This cross-sectional study was carried out between 1^st January 2021 to 31^st March 2022 in Qassim Region, Saudi Arabia, which is located in the central part of Saudi Arabia with an estimated population of 1.5 million in 2020 [38]. There are 19 Governmental hospitals and 165 PHCCs providing health care services under different specialties in the region. The target population was patients who were diagnosed with positive PCR of COVID-19 in the Qassim region.

The sample size was calculated using the Epi Info Stat calculator. According to the Saudi CDC, the total number of reported positive cases of COVID-19 in the Qassim region was 14,129 cases (2^d February 2021). We assumed the prevalence rate of COVID-19, 50% for the calculation of the sample size in this study. At 95% confidence level, 5% margin of error, and a design effect of 2.0. So, the required sample size was 375 participants. Assuming the non-response rate of participants was 10% (38 cases), in addition to 375, it gave a total of 413 participants needed to be invited to achieve the required sample.

Convenience sampling was applied for the selection of positive PCR Covid-19 cases. The enrolled participants were obtained from the official governmental registered system (HESN surveillance program of COVID-19. Inclusion criteria were adult confirmed COVID-19 patients with +ve PCR results registered in the surveillance system. After explaining the purpose of the study and getting approval from the administration, participants were contacted and invited to participate in this study. A total of 413 respondents filled the questionnaire through a telephone survey.

A structured questionnaire [COVID-19 Yorkshire Rehabilitation Scale (C19-YRS)] was used for collecting the data [39]. Patients over 18 years old who were diagnosed as positive COVID-19 (WHO criteria) in Tetamman clinics and registered in the records, were interviewed by telephone survey. The questionnaire contained 35 items divided into three sections. Questions in the first section collected information about patients’ age, gender, nationality, education, family size, history of comorbidity, smoking status, and regular exercise. The second section collected the clinical characteristics of the patients, including symptoms at the beginning of the disease and after 2 weeks, medication vaccination status, and duration of isolation. The third part assessed the patient’s clinical status by using the C19-YRS checklist [40]. The checklist was administered by telephone and guided the interview. It aimed to underline the persistent symptoms and their intensities concerning the pre-infection condition in a bio-psycho-social way. Moreover, it highlighted three different classes of Post Covid Syndrome (PCS) severity for each symptom (<3 = mild; 3 - 5 = moderate; 6 - 10 = severe). [40] The clinical assessment through the C19-YRS application covered all the domains according to the International Classification of Functioning (ICF), thus investigating symptoms related to body functions and structures, limitations to activities, and participation restrictions considering personal and environmental factors. We selected 10 of the 22 items, the ones directly or indirectly measurable through validation. In the tests and questionnaires, thus we were concerned with: breathlessness at rest, during dressing and stairs, fatigue, pain/discomfort anxiety, depression, communication, mobility, personal care, usual activities, and global health.

The collected data were entered and analyzed in SPSS (version 21) Chicago, IL, USA. Descriptive statistics (mean, standard deviation, and frequency) were calculated for all clinical parameters and C19-YRS items for ICU-hospitalized, Ward-hospitalized patients, and Home isolated patients. The Chi-Square test was used for between-groups differences. C19-YRS outcomes have been examined considering frequency and intensity in the answers given. The scale’s internal consistency has been checked by Cronbach’s alpha coefficient, a magnitude index for the between-items coherence, where values of >0.70 represent high consistency. The level of significance will be p < 0.01.

The ethical approval was taken from the Regional Research Ethics Committee, Qassim region (Approval #: 1442-1459584). A permission letter was obtained from the regional director of the Qassim MOH before starting the data collection. Verbal Informed consent was obtained from each participant before commencing the data collection. The researcher preserved the participants’ confidentiality at all steps of the study for the data collection, analysis, and results.

A total of 413 confirmed COVID-19 patients were enrolled in this study; their data was obtained from the HESN surveillance program of COVID-19, Qassim Health Cluster. The personal characteristics of COVID-19 Patients are given in Table 1.

Male patients were 219 (53.0%) while females were 194 (47.0%). Their average age was 38.7 (±14.97) years. All of them were of Saudi nationality. More than half of the patients had college and postgraduation education 270 (65.4%). The reported patients were from different geographical areas in the Qassim region but the bulk of cases was from Buraydah city153 (37.0%). More than two-thirds of the patients were non-smokers 330 (79.9%) and didn’t practice regular physical exercise 297 (71.9%), Table 1.

One hundred and sixty-six (40%) COVID-19 patients had a history of chronic diseases. Among them, Diabetes 64 (15.5%) and hypertension 60 (14.5%) were the dominant co-morbidity. Table 2 Majority of the covid-19 patients 371 (89.8%), were isolated at home, and of them, 37 (9.0%) were admitted to the hospital, and only 5 (1.2%) cases were treated in the Intensive Care Unit (ICU). Most of the surveyed patients 382 (92.5%) had been covered with the 1^st dose of the COVID-19 vaccine at the moment of the data collection; while a few of them 60 (14.5%) had taken the Flu vaccine. The average duration of patients’ isolation was 14.8 (±5.53) days. The patients’ treatment is mentioned in Table 2.

Table 3 shows the patients’ symptoms at the beginning of the COVID-19 infection, fever was the most common complaint 332 (80.4%), with 267 (64.6%) of patients reporting fatigue of varying severity, followed by loss of smell 230 (55.7%). Near half of the patients felt body ache and muscle pain 202 (48.9%), followed by loss of taste 197 (47.7%). Among the respiratory symptom, Cough

158 (38.3%) was the commonest followed by shortness of breathing (SOB) 129 (31.2%), congestion or running nose 97 (23.5%), sore throat 88 (21.3%), and chest pain or pressure 75 (18.2%). Approximately one-third of patients also experienced nausea (32.0%) and other Gastrointestinal symptoms such as diarrhea 70 (16.9%) and vomiting 55 (13.3%). A few patients had psychological problems such as anxiety 23 (5.6%) and depression 14 (3.4%). Other symptoms also reported such as dizziness, sweating, skin rash, Hair falling, Bad dreams, and Hallucinations were troublesome for very few of the respondents, Table 3.

We compared the patients’ symptoms at the beginning of covid-19 and after 15 days from the onset. We found the majority of the patients’ symptoms decreased or subsided. But still, some patients suffered from persistent symptoms. Among the highest percentage of the patient’s symptoms at the beginning, it’s found loss of smell 89 (21.5%) was the commonest continued symptom followed by tiredness 69 (16.7%), cough 59 (14.3%), and loss of taste 58 (14.0%). Moreover, the average duration of patients’ COVID-19 Symptoms was 8.0 (±7.2) days. In less than half of the patients 174 (42.1%) the disease symptoms continued for more than 14 days, Table 3.

In this study, the severity and persistence of COVID-19 symptoms were assessed by the C19-YRS checklist, in Figure 1.

The Patients’ symptoms scores and sub-scales are presented in mild, moderate, and severe categories. Among the Body Functions and Structures items, we found the severity of the breathlessness on walking was the prominent symptom compared to other examined symptoms. Followed by breathlessness symptoms during patients’ rest and dressing. The severity of depression and anxiety were also highly reported during the disease, followed by fatigue and loss of appetite. Among the activity items, Mobility intensity and unusual activities were similar in the degree of severity, but the personal care intensity was the least, Figure 1.

Patients who were admitted to an intensive care unit (n = 5) were significantly elderly patients (P < 0.001), with chronic diseases (P < 0.01) mainly Diabetes Mellitus (P < 0.01) and Hypertension (P < 0.01). However, Gender, education, family size, smoking status, and physical exercise had no significant effects on the patient’s type of admission or isolation, Table 4.

Abbreviations: ICU = Intensive Care Unit; DM = Diabetes Melilites HTN = Hypertension.

Furthermore, the researchers assessed the intensity and severity of the patient’s symptoms after 4 weeks concerning the types of admission shown in Table 5; 100% breathlessness was reported in patients admitted to the ICU, 89.1% in patients admitted in the word, and 25% in home isolated patients. (P < 0.01). About 60%, pain or discomfort, 40.5% Fatigue, and 32.4% loss of appetite (Body Functions and Structures). Breathlessness was more present during highly demanding tasks, such as climbing stairs, with a C19-YRS reported intensity of 7.6 (2.5) for those who had a history of admission to ICU. Similarly, the laryngeal complication was rated with an intensity of 7.6 (2.5). Finally, anxiety and depression were scored with 0.6 (1.8) and 0.6 (1.7) intensity. Among Activities, reduced mobility was the most significant limitation highlighted (35.1%) after 12 weeks, with a significant influence on usual activities (27%) and personal care (8.1%) (history of word admission), Table 5.

Among the Body Functions and Structures items, the correlations were high between breathlessness, fatigue, pain or discomfort, loss of appetite, voice changes symptoms, and hospital admission (p < 0.01). At the same time, 2 items from activities had a significant statistical correlation between mobility, unusual activities, and history of hospital admission. The Global Health perception was also highly significant (p < 0.01), Table 6.

Further correlations were reported in Table 6. Symptoms after 4 weeks, except for anxiety and bladder continence, all the Body Functions and Structures items, symptoms were still present but significantly reduced except for laryngeal complication and swallowing changes which were slightly increased after 2 weeks (P < 0.01). Physical symptoms such as breathlessness improved by 19.1%, and depression by 6.7%, whereas the variation in intensity such as fatigue means and SD 0.9 (1.4) was less pronounced. Conversely, pain (+6.8%) and loss of appetite (+4%) were more represented evidencing persistence over time. Among activities, a significant improvement in usual activities (11.5%) and personal care (2%), were found, whereas mobility became worse (+7.8%). The variation of intensities and the distribution-based measures of responsiveness were reported in Table 6.