Before widespread global vaccination, the COVID-19 pandemic was responsible for the deaths of millions and had devastating economic consequences. The consequences of the pandemic may continue to affect people directly through their long-term physical and psychological consequences and indirectly through their negative socio-economic impacts [19, 20]. In this study, we focused on the long-term effects of COVID-19. Recovered patients with COVID-19 were examined approximately twice, 6 months (baseline) and 18 months (follow-up) after recovery.
There was a mean statistically significant decrease in the physical domain score and a significant increase in the participants’ psychological, social, and environmental domain scores from baseline to the follow-up interview. However, this varies according to the characteristics of different participants. Taking into account intra-individual variation between the two interviews, we found that higher age, female sex, history of hospital admission during COVID-19, smoking, and a greater number of chronic diseases were associated with a lower score in various domains . On the other hand, higher education, employment, and marriage are associated with higher scores in various domains. This is similar to previous studies of QoL in patients with COVID-19 conducted during their active disease or between 1 and 6 months after recovery, where older age, female gender, history of hospitalization, unemployment, and comorbidities are associated with low levels of QoL [21]. Contrary to a study in Pakistan [22], who showed an improvement in physical QoL over 6 months after diagnosis, we found an overall decrease in physical QoL over a longer period of time. In multivariable logistic regression analysis, we found several independent determinants of this decline, including new onset of chronic disease and re-infection with SARS-CoV-2. Although the overall physical domain QoL score increased and other domains decreased, each patient either had an increase or decrease or no change in QoL scores between the first and second interviews. Therefore, we sorted participants who experienced a decline in score and examined the determinants of decline through multivariable regression.
Multivariate logistic regression analysis also revealed that after adjusting for other variables, the decline in the physical domain occurred mainly in participants from the highest income category (> 60,000 BDT) and participants other than health workers. Interestingly, the reduction was significant in those who had no comorbidities at the time of the first interview but who later developed a chronic illness. This indicates that the mean decline in physical domain scores in the older age groups (36–45 and ≥ 46 years), as found in the bivariate analysis, was due to the new onset of chronic disease within a year and a half after COVID-19 infection. On the other hand, people from higher socio-economic categories are more likely to have insufficient physical activity [23] even after the lifting of quarantine and movement restrictions, and this may explain their tendency to develop chronic diseases and physical decline. Nevertheless, because participants had a 1-year increase in age between the two interview periods, aging may be a determinant of a negative trend in physical QoL. A study conducted among elderly people in Bangladesh found a lower mean QoL score [24], even lower than ours. Healthcare workers are likely to be more cautious about their health due to their high-risk perception and knowledge of COVID-19 [15, 25, 26]which may have allowed them to maintain good health over time.
Although the mean psychological domain score improved in all patients, participants who experienced re-infection with SARS-CoV-2 between the first and second interviews were significantly more likely to decrease the score. Also, the chances of decline are higher for those living in rural areas and having higher incomes (> 40,000 BDT). COVID-19 can lead to a general deterioration in the mental health of the affected person [27,28,29]. In addition, the rural economy of Bangladesh has been severely adversely affected by the COVID-19 pandemic [30]. Repairing this loss would subsequently place enormous psychological stress on those who have recovered from COVID-19 in rural areas compared to urban areas. Participants in high-income categories may have fallen into difficult social and economic circumstances, which is deeply related to a person’s psychological health [28]. This study also found that the highest monthly income category (> 60,000 BDT) was significantly associated with decline in social and environmental domains. The odds of a psychological domain score decline were lower for participants with chronic illness at the first interview, possibly because a proportion of those without a chronic illness at baseline developed a chronic illness at follow-up, increasing the effect size in the second group.
The WHOQOL-BREF instrument measures social domain outcomes based on participants’ perceptions of their relationships, sex life, and support from friends. According to our findings, it was primarily older adults and women who were affected by this change in perspective. After multivariate adjustments, other domains remained unaffected by participant age or gender. In addition, living in a rural area, higher monthly income (40,001–60,000 and > 60,000 BDT), marriage, and re-infection with COVID-19 between the first and second interviews were independently associated with a decline in social functioning. This finding is consistent with previous evidence, as female gender and older age have been reported to be associated with low QoL in many studies conducted on the impact of COVID-19 on mental health [21]. We found the same picture in our bivariate and GEE analysis. COVID-19 sufferers reported to experience more significant effect on family activity and sex life [21]. Furthermore, re-infection and new-onset chronic illness may have created increased needs for social support, only to be left unmet by an equally affected community. Sexual satisfaction may be the primary modifier of social QoL for married individuals. However, despite being more socially connected, rural residents may not have been able to benefit from the expected levels of support due to the greater economic impact of COVID-19 in rural areas [30].
In the environmental domain, in addition to higher monthly income, another independent predictor of outcome was a history of hospitalization due to COVID-19, an indicator of severe illness. Accessibility and availability of health and social care, which are essential components of the environment [17], may have been inadequate in those participants requiring follow-up hospital visits to restore and/or maintain physical function and mental health. Several previous studies [31,32,33] conducted on patients admitted to hospital for severe illness and critical illness reported that these patients suffered from low QoL up to 6 months after hospital discharge, especially in the physical and psychological components.
Our analysis revealed that the new onset of chronic diseases after recovery from COVID-19 was a significant negative determinant of QoL among sufferers. A recent study investigating QoL among patients with type 2 DM found a very low mean score in all four domains, supporting our hypothesis [34]. On the other hand, since chronic disease may be associated with older age [35]the lower QoL score may be due to aging [24].
Unfortunately, our study could not compare QoL outcomes between individuals who were not infected with COVID-19 and those who recovered from the disease. Nevertheless, earlier research conducted in a healthy population in Bangladesh showed that adolescents and adults had a mean QoL score of 80–90 between 2005 and 2007. [36, 37]. In contrast, our study found lower mean QoL scores among participants. Although a general improvement in QoL may be expected after recovery from COVID-19, the contrasting results observed in our study may reflect the adverse socioeconomic effects of the pandemic on the country’s population. However, drawing realistic conclusions about this situation is challenging due to the lack of an actual control group.
Our study highlighted the fact that the COVID-19 pandemic and the drastic control measures taken during this period had long-term consequences among people affected by the disease. Although many people adapted well over time, a significant number suffered a decline in quality of life. Nevertheless, authorities and politicians could take into account the determinants of decline and plan the necessary actions to reverse the decline process. In particular, the risk of re-infection may be a major mediator of reduced QoL among recovered victims of the disease. Lessons learned from COVID can be applied to unforeseen disease outbreaks in the future. Instead of applying careless or drastic measures, applying dynamic control mechanisms based on realistic unbiased calculations [38, 39] can be useful in effectively containing highly infectious diseases such as COVID-19 by ensuring that all government systems work without being prompted.
This study had some limitations. First, many participants were lost to follow-up. Second, the effect of sociocultural determinants such as availability of health services, economic security, rehabilitation measures and health-seeking behavior on QoL cannot be assessed. Third, the impact of persistent and disabling symptoms after COVID-19 has not been studied. Fourth, there were no true controls to compare QoL outcomes with those of individuals not suffering from COVID-19. However, our study was one of the few to consider QoL of COVID-19 after prolonged duration and describe possible implications for policy-level strategies to prevent further death and restore these individuals to full health.