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. 2023 Feb 17;32(3):608–617. doi: 10.1177/10547738231155729

The Symptom Experience and Functioning of Non-Hospitalized COVID-19 Patients Within the First 20 days

Eylem Tütün Yümin 1, Mahmut Sürmeli 2,✉, Ceyhun Topcuoğlu 3, Merve Başol Göksülük 4, Murat Yümin 5
PMCID: PMC9941454  PMID: 36799261

Abstract

The adverse physical, psychological, and mental health consequences associated with COVID-19 illness are well-documented. However, how specific symptoms change over time and how COVID-19 affects one’s day-to-day activities of daily living (ADL), Quality of Life (QoL), sleep quality, and fatigue severity are not well described. This longitudinal and descriptive study examined the changes in COVID-19 symptoms, ADL, QoL, sleep quality, and fatigue severity within the first 20 days. A convenience sample (n = 41) of non-hospitalized SARS-CoV-2 positive patients were recruited and followed for 20 days. Participants completed self-report measures: COVID-19 symptoms, ADL, QoL, sleep quality, and fatigue severity at days: 1, 10, and 20 following a diagnosis. Findings revealed that symptoms decreased over 20 days (p < .001). In parallel with the decrease in symptoms, QoL and ADL improved over 20 days (p < .05). However, sleep quality and fatigue severity did not improve within 20 days (p > .05). Our findings contribute to the growing evidence that COVID-19 symptoms can linger, especially fatigue and sleep quality, that affect overall day-to-day functioning for at least 20 days after diagnosis. To mitigate the effect of COVID-19 on QOL and ADL, findings underscore the need for clinicians to work collaboratively with patients to develop a symptom management plan for a variety of symptoms including fatigue and sleep quality. Beginning to repurpose existing self-management strategies for the longer term COVID-19 symptoms could be beneficial and help to optimize patient outcomes. Future work should examine these variables over a longer timeframe and among different samples of non-hospitalized patients.

Keywords: COVID-19, quality of life, activities of daily living, sleep quality, fatigue

Introduction

When COVID-19 was initially reported, more than 250 million cases and five million deaths were recorded, and these numbers have been increasing considerably (World Health Organization [WHO] Coronavirus (COVID-19) Dashboard, 2021). Infected patients showed various symptoms, including fever, chills, cough, shortness of breath, fatigue, sore throat, and pain. While some patients reported being asymptomatic, some non-hospitalized patients reported COVID-19 symptoms that extended well beyond the expected time period for recovery (Huang et al., 2020; Lai et al., 2020; Xu et al., 2020). Severity of initial symptom presentation, the types of symptoms, as well as functional impairment and physical and psychological health are affected to different degrees (Alinia et al., 2021; Carenzo et al., 2021; Temperoni et al., 2021). While there is substantial evidence in the literature, especially for hospitalized patients, the functional or daily impacts of non-hospitalized patients are relatively less emphasized. Non-hospitalized patients who were assumed to have a mild course of illness, reported symptom like memory problems, psychological disorders and sleep disturbances (Wang et al., 2020; Titze-de-Almeida et al., 2022). Moreover, some findings show a decline in their mental health and quality of life (QoL) (Alimoradi et al., 2021; Jahrami et al., 2021).

Extended courses of illnesses, and accompanying symptoms, across several conditions have been associated with difficulties performing activities of daily living (ADL) and poor QoL (Chen et al., 2020; Malik et al., 2022). Even among non-hospitalized patients, beginning evidence suggest that COVID-19 symptoms can affect daily functioning, like performance of ADL, and strongly affects the psychological well-being (Dubey et al., 2020; Fernández-de-las-Peñas et al., 2021; Kong et al., 2020; Singh, 2020; Yang et al., 2020). Thus, the purpose of this study was to examine the changes in COVID-19 symptoms, ADL, QoL, sleep quality, and fatigue severity within the first 20 days in non-hospitalized patients.

Materials and Methods

Study Design, Setting, and Participants

The study design was longitudinal and descriptive. This multicenter study included three health centers in Bolu, Turkey, including Beşkavaklar, 12 Kasım, and Tevfik Atay Public Health Centers, affiliated with the Republic of Turkey Ministry of Health. The study approved by Bolu Abant Izzet Baysal University Ethics Committee (Approval date: 02.03.2021, Approval number: 2021/57). A convenience sample (n = 41) of non-hospitalized adults patients diagnosed with COVID-19 illness was recruited from between March 20, 2021, and May 21, 2021.

Inclusion criteria were: The patients who were diagnosed by the polymerase chain reaction (PCR) assay within 2 days of collecting nasal pharyngeal swab specimens and wished to participate in the study were included. Exclusion criteria were: Patients who were unable to speak, read, and/or write and under the age of 18 were excluded. Additionally, patients who had respiratory diseases (such as chronic obstructive respiratory disease (COPD), idiopathic pulmonary fibrosis, severe asthma, etc.), psychological disorders, were under psychiatric medication, or needed to be hospitalized were also excluded.

Procedure

The study was conducted by web-based assessments using online questionnaires. Data on symptoms, demographic characteristics, ADL, QoL, sleep quality, and fatigue severity of the patients, were collected via electronic forms. To investigate the time-dependent changes in the status of patients, measurements were performed at three time points, that is, within the first 2 days immediately after the diagnosis of COVID-19, on days 10 and 20 from the first measurements.

The information of the patients was obtained from the public health center where they were registered. Next, the patients were contacted over the telephone and informed about the purpose, content, and method of the study. After obtaining consent from the volunteers who wanted to participate, the link of the electronic form, which contained the informed consent form of the study and information on the demographic data, the symptoms, and the questionnaires, was sent to the patients. For recording the follow-up measurements on days 10 and 20, participants were contacted, and the link of the electronic form was sent again. The participants who could not be reached for follow-up measurements by calling over the telephone were sent text messages via online messaging applications such as WhatsApp or Telegram and asked to answer the questionnaire and fill out the forms. If the patients did not respond to phone calls or messages and did not provide follow-up measurements, they were considered to be dropouts.

To get a research permission, an online application with the research detail report was submitted to the Ministry of Health COVID-19 Scientific Research Evaluation Commission (https://bilimselarastirma.saglik.gov.tr/). Then, the second application was filed to the Local Clinical Ethics Committee. Following the approvals, a petition was sent to the Bolu Provincial Health Directorate affiliated with the Ministry of Health, to carry out the research. Then, The Provincial Health Directorate recommended the public health centers under its regional control to share the database including only the contact information and names of the COVID-19 patients who accepted to be a volunteer to participate in the study.

The researchers checked the date on which they were diagnosed with COVID-19 from the data pool and contacted the patients who were eligible for the study. The researchers first introduced themselves and explained to the participants why they were contacted. They were informed about the aims and method of the research. Furthermore, the significance of participation in the research was explained to be encouraged. Those who indicated an interest in participating in the research during the phone interview were provided the study’s online data collecting form. Those who did not want to participate were not insisted on attending.

One hundred thirteen people viewed and approved informed consent and accepted to enroll in the study. All patients made their initial assessment within the first 2 days from diagnosis, and six patients with COPD were excluded from follow-up measurements. Sixty-seven patients made their second assessments on the day 10. Of those 67 patients, 41 completed assessments on day 20.

Sample Size Justification

To conduct the study, at least 35 patients were required to meet the sample size criterion and accurately detect the changes in the variables over time with a medium effect size (w = 0.25), 80% power, and 95% confidence level. The data were analyzed statistically by performing repeated-measures ANOVA tests (Cohen, 1988). The sample size was calculated by the G-Power 3.0.10 program.

Ethical Considerations

The study approved by Bolu Abant Izzet Baysal University Ethics Committee (Approval date: 02.03.2021, Approval number: 2021/57) and was conducted in line with the principles of the Declaration of Helsinki (General Assembly of the World Medical Association 2014).

Data Collection

The participants’ age, height, body weight, and gender, as well as comorbidities and existing disease-related signs and symptoms such as shortness of breath, fever, pain, and fatigue were collected. Moreover, severity, type, duration, and location of pain were assessed. They were instructed to select the proper choice for the type and localization of their pain, and if necessary, to write the localization or type as they felt it on the bottom line. Similarly, they were asked to specify their own symptoms on the form that listed among frequent Covid-19 symptoms, and to add those that were not on the list by putting them on the bottom line.

Pain: Visual Analog Scale was used for the measurement of pain intensity, it will be asked to mark the level of perceived pain intensity between these numbers, assuming that “0” is no pain, and “10” is unbearable (Carlsson, 1983).

QoL: Evaluated by the Nottingham Health Profile (NHP) questionnaire. NHP consists of 6 sub-dimensions and 38 questions in total, including Pain, Physical Activity, Energy Level, Sleep, Social Isolation, and Emotional Reactions. The questions are answered with yes or no. The highest score is 600, and the lowest score is 0; For each of the sub-dimension score included in the questionnaire, the highest score is 100, the lowest score is 0, and high scores indicate poor QoL for each sub-dimensions and total score (Hunt et al., 1981). The development and psychometric assessment of the Turkish version of the NHP was done by Kücükdeveci et al. (2000). The value for Cronbach’s Alpha of the scale for our study was α = .762

Activity of daily living (ADL): London Chest Activity of Daily Living Scale (LCADL) was used. The questionnaire consists of four components: personal care (4 items), housework (6 items), physical (2 items), and leisure (3 items). Each item is given a score ranging from 0 to 5. Higher scores indicate greater limitation in ADL. It can be evaluated as total score, component score, and question score. The total score can reach a maximum of 75. At the same time, there is only one question on the LCADL scale that determines how much the perception of dyspnea affects daily life in general (Garrod et al., 2000). Adaptation, reliability, and validity of the LCADL was done by Saka et al. (2020). The value for Cronbach’s Alpha of the scale for our study was α = .798

Sleep quality: The Pittsburgh Sleep Quality Index (PSQI) was used for assessment of the sleep quality. This questionnaire is a 19-item scale that assesses sleep quality and disturbance over the past month. Each item of the questionnaire is scored between 0 and3 points. The scale consists of seven subdimensions that assess subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disorders, use of sleep medication, and loss of daytime functionality. A total score ranges between 0 and 21. A total score of <5 points indicates good sleep quality. On the other hand, >5 points of total score indicates severe impairment in at least two of the above-mentioned domains or moderate impairment in three domains (Buysse et al., 1989). Turkish Adaptation, Validity, and Reliability of the PSQI was done by Ağargün et al. (1996). The value for Cronbach’s Alpha of the scale for our study was α = .713

Fatigue: Fatigue Severity Scale (FSS) was used to assess the fatigue of the patients. The scale consists of nine Likert type questions. Patients are asked to mark the appropriate options for each question, considering their situation in the last month. Each question is scored as 1 = strongly disagree, 2 = disagree, 3 = tend to disagree, 4 = undecided, 5 = tend to agree, 6 = agree, 7 = strongly agree. The score of the scale varies between 9 and 63, while a total score of 36 and above indicates fatigue (Krupp et al., 1989). The adaptation, validity, and reliability of the FSS was done by Armutlu et al. (2007). The value for Cronbach’s Alpha of the scale for our study was α = .682.

Statistical Analysis

The data were described with mean and standard deviation or median and minimum-maximum values for continuous variables and frequency and percentage for categorical variables. The assumption of normality distribution was checked using hypothesis test (Kolmogorov–Smirnov test) and graphical methods. The change over time was examined with Analysis of Variance or Friedman test for continuous variables. The Cochran Q test was used to evaluate the difference between time points for the categorical variables. The post-hoc tests were used to determine which time point(s) was/were different. Statistical analyses were performed using IBM SPSS v.21. The significance level was taken as p < .05.

Results

The study was completed with a total of 41 patients who completed all three assessments and were not hospitalized (Figure 1). Baseline comparisons between patients completed (n = 41) and dropouts (n = 72) were compared, and no differences were found between baseline demographic, anthropometric, and clinical characteristics (except of the cough) of participants. The results are shown in Table 1.

Figure 1.

Figure 1.

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Flowchart of the participation to the study.

Table 1.

Baseline Comparisons of Demographic, Anthropometric, and Clinical Characteristics of Participants.

Group of participants p
Completed (n = 41) Dropouts (n = 72)
Age (y) 35 (18–56) 38.5 (17–63) .444
Height (m) 1.70 (1.50–1.87) 1.68 (1.55–1.90) .979
Weight (kg) 73.22 ± 13.35 75.01 ± 13.94 .506
BMI (kg/m2) 25.85 ± 3.56 26.41 ± 4.04 .460
Gender
 Female 23 (56.1) 42 (58.3) .817
 Male 18 (43.9) 30 (41.7)
Comorbidities
 None 32 (78.0) 55 (76.4) .840
 Exist 9 (22.0) 17 (23.6)
 Hypertension 3 (7.3) 8 (11.1) .743
 Diabetes 2 (4.9) 1 (1.4) .298
 Asthma 2 (4.9) 3 (4.2) 1.000
 Heart disease 0 (0.0) 4 (5.6) .295
 Chronic kidney disease 1 (2.4) 1 (1.4) 1.000
 Angina 1 (2.4) 0 (0.0) .363
 Congenital adrenal hyperplasia 1 (2.4) 0 (0.0) .363
 Food allergy 0 (0.0) 1 (1.4) 1.000
 Goiter 0 (0.0) 1 (1.4) 1.000
 Rheumatoid arthritis 0 (0.0) 1 (1.4) 1.000
 Epilepsy 0 (0.0) 1 (1.4) 1.000
 Reflux 0 (0.0) 1 (1.4) 1.000
Pain
 None 5 (12.2) 14 (19.4) .322
 Exist 36 (87.8) 58 (80.6)
 Pain severity 3.0 (0.0–10.0) 3.0 (0.0–9.0) .431
 Pain duration 2.5 (0.0–28.0) 2.0 (0.0–10.0) .338
Symptoms
 None 9 (22.0) 17 (23.6) .840
 Exist 32 (78.0) 55 (76.4)
 Breathlessness 4 (9.8) 3 (4.2) .253
 Fever 3 (7.3) 9 (12.5) .531
 Cough 23 (56.1) 26 (36.1) .039*
 Sore throat 16 (39.0) 21 (29.2) .283
 Flicker 2 (4.9) 10 (13.9) .206
 Fatigue 21 (51.2) 32 (44.4) .488
 Ageusia and anosmia 4 (9.8) 14 (19.4) .176
 Nausea 1 (2.4) 2 (2.8) 1.000
 Diarrhea 1 (2.4) 0 (0.0) .363
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Note. BMI = Body mass index; y = year; m = meter; kg = kilogram; n (%): sample size, mean ± SD or median (min-max).

*

p < .05 was accepted as statistically significance value.

Although 9 (22%) of the patients had comorbidities at all time points, most of the patients diagnosed with COVID-19 infection did not have a comorbid health problem (n = 32 [78%]). There was no changing the number of comorbidities in time. 36 (87.8%) patients had pain on day 1, and the average severity was 3 (0–10). Some patients had widespread pain in more than one region, and the most frequently described painful areas were head (42.5%), upper (37.5%), and lower back (37.5%). The muscles (37.5%) and joints (32.5%) were other painful areas described by patients on day 1. There was a significant change over time in patients’ pain status (p < .001). While having pain was 87.8% in the first 2 days, this rate decreased significantly to 34.1% and 39.0% on days 10 and 20, respectively. In addition, pain intensity was higher in the first 2 days and decreased over time significantly (p < .001). Among the types of pain, the percentage of headache, pain of neck, upper back, and lower back, joints, and muscles were significantly higher on day 1 (p = .014, p = .008, p = .001, p = .001, p = .018, and p = .002; respectively). The group that made the difference was the first 2 days’ time point for each painful area. There was a significant decrease related to the presence of symptoms on day 20 (p < .001). The symptom of cough in patients was different between each time point (p < .001 and p = .007; respectively). While fatigue and dry throat were the common symptoms at the initial assessment, they decreased significantly at days 10 and 20 compared to the first day (p < .001 and p < .001; respectively). The ageusia and anosmia were found significantly higher on day 10 (p = .012). Comorbidities, symptoms, and pain characteristics were shown in Table 2.

Table 2.

Symptoms and Pain Characteristics of the Patients Who Completed All Assessments.

1st day 10th day 20th day p
Symptoms
 None 9 (22.0) 16 (39.0) 31 (75.6) <.001 *
 Exist 32 (78.0)A 25 (61.0)A 10 (24.4)B
 Breathlessness 4 (9.8) 4 (9.8) 2 (4.9) .607
 Fever 3 (7.3) 1 (2.4) 0 (0.0) .174
 Cough 23 (56.1)A 15 (36.6)B 3 (7.3)C <.001 *
 Sore throat 16 (39.0)A 6 (14.6)B 1 (2.4)C <.001 *
 Flicker 2 (4.9) 1 (2.4) 0 (0.0) .368
 Fatigue 21 (51.2)A 5 (12.2)B 2 (4.9)B <.001 *
 Ageusia and anosmia 4 (9.8)A 12 (29.3)B 5 (12.2)A .012 *
 Nausea 1 (2.4) 1 (2.4) 1 (2.4) 1.000
 Diarrhea 1 (2.4) 0 (0.0) 0 (0.0) .368
Pain
 None 5 (12.2) 27 (65.9) 25 (61.0) <.001 *
 Exist 36 (87.8)A 14 (34.1)B 16 (39.0)B
 Pain severity 3 (0–10)A 0.0 (0–10)B 0.0 (0–9)B <.001 *
 Pain duration 2.5 (0–28) 0.0 (0–15) 0.0 (0–24) .156
Pain location
 Headache 17 (42.5)A 9 (22.0)B 7 (17.1)B .015 *
 Upper back 15 (37.5)A 4 (9.8)B 4 (9.8)B <.001 *
 Neck 9 (22.5)A 2 (4.9)B 2 (4.9)B .012 *
 Lower back 15 (37.5)A 5 (12.2)B 3 (7.3)B .001 *
 Throat 1 (2.5) 0 (0.0) 0 (0.0) .368
 Joints 13 (32.5) 5 (12.2) 6 (14.6) .018
 Muscles 15 (37.5)A 4 (9.8)B 7 (17.1)AB .002 *
Types of pain
 Throbbing 10 (25.0) 4 (9.8) 8 (19.5) .165
 Pricking/Lancinating 9 (22.5)A 3 (7.3)AB 1 (2.4)B .003 *
 Thermal 1 (2.5) 2 (4.9) 3 (7.3) .607
 Sharp/Lacerating 3 (7.3) 3 (7.3) 0 (0.0) .165
 Pinching/Crushing 5 (12.5) 0 (0.0) 1 (2.4) .030 *
 Widespread 5 (12.5) 3 (7.3) 1 (2.4) .180
 Regional 13 (32.5) 9 (22.0) 6 (14.6) .157
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Note. Descriptive statistics are given with frequency and percentage; *Cochran’s Q test; p < .05 was accepted as statistical significance value and the difference was marked in bold ; The superscript letters A,B and C indicate the post-hoc test results, and the difference between the letters of the variable in the same line indicates that there is a difference between the groups A, B or C.

There was a significant decrease over time in the patients’ total QoL score (p = .024) and sub-dimensions of pain (p = .001), physical activity (p = .0012), and sleeping (p = .012). For the physical activity sub-score and total score of QoL, there was a significant difference between the first 2 days and day 20. While the pain sub-score was significantly decreased in the first 2 days, the difference was found important on day 20 for the sleeping sub-score.

A significant decrease was observed over time in the total score of ADL (p = .045) and sub-score of domestic activities and leisure activities (p = .005 and p = .026, respectively). The difference consisted of the first 2 days and day 20. Changes in the QoL and ADL scores at all time points were shown in Table 3.

Table 3.

Quality of Life (QoL) and Activity of Daily Living (ADL) of the Patients.

1st day 10th day 20th day p
QoL
 Pain 20.48 (0–100)A 0.0 (0–100)B 0.0 (0–100)B 0.001*
 Physical activity 11.2 (0–66.01)A 0.0 (0–56.71)A,B 0.0 (0–53.4)B 0.012*
 Energy level 0.0 (0–100) 0.0 (0–100) 0.0 (0–100) 0.525
 Sleeping 12.57 (0–77.63)A 12.57 (0–77.63)B 0.0 (0–65.06)B 0.012*
 Social isolation 0.0 (0–100) 0.0 (0–100) 0.0 (0–80.64) 0.911
 Emotional reactions 0.0 (0–100) 0.0 (0–100) 0.0 (0–73.69) 0.738
 Total score 123.36 (0–452.45)A 49.37 (0–446.25)A,B 38.71 (0–432.82)B 0.024*
ADL
 Self-care 0.0 (0–15) 0.0 (0–20) 0.0 (0–20) 0.256
 Domestic activities 6.0 (0–30)A 2.0 (0–29)A,B 0.0 (0–24)B 0.005*
 Physical activities 2.0 (0–10) 0.0 (0–10) 0.0 (0–10) 0.061
 Leisure activities 2.0 (0–15)A 0.0 (0–15)A,B 0.0 (0–15)B 0.026*
 Total score 17.0 (0–64)A 6.0 (0–66)A,B 4.0 (0–69)B 0.045*
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Note. Descriptive statistics are given with median (minimum-maximum); *Friedman test; **p < 0.05 was accepted as statistical significance value and the difference was marked in bold; The superscript letters A,B and C indicate the post-hoc test results, and the difference between the letters of the variable in the same line indicates that there is a difference between the groups A, B or C.

The sleep quality of the patients was found to be poor at the first evaluation, and it did not change on the days 10 and 20 (p > .05). In addition, no significant change was found in fatigue severity at all time points (p > .05). Scores of the PSQI and FSS was shown in the Table 4.

Table 4.

Pittsburg Sleep Quality Index (PSQI) and Fatigue Severity Scale (FSS) of the Patients.

1st day 10th day 20th day p
PSQI
 Subjective sleep quality 1.0 (0–3) 1.0 (0–3) 1.0 (0–3) .141
 Sleep latency 1.0 (0–2) 1.0 (0–2) 1.0 (0–2) .465
 Sleep duration 0.0 (0–3) 0.0 (0–3) 0.0 (0–2) .199
 Habitual sleep efficiency 3.0 (0–3) 3.0 (0–3) 3.0 (0–3) .584
 Sleep disturbances 1.0 (0–2) 1.0 (0–3) 1.0 (0–2) .082
 Use of sleep medication 0.0 (0–1) 0.0 (0–2) 0.0 (0–0) .607
 Daytime dysfunction 1.0 (0–3) 1.0 (0–3) 1.0 (0–2) .811
 Total Score of PSQI 7 (1–12) 7 (1–15) 7 (0–13) .641
FSS
 Fatigue severity 4.15 (1.76) 3.72 (1.84) 3.83 (1.89) .661
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Note. Descriptive statistics are given with median (minimum-maximum); Friedman test; p < .05 was accepted as statistical significance value.

Discussion

The most prevalent symptoms of COVID-19 infection in this study were pain, cough, fatigue, and sore throat. The symptoms decreased significantly within 10 days from the onset of diagnosis. Additionally, the QoL of the patients during the symptomatic period following the diagnosis was low, and they had difficulties in performing ADL. Along with the reduction of symptoms on day 20, there was an improvement in QoL and ADL. On the other hand, the patients’ sleep quality did not improve in the short term, nor did the fatigue severity reduce over time.

The initial research examined the physical impacts, signs, and symptoms of the disease, as well as treatment strategies for resolving them. It was seen that the disease had not only physical signs and symptoms in the short term but also in the long term, and so a condition known as the “long-COVID” syndrome was described (Cirulli et al., 2020; Sudre et al., 2020). Since the spread of the disease and it becoming a global crisis, a growing body of evidence has begun to indicate that the clinical picture would not be limited to vital and physical dimensions, and that psychological and social consequences of the disease have also become critical effects across multiple populations (Ali & Alharbi, 2020; Alimoradi et al., 2021; Alinia et al., 2021; Armbruster & Klotzbücher, 2020; X. Li et al., 2021). The majority of the first data from the outbreak, which grew into an unmanageable worldwide disaster, comprised of pain and hospitalization of patients owing to the disease’s life-threatening nature. Some patients, though, were symptomatic, did not require hospitalization, and were observed and followed remotely. The purpose of this study was to investigate the symptom experiences and changes in the everyday lives of the subjects who were observed at home from the time they were diagnosed.

The symptoms of the patients were grouped into two different categories: pain and other symptoms. The most prevalent symptoms were pain, cough, fatigue, and dry throat. On the other hand, breathlessness, fever, chills, nausea, diarrhea, ageusia, and anosmia were scarce. Cough and sore throat reduced on the days 10 and 20. However, incidence and intensity of pain, and fatigue decreased on the day 10 but did not improve beyond that. Prevalence of painful areas dropped in the first 10 days but did not change in the following 10 days. Overall, these results suggests that non-hospitalized COVID-19 patients demonstrate different signs and symptoms ranging from mild to severe clinical manifestations, while some of them may have no symptoms at all. Most of the initial symptoms improve within 10 days. In addition, although some symptoms keep going to resolve further, the clinical course of others may remain for days. These results are consistent with the existing reports indicating that most affected people had no symptoms (Cao et al., 2020; Huang et al., 2020; Moradian et al., 2020), while those symptomatic demonstrate various clinical manifestations in terms of the duration and severity of symptoms (Reddy et al., 2021). Symptoms improve within a week in moderate instances; however, in severe cases, the recovery may take several weeks (Li, 2020).

We found that, even though the symptoms were not severe, QoL was poor during the initial days when symptoms were more prevalent. Notably, a decline in the pain, physical activity, and sleep pattern-related dimensions of QoL were shown at the start of the disease but improved within 10 days, harmonizing with the improvement in symptoms. However, this improvement has had little effect on overall QoL in the same period. On the other hand, a considerable improvement in QoL arose on day 20. Concordantly, we may say that QoL will improve as symptoms relieve; nevertheless, meaningful improvement should be expected within 20 days in these patients. In a study, the QoL of hospitalized patients was found to be worse than those non-hospitalized but under quarantine at home. In addition, patients admitted to the intensive care unit had lower QoL compared to those without severe lung infection (Alinia et al., 2021). Thus, the hospitalization and lung health were proposed as useful indicators of the QoL of COVID-19 patients. Another study that monitored symptomatic COVID-19 patients for a month showed that the QoL of symptomatic patients was considerably low. The authors attributed this decrease in the QoL to the symptomatic effects of the disease, the patients’ limited connection with society, and their social fears (Chen et al., 2020). Malik et al. (2022) performed a meta-analysis and found that the symptoms that associated with COVID-19 infection remain to have an effect on patients’ QoL and mental health.

In this study, the ADL of the non-hospitalized COVID-19 patients was impaired following diagnosis. Although most symptoms resolved in 10 days, improvement in ADL was evident within 20 days. Similarly, the domestic, leisure, and physical activities-related components of ADL improved within 20 days after diagnosis. We suggest that COVID-19 infection reduces the ability to maintain patients’ ADL relating to domestic, leisure, and physical activities. ADL improves in line with the recovery of the symptoms; however, unlike the resolving of symptoms, significant improvements in ADL might take up more days. Fernández-de-las-Peñas et al. (2021) examined 1,969 patients hospitalized due to COVID-19 and followed up after discharge. They found that admission to the hospital and the intensive care unit with symptoms limited their daily activities at work and home, thus, affecting their leisure, social, and basic needs. Additionally, at least 20% of the COVID-19 survivors still had limitations on ADL 8 months after hospitalization. Larsson et al. (2021) found that, although the patients did not have any inadequacies, they had difficulties in performing ADL. In addition, impaired physical and cognitive functions adversely affected the patients’ ADL. Another study showed the relationship between cognitive dysfunction and decline in daily activities (Tabacof et al., 2022).

Sleep disturbances and psychological disorders are widespread in disease-related outbreaks (Ji et al., 2017; Zhang et al., 2020). Studies showed that they were also widespread in the current pandemic, particularly among COVID-19 patients (Alimoradi et al., 2021). Moreover, even after initial recovery from the disease, the complaints and symptoms may persist for days (Lopez-Leon et al., 2021). In this study, we found that the patients’ sleep quality was poor from the onset of disease, and they had a complaint of fatigue during 20 days. Although the many complaints and the symptoms reduced in time, sleep quality, and fatigue remained unchanged in the short term. Considering the effects of psychological health and sleep quality on each other, the lack of improvement in sleep quality in the short term might be related to the poor psychological health of the patients. However, to prove this hypothesis, it is necessary to evaluate, including but not limited to, psychological health, socioeconomic factors and examine their effects on sleep quality. X. Li et al. (2021) discovered that COVID-19 patients had poor sleep quality and decreased mental health. Our study also found a similar result regarding the decrease in the sleep quality of these patients. However, X. Li et al. (2021)’s comprehensive study yielded more reliable results in terms of evidence-based physiological connections between immunity and mental health. Herein, that study is valuable in revealing deterioration of sleep quality and mental health weakening the immune system in COVID-19 patients.

Although this study provides insight on symptom experiences and daily functioning, it also has limitations. To begin, listing the factors related with the setting and participation would be appropriate for generalizability. Even though over a 100 patients completed the initial measurements, there were a significant number of dropouts in repeated longitudinal measures. In addition, despite the permission of the Ministry of Health to record and facilitate COVID-related cases and obtain information on clinical courses and responses to treatment, only a few public health centers accepted to participate in the study. Thus, it was conducted based on the required minimum sample size, and the findings might not be generalizable. Therefore, given the low response rate and high attrition, these were major limitations of the study. Second, lack of data on any pharmacological or over-the-counter medication during the course of the study was another limitation. Since the medications used for symptom management would have reduced the prevalence and severity of the symptoms, it would not be correct to interpret the early symptom experiences as the clinical course of the disease. Third, the association between the symptom experiences, ADL, and QoL was not examined. So, it was not possible to definitively interpret whether the symptoms had an impact on functional and physical experiences in daily life. To sum up, these limitations should be considered when interpreting the study findings, and additional research should be planned to eliminate the weaknesses and inadequate attention to sampling bias. However, demographic, anthropometric, and medical characteristics were the same between patients who completed and did not complete (dropouts) all measurements. Thus, sampling bias was somewhat overcome when interpreting the study results. Additional studies with more participants and a higher response rate might reflect more accurate and generalizable results.

Conclusion

In closing, these results contribute to our awareness on symptomatic, non-hospitalized, and remotely monitored patients having a poor QoL after diagnosis and struggle to maintain their ADL. A decrease in symptoms, as well as an improvement in QoL and ADL is shown in a short period of time. However, poor sleep quality and fatigue may continue longer than the other typical symptoms.

Although most symptoms and daily functioning improve in a short period of time, some patients may experience them longer. Further research should expand to cover different populations by categorizing the profession, income status, and age, review the patients’ conditions in a variety of aspects, including physical, functional, and psychological well-being from the initial stage of the disease to long-term. It might help to better understand the symptoms and its effects, as well as treatment and healthcare strategies to cure and cope with them. Furthermore, with the developing health and digital health literacy, the delivery of healthcare may be implemented via telehealth technologies for those non-hospitalized COVID-19 patients. It can assist in overcoming the challenges that may occur during such crises, which place a substantial burden on individuals, communities, and healthcare systems.

Acknowledgments

We would like to thank study participants for their kind efforts. We would also like to thank the physicians in Public Health Centers for their help in providing the cases of the study.

Author Biographies

Eylem Tütün Yümin, PT, is an associate professor at the Department of Physiotherapy and Rehabilitation, Bolu Abant Izzet Baysal University, Bolu, Turkey.

Mahmut Sürmeli, PT, is a research assistant at the Faculty of Health Sciences, Tokat Gaziosmanpasa University, Tokat, Turkey.

Ceyhun Topcuoğlu, PT, is a research assistant at the Faculty of Health Sciences, Munzur University, Tunceli, Turkey.

Merve Başol Göksülük, PhD, is a bio-statistician at the Erciyes University, Kayseri, Turkey.

Murat Yümin, MD, is a medical doctor at the Beskavaklar Family Health Center, Ministry of Health, Bolu, Turkey.

Footnotes

Authors’ Contribution: Eylem Tutun Yumin: Conceptualization, Methodology, Resources, Supervision, Review & Editing. Mahmut Surmeli: Conceptualization, Methodology, Investigation, Resources, Writing – Original Draft. Ceyhun Topcuoglu: Conceptualization, Methodology, Investigation, Resources, Review & Editing. Merve Basol Goksuluk: Formal Analysis, Review & Editing. Murat Yumin: Resources, Review & Editing.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD: Mahmut Sürmeli Inline graphichttps://orcid.org/0000-0002-5661-922X

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