**1. Introduction**

According to the World Health Organization (WHO) there have now been about 600 million confirmed cases of COVID-19 worldwide [1], and the virus still continues to infect people. A feature of COVID-19 that differs from other respiratory infections is the multi-system symptomatology and long-term sequelae [2]. Most persons who develop COVID-19 fully recover, but current research suggests that approximately 10 to 20% experience a variety of mid- and long-term symptoms after their initial illness, known as post-COVID-19 condition [1].

Post-COVID-19 is defined as a condition that occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, with symptoms that last for at least two months and cannot be explained by an alternative diagnosis [3]. The mechanisms behind post-COVID-19 are not fully understood, but it has been suggested that they are associated with dysregulation of the immune and autonomic nervous systems due to viral injury, oxidative stress, immunologic abnormalities and inflammatory damage [4]. Post-COVID-19 can involve a range of symptoms, such as fatigue and muscle weakness, chest and muscle pain, shortness of breath, anosmia/ageusia, fever, cognitive dysfunction/brain

**Citation:** Ekstrand, E.; Brogårdh, C.; Axen, I.; Fänge, A.M.; Stigmar, K.; Hansson, E.E. Perceived Consequences of Post-COVID-19 and Factors Associated with Low Life Satisfaction. *IJERPH* **2022**, *19*, 15309. https://doi.org/10.3390/ ijerph192215309

Academic Editors: V. K. Kumar and Jasmin Tahmaseb-McConatha

Received: 13 October 2022 Accepted: 17 November 2022 Published: 19 November 2022

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fog, headache, tachycardia and intestinal disorders [5–7]. The symptoms can persist from the acute COVID-19 infection, but new symptoms may also occur after initial recovery and can fluctuate or relapse over time [3].

The severity of the acute COVID-19 infection, comorbidities and advanced age have been identified as risk factors for post-COVID-19 [5,8,9]. However, it has been shown that it also affects younger persons with a mild acute illness that did not need hospital or intensive care [8,10–12]. Studies, including mostly younger (<60 years) and non-hospitalized persons, have reported fatigue as the most common post-COVID-19 symptom [13–16]. A longitudinal online survey investigating post-COVID-19 in mostly non-hospitalized persons from 56 countries showed that over 90% experienced symptoms seven months after the acute infection, and about 70% of unrecovered persons had not returned to previous levels of work due to their illness [13]. Cross-sectional studies have reported reduced physical activity levels, cognitive impairments and limitations in daily activities after milder COVID-19 infections [14–16]. Thus, COVID-19 can lead to long-term disability, which may have a significant impact on physical and mental health and on the ability to manage everyday activities and work.

As long-term disability can impact life satisfaction negatively [17], it is important to study how persons with post-COVID-19 perceive the consequences of the disease and how it affects their life satisfaction. Perceived life satisfaction is related to concepts such as well-being, contentment and happiness and is also affected by expectations and aspirations as well as the subjective appraisal of the extent to which these are being met [18,19]. The level of life satisfaction can be assessed as the perceived overall life satisfaction and also in relation to different aspects of life such as provision, leisure, close relations and health [20,21]. Previous studies have shown that various factors such as age, family situation, educational level, employment situation, residential area and comorbidities can affect the level of perceived life satisfaction [21–26].

Currently, there is a lack of knowledge of perceived consequences and life satisfaction with post-COVID-19. Increased knowledge can improve the ability of welfare authorities and the healthcare system to support these people. The aim of the study was, therefore, to investigate perceived consequences regarding everyday life, health, physical activity and work post-COVID-19 and the factors associated with low life satisfaction.

#### **2. Materials and Methods**

#### *2.1. Study Design*

This study had a cross-sectional design and was part of a larger project on life after COVID-19 (The LAC project) investigating different aspects of the long-term consequences of COVID-19 and their impact on life.

#### *2.2. Recruitment and Participants*

Recruitment of participants was conducted by means of an announcement on social media, posted between the 21 October and the 13 November 2021. Persons 18 years or older, able to read and understand Swedish and having had a COVID-19 infection with remaining symptoms, were invited to participate. The current study included people with remaining symptoms for at least 2 months after the acute infection.

A Facebook page with information about the project was targeted to persons in the three most populated regions of Sweden (Stockholm, Gothenburg and Skåne) but could also be shared with users outside these areas. The link to the invitation was also posted on Instagram and Twitter. The project webpage was hosted at Lund University and included general project information, a participant information sheet, and a link to the survey. The survey was open until 12 February 2022, which resulted in a total of 867 persons participating in the survey. Of those, 52 persons did not meet the inclusion criteria on remaining post-COVID-19 symptoms for at least 2 months, and 49 persons were excluded due to not completing the mandatory background questions, giving a total of 766 participants who were included in the study.

#### *2.3. Data Collection*

Data collection was completed using REDCap (Research Electronic Data Capture), a secure, web-based application designed to support data capture for research studies [27,28]. Outcome measures were chosen based on recent descriptions of symptoms and potential consequences of post-COVID-19 [29].

The online survey included sociodemographic questions regarding age, sex (man or woman), family situation (single, married/cohabiting or partner but not cohabiting), residential community characteristics (city, town or village) and level of education (primary school, secondary school or higher education), provision (work, student grants, benefits due to sickness, unemployment or social security issues or other sources of income) and comorbidities (yes or no). The participants answered questions on the acute COVID-19 infection (onset, symptoms and need for hospital care) and post-COVID-19 condition (duration and symptoms). They also responded to questionnaires on the perceived consequences of COVID-19.

#### *2.4. Questionnaires on Perceived Consequences of COVID-19*

Physical fatigue was assessed with the Fatigue Severity Scale (FSS) [30], which has demonstrated adequate validity and reliability (Cronbach's alpha 0.93–0.96; intraclass correlation coefficient (ICC) 0.84; Kappa coefficient 0.75) in various diagnoses [31–33]. The FSS consists of 9 statements concerning the impact of fatigue on daily life that are scored from 1 (strongly disagree) to 7 (strongly agree). The total score of the FSS ranges from 1 to 7 (mean of the 9 statements), where a greater score indicates more fatigue and a cut-off score of ≥4 signifies physical fatigue [34].

Mental fatigue was assessed with the Mental Fatigue Scale (MFS) [35]. The MFS was developed to capture mental fatigue regardless of illness and has demonstrated high internal consistency (Cronbach's alpha 0.94) [35]. It includes 15 items scored from 0 (normal function) to 3 (maximal symptoms). The total score is calculated as the sum of items 1–14, and item 15 provides additional information on daytime variation of symptoms. A sum score ≥10.5 indicates mental fatigue [36].

Perceived dizziness and balance impairment related to COVID-19 were assessed by a single question (yes or no) that has been used in previous studies of dizziness [37].

Level of dependence on another person in daily activities (ADL) was assessed by the ADL Staircase [38] that has shown acceptable construct validity and internal consistency (Cronbach's alpha 0.88) in various age groups [39]. The ADL Staircase comprises 5 personal (P-ADL) and 5 instrumental daily activities (I-ADL) that are rated on a 4-graded scale as independent without difficulties (0), independent with difficulties (1), partly dependent (2) or dependent (3). The subscores of P-ADL and I-ADL range from 0 to 15, and the total score ranges from 0 to 30.

Current perceived aerobic capacity was assessed by the Rating of Perceived Capacity scale (RPC) [40]. RPC is valid and considered a valuable tool for the estimation of aerobic capacity in research studies [40,41]. The RPC is based on metabolic equivalents (METs) that are linked to physical activities on a progressive scale. The most strenuous activity that can be sustained for at least 30 min is rated from 1 (sit) to 20 (elite aerobic training). The maximal value (elite aerobic training) is different for the two genders, 18 for women and 20 for men.

Work ability was measured with the Work Ability Score (WAS) [42]. The WAS has been proven valid and reliable (ICC 0.89) for assessing work ability in research [42,43]. The WAS is based on the perceived current work ability in relation to lifetime best, ranges from 0 to 10 and can be categorized as poor (0–5 points), moderate (6–7 points), good (8–9 points) or excellent (10 points) [44].

Life satisfaction was rated using the Life Satisfaction Questionnaire (LiSat-11) [21,22]. The LiSat-11 is valid and reliable (Kappa coefficient 0.59–0.97), and reference values are available based on ratings of 2533 Swedish individuals aged 18 to 65 years [22,45,46]. The questionnaire includes 11 items and assesses how satisfied an individual is with overall

life satisfaction, Life as a whole (item 1) and with 10 domain-specific items regarding vocation, economy, leisure, contacts with friends and acquaintances, intimacy, activities of daily living (ADL), family life, partnership/relationship, physical health and psychological health. The items are rated as very dissatisfying (score 1), dissatisfying (score 2), rather dissatisfying (score 3), rather satisfying (score 4), satisfying (score 5) and very satisfying (score 6). The score can be dichotomized into low life satisfaction (score 1–4) and high life satisfaction (score 5–6) [22]. In the current study, the participants also reported if they experienced Life as a whole as deteriorated, unchanged or improved compared to before the COVID-19 infection and if they felt that the change was due to COVID-19.

## *2.5. Statistical Analyses*

Statistical analyses were performed with SPSS version 28.0 (IBM Corporation, Armonk, New York, NY, USA). Probability values less than 0.05 were considered statistically significant. For descriptive data, means (standard deviations, SD), frequencies and medians (interquartile ranges, IQR and maximum and minimum values) were calculated.

The proportion of participants with low life satisfaction (LiSat-11 score 1–4) was presented for each item of LiSat-11 and compared to the proportion of satisfied persons in the Swedish reference sample [22] by means of the One Sample Proportion Test.

The association of potential explanatory factors with life satisfaction was investigated with logistic regression analyses. Life as a whole (item 1 in LiSat-11) was used as an overall measure of perceived life satisfaction (dependent variable) and dichotomized into low and high life satisfaction. Potential explanatory independent variables added in the regression building were sociodemographic factors that, in previous studies, have been shown to impact life satisfaction [21–26] and potential explanatory factors of consequences related to post-COVID-19. The sociodemographic factors included in the model building were: age, sex (man vs. woman), family situation (single vs. married/partner), educational level (lower vs. higher education), provision (not working vs. working), residential community (city vs. town/village) and comorbidities (no vs. yes). Consequences related to post-COVID-19 were: physical fatigue (no vs. yes), mental fatigue (no vs. yes), dizziness (no vs. yes), balance impairment (no vs. yes), ADL (ADL staircase score), aerobic capacity (RPC score) and work ability (moderate–excellent ability vs. poor ability).

The associations with overall life satisfaction (i.e., Life as a whole) were evaluated for each explanatory factor separately using univariate logistic regression analyses. The odds ratio, 95% confidence interval (CI), explanatory value (Nagelkerke R Square) and *p*-value were calculated. A generous inclusion criterion (*p* ≤ 0.20) was used to ensure that no potential variable was omitted in the following multivariate regression analysis. The variable with the lowest p-value (if ≤ 0.20) from the univariate analysis was included in the model. Thereafter, the other factors were tentatively added, one at a time. The model with the highest explanatory value and the two independent variables with the lowest *p*-values (if both *p* ≤ 0.20) were kept. Thereafter, the remaining factors were again added, one at a time, and the model with the highest explanatory value and variables with the lowest *p*-values (if *p* ≤ 0.20) were retained. Thus, in each step, one variable was added to the model. This procedure was continued as long as the *p*-value of all the included variables in the model was *p* ≤ 0.20 and the explanatory value increased.
