than in males (28.7% vs 17.7%). Weakness (14, 33.4%), weight loss (6,14.3%), memory problems (6, 14.3%), and headache (4, 9.5%) were common reported LCSs. Univariable analysis revealed a significantly lower risk of LCS in the age group of 26-35 years (OR 0.32, 95% CI: 0.10-0.83, P = 0.019). In contrast, higher risk was observed with lower education (OR 4.46, 95% CI: 1.47-13.78, P = 0.003), and pre-existing morbidities such as seeing difficulty (OR 2.91, 95% CI: 1.09-7.58, P = 0.021, difficulty in self-care (OR 3.72, 95% CI: 1.07-12.88, P = 0.021), and communication difficulties (OR 5.28, 95% CI: (0.76-45.74, P = 0.046).
Conclusion:
A higher probability of LCS is found among females of older age, participants with lesser education, and pre-existing comorbidities.
Keywords: COVID-19 pandemic, India, long COVID symptoms, rural population, self-reported
INTRODUCTION
Coronavirus disease 2019 (COVID-19), the viral illness caused by the new severe acute respiratory syndrome coronavirus (SARS-CoV-2), is an emerging infectious disease, traced to a wet market in Wuhan China, from December 2019.[1] Although most of the cases who contracted COVID-19 were asymptomatic or had mild to moderate complaints, roughly 5–8% of the infected cases developed hypoxia, bilateral lung infiltrates, and decreased lung compliance requiring noninvasive ventilation (NIV) or mechanical ventilatory support.[2,3] The simplified clinical criteria for categorizing patients were based on saturation of peripheral oxygen (SpO2) and respiratory rate (RR). Those with SpO2 <90% and RR >30 were categorized as severe COVID-19, while those with SpO2 <93% and RR ≥24 were classified as moderate.[4] COVID-19 survivors witnessed long-lasting cerebral, cardiovascular, hematologic, pulmonary, dermatologic, neurologic, and psychologic ailments, known as post-COVID-19 syndrome (PCS), long COVID-19 symptoms (LCSs), chronic COVID-19, and long haulers.[5] The clinical spectrum of COVID has been divided into mild, moderate, and severe categories, with post-COVID conditions prevalence increasing with the severity of infection. This post-COVID conditions are defined by The Centers for Disease Control, Atlanta (CDC) as health effects that persist further than 4 weeks after initial COVID-19 diagnosis.[6] These include long COVID (which consists of a wide range of symptoms that can last even after 12 weeks) or persistent post-COVID syndrome (PPCS), multiorgan effects of COVID-19, or effects of COVID-19 treatment/hospitalization.
Long-COVID syndrome is recognized as a new clinical entity in the context of SARS-CoV-2 infection.[7] For example, a cross-sectional study conducted in Haryana showed corelations between COVID-19 expsoure in the past and the lingring effects of it.[8] The most common long-COVID symptoms reported in the literature include fatigue, dyspnea, olfactory and gustatory dysfunction, chest pain, join pain, myalgia, sleep diorders, and mental disorders.[9] In recent times, the knowledge of long-COVID syndrome has expanded, substantially due to the multiorgan effects of COVID-19 including clinical manifestations of the cardiovascular, pulmonary, renal, and neuropsychiatric organ systems, although the duration of this multiorgan dysfunction is unclear. It is estimated that the incidence of PCS or LCS ranges from 10% to 35% among cases not hospitalized, regardless of comorbidities.[10] Still, rates as high as 85% have been reported among rehabilitated cases and cases with severe ailments.[11,12] The prevalence of LCS is known to be the highest among severe and critical forms of disease. However, its occurrence and risk factors after mild or moderate SARS-CoV-2 infection have not been extensively investigated. (15) Individuals hospitalized due to COVID-19 present high levels of disability, dyspnea, dysphagia, and dependence for both activities of daily living (ADL) and instrumental activities of daily living (IADL). (16) Understanding long-COVID-19 symptoms is consummate to developing applicable structure and manpower and designing long-COVID-19 clinics in hospitals. Although evidence indicates that most cases with LCS or PCS have a good prognosis, registries to follow them prospectively are required to define the full clinical spectrum and its long-term sequelae.
Most of the studies on LCS from India have been conducted in urban areas and hospital settings, with very limited representation from rural areas. Also, the impact on quality of life has not been studied among the adult population infected with the virus. Numerous researchers prognosticate that certain existing health conditions, for example, visual or hearing impairment and physical disabilities, may pose an advanced threat of getting infected with the COVID-19 contagion and also lead to long-term sequelae. The previous epidemics of SARS-CoV and MERS-CoV left individuals who recovered from these viral illnesses with persistent symptoms of severe fatigue, decreased quality of life, persistent shortness of breath, and behavioral health problems that resulted in a significant burden on local healthcare systems where the epidemics occurred.[13] A similar burden is looming on the Indian healthcare system, considering the huge number of infected persons who recovered from the COVID-19.
Although the pandemic has passed, it is imperative to understand their implications on health, including persistent COVID-19 symptoms across various geographical areas. There is a need to assess long-COVID-19 symptoms or sequelae among rural populations to elucidate the long-term health problems and their associated factors. Therefore, the current study was done to investigate patterns of long COVID-19 symptoms in recovered COVID-19 adult cases and find their determinants in a predominantly rural community.
METHODOLOGY
This population-based cross-sectional study was conducted among the rural population in northern India from 2023, post-pandemic periods. One predominantly rural district was selected for the survey (Jhajjar, Haryana) to cover the estimated sample size. The detailed methodology of the study, including sample size estimation, sampling, and study instruments, has been published in a previous publication.[14] In brief, a semistructured questionnaire (study tool) was developed using the SurveyMonkey© digital platform for interviewing the participants. The SurveyMonkey is cloud-based online survey software for developing and administering survey questionnaires. The platform was used for face-to-face data collection by trained interviewers using computer-assisted personal interview (CAPI) techniques. The data captured were directly integrated into a digital format, minimizing transcription errors that can occur with paper-based surveys. Training team members on the digital tool and vernacular translation while interviewing the participants was standardized to reduce bias.
The study tool consisted of a sociodemographic profile, health problems (self-reported) before the pandemic, long-COVID-19 symptoms, and their duration. The data regarding infection with COVID-19 were collected based on self-reported positive testing for SARS-CoV-2 on reverse transcriptase polymerase chain reaction (RT-PCR). Diagnostic test reports of RT-PCR were checked, if available, but the self-report was considered sufficient for the study. The Washington Group Short Set (WGSS) Questionnaire was also administered to the participants to determine their functional limitations, irrespective of their COVID-19 status. It measured difficulties in six functional domains (seeing, hearing, walking, cognition, hygiene, and communication) and provided an estimation of self-reported disability status, based on the biopsychosocial model of disability. The current study also employed anthropometry for determining the participants’ height and weight, and estimation of blood pressure and blood sugar using simple portable instruments.
Ethics clearance
The study was approved by the institute ethics committee of a tertiary care hospital (Ref. no. IEC-260/04.03.2022, RP36/2022), and it adhered to the tenets of the Declaration of Helsinki, 2000. The study supervisors explained to each eligible participant in their vernacular language (Hindi) about the study and provided them with a hard copy of the patient information sheet (PIS) with the contact details of the investigators. Informed consent was obtained by asking the subjects about their willingness to participate, and the same was recorded on electronic forms.
Study definitions
Long-COVID syndrome (LCS): Persistence of symptoms beyond 12 weeks from the date of SARS-CoV-2 positive test conducted using either RT-PCR or Cartridge Based Nucleic Acid Amplification Test (CBNAAT).
Data analysis
The data analysis was done on STATA software, and categorical variables were compared using Chi-square statistics. Univariable analysis was performed to find predictors of LCS, and all those independent variables with P value >0.1 were also subjected to multivariable adjusted analysis to determine the adjusted odds ratio. All the assumptions of logistic regression were satisfied, and the significance level was set at P < 0.05.
We reported presence of LCS among individuals with the confirmed COVID-19 infection. Additionally, we also presented the prevalence of LCS in sampled population as this reflected its magnitude in the general population and was more relevant for public health strategies. It provides an estimate of how common LCS is in the broader community, not just among previously diagnosed COVID-19 cases.
RESULTS
Description of the study population
In total, 3700 participants were enrolled, out of which 2954 were interviewed (79.8% response rate). Of the total respondents, males comprised 45.2% [1335, Table 1]. The mean age was 34.5 years (SD 21.8). Around one-quarter of the participants either were illiterate or studied only up to primary school. Further, 1750 (60%) were unemployed, which meant that they were homemakers or farmers by occupation. As per WGSS, difficulty in walking (at least some or more) was the most frequently reported functional difficulty (418, 14.2%), followed by difficulty in vision (291,9.9%) and hearing difficulty (154, 5.2%) among the sampled population [Table 1].
Table 1.
Prevalence of long-COVID symptoms (LCSs) among COVID-19 (+) ve and sampled population
| Characteristics | Sampled Population (n) | COVID+ n | LCS+ n | LCS prevalence in sample (%) (95%CI) | LCS prevalence in COVID +(%), (95%CI) |
|---|---|---|---|---|---|
| Total | 2954 | 183 | 42 | 1.4 (0.9-1.8) | 22.9 (17.1-29.7) |
| Gender | |||||
| Male | 1335 | 96 | 17 | 1.3 (0.7-1.9) | 17.7 (9.9-25.5) |
| Female | 1619 | 87 | 2 | 1.5 (0.9-2.1) | 28.7 (19-38.4) |
| Age (years) | |||||
| 18-25 | 589 | 22 | 3 | 0.5 (0.1-1.1) | 13.6 (1.9-29) |
| 26-35 | 636 | 47 | 5 | 0.7 (0.0-1.5) | 10.6 (1.5-19.8) |
| 36-45 | 573 | 33 | 11 | 1.9 (0.8-3.0) | 33.3 (16.4-50.3) |
| 46-55 | 450 | 34 | 9 | 2.0 (0.7-3.3) | 26.5 (10.8-42.1) |
| 56-65 | 360 | 24 | 7 | 1.9 (0.5-3.3) | 29.2 (9.6-48.8) |
| 66-75 | 226 | 14 | 4 | 1.8 (0.0-3.5) | 28.6 (1.5-55.6) |
| Age ≥76 | 120 | 9 | 3 | 2.5 (0.3-5.3) | 33.3 (5.1-71.8) |
| Education | |||||
| Illiterate | 427 | 15 | 4 | 0.9 (0.0-1.8) | 26.7 (1.3-52.0) |
| Primary school certificate | 284 | 15 | 8 | 2.8 (0.8-4.8) | 53.3 (24.7-81.9) |
| Middle school certificate | 359 | 14 | 4 | 1.1 (0.0-2.2) | 28.6 (1.5-55.6) |
| High school certificate | 491 | 22 | 5 | 1.0 (0.0-1.9) | 22.7 (3.7-41.7) |
| Senior secondary school | 787 | 50 | 11 | 1.4 (0.0-2.2) | 22 (10.1-33.9) |
| Graduate and above | 606 | 67 | 10 | 1.7 (0.6-2.6) | 14.9 (6.2-23.7) |
| Occupation | |||||
| Unemployed/Retired/Homemaker | 1750 | 92 | 22 (52.3) | 1.3 (0.7-1.7) | 23.9 (15.0-32.8) |
| Agriculture | 310 | 20 | 4 | 1.3 (0.0-2.5) | 20 (0.8-39.2) |
| Business/Shop | 170 | 21 | 6 | 3.5 (0.7-6.3) | 28.6 (7.5-49.6) |
| Government Job | 100 | 8 | 2 | 2.0 (0.7-4.8) | 25 (13.7-63.7) |
| Private Job | 333 | 29 | 8 | 2.4 (0.7-4.1) | 27.6 (10.2-44.9) |
| Student | 270 | 13 | 0 | 0 | 0 |
| Others | 21 | 0 | 0 | 0 | 0 |
| BMI | |||||
| Underweight | 254 | 8 | 2 | 0.8 (0.3-1.9) | 28.6 (16.6-73.7) |
| Healthy weight | 1762 | 109 | 26 | 1.5 (0.9-2.0) | 23.9 (15.7-32) |
| Overweight | 742 | 54 | 10 | 1.3 (0.5-2.1) | 18.5 (7.8-29.2) |
| Obesity | 177 | 12 | 4 | 2.3 (0.0-4.4) | 33.3 (2.0-64.6) |
| Seeing difficulty | |||||
| No | 2663 | 162 | 33 | 1.2 (0.8-1.6) | 20.4 (14.1-26.6) |
| Yes | 291 | 21 | 9 | 3.1 (1.0-5.0) | 42.8 (19.7-65.9) |
| Hearing difficulty | |||||
| No | 2800 | 178 | 41 | 1.5 (1.0-1.9) | 23 (16.8-29.3) |
| Yes | 154 | 5 | 1 | 0.7 (0.6-1.9) | 20 (35.5-75.5) |
| Walking difficulty | |||||
| No | 2536 | 155 | 32 | 1.3 (0.8-1.6) | 20.6 (14.2-27.1) |
| Yes | 418 | 28 | 10 | 2.4 (0.9-3.9) | 35.7 (16.8-54.6) |
| Cognition (Remembering difficulty) | |||||
| No | 2814 | 173 | 38 | 1.4 (0.9-1.7) | 22 (15.7-28.2) |
| Yes | 140 | 10 | 4 | 2.9 (0.0-5.7) | 40 (3.1-76.9) |
| Hygiene and Self-care difficulty | |||||
| No | 2832 | 171 | 36 | 1.3 (0.8-1.7) | 21.1 (14.9-27.2) |
| Yes | 141 | 12 | 6 | 4.9 (1.0-8.8) | 50 (16.8-83.2) |
| Communication difficulty | |||||
| No | 2873 | 178 | 39 | 1.4 (0.9-1.8) | 22 (15.7-28) |
| Yes | 78 | 5 | 3 | 3.7 (0.4-7.9) | 60 (8.0-128) |
Prevalence of long-COVID-19 symptoms
All self-reported COVID-19-infected individuals were asked about the presence of post-COVID symptoms after 12 weeks of the illness to investigate LCS. A total of 183 (6.2%) participants reported being positive for SARS-CoV-2, out of which 42 (22.9%, 95% CI: 17.1-29.7) reported LCS [Table 1]. The proportion of females with LCS was higher than males [59.5% versus 40.5% respectively, Table 2]. The most frequent LCS manifested was weakness (14, 33.4%), followed by weight loss (6, 14.3%), memory problems (6, 14.3%), and headache (4, 9.5%). Further, the prevalence of LCS among COVID-positive females was higher compared to their male counterparts [28.7% v/s 17.7%, Table 1]. Among the 183 COVID-positive participants, the age group with the lowest prevalence of LCS was 26–35 years (10.6%), while the highest was among 36–45 years age groups and ≥76 years (33.3%). The overall prevalence of LCS in the study population irrespective of COVID status was 1.4% (42/2954) (95% CI: 0.9-1.8). The overall prevalence of LCS in males was 1.3% (95% CI: 0.7-1.9), and in females, it was 1.5% (95% CI: 0.9-2.1).
Table 2.
Factors associated with LCS among the COVID-positive participants (n=183)
| Characteristics | LCS (+) ve (%)# | LCS (-) ve (%) | OR (95%CI) | Adjusted OR, 95%CI |
|---|---|---|---|---|
| Total | 42 | 141 | ||
| Gender | ||||
| Male | 17 (40.5) | 79 (56) | 0.536 (0.262-1.079) | 1 |
| Female | 25 (59.5) | 62 (44) | 2.5 (0.7-8.9) | |
| Age (in years) | ||||
| 18-25 | 3 (7.1) | 19 (13.5) | 0.496 (0.112-1.634) | 1 |
| 26-35 | 5 (11.9) | 42 (29.8) | 0.320 (0.105-0.831)* | 0.4 (0.0 – 14.3) |
| 36-45 | 11 (26.2) | 22 (15.6) | 1.912 (0.813-4.354) | 0.6 (0.0 – 20.7) |
| 46-55 | 9 (21.4) | 25 (17.7) | 1.264 (0.514-2.938) | 0.2 (0.0 – 8.7) |
| 56-65 | 7 (16.7) | 17 (12.1) | 1.456 (0.525-3.746) | 0.3 (0.0 – 11.8) |
| 66-75 | 4 (9.5) | 10 (7.1) | 1.376 (0.356-4.548) | 0.6 (0.0 – 40.4) |
| Age ≥76 | 3 (7.1) | 06 (4.3) | 1.725 (0.339-7.258) | 0.4 (0.0 – 29.7) |
| Education | ||||
| Illiterate | 4 (9.5) | 11 (7.8) | 1.242 (0.326-4.022) | 1 |
| Primary school certificate | 8 (19.0) | 7 (5) | 4.456 (1.47-13.78)* | 8.3 (0.8 – 81.4) |
| Middle school certificate | 4 (9.5) | 10 (7.1) | 1.376 (0.356-4.548) | 2.0 (0.2 – 23.1) |
| High school certificate | 5 (11.9) | 17 (12.1) | 0.986 (0.307-2.769) | 1.6 (0.2 – 15.0) |
| Senior secondary school | 11 (26.2) | 39 (27.7) | 0.928 (0.411-2.008) | 2.0 (0.2-21.4) |
| Graduate and above | 10 (23.8) | 57 (40.4) | 0.462 (0.202-0.999)* | 0.5 (0.0-5.8) |
| Occupation | ||||
| Unemployed/Retired/Homemaker | 22 (52.4) | 70 (49.6) | 1.115 (0.556-2.243) | 1 |
| Agriculture | 4 (9.5) | 6 (4.3) | 2.355 (0.560-9.042) | 0.4 (0.1-2.4) |
| Business/Shop | 6 (14.2) | 21 (14.9) | 0.953 (0.329-2.477) | 2.1 (0.3-15.3) |
| Government Job | 2 (4.8) | 15 (10.6) | 0.422 (0.063-1.702) | 1.2 (0.1-16.2) |
| Private Job | 8 (19.0) | 16 (11.3) | 1.831 (0.689-4.621) | 1.9 (0.4-10.0) |
| Student | 0 | 13 (9.2) | 1 | |
| BMI | ||||
| Underweight | 2 (4.8) | 6 (4.2) | 1.124 (0.151-5.542) | 1 |
| Healthy weight | 26 (62) | 83 (58.9) | 1.135 (0.559-2.343) | 0.6 (0.0 – 10.0) |
| Overweight | 10 (23.8) | 44 (31.2) | 0.690 (0.299-1.507) | 0.3 (0.0-5.6) |
| Obesity | 4 (9.5) | 8 (5.7) | 1.744 (0.437-6.097) | 0.7 (0.0-25.9) |
| Seeing difficulty | ||||
| Yes | 9 (21.4) | 12 (8.5) | 2.911 (1.094-7.578)* | 1 |
| No | 33 (78.6) | 129 (91.5) | 4.8 (1.01 – 23.1) | |
| Hearing difficulty | ||||
| Yes | 1 (2.4) | 4 (2.8) | 0.836 (0.033-6.866) | 1 |
| No | 41 (97.6) | 137 (97.2) | 1 | |
| Walking difficulty | ||||
| Yes | 10 (23.8) | 18 (12.8) | 2.125 (0.865-5.05) | 1 |
| No | 32 (76.2) | 123 (87.2) | 0.2 (0.0 – 2.3) | |
| Cognition (Remembering difficulty) | ||||
| Yes | 4 (9.5) | 6 (4.3) | 2.485 (0.590-9.56) | 1 |
| No | 38 (90.5) | 135 (95.7) | 4.8 (0.2-109.0) | |
| Hygiene and Self-care difficulty | ||||
| Yes | 6 (14.3) | 6 (4.3) | 3.716 (1.074-12.88)* | 1 |
| No | 36 (85.7) | 135 (95.7) | 22.4 (1.1-478.5) | |
| Communication difficulty | ||||
| Yes | 3 (7.1) | 2 (1.4) | 5.282 (0.761-45.74)* | 1 |
| No | 39 (92.9) | 139 (98.6) | 1 | |
#Column %; *Statistically significant
WGSS Questionnaire
The proportion of COVID-19-infected participants reporting functional difficulties was higher compared to their noninfected counterparts on five functional domains, although the difference was not statistically significant [Table 1]. Only hearing difficulty was twice as commonly reported by noninfected participants as compared to COVID-19-positive ones (5.2% versus 2.7%). Among the infected, the most common functional difficulties reported were mobility (28, 15.3%), vision (21, 11.5%), hygiene, and self-care (12, 6.6%). Less commonly reported were cognitive problems (10, 5.5%), hearing difficulties (5, 2.7%), and communication difficulties (5, 2.7%). The proportion of LCS was reported to be higher among those with functional difficulties, except for hearing difficulties, compared to those with no functional limitations. The difference was statistically significant for seeing difficulty (21.4% versus 8.5%, P value = 0.021), hygiene and self-care difficulty (14.3% versus 4.3%, P value = 0.021), and communication difficulties (7.1% versus 1.4%, P value = 0.046) [Table 2].
Factors associated with long-COVID-19 symptoms
Univariable analysis revealed a significanlty lower risk of LCS among inadividuals aged 26-35 years (odds ratio 0.32, 95% CI: 0.10-0.83, P value = 0.019), but significant higher risk with lower education (OR 4.46, 95% CI: 1.47-13.78, P value = 0.0003), and functional problems like seeing difficulty (OR 2.91, 95% CI: 1.09-7.58, P value = 0.021), difficulty in self-care (OR 3.72, 95% CI: 1.07-12.88, P value = 0.021), and communication difficulties (OR 5.28, 95% CI: (0.76-45.74, P value = 0.046). The multivariable logistic regression model showed presence of comorbidities such as seeing difficulty and poor hygiene as independent predictors for long-COVID-19 symptoms [Table 2].
DISCUSSION
The present study investigated pre-existing functional impairments among individuals recovered from COVID-19 and examined their association with long-COVID-19 symptoms and its determinants. Data were collected using the computer-assisted personal interview (CAPI) method from participants in the predominantly rural district of Jhajjar, Haryana, India. Given the unprecendented widespread of COVID-19 across India, investigation about LCS burden and other postpandemic health issues in rural settings is paramount. Moreover, lingering COVID-19 symptoms after the pandemic can result in a poor economically productive life as well as a poor quality of life, especially in places with fewer healthcare facilities.
The present study showed that the prevalence of LCS among COVID-19 cases is 22.9%. A similar self-reported study among 315 adult hospitalized patients reported that 25.9% of patients with at least one LCS after 1 year of recovery.[9] An umbrella review had estimated the prevalence of persistent post-COVID-19 symptoms ranging from 7.5% to 41% in nonhospitalized adults, 2.3%-53% in mixed adult samples, 37.6% in hospitalized adults, and 2%-3.5% in primarily nonhospitalized children.[15] Previous community-based studies from rural India had reported the prevalence of persistent COVID-19 symptoms as 17.5%, while hospital-based studies from northern India had reported a prevalence of 16.7%.[16,17]
Univariable and multivariable analyses were used to assess the impact of sociodemographic variables on LCS and revealed that female gender, older age, and lower education were risk factors for LCS. Numerous studies have reported female gender, older age, and obesity as predictors of LCS.[15,18] A study among infected healthcare workers from Malaysia revealed that female gender and older age groups were more likely to have postacute COVID syndrome.[19] The current study also reported this association between age and gender with LCS; however, it was not statistically significant for all age groups. The reason could be due to the lesser number of participants in the age categories.
Another online study on 315 COVID-19-recovered individuals from India reported that persistent muscle pain and weakness waxed and waned, throughout the first year after recovery.[20] The current study also reported weakness, weight loss, memory problems, and headache as the most common post-COVID persistent symptoms. In a previous study by the same authors, 257 COVID-recovered healthcare workers had also reported weakness (204, 79.4%), weight loss (46, 17.9%), memory problems (36, 14.0%), and headache (70, 27.2%) as common PCS symptoms.[21]
Out of the six functional difficulties studied, problems in seeing, hygiene, and remembering were more likely to be reported by those exposed to COVID-19. A previous registry-based nationwide study from Norway had also reported a higher risk of memory disturbance among participants exposed to COVID-19.[22] The accessibility challenges of rural areas are well documented, and providing universal health coverage to vulnerable rural populations needs innovative interventions. One such model was piloted in Germany by a mobile health clinic for post-COVID-19 syndrome patients, which reported better and timely provision of interdisciplinary care to these patients, despite substantial organizational challenges.[23]
The current study has a few limitations. First, LCS was based on self-report, and recall or social desirability biases may have led to over or underestimation of prevalence. Second, a cross-sectional design limits the determination of causality of risk factors, and only an association can be ascertained. However, the strength of the study lies in its community-based design in a rural setup, with rigorous sampling methodology and estimation of LCS along with its determinants. Third, factors like repeated infection and other important systemic comorbidities that potentially link with lingering COVID-19 symptoms were not collected in the present study.
CONCLUSION
The study concluded that nearly one-fifth of those who were previously infected with COVID-19 have developed LCS. The determinants of LCS are female gender, older age >50 years, lower education, and presence of comorbidities like seeing difficulty, and problems with hygiene or self-care. The functional difficulties were higher among the COVID-infected participants, especially those with LCS. Comprehensive care of these cases in the outpatient setting needs targeted interventions with integration between various healthcare disciplines.
Author contributions
SSS was responsible for the conception, study design, definition of intellectual content, literature search, data acquisition, interpretation of data, manuscript preparation, and funding acquisition. GG was responsible for data collection, cleaning and management, and manuscript preparation. SM helped with data acquisition, data analysis, and manuscript preparation. YPSB, GY, RA, and LN supported data collection study design and definition of intellectual content. All authors listed met authorship criteria, reviewed the manuscript before finalization, and had full access to the data. SSS is the principal investigator and guarantor.
Conflicts of interest
There are no conflicts of interest.
Data sharing statement
The raw data can be requested from the corresponding author after proper communication and signing an agreement with the requestor.
Acknowledgement
We want to thank all district health authorities and ASHA workers for their unconditional data collection support. We appreciate all the staff at RP Centre who helped us with financial management and obtaining relevant official permissions.
Funding Statement
Indian Council of Medical Research, New Delhi funded (Project Grant no. 2021-6506/F1) this study. The funder does not have any role in the design and conduct of the present study.
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