Introduction
Coronavirus disease (COVID-19) was recognized by the World Health Organization (WHO)
on March 11, 2020, as a pandemic disease related to Sars-CoV-2, capable of causing
mild flu-like symptoms to systemic disorders and death 1,2.
During the pandemic, it was found that some patients remained affected by the disease
even several weeks after the onset of symptoms. This condition has been named in a
variety of ways, such as "long COVID-19", "post-COVID-19", "post-acute COVID-19" or
"acute post-COVID-19 syndrome" 3. Subsequently, it was found that the symptoms observed in some patients were similar
to those presented during the acute phase of the infection. However, new symptoms
reported by patients were identified which were not associated with other pre-existing
diseases or comorbidities. These new symptoms had a significant impact on the health
and functional capacity of the affected individuals, compromising their daily activities
4,5.
As a result, studies have started reporting symptoms that are frequently present in
the population with the acute post-COVID-19 syndrome condition, including fatigue,
headache, memory loss, and arthralgia. These symptoms compromise the quality of life
and well-being of individuals, resulting in a significant deficit in self-care and
a loss of functional capacity 6.
The concept of self-care, according to Dorothea Orem's self-care theory, refers to
the maintenance of health and the prevention of complications. In contrast, the self-care
deficit theory is related to the demands for therapeutic care, considering that an
individual may not have sufficient skills to meet these demands and may need assistance
from others. Both theories are used to evaluate the level of impairment or self-care
capacity of individuals 7.
In this context, the present study is based on the hypothesis that the evaluation
of functional capacity and self-care can identify impairments that impact the well-being
and quality of life of post-COVID-19 patients. Furthermore, it is suggested that,
given the identification of these parameters, it is necessary to develop specific
health education and strategies for recovery. Therefore, the objective was to evaluate
functional capacity and self-care in post-COVID-19 patients.
Materials and methods
This is a quantitative, descriptive-exploratory study conducted with patients receiving
care in an acute post-COVID-19 Syndrome Functional Recovery Program at a public university
located in the city of Petrolina, Pernambuco, Brazil, from August 2022 to August 2023.
The preparation of this article followed the guidelines of the Consolidated Standards
of Reporting Trials [Consort] 8.
The study population includes all patient records, totaling 71 individuals. However,
18 records were excluded due to incomplete data required for analysis. Thus, the final
sample consisted of 53 medical records of participants of both sexes, aged over 18,
who self-reported a confirmed clinical diagnosis of COVID-19 and presented a condition
compatible with acute post-COVID-19 syndrome, according to the initial evaluation
performed by the interdisciplinary team.
The data were collected using an instrument developed by the authors, which included
the following variables: identification (sex, age, and race), initial signs and symptoms
of COVID-19 and post-COVID-19, main complaint, lifestyle habits (use of tobac tobacco,
alcohol, and/or other drugs), sociocultural or economic conditions (education, religion,
marital status, family relationships), and health conditions (pre-existing illnesses,
family history of illnesses), vital signs, and anthropometric measurements.
In addition, the self-care ability score was evaluated using the Appraisal of Self-Care
Agency Scale [ASA-A] 9, consisting of 24 questions with five alternative answers (1 - totally disagree;
2 - disagree; 3 - neither agree nor disagree; 4 - agree; 5 - totally agree). The scale
classifies self-care capacity as high (97-120 points), medium, (49-96 points) or low
(24-48 points).
Furthermore, functional capacity was assessed using the instrumental activities of
daily living [IADL] assessment tool 10, which covers seven components, namely: phone, travel, shopping, meal preparation,
housework, medication, and money, each with three answer options, classed as dependent
(7 points), independent (21 points), and partially dependent (8-20 points).
The data was coded into Microsoft Office Excel® spreadsheets and then transferred
to the Statistical Package for the Social Sciences (SPSS) software, version 22.0,
for analysis. Descriptive analyses were performed using frequency distribution, central
tendency, and dispersion measurements. To calculate the statistical significance of
the associations, nonparametric tests such as Pearson's Chi-squared or Fisher's exact
were conducted, with a significance level set at 5 % (p < 0.05) to identify possible
associations.
The study was approved by the Research Ethics Committee of the Centro Integrado de
Saúde (Integrated Health Center) Amaury de Medeiros, at the Universidade de Pernambuco,
under protocol number 4.728.269, respecting all ethical precepts.
Results
Most of the sample consisted of female individuals (86.8 %), aged 50 or over (47.2
%), of mixed race (62.3 %), and married (45.3 %). In terms of their level of education,
49.1 % had completed high school. More than half of the sample followed the Catholic
faith (52.8 %) and 41.5 % reported a family income of more than 1.5 times the national
minimum wage. Most participants were residents of the city of Petrolina, Pernambuco
(92.5 %).
Regarding hospitalization, 15.1 % of the sample reported having been admitted to an
intensive care unit (ICU), with a mean length of stay of 30.5 days with a standard
deviation of ± 19.19 or had been admitted to a ward for 13.2 days with a standard
deviation of ± 22.36 days (Table 1).
Table 1
Length of Patient Stay in ICUs and Wards. Petrolina, Pernambuco, Brazil, 2022-2023
|
Variables
|
Mean (SD)
|
Standard Deviation
|
|
Length of ICU stay (days)
|
30.5
|
19.19
|
|
Length of stay in a ward (days)
|
13.2
|
22.36
|
Only 5.7 % were smokers and 34 % used alcoholic beverages; 62.3 % reported having
a pre-existing condition and 37.7 % of the patients had a body mass index above 30,
classifying them as obese. The signs and symptoms were categorized according to the
system affected. In the respiratory system, the most frequently reported symptoms
included coughing, dyspnea, fatigue, coryza, and flu-like symptoms. In the musculoskeletal
system, the prevalent symptoms were fatigue, muscle pain, and arthralgia. Regarding
the central nervous system, the main symptomsfound were changes in memory, lack of
concentration, mental confusion, headaches, and sleep disturbances.
Regarding the symptoms presented during the acute and post-acute stages of COVID-19,
more than half of the participants (54.7 %) reported symptoms involving three or more
systems, while 18.9 % reported simultaneous symptoms in the musculoskeletal and central
nervous systems during the infection. In the post-acute stage, a similar pattern was
found, with 37.7 % of patients reporting symptoms in three or more systems and 18.9
% presenting symptoms in the musculoskeletal and central nervous systems.
In the physical evaluation, vital signs such as respiratory rate, heart rate, systolic
and diastolic blood pressure, oxygen saturation, and axillary temperature were within
normal standards. It was possible to identify an association (p < 0.05) between self-care
capacity, length of hospitalization, and whether the patient had already undergone
surgery regarding the level of dependence in terms of performing instrumental activities
of daily living.
Table 2
Association of IADL according to Sociodemographic, Clinical, and Behavioral Characteristics
and Self-Care Ability. Petrolina, Pernambuco, Brazil, 2022-2023
|
IADL
|
Independent
|
Partially Dependent
|
|
Variables
|
n (%)
|
n (%)
|
p-value
|
|
Sex
|
|
Male
|
2 (28.6)
|
5 (71.4)
|
0.11**
|
|
Female
|
29 (63)
|
17 (37)
|
|
Age
|
|
|
|
|
From 18-29 years
|
9 (69.2)
|
4 (30.8)
|
0.52*
|
|
From 30-39 years
|
5(55.6)
|
4 (44.4)
|
|
From 40-49 years
|
2 (33.3)
|
4 (66.7)
|
|
Aged 50 or over
|
15 (60)
|
10 (40)
|
|
Hospitalization |
|
Yes
|
2 (25)
|
6 (75)
|
0.03*
|
|
No
|
29 (64.4)
|
16 (35.6)
|
|
Symptoms During Infection |
|
Asymptomatic
|
1 (100)
|
0 (0)
|
0.49*
|
|
MSS
|
1 (100)
|
0 (0)
|
|
CNS
|
1 (100)
|
0 (0)
|
|
RS
|
1 (50)
|
1 (50)
|
|
MSS+CNS
|
6 (60)
|
4 (40)
|
|
MSS+RS
|
2 (66.7)
|
1 (33.3)
|
|
CNS+RS
|
0 (0)
|
3 (100)
|
|
3 or more systems
|
16 (55.2)
|
13 (44.8)
|
|
Current Symptoms (after Clinical Cure) |
|
MSS
|
2 (33.3)
|
4 (66.7)
|
0.39*
|
|
CNS
|
4 (66.7)
|
2 (33.3)
|
|
MSS+CNS
|
5 (50)
|
5 (50)
|
|
MSS+RS
|
3 (100)
|
0 (0)
|
|
CNS+RS
|
4 (80)
|
1 (20)
|
|
3 or more systems
|
12 (60)
|
8 (40)
|
|
Pre-existing Medical Condition |
|
Yes
|
17 (51.5)
|
16 (48.5)
|
0.06*
|
|
No
|
12 (80)
|
3 (20)
|
|
Which Condition? |
|
CNCD
|
12 (52.2)
|
11 (47.8)
|
0.56*
|
|
Respiratory diseases
|
1 (100)
|
0 (0)
|
|
Heart diseases
|
0 (0)
|
1 (100)
|
|
2 or more
|
4 (50)
|
4 (50)
|
|
Other conditions? |
|
Yes
|
7(53.8)
|
6 (46.2)
|
0.58*
|
|
No
|
17 (63)
|
10 (37)
|
|
Do you use any medication? |
|
Yes
|
25 (59.5)
|
17 (40.5)
|
0.51**
|
|
No
|
6 (54.5)
|
5 (45.5)
|
|
Previously undergone surgery |
|
Yes
|
17 (47.2)
|
19 (52.8)
|
0.01*
|
|
No
|
14 (82.4)
|
3 (17.6)
|
|
Family History of a Condition |
|
CNCD
|
21 (55.3)
|
17 (44.7)
|
0.40*
|
|
Heart diseases
|
2 (100)
|
0 (0)
|
|
2 or more
|
6 (66.7)
|
3 (33.3)
|
|
ASA-A |
|
High self-care capacity
|
17 (73.9)
|
6 (26.1)
|
0.04*
|
|
Medium self-care capacity
|
14 (46.7)
|
16 (53.3)
|
Regarding ASA-A, which evaluates self-care capacity, approximately 56.6 % of the sample
showed medium self-care capacity. Regarding functional capacity to perform IADL, 53.3
% also were partially dependent -i.e., having medium self-care capacity, which implies
dependence to perform IADL.
Discussion
Among the study's findings, it is worth discussing the association between IADL and
sociodemographic, clinical, and behavioral characteristics as well as self-care capacity.
Firstly, it is relevant to mention that some studies indicate that post-COVID-19 syndrome
develops more markedly in individuals who have presented severe forms of the disease
in the acute stage. However, other studies have shown the presence of this condition
even in patients who have manifested mild forms of the disease 10-12.
In the present study, it was found that acute post-COVID syndrome can exhibit a range
of signs and symptoms, regardless of age, gender, the presence or absence of comorbidities,
or the level of severity of the initial onset of COVID-19, corroborating the findings
of the aforementioned studies 10-12.
Being able to perform instrumental activities of daily living is directly related
to self-care and quality of life. These activities are associated with preserving
a life in the community, including tasks such as shopping, using the phone, traveling,
managing money, doing household chores, and preparing meals. These activities are
essential for individuals' autonomy and, consequently, for their integration and functionality
in society. The ability to perform IADL is a crucial indicator of the level of independence
and well-being of patients, especially those who have recovered from COVID-19 13.
In this sense, one study 14 found that a small proportion of | post-COVID patients presented impaired functional
capacity even six months after the onset of symptoms, and this functional loss may
be even greater among patients who had muscle or joint pain at the onset.
Functional capacity is related to physical fitness, enabling individuals to perform
their daily activities independently, mainly with the objective of self-care, health
and, consequently, quality of life. Another study 6 shows that COVID-19 affects the functionality of patients, leading to prolonged sequelae
that impair their IADL.
A recent study 14 found that almost 60 % of Brazilians who had COVID-19 developed the post-COVID-19
condition. Fatigue, anxiety, memory loss, and hair loss were the most commonly mentioned
symptoms, but more than 50 symptoms were mentioned and grouped into 10 categories,
including cardiovascular/ coagulation, dermatological, endocrine-metabolic, gastrointestinal,
musculoskeletal, renal, respiratory, neurological, and mental health-related symptoms,
as well as general symptoms such as pain and dizziness.
According to the WHO estimates 15,16, between 10 % and 20 % of patients -corresponding to between 2.8 million and 5.6
million Brazilians- may suffer from acute post-COVID-19 syndrome and, as a result,
will need healthcare due to the condition. When relating the symptoms to the Sars-CoV-2
virus variants, it can be noted that the original strain has as common symptoms fevers,
dry cough, tiredness, and loss of taste or smell. For the omicron variant, frequent
symptoms include extreme tiredness, body pain, headache, and sore throat. In the delta
variant, the prevailing symptoms are coryza, headache, sneezing, sore throat, persistent
coughing, and fever. The gamma variant has symptoms such as fever, coughing, sore
throat, shortness of breath, diarrhea, vomiting, body pain, tiredness, and fatigue.
For the alpha variant, the common symptoms are loss or alteration of smell, loss or
alteration of taste, fever, persistent coughing, chills, loss of appetite, and muscle
pain. Finally, in the beta variant, the most common symptoms are fever, coughing,
sore throat, shortness of breath, diarrhea, vomiting, body pain, tiredness, and fatigue
16,17.
Another relevant finding refers to the prevalence of women aged 50 and over, which
can be explained by the increased demand for healthcare services by this age group.
Women seek healthcare services more than men in any age group 18. Other authors 5 conducted a study with a sample of 221 patients who had COVID-19 and found that women
were the most affected (63.8 %), with a mean age of 43.6 years, 56.6 % were of mixed
race and 55.7 % were married, with a higher risk of low levels of functional capacity
and general state of health. The study points to greater social pressure, new roles
assumed by women during the pandemic, and increased emotional overload as possible
causes.
Regarding monthly family income, some studies show that care and demand for healthcare
services are higher among the most vulnerable population or those with a monthly income
ranging from one to two times the minimum wage in Brazil 17-19. Regarding religion and skin color, the sample is in line with the national reality,
in which data from a survey conducted in 2022 by the Instituto Brasileiro de Geografia
e Estatísticas (Brazilian Institute of Geography and Statistics) [IBGE] 20 showed that 45.3 % of Brazilians declare themselves to be of mixed race, which demonstrates
a significant increase in the mixed-race population since 2017; in turn, self-declared
white people represent 42.8 % of the population. In addition, data from the 2010 IBGE
census 21 reported that approximately 64.63 % of Brazilians are Catholics, corroborating the
sample studied; no information on religion was found in the most recent census.
It was also possible to find an association between hospitalization and partial dependence
to perform IADL. A study conducted in 2019 reported that hospitalization can interfere
with a person's autonomy and independence since hospitalization itself is already
a factor that leads to dependence 22. Another study conducted in 2018 found that, regardless of the cause of hospitalization,
approximately 41.6 % of the sample showed a decline in patients' autonomy S and independence
compared to the period prior to hospitalization. In addition, an association was found
between a previous history of surgery and partial dependence on performing IADL. This
finding may be related to the delay or cancellation of elective surgeries during the
pandemic, in which prolonged waiting for these procedures may lead to the need for
more complex surgeries or multiple interventions. In addition, surgeries can compromise
functional capacity in some respects in the long term.
A study conducted to evaluate the quality of life one year after transtrochanteric
femoral surgery showed that, when comparing the values assigned to basic activities
of daily living (BADL) and IADL in the preoperative stage and one year after surgery,
there was a higher level of functional dependence one year after surgery. The IADL
was significantly worse in more than 50 % of cases. The study also emphasizes that
the use of treatments that enable an early recovery should be the goal of the surgical
team to minimize the negative impact on patients' functional capacity and self-care
24-26.
Another study shows that the persistence of post-COVID-19 syndrome symptoms is indicative
of a deteriorating quality of life, with an impact on the physical and mental health
of those affected, reducing their functional status, limiting their activities, and
hindering self-care 26. The data provides a better understanding of the impact that post-COVID-19 syndrome
has on the performance of activities and the impact on quality of life.
In this sense, one study shows that the rate of self-care autonomy decreased for those
who were already considered partially dependent approximately three months after infection.
In patients who considered themselves independent in terms of daily activities and
self-care, dependence was also evaluated and increased from 6 % before the infection
to 41 % after it. In other words, both individuals who already had impaired functional
capacity and self-care and those who were independent suffered changes three months
after infection by the virus 27.
Some authors emphasize the need for longer post-COVID-19 functional monitoring to
provide complete care for these patients, given that if there is a loss of functional
capacity, patients' mobility, self-care, usual activities, comfort, and mental health
will also be impaired, resulting in a reduced quality of life 11.
Thus, patients affected by Sars-CoV-2 need support for their recovery, both in the
acute and post-acute stages, and this recovery process should be performed by a multidisciplinary
and multiprofessional team, considering the specificities of each individual, carefully
analyzing their symptoms and comorbidities or disabilities 28.
The study's limitations stem mainly from the sample size, which was influenced by
the epidemiological context and the collection site, which was considered distant
by participants with mobility deficits and limited financial resources to cover the
commuting costs. Another limitation was the fact that most studies on IADL are associated
with the elderly; few studies have been developed and published on IADL among young
adults.
Conclusion
The study enabled the evaluation of the functional capacity and self-care in post-COVID-19
patients, allowing the profile of the affected patients to be identified. Most were
female, aged over 50, and receiving home care during the acute infection. Associations
were found between the length of hospitalization, having a history of surgery, and
a medium self-care capacity with the functional capacity to perform IADL.
Thus, acute post-COVID-19 syndrome is associated with a medium self-care capacity
and partial dependence in terms of IADL in the study participants. The finding contributes
to the development of health education and care strategies aimed at recovery, allowing
for care planning and personalized assistance in the procedures and interventions
that must be performed for effective recovery.
It is considered that, even with the end of the acute stage of the pandemic, its implications
for the functional capacity and self-care of those affected need to be further investigated.
