**4. Discussion**

The aim of this study was to investigate perceived consequences regarding everyday life, health, physical activity and work post-COVID-19 and factors associated with low life satisfaction. We found that a majority of our sample with post-COVID-19 experienced physical fatigue, mental fatigue, dizziness, balance impairments, reduced aerobic capacity and work ability. In addition, most perceived low satisfaction with Life as a whole, and all but one of the domain-specific items of LiSat-11 showed a higher proportion with low satisfaction relative to reference values. Poor work ability was the most important factor for perceiving low overall life satisfaction. Reduced aerobic capacity, mental fatigue, living in a city and physical fatigue were factors that also increased the odds of experiencing low life satisfaction in post-COVID-19.

The results of the present study showed that post-COVID-19 may persist long after recovery from the acute COVID-19 infection, even in this sample of younger patients with milder initial infection. The most commonly reported consequence of post-COVID-19 was fatigue (both physical and mental fatigue), which is in accordance with previous studies [13–16]. In addition, dizziness was commonly experienced as well as balance impairments which also have been reported in previous studies, probably due to the involvement of vestibular and visual systems in SARS-CoV-2 infections [13,14,47].

The most strenuous activity that could be sustained for at least 30 min was walking or cycling slowly (median RPC = 5), which is considerably lower compared to levels of physical activity reported in a Swedish study among adults during the first wave of the pandemic [48]. In that study, the mean RPC was 11.5, i.e., being able to run for at least 30 min. Reduced levels of physical activity have been found in previous studies of post-COVID-19 [14,15]. It was also found that physical exertion can cause a worsening or relapse of symptoms [13,14]. In contrast, it has been suggested that physical exercise may alleviate the sequelae of COVID-19 through the release of circulating factors that mediate the anti-inflammatory response and support brain homeostasis [49]. Long-term sequelae and difficulties in regaining required levels of physical activity in this relatively young population may lead to longer-term health risks of inactivity. Therefore, more research is needed to recommend and pace rehabilitation interventions regarding physical activity for persons with post-COVID-19.

Furthermore, our results showed that many of the participants perceived reduced work ability. This is in line with a previous study where a majority of the respondents with remaining COVID-19 symptoms reported working fewer hours or were in need of a reduced work schedule. In addition, many perceived that the worsening of COVID-19 symptoms could be triggered by stress and mental exertion at work [13]. This emphasizes the importance of work capacity assessments, workplace adjustments and consideration of returning to work in relation to recovery from COVID-19.

A majority (77%) of our participants perceived low satisfaction with Life as a whole, and almost all responded that they perceived a deterioration in life satisfaction due to COVID-19. The percentage of low satisfaction in the present study was considerably higher than in the Swedish reference sample [22] and in community-dwelling persons during the first wave of the COVID-19 pandemic in Sweden [26] and also compared to people with chronic conditions such as stroke [17], traumatic brain injuries [50] and Parkinson's disease [51]. For the domain-specific items in the current study, all but one showed a significantly higher proportion of persons perceiving low satisfaction with life compared to the Swedish reference sample [22]. Many of our participants (>70%) experienced low satisfaction with Physical health, Leisure, Intimacy, Psychological health, Contacts with friends and Vocation. For items of close relations, such as Family life and Partner relationship, half of the participants perceived low satisfaction. Our results sugges<sup>t</sup> that the participants perceived more difficulties in engaging in activities and social contexts outside the family, which is reasonable to expect as many of the participants perceived fatigue and had difficulties managing their work. In addition, the pandemic restrictions might also have contributed to more difficulties in being able to participate in usual leisure activities and social events.

Economy was the only domain-specific item of LiSat-11 that did not differ significantly in the proportion of persons with low satisfaction in comparison with the reference values [22]. This might be due to the fact that most persons were working and that the social security system in Sweden provides for persons on sick leave. Thus, the participants might not have been economically affected in this stage, but in a longer perspective, the financial situation may be a more important issue.

In the multivariate regression model, poor work ability showed the highest odds of perceiving low satisfaction with Life as a whole. This result demonstrates the importance of work for well-being. In a recent cohort study, workplace modifications have been found to be the most important factor in supporting the return to work for persons with post-COVID-19 [52]. Therefore, in the future, focus should be given to how a return to work and stay at work can be supported after COVID-19.

Aerobic capacity and mental and physical fatigue were also included in our final logistic model. Those who reported lower aerobic capacity and a high level of fatigue generally had higher odds of perceiving low satisfaction with Life as a whole. However, the explanatory values of these variables were relatively low, probably due to their relation to work ability. Adapted rehabilitation interventions focusing on increasing physical activity levels and reducing fatigue may have a positive effect on life satisfaction post-COVID-19.

The logistic regression model also showed that persons living in cities compared to less densely populated areas in towns and villages had higher odds of perceiving low life satisfaction. In previous studies, similar findings have demonstrated that a higher population density can affect life satisfaction negatively [24,25]. The reason may be that larger cities are associated with anonymity and poorer neighborhood quality, as well as less support from family and contact with friends [25].

Interestingly, comorbidity was not significantly associated with low life satisfaction, despite the fact that comorbidity is a risk factor for developing post-COVID-19 and that comorbidity might increase post-COVID-19 [9]. An explanation for this may be that persons with chronic conditions are used to adapting life to fluctuations in their disease [53], while healthy persons might not expect long-term sequelae and have less experience in handling such situations. As there is little information and resources in the healthcare system to support people with post-COVID-19, there is also a risk that their symptoms have been diminished or ignored [54]. Such psychological aspects might contribute to the perception of low life satisfaction in people with post-COVID-19. More knowledge is thus needed to

further understand the patient experience of post-COVID-19 in order to be able to address these issues in rehabilitation programs.

#### *4.1. Strengths and Limitations*

A strength of the current study was that validated questionnaires were used to assess the perceived consequences of post-COVID-19, and the large sample size allowed for the use of multivariate regression analyses. However, the study has some limitations that should be regarded when interpreting the results. By recruiting via social media, the study attracted a selected group of mostly well-educated women that are more frequent on Facebook, Instagram, etc. Nevertheless, the fact that more women participated may partly be because post-COVID-19 is twice as common in women younger than 60 [55,56]. Furthermore, there is a possibility of recall bias and subjective rating of symptoms in this type of survey. Moreover, the participants in the current study did not have to prove a test-verified COVID-19 infection. However, it has been shown that symptoms do not differ between persons who have tested positive for COVID-19 infection and those who have not been tested but show suggested symptoms [13]. Moreover, it cannot be excluded that other factors may be of importance for life satisfaction, such as cognitive and emotional functions, support from healthcare and social services, as well as socioeconomic status and cultural background.

## *4.2. Study Implications*

This study has important healthcare implications. As people with post-COVID-19 report a wide range of long-term consequences, this may have a large impact on their return to normal life, including previous levels of physical activity and work. Recovery may also be negatively affected by stress and exertion that can worsen or cause a relapse of symptoms. In addition, our findings imply that post-COVID-19 has a major negative impact on general well-being. Post-COVID-19 may, therefore, increase the burden on the healthcare system and also have a wider economic impact on society. Thus, people with long-term consequences post-COVID-19 may need comprehensive assessments of their physical and cognitive function, ability to manage daily life, work and quality of life. Person-centered multidisciplinary rehabilitation ought to be provided by healthcare professionals that have a thorough understanding of the post-COVID-19 condition and knowledge of how to optimize recovery.
