Abstract
This study compared occupational participation and physical activity levels between adults fully recovered from acute COVID-19 and those still recovering.
By the beginning of 2021, the SARS-CoV-2 virus had infected more than 93 million people globally (Wang et al., 2021). Although most individuals recover from the acute infection within a few weeks, some continue to experience symptoms referred to as long COVID (Davis et al., 2023). Findings from the U.S. Census Bureau’s Household Pulse Survey, which collected data from almost half a million Americans between June and December 2022, revealed that 14% of individuals reported experiencing long COVID at some point, with half reporting it during the survey period (U.S. Census Bureau, 2024). The incidence of long COVID varies significantly across the United States, ranging from 11% in Hawaii to 18% in West Virginia (Blanchflower & Bryson, 2023). In addition, it is more prevalent among women than men and among Whites compared with Blacks and Asians. The prevalence rate decreases with higher education and income levels (Taquet et al., 2021). This condition is most prominent in midlife, similar to the negative impact it causes (Perlis et al., 2022; Subramanian et al., 2022).
The long-term impact of COVID-19 encompasses symptoms such as fatigue, breathing difficulties, and cognitive challenges that significantly affect daily life. Research has revealed that some COVID-19 patients may experience distinct symptoms such as loss of smell and taste, skin rashes, and joint pain, which can persist after initial recovery or fluctuate over time (Aiyegbusi et al., 2021; Subramanian et al., 2022). In addition to physical symptoms, COVID-19 can also have an impact on mental health, contributing to heightened depression, anxiety, suicidal thoughts, posttraumatic stress disorder, and reduced life satisfaction and daily functioning among affected individuals (Goodman et al., 2023). It is essential to investigate the connection between COVID-19 infection and postviral functional recovery, especially given the widespread prevalence of lingering symptoms following infection. The long-term consequences of COVID-19 can profoundly influence an individual’s health and functional capabilities. Therefore, it is vital for those recovering from the illness to gradually reintegrate into their occupational participation and physical activity.
According to the Model of Human Occupation (MOHO) theory, occupational participation encompasses a person’s subjective engagement in work, play, and daily activities within a sociocultural context and is crucial for their overall well-being (Taylor et al., 2024). MOHO assumes a strengths-based understanding of physical and mental impairment, whether short term or long term. This conceptual practice model guides rehabilitation professionals to form an empathic understanding of people according to four dimensions so that their participation in life activities and, ultimately, their quality of life may be optimized. First, it is important to understand people in terms of their volition, or motivation for occupation. Second, it is important to understand how people’s occupations of value do or do not become habituated over time, forming role identification and life routines. Third, it is important to understand people’s experience of their own bodies and minds from their own perspective; this is referred to as the subjective experience of performance capacity. The lived experience of disability is a closely related concept. Fourth, people’s environments are critical to their ability to integrate their volition, habituation, and performance capacity into the actual “doing” of occupations.
MOHO works with people to narrate their own occupational histories and helps them to change their narratives on one or more dimensions to maximize occupational participation and performance. MOHO suggests that when an illness affects an individual’s perceived competence, it can disrupt their motivation, including their thoughts and feelings about their ability to engage with the world. These perceptions influence their expectations, choices, experiences, and evaluations of their actions, as well as how they assign value, find interest, and perceive competence in everyday activities such as work, play, and self-care.
We aimed to compare the levels of physical activity and occupational participation—measured in terms of value for occupation and perceived competency in performing occupations—between adults who had recovered from acute COVID-19 infection and those who had not recovered within the past 4 yr, excluding individuals infected within the past 6 mo. We hypothesized that adults experiencing long COVID would exhibit more limitations in their perceived competence and value for occupational participation, as well as limitations in physical activity. Substantial evidence highlights the persistent symptoms and functional impairments individuals face in hospital settings following COVID-19 (Leite et al., 2021). However, there remains a notable gap in data regarding occupational participation and physical activity within community-based contexts. Gaining a clearer understanding of these issues could be instrumental in identifying the need for cost-effective occupational therapy and rehabilitation support, particularly for those suffering from long COVID. This could address a gap in evidence that contributes to health care policies by identifying the factors that influence the risk of developing long COVID or exacerbating its impact on everyday activities, as well as identifying areas in which further measures are required.
Method
Study Design
This study was a retrospective comparative cohort descriptive study that compared the measures of occupational participation and physical activity. The institutional review board at the University of Illinois at Chicago approved the study (2023-0691).
Participants
We recruited 50 English-speaking adults age 18 and older who tested positive for COVID-19 in the past 4 yr, excluding the past 6 mo. Individuals experiencing persistent COVID-19 symptoms were designated as the first cohort, whereas those without persistent symptoms were designated as the second cohort. Exclusions included infants, children, adolescents, individuals with impaired decision-making abilities, non-English speakers, individuals with communication difficulties, and those who had experienced acute COVID-19 infection within 6 mo before the study.
Measurement Tools
Occupational Self-Assessment–Short Form
As the emphasis on client-centered care continues to grow in rehabilitation, occupational therapists increasingly require valid and reliable assessment tools for effective goal setting and treatment planning. The Occupational Self-Assessment–Short Form (OSA–SF) is a comprehensive assessment instrument consisting of 12 items rated on competence and value scales (Popova et al., 2019). Popova et al. (2019) showed that the competence and value scales of the OSA–SF are similar to the previously established OSA Version 2.2 (Kielhofner et al., 2009). These findings offer preliminary evidence supporting the validity and reliability of the OSA–SF as a measure of occupational competence and value in acute inpatient rehabilitation contexts. This tool offers valuable insights into occupational satisfaction based on the respondent’s ratings. The OSA–SF typically takes 8 to 12 min to complete.
Modifiable Activity Questionnaire
The Modifiable Activity Questionnaire (MAQ), originally developed by Kriska et al. (1990), is a self-reported instrument designed to capture the frequency and duration of various physical activity levels. It has been modified to assess physical activity during both leisure and occupational periods. Kriska et al. (1990) discovered a Spearman correlation coefficient of .37 for leisure time physical activity over the past year among individuals ages 10 to 20 yr, indicating that the test–retest reliability of this measure is consistent across all age groups. Furthermore, they investigated the validity of the past week’s MAQ leisure time physical activity, finding moderate to high validity with correlation coefficients of .80 and .62, both statistically significant (p < .05; Kriska et al., 1990). We used the MAQ to survey participants about their leisure and occupational physical activity, as well as physical inactivity, over the past year and week. However, longer time frame questionnaires may be unreliable because of potential memory lapses and uncertain correlation between past-year and present activity levels (Delshad et al., 2015).
Procedures
To recruit participants for our study, we implemented a range of strategies, including digital advertising, the distribution of informational flyers, and outreach to private practitioners across the United States. Our advertising efforts were focused on individuals who had tested positive for COVID-19 within the past 4 yr but not within the past 6 mo. Those who expressed interest underwent a phone-based screening to determine their eligibility and then completed a 20- to 40-min survey. Enrollment took place between October 2023 and January 2024, and we successfully enrolled 50 eligible participants. After providing digital consent, participants completed sociodemographic questionnaires, the OSA–SF, and the MAQ on REDCap.
Data Analysis
We used 2 × 2 χ2 tests and independent-samples t tests to compare the sociodemographic characteristics of nonrecovered participants with those of recovered participants. In addition, we evaluated participants’ occupational competency, values, and physical activity by using independent samples t tests. Our dataset included mean and standard deviation values for continuous variables, as well as frequency and percentage values for categorical variables. The results were analyzed by using IBM SPSS Statistics (Version 27.0) and documented in an Excel spreadsheet. We computed raw scale scores and followed the guidelines outlined in the OSA–SF and MAQ survey manual and interpretation guide for data transformation.
Results
Sociodemographic Characteristics of the Sample
Our study centered on individuals who had been diagnosed with COVID-19, with a mix of those who had fully recovered and those who had not. The ratio of individuals who did not recover to those who did was 2:1. Our analysis revealed no notable variances in gender, race/ethnicity, education, or employment status between the two groups. However, age (p = .002), marital status (p = .026), body mass index (BMI) classifications (p = .003), and post-COVID-19 disability income (p = .034) were significant variables affecting recovery (see Table 1). Our results suggested that middle-aged or older individuals who were married, were obese, and received disability income were not recovering from COVID-19.
Sociodemographic and Other Characteristics of Participants Who Recovered and Did Not Recover After COVID-19
Note. BMI = body mass index.
Occupational Participation (Competence and Values)
According to the results of independent samples t tests, individuals who were still recovering from COVID-19 reported lower perceived competence scores, t(47) = 2.02, p = .049, than their healthy counterparts. However, there were no significant variations in the perceived value for occupation participation between the nonrecovered participants and the healthy group (see Table 2). Younger participants who tested positive for COVID-19 displayed higher perceived competence scores in occupational participation, t(42) = 3.50, p = .001, compared with middle-aged and older participants. Nevertheless, there were no significant disparities in perceived value for occupation participation between the younger and older groups.
Occupational Participation Among Adults Who Recovered and Did Not Recover From Acute COVID-19 Infection
Note. MET = metabolic equivalent of task.
aMeasured in hr/wk averaged over past yr.
Physical Activities Within Past Year
Individuals who did not recover from COVID-19 exhibited significantly lower levels of occupational activity hours, t(48) = 4.22, p < .001, and energy expenses, t(20) = 4.19, p < .001, compared with those who did recover. However, there were no significant differences found in terms of leisure and total activity hours and energy expenses between the two groups. It is interesting that those who did not recover spent more time watching television, t(46) = 2.37, p = .022, in the past year than those who fully recovered (see Table 2).
Discussion
The literature review revealed a significant lack of comprehensive data regarding the long-term effects of COVID-19 on physical activity and occupational participation among individuals who have not fully recovered from the virus. To address this knowledge gap, we conducted a study involving adults who contracted COVID-19, with recovery periods ranging from 6 mo to 4 yr.
Our research indicated that middle-aged and older married individuals with a higher BMI tended to experience longer recovery times from COVID-19 compared with younger people. These findings align with the National Health Interview Survey cited by Adjaye-Gbewonyo et al. (2023), which showed that middle-aged adults are more susceptible to experiencing long COVID compared with younger or older adults. Their study also revealed that women were more likely than men to have experienced long COVID (Adjaye-Gbewonyo et al., 2023). However, our study did not show clear gender disparities, possibly because of the small and unequal cohort size. It is important to note that being overweight or obese significantly increases the risk of developing multiple diseases, such as diabetes, cardiovascular disease, and lung disease. Rebello et al. (2020) found that individuals with these underlying health conditions have an increased likelihood of needing hospitalization and intensive care unit admission if they contract COVID-19. Barrea et al. (2022) provided practical guidelines for nutritionists to customize dietary interventions for patients recovering from COVID-19 infections. Further research is essential to determine whether dietary interventions, weight-loss programs, and increased physical activity can reduce the effects of long COVID, even among individuals experiencing extreme fatigue.
Our research findings indicated that individuals who had not fully recovered from COVID-19 perceived themselves as less competent in their occupational participation compared with those who had fully recovered. However, both groups placed the same value on their everyday occupational participation. This suggests that COVID-19 patients who have not fully recovered placed equal value for their occupational participation as others; however, they encountered difficulties in performing their tasks effectively. This finding underscores that individuals with long COVID have equal value for their occupational participation, even though they are not competent enough to participate. Consequently, they spend an equivalent amount of time and energy on leisure activities as do others, but they face difficulties when performing more physically demanding tasks effectively. These findings highlight the close relationship between perceived occupational competence, actual impairment level, and diagnostic status, particularly among individuals with long COVID. This aligns with MOHO theory, which states that even with physical limitations, engaging in occupations remains crucial because of the high value people place on them (Taylor et al., 2010, 2024). Given that nonrecovered individuals in the study reported lower levels of competency, we suggest that future research include infectious individuals from the early stages of their illness. Early support can bolster their determination and facilitate their return to work and a higher quality of life in the community.
We also noticed that individuals who received disability income for long COVID did not experience a significant recovery from COVID-19. This finding provides two crucial insights. First, individuals experiencing long COVID sought disability social benefits, indicating the severe impact of the virus on their ability to work. Second, even after receiving disability benefits, they were still unable to alleviate the diverse symptoms, leading to their persistent nonrecovery status. Because of notable variances in sociodemographic factors, comorbid conditions, and health outcomes among nonrecovered COVID-19 patients, there is an acknowledged need for specialized rehabilitation services for long COVID patients. As with all studies, our study had several limitations that must be considered when interpreting the findings. First, the self-reported competency and physical activity ratings provided by the participants were not verified through observational or functional capacity measures, potentially introducing additional variables that could have affected the observed differences between groups. Second, the unequal sample size and small cohort may have increased the risk of Type II error.
Implications for Occupational Therapy Practice
This study has the following implications for occupational therapy practice: Participants with long COVID faced challenges in their occupational competency and the ability to perform physically demanding activities. Therefore, occupational therapists and other rehabilitation practitioners are recommended to set therapeutic goals by implementing MOHO-based remotivation programs (Kielhofner, 2008). This approach could provide valuable insights into shifts in occupational competency, allowing individuals to identify what they value most and feel more competent in, which could ultimately enhance the quality of health care provision. Despite the receipt of disability benefits, participants continue to report diminished competency and increased physical inactivity as a result of long COVID. Consequently, further rehabilitation services, such as occupational therapy, may prove to be an effective intervention for facilitating recovery from long COVID. For those who are severely disabled, approaches to energy conservation, pain management, complementary therapies, and gentle movement could be effective. Those who are higher functioning could be offered flexible vocational training and work rehabilitation that accommodate light physical activities, aiding in their reintegration into income-generating activities, ultimately enhancing their quality of life and providing support for their families, especially considering that many were still seeking disability income (Taylor et al., 2024).
Conclusion
Data in the study indicated that nonrecovered long COVID participants reported lower perceived competency in performing everyday occupations and lower levels of occupational activities requiring physical or mental exertion. However, their value for occupations remained the same. These findings are consistent with past studies of physical activity among adolescents with delayed recovery from mononucleosis (Huang et al., 2010). Our findings suggest that occupation-focused rehabilitation programs would do well to address not only functional limitations but also the volitional consequences of reengaging in daily occupations.
Footnotes
Acknowledgments
We express our gratitude to all the voluntary research assistants at the University of Illinois at Chicago. Funding for this study was provided by the Walder Foundation (Award No. 101724).