https://doi.org/10.15218/ejnm.2023.13 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article Prevalence and Persistent Fatigue among Patients Post COVID-19 in Erbil City ABSTRACT Background and objectives: Fatigue is one of the most common symptoms, affecting more than 75% of people. It is a subjective lack of physical or mental energy. The goal of the study was to assess persistent fatigue among patients Post-COVID-19 in Erbil city. Methods: A quantitative, descriptive cross-sectional study was conducted at a private clinic and home for patients in Erbil city. A nonprobability-purposive sample was select- ed for 300 Post-covid patients. Data was collected through interviews using a question- naire and a modified fatigue impact scale was used to assess patients’ fatigue in post- COVID-19. Results: The results show that one third (31.7%) of the study samples were older than 50 years, and more than half (52.3%) were males, less than one third (28.3%) graduated from an institute, and more than one third (32.3%) were housewives. The majority of the samples (84.7%) lived in areas, and almost all the samples (81.7%) were married. Most of the samples (73.0%) without comorbidity disease about 75.3 were overweight, and the samples (83.0%) were not hospitalized during COVID-19, about more than half (67.0%) were not received oxygen. Less than half (46.3%) of the samples have physical fatigue, and more than half (63.7%) have mild mental fatigue. There was a significant association between fatigue and gender, hospitalization, and receiving oxygen during COVID-19 at P-value ≤ 0.05. Conclusion: The study concluded that the participants have physical and mental fatigue and physical and mental fatigues are decreasing by increasing the duration of illness from the first to the sixth month. A significant difference was found between fatigue and the female gender. Keywords: Post Covid-19 Fatigue; COVID-19; Chronic Fatigue Syndrome. Shagul Hasan Hussein;Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: shagul.00073154@gmail.com) Ronak Nihmatala Hussain; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 116 Received: 31/07/2022 Accepted: 13/09/2022 Published: 30/11/2023 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:Shagul.00073154@gmail.com?subject=Shagul.00073154@gmail.com mailto:Shagul.00073154@gmail.com?subject=Shagul.00073154@gmail.com https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.13 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article The coronavirus disease (COVID-19) out- break of 2019 was originally detected in Wuhan, China, and is now spreading do- mestically and worldwide. COVID-19 is a viral illness induced by SARS-CoV-2 that mostly affects the pulmonary system, ac- cording to Rothan and Byrareddy [1]. On March 12, 2020, the World Health Organi- zation declared the COVID-19 outbreak a pandemic. Since then, the virus has spread swiftly throughout China and around the world, affecting about 12,000,000 con- firmed patients and 500,000 deaths in over 200 nations, areas, or territories with con- firmed cases by July 2020, resulting in a catastrophic global health disaster [2].Long term Covid is used to describe illness in persons who have either healed from Covid-19 but still have long-term sequelae from the infection or who have experi- enced the regular symptoms for far longer than expected [3]. In spring 2020, when COVID-19 patients still had symptoms sev- eral weeks after their acute infection and soon after the first cases emerged, post- COVID syndrome, also known as long- COVID, was first described as a clinical enti- ty; in particular, relevant information emerged from the first detailed patient survey of post-COVID syndrome [4]. Even after a very minor acute illness, post-COVID syndrome appears to be a multisystem dis- ease [5].Chronic fatigue syndrome (CFS) is characterized by extreme mental and phys- ical exhaustion, sleep disturbances, and persistent discomfort. Fatigue is one of the most prevalent symptoms in people infect- ed with SARS-CoV-2, the virus that is caus- ing the current COVID-19 pandemic [6]. Chronic fatigue syndrome (CF) affects 2.5 million Americans, according to the centres for Disease Control and Prevention (CDC) [7]. It is a multisystem condition that caus- es devastating symptoms such as extreme fatigue, post-exercise malaise, restless sleep, cognitive impairments, and orthostatic intolerance. In the United States alone, the Centers for Disease Control and Prevention and the National Academy of Medicine estimate that 836,000 to 2.5 million people have ME/CFS [8].According to recent findings, weariness has been noted in about one-third of COVID-19 patients, where it has been linked to a worse prognosis and can last for at least six months following infection. According to studies on the prevalence of fatigue following COVID-19, between 9 and 49% of patients exhibit fatigue 4 weeks after the onset of symptoms and between 30 and 16 weeks later. According to a recent study, at least one-third of COVID- 19 patients may experience fatigue for up to a year after [9]. Coronavirus causes several complications or several of symptoms after the patient recovers from the virus. Fatigue is a more common symptom after recovery from the coronavirus and many people have been diagnosed with post-Covid fatigue, Limited studies in the kurdstan region assess fatigue among patients in post-COVID-19 in Erbil city. The aim of the study was to assess the prevalence persistent fatigue among patients post-COVID-19. Adescriptive cross- sectional study was conducted in Erbil city, Kurdistan region. Non-probability (Purposive sample) of 300 post-COVID-19 patients in six months at a private clinic and home visit from 1st September 2021 to 1st September 2022, data were collected through direct interviews (face to face). Info software program version 8 was used for sample size estimation. The expected frequency (26.5) based on the proportion COVID-19 patients in Erbil city because the number of patients infected with COVID-19 about 117 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.13 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article percentage). AN independent sample t- test is used to compare two independent variables; one-way ANOVA analysis of vari- ance is used to test the claim that there are three or more variables, Correlation and Simple Regression analysis was used to determine the relationship between in- dependent variables and dependent varia- bles. A P-value statistically significant level of ≤ 0.05. The results show that (31.7%) of the pa- tient were older 50 years, males (52.3%) were higher than females; high percentage of them graduated from institute (28.3) and housewife (32.3), the majority of the patients lived in urban(84.7), and married (81.7), as shown in the table 1. 95%. The population size is 57000 number of recovered covid19 patients in Erbil city from June 2021 to December 2021[10]. Accordingly, 300 samples were estimated for the study. They were chosen according to the criteria of the study, more than 18 years old, female and male 6 months of recovery after infected COVID-19 and all hospitalization and non-hospitalization pa- tients. The instruments used for data col- lection consist of three parts based on the objectives of the study. Part one socio- demographic about patients such as (age, gender, level of education, occupation sta- tus, residence and marital status). Part two medical data consisted of different items about patients such as (body mass index ‘BMI’, chronic disease, hospitalization dur- ing COVID-19, and receiving oxygen during COVID-19). Part three was fatigue impact. Fatigue prevalence items include 21 (11 ‘’Physical’’ items and 10 ‘’mental’’ items); the total score of the MFIS ranges from 0 to 84. The MFIS-5 scores each item on a five-point Likert scale from 0 to 4. It means never (0), rarely (1), sometimes (2), often (3), always (4). Fatigue level was split into three categories: ‘mild fatigue,’ moderate fatigue,’ severe fatigue’. The score for mild fatigue ranged from (0 to 1), moderate fa- tigue ranged from (2), severe fatigue ranged from (3 to 4) [11].The study proto- col was approved by the ethical committee of the College of Nursing at Hawler Medi- cal University code number is 97 on 7th October 2021 and the official permission was obtained from the Ministry of Health in Erbil, Director of health to take the num- ber of recovery patients in Erbil city. The permission was obtained from each partici- pant; they were informed and explained the purpose of the study and the confiden- tiality of the information. Data were ana- lysed using the statistical package for social sciences (SPSS, version 28) to calculate de- scriptive statistical analysis (frequency and 118 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULT Table 1: Socio Demographic data of 300 Covid19 Patients Variables N. (%) Age 20 - 29 51 (17) 30 - 39 93 (31) 40 - 49 61 (20.3) ≥50 95 (31.7) Gender Male 157 (52.3) Female 143 (47.7) Level education Illiterate 32 (10.7) Primary school 70 (23.3) Secondary school 52 (17.3) Institute 85 (28.3) University and above 61 (20.3) Occupation Employee 91 (30.3) Unemployed 88 (29.3) Retired 12 (4) House wife 97 (32.3) Student 12 (4) Residence Urban 254 (84.7) Suburban 46 (15.3) Marital status Married 245 (81.7) Unmarried 55 (18.3) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.13 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article (75.3%) of patient were overweight, a high percentage of them did not have any comorbidity disease (73%), since most of them (60.5%) have diabetic disease, the majority of the patients have not been ad- mitted at hospital during their COVID-19 (83%)since the range of their remained to the hospital was 4-6 days and more than half of the samples (67%) did not receive oxygen while the range of using oxygen was 6-10 days, as shown in the table 2. The prevalence of fatigue post-Covid-19 of the study samples was less than half (46.3%) of the study samples had severe physical fatigue and more than half (63.7%) of the study samples had mild mental fatigue. The mean of physical fa- tigue in general (26.657) is higher than the mean of mental fatigue (11.667), which means the patients post COVID-19 had a physical fatigue compared with mental fatigue. As shown in the figure 1. The results show a very strong negative correlation between the independent var- iable (duration of illness) and the depend- ent variable (physical problem) (-0.75) while there is a strong negative correla- tion between the independent variable (duration of illness) and the dependent variable (mental problem) (-0.66). 119 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 2: Medical data of 300 post covid 19 patients Variables N. (%) Body Mass Index Normal 37 (12.3) Overweight 226 (75.3) Obese 37 (12.3) Do you have any chronic disease? Yes 81 (27) No 219 (73) What is it? Asthma 1 (1.2) diabetic 49 (60.5) hypertension 28 (34.6) thalassemia 3 (3.7) Did you hospitalize during Covid-19 Yes 51 (17) No 249 (83) How many days 1-3 11 (21.6) 4-6 21 (41.2) ≥7 19 (37.3) Did you receive oxygen therapy Yes 99 (33) No 201 (67) Received oxygen/ days 1-5 46 (46.5) 6-10 22 (22.2) 11-15 15 (15.2) ≥15 16 (16.2) Figure1: prevalence and incidence Percentage for Physical and Mental https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.13 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article 120 duration of illness is -0.084, which means, that increasing one unit for dura- tion of illness will decrease the mental problem by 0.084. As shown in table 3. p-values were less than the significant level of α=0.05. Patients who lived in are- as and married perceived non-significant with physical and mental fatigue com- pared to those who lived in suburban and single patients because their p-values were higher than the significant level of α=0.05, as shown in able 4. Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 3: prediction of the duration of COVID-19 recovery on physical and Mental Fatigue Simple Regression Coefficient (B) for dura- tion of illness is -0.144, which means, that increasing one unit for duration of illness will decrease the physical problem by 0.144. Regression Coefficient (B) for Female patients perceived significantly more physical and mental fatigue than male patients with comorbidity disease, hospitalization and received oxygen during COVID-19, perceived significantly more physical and mental fatigue than non- comorbidity disease, non-hospitalization and received oxygen because their Model B t P-value Corr. R2 F P-value Physical (Constant) 41.704 48.077 0.001 -0.75 0.556 372.6 0.001 How long your illness recovered completely -0.144 -19.313 0.001 Mental (Constant) 20.450 31.644 0.001 -0.66 0.434 228.3 0.001 How long your illness recovered completely -0.084 -15.131 0.001 Table 4: Comparison between characteristic and Physical and Mental fatigue P-value t Std. Deviation Mean N variables 0.002 3.058 9.778 25.013 157 Male Physical Gender 9.735 28.462 143 Female 0.039 2.078 6.598 10.924 157 Male Mental 6.381 12.483 143 Female 0.585 0.547 9.737 26.524 254 Urban Physical Residence 10.796 27.391 46 Suburban 0.596 0.531 6.689 11.752 254 Urban Mental 5.620 11.196 46 Suburban 0.127 1.529 9.679 27.069 245 Married Physical Marital status 10.695 24.818 55 Unmarried 0.727 0.35 6.191 11.604 245 Married Mental 7.931 11.945 55 Unmarried 0.002 3.049 9.022 29.481 81 Yes Physical Chronic disease 10.015 25.612 219 No 0.012 2.531 6.582 13.222 81 Yes Mental 6.432 11.091 219 No 0.001 5.298 8.177 33.059 51 Yes Physical Hospitalize during covid 9.714 25.345 249 No 0.001 4.285 6.561 15.137 51 Yes Mental 6.306 10956 249 No 0.001 4.303 9.658 30.061 99 Yes Physical Receiving oxygen during covid 19 9.594 24.980 201 No 0.001 3.385 6.484 13.455 99 Yes Mental 6.388 10.786 201 No 0.041 2.128 9.990 26.974 274 One time Physical Infected with covid 19 8.240 23.308 26 Two times 0.025 2.257 6.577 11.927 274 One tie Mental 5.411 8.923 26 Two times https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.13 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article The results of this study show that the mean of physical fatigue (26.65) higher than the mean of mental fatigue (11.66). This result is supported by the study done at Dublin, Ireland, St James’s Hospital (SJH) about 128 post-recovery patients by using the Chalder Fatigue Scale (CFQ-11), that results illustrate that mean physical (11.38) higher than the mean mental (4.72) [32]. Moreover; it was agreed with the study conducted in El Minya / Egypt about 81 patents. By using MFIS (21 items), this study shows that the mean physical (24.62) is higher than the mean mental (17.68) [31].On other hand the results of the current study disagree with the finding of the other two studies. A cross-sectional survey was conducted in China about 2614 post recovery patients using Fatigue Self- Assessment Scale (FSAS) 23 items, the re- sults of this study show that the mean of physical (20.1) is less than the mean of mental (23.6) [23]. Another study was done in Barcelona (Spain) about 136 pa- tients using MFIS (21 items). The study found that the mean of physical (52.5) less than the mean of mental (57.9) [33].The current study illustrates the prevalence of fatigue in the first month post-COVID high- er than other months and decreasing phys- ical and mental fatigue month by month until complete recovery. This result con- sistent with many of the results of the study. Some studies done by Tenforde MW et al (2020), Townsend L et al (2020), Tomar BS et al (2021), Tosato M et al (2021), Ganesh R et al (2021), Diem L et al (2022) display that most of the study sam- ples had fatigue at the first month after recovery [26, 34-38]. However other stud- ies conducted in the United Kingdom, Chi- na, and Egypt show that the majority of the study participants had fatigue in the second month [16, 23, 25]. A cross- sectional survey in Egypt, cohort study in Mexico, and a cross-sectional in Denmark 121 The highest percent age of the present study is 31.7 which is similar to the result of observational Study at King Abdulaziz Medical City, Jeddah, Saudi Arabia and prospective study was conducted in Anka- ra City the percent of age was (41.3, 39.9), the age ≥ 50 years [12,13]. More than half of the participants in this study were a male which agrees with the results of some studies [12-18]. The current study findings illustrate that the highest per- centage (28.3) of participants graduated from the institute this result disagrees with some study results [19-21]. In this study one-third of the study samples were housewives as consent by a cross- sectional study conducted in Istanbul, Tur- key [22]. Most of the participants were lived in urban areas this result corrobo- rates some studies [20, 23, 24]. Current study shows that most of the participants were married, as supported by the results of the studies [19, 23, 24]. Results illus- trate that a high percentage of the study samples were overweigh which agrees with the results of more than the studies [16, 25]. The majority of this study’s sam- ples don’t have any chronic disease which is similar to the results of many studies [23, 25, 26]. The present study results show that more than half of the partici- pants have diabetes which agrees with the results of the studies [15, 27-29]. Most of the study samples this study were not hospitalized during COVID-19 this re- sult is supported by some studies [12, 30, 31]. Current study results show that 67 percent of the participants did not receive oxygen during COVID 19 which agrees with the results of the previous study [25]. In this study, all the participants were fa- tigued 46.3 % had severe physical fatigue and 63.7 % had mild mental fatigue; which means participants had physical fatigue more than mental fatigue. Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. DISCUSSION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.13 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article There are no conflicts of interest or sources of financial support for any of the authors. [1] Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. Journal of autoimmun- ity. 2020 May 1;109:102433. [2] Qian Q, Asinger PA, Lee MJ, Han G, Mizrahi Rodriguez K, Lin S, et al. MOF-based mem- branes for gas separations. Chemical re- views. 2020 Jul 1;120(16):8161-266. [3] Mahase E. China coronavirus: WHO declares international emergency as death toll ex- ceeds 200. BMJ: British Medical Journal (Online). 2020 Jan 31;368. [4] Li R, Wang W, El-Sayed ES, Su K, He P, Yuan D. Ratiometric fluorescence detection of tetracycline antibiotic based on a polynucle- ar lanthanide metal–organic framework. Sensors and Actuators B: Chemical Refining Laboratory. 2021 Mar 1;330:129314. [5] Pavli A, Theodoridou M, Maltezou HC. Post- COVID syndrome: Incidence, clinical spec- trum, and challenges for primary healthcare professionals. Archives of medical research. 2021 Aug 1;52(6):575-81. [6] Gunnell D, Appleby L, Arensman E, Hawton K, John A, Kapur N, et al. Suicide risk and prevention during the COVID-19 pandemic. The Lancet Psychiatry. 2020 Jun 1;7(6):468- 71. [7] Mardani R, Vasmehjani AA, Zali F, Gholami A, Nasab SD, Kaghazian H, et al. Laboratory parameters in detection of COVID-19 pa- tients with positive RT-PCR; a diagnostic ac- curacy study. Archives of academic Emergen- cy medicine. 2020;8(1). [8] Galloway SE, Paul P, MacCannell DR, Johans- son MA, Brooks JT, MacNeil A, et al. Emer- gence of SARS-CoV-2 b. 1.1. 7 lineage— united states, december 29, 2020–january 12, 2021. Morbidity and Mortality Weekly Report. 2021 Jan 1;70(3):95. Available from https://doi.org/10.15585% 2Fmmwr.mm7003e2. [9] [9] Calabria M, García-Sánchez C, Grunden N, Pons C, Arroyo JA, Gómez-Anson B, et al. Post-COVID-19 fatigue: the contribution of cognitive and neuropsychiatric symptoms. Journal of neurology. 2022 Apr 30:1-0. illustrate that more than half of the survi- vors had fatigue at the third month [20, 27, 39]. According to a couple of the stud- ies in the 4th months half of the samples had fatigue. The studies were conducted in France and Norway [29, 40]. Augustin M et al (2021) conducted a cohort study in Norway and Khatib S et al (2022) did a cross-sectional study in Missouri. Both studies show that less than half of the samples had fatigue in the 5th month [30, 41]. About 6th month in Mexico the study was conducted by González-Hermosillo JA et al (2021), and in Saudi Arabia, the study was done by Garout MA et al (2022) both studies indicate that one-third of the study survivors had fatigue [27, 42].The present study findings illustrate that female gen- der is significantly associated with fatigue, which agrees with the results of some studies [15, 30, 40,], but it disagrees with other studies [41]. In this study, fatigue was perceived significantly in patients with comorbidity disease; this result is support- ed by some studies [12, 25, 39, 41]. The current study shows that fatigue differ- ence is significant with hospitalized during the disease or COVID-19 which agrees with the results of the three studies [12, 16, 17]. The study finding display that there is a significant difference between fatigue and receiving oxygen during COVID-19 which is similar to the results of the study [36]. The present study shows no differ- ence between fatigue with residence and marital status; this result is corroborated by two studies [20]. The study concluded that less than half of the participants had severe physical fa- tigue and more than half had mild mental fatigue. Statistical difference is significant between fatigue in females, patients with comorbidity diseases, hospitalization, and receiving oxygen during COVID- 19. 122 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. 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