Post-COVID-19 health-related quality of life in India: A systematic review and meta-analytic assessment of recovery outcomes

Abstract

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has had profound physical, psychological, and social consequences, with lasting effects on health-related quality of life (HRQoL) among people with a history of COVID-19.

AIM

To synthesize the current evidence on HRQoL and long-term health outcomes among people with a history of COVID-19 in India.

METHODS

We incorporated studies from India reporting post-COVID HRQoL outcomes using validated instruments, including the 5-level EuroQol 5-Dimensional questionnaire, the EuroQol Visual Analogue Scale, the Short Form-36 Health Survey, the World Health Organization Quality of Life-Brief Version, and the European Health Interview Survey-Quality of Life. Pooled mean 5-level EuroQol 5-Dimensional questionnaire scores with 95%CIs were calculated for HRQoL. Adjusted odds ratios were pooled for comorbidity, disease severity, intensive care unit admission, age, sex, and vaccination status using random-effects models.

RESULTS

Three studies (n = 1526) reported EuroQol instruments, with the 5-level EuroQol 5-Dimensional questionnaire utility scores suitable for quantitative pooling. The pooled mean utility was 0.83 (95%CI: 0.75-0.92), although heterogeneity was high because the included studies represented clinically distinct populations. Across all studies, several determinants were consistently associated with impaired HRQoL. Older adults (≥ 60 years) had higher odds of poor HRQoL [pooled odds ratio (OR) = 1.83, 95%CI: 1.43-2.35], and females were more likely to experience impaired HRQoL (pooled OR = 1.74, 95%CI: 1.44-2.10), whereas males had a lower risk (pooled OR = 0.58, 95%CI: 0.48-0.70). Being unvaccinated increased the likelihood of persistent symptoms or reduced HRQoL (pooled OR = 1.60, 95%CI: 1.21-2.14). Comorbidity (pooled OR = 1.94, 95%CI: 1.43-2.63) and severe acute COVID-19 or intensive care unit admission (pooled OR = 2.77, 95%CI: 2.13-3.59) were also strongly associated with poorer HRQoL Six additional studies utilizing disparate instruments (EuroQol Visual Analogue Scale, Short Form-36 Health Survey, World Health Organization Quality of Life-Brief Version, European Health Interview Survey-Quality of Life) were excluded from quantitative synthesis due to measurement heterogeneity.

CONCLUSION

Post-COVID HRQoL in people with a history of COVID-19 in India is suboptimal, with greater impairment observed among older adults, females, patients with comorbidities or severe disease, and unvaccinated individuals. These findings highlight the need for targeted rehabilitation and preventive strategies.

Key Words: Health-related quality of life; Post-COVID-19; Recovery outcomes; Meta-analysis; Quality of life; COVID-19 survivors

Core Tip: This systematic review and meta-analysis is the first to comprehensively assess post- coronavirus disease 2019 health-related quality of life in India using validated instruments such as 5-level EuroQol 5-Dimensional questionnaire, Short Form-36 Health Survey, World Health Organization Quality of Life-Brief Version, and St. George’s Respiratory Questionnaire. Findings highlight that overall health-related quality of life recovery was suboptimal, especially among vulnerable groups including older adults, women, and patients with chronic conditions who experienced disproportionately poorer outcomes. The study underscores the importance of targeted, multidisciplinary rehabilitation strategies that address physical, psychological, and social domains of health to improve long-term recovery in post- coronavirus disease 2019 populations.

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic, instigated by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in unprecedented global health challenges, affecting millions of lives and healthcare systems worldwide[1]. Recent estimates from the World Health Organization suggest that 10%-20% of individuals globally experience long COVID following SARS-CoV-2 infection, with variation by age, sex, and severity of acute illness[2,3]. In India, cohort studies and national surveys have reported a prevalence ranging from 15% to 30% among recovered patients, with higher rates among those with comorbidities and severe disease[4]. As of 2024, India has recorded over 45 million confirmed cases and close to 5.5 Lakh deaths due to COVID-19, positioning itself as one of the hardest-hit nations globally[5]. While the acute phase of COVID-19 has been the primary focus of clinical management and research, subsequent evidence indicates that a significant proportion of individuals continue to experience persistent symptoms and health complications long after the resolution of the initial infection[6]. This condition, often referred to as "long COVID", has profound implications for patients' health-related quality of life (HRQoL) and long-term health outcomes[7].

HRQoL is a multidimensional construct that encompasses the physical, psychological, and social aspects of well-being[8] and serves as a crucial indicator of the overall impact of chronic diseases and medical conditions on individuals' daily lives. In the context of long-COVID, patients report a wide range of enduring symptoms, including fatigue (13%-87%), dyspnea (10%-71%), chest pain/tightness (12%-44%), cough (17%-34%), cognitive impairment, and psychological distress (13%-35%), which collectively impair their HRQoL[9-11]. Moreover, long-term health complications associated with COVID-19, such as cardiovascular, respiratory, neurological, and renal further accentuate the burden on affected individuals and healthcare systems[12,13].

A study conducted in Bangladesh found that while participants showed improvements in psychological and social domains of HRQoL over a year after contracting from COVID-19, physical health scores remained lower than pre-infection levels, indicating ongoing challenges for many survivors[14]. Similarly, a cross-sectional analysis in Italy revealed that factors such as gender, age, and disease severity significantly influenced HRQoL outcomes in long-term post COVID health implications with females and older adults reporting significantly poorer quality of life and the impact was more pronounced among those with severe disease[15].

These findings emphasize the necessity for comprehensive assessments of HRQoL in post-COVID-19 patients to identify specific needs and tailor interventions effectively. By addressing the multidimensional impacts of COVID-19 on health and well-being, healthcare providers can better support recovery and improve the overall quality of life for affected individuals.

Comparative studies have reported international variation in post-COVID HRQoL, with evidence from Italy and Belgium highlighting differences in symptom persistence and recovery trajectories. For example, a systematic review revealed that post-COVID-19 patients in countries such as Italy and Belgium experienced lower HRQoL scores compared to individuals who had not been infected with COVID-19, with notable impairments in both physical and mental health domains[16,17].

India's vast and demographically diverse population presents unique challenges in understanding and addressing the long-term consequences of COVID-19. Socioeconomic disparities, variations in healthcare access, and differences in population health profiles necessitate a comprehensive examination of HRQoL and long-term health outcomes in people with a history of COVID-19 across the country[18,19]. Existing studies have primarily concentrated on short-term outcomes or specific health domains, rather than addressing overall HRQoL. This has created a significant gap in the literature concerning the long-term impact of the disease on patients' lives[20-22].

However, only a limited number of studies from India have specifically examined post-COVID HRQoL, underscoring a major evidence gap. This systematic review and meta-analysis (SRMA) synthesize the current evidence on HRQoL and long-term health outcomes among people with a history of COVID-19 in India. By consolidating data from various studies, we aim to provide a nuanced understanding of the chronic manifestations of COVID-19 and their implications for public health and clinical practice.

MATERIALS AND METHODS

Study protocol and search strategy

The SRMA were carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines[23]. This SRMA were prospectively designed and registered with the International Prospective Register of Systematic Reviews under registration number of CRD42024511990.

A comprehensive and systematic literature search was conducted across five major electronic databases: PubMed, EMBASE, DOAJ, Google Scholar, and ProQuest, to identify studies evaluating HRQoL in post-COVID-19 patients from India. The search encompassed peer-reviewed publications from January 2020 to April 2024, and was designed to capture both general and India-specific literature.

The search strategy combined Medical Subject Headings and free-text keywords tailored to each database. Core search terms included: (1) “COVID-19” OR “SARS-CoV-2”; (2) “Health-related quality of life” OR “HRQoL”; (3) “Post-recovery”; (4) “Long COVID” OR “post-COVID syndrome”; and (5) “India”. Boolean operators such as “AND” and “OR” were applied to maximize coverage. Additional modifiers such as “Indian patients”, “South Asia”, and “India-specific” were included to ensure relevance to the target population (Table 1).

Table 1 Search terminology: Medical Subject Headings terms and synonyms used for literature retrieval.

Concept	Medical Subject Headings terms	Synonyms
COVID-19	COVID-19, SARS-CoV-2, coronavirus	2019-nCoV, novel coronavirus, COVID
Health-Related Quality of Life	Health-related quality of life, HRQoL, quality of life, well-being	Patient-reported outcomes, life quality, wellness, health status
Post-COVID Recovery	Post-recovery, post-acute sequelae, long COVID, post-COVID syndrome	COVID-19 recovery, post-acute COVID, chronic COVID syndrome
India	India, Indian patients, South Asia	Indian population, India-specific
Measurement tools	SF-36, EuroQol 5-Dimensional questionnaire, PROMIS, WHOQOL, HRQoL instruments	Health-related quality of life scales, health surveys, patient-reported outcome measures

COVID: Coronavirus disease; HRQoL: Health-related quality of life; PROMIS: Patient-Reported Outcomes Measurement Information System; SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; SF-36: Short Form-36 Health Survey; WHOQOL: World Health Organization Quality of Life; 2019-nCoV: 2019 novel coronavirus.

The search was restricted to English-language, peer-reviewed articles that explicitly focused on Indian populations or presented disaggregated data relevant to India. Reference lists of the included studies were manually screened to identify additional eligible studies not captured through the initial search. Grey literature and regional repositories, including the Indian Citation Index, were also explored to enhance comprehensiveness.

Study selection and review

The study selection procedure was structured according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards[24]. After importing all search results into a reference management software, 564 duplicate records were removed, leaving 1474 studies for initial screening. Titles and abstracts were independently screened by four reviewers. Articles that clearly failed to meet the inclusion criteria were excluded at this stage. Full texts of 381 potentially eligible studies were retrieved for in-depth assessment. Of these, 370 studies were excluded due to various reasons: (1) Inadequate methodological quality (n = 88); (2) Small sample size (n = 41); (3) Irrelevant outcomes (n = 18); (4) Non-target populations (n = 31); (5) Inaccessible full texts (n = 7); (6) Inappropriate study design (n = 63); and (7) Focusing on quality of life unrelated to post-COVID-19 conditions (n = 120). Ultimately, 11 studies satisfied all inclusion criteria and were incorporated into the final analysis (Figure 1, Table 2). Disagreements during the selection and review stages were resolved through discussion and consensus among the reviewers.

Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of study selection. COVID-19: Coronavirus disease 2019.

Table 2 Inclusion and exclusion criteria for studies assessing post-coronavirus disease 2019 health-related quality of life in India.

Criteria	Inclusion	Exclusion
Population	Adults (≥ 18 years) with confirmed COVID-19 infection in India	Studies involving paediatric populations (< 18 years)
Focus area	Studies specifically assessing HRQoL post-COVID-19 in Indian patients	Studies focusing on other regions or populations outside of India
Outcome	HRQoL assessed using validated/standardized instruments (e.g., Short Form-36 Health Survey, EuroQol 5-Dimensional questionnaire, Patient-Reported Outcomes Measurement Information System)	Studies without HRQoL outcomes or using non-validated HRQoL measures
Study design	Observational, longitudinal, cohort, and cross-sectional studies	Case reports, editorials, reviews, and non-peer-reviewed sources
Language	Studies published in English	Studies published in languages other than English
Time period	Studies published from 2020 to 2024	Studies published outside the specified time frame
COVID-19 specificity	Studies focused on patients’ post-COVID-19 recovery (including post-acute sequelae)	Studies involving other infectious diseases or comorbid conditions unrelated to COVID-19

COVID-19: Coronavirus disease 2019; HRQoL: Health-related quality of life.

Data extraction and synthesis

Data were independently extracted by two authors using a standardized template. Extracted information included: (1) Study identifiers (author, year, setting); (2) Study design and sample size; (3) Participant demographics (age, gender); (4) COVID-19-specific variables [disease severity, hospitalization or intensive care unit (ICU) status, recovery duration]; and (5) HRQoL measures (tools used, domains assessed, utility scores). Any discrepancies in data extraction were resolved by consensus.

A narrative synthesis of the included studies was conducted to describe the HRQoL profiles of post-COVID-19 patients in India. The extracted data were summarized in tabular form (Table 3)[25-35].

Table 3 Characteristics of included studies assessing health-related quality of life among post-coronavirus disease 2019 patients in India, mean ± SD/median (interquartile range).

Ref.	Region	Study design	Sample size	HRQoL assessment tool	Type of comorbidities measured in the sample population	Duration of study	Age (in years)	Male	Female	Findings
Barani et al[30], 2022	Tamil Nadu	Cross sectional study	372	EQ-5D-5 L	DM, HTN, CVD, CKD, RD, Cancer	2 months (from November 2020 to December 2020)	44.5 ± 15.3	57.5%	42.5%	The mean EQ-5D utility score was 0.925 ± 0.150, and the mean EQ-VAS was 90.68 ± 11.81. Men had a higher utility value than women. Those with comorbidities and longer hospital stays had lower utility scores
Christopher et al[34], 2024	Vellore, Tamil Nadu	Cross-sectional study	207	SGRQ	DM, HTN, Ischemic heart disease, RD, CKD, Cancer	6 months (from August 2020 to January 2021)	48.7 ± 14.2	68.1%	31.9%	The COVID-19 pneumonia group when compared to the mild COVID-19 group had a greater mean total SGRQ score (29.2 vs 11.0; P < 0.0001). It was found that post-COVID-19 lung damage leads to significant impairment of lung function, and quality of life
Elumalai et al[35], 2023	Tamil Nadu	Cross-sectional study	1047	EQ-5D-5 L	DM, HTN, CVD, RD, Thyroid	7 months (from June 2020 to January 2021)	38 (29-51)	68%	32%	The mean EQ-5D-5 L utility score was 0.98 ± 0.05 and EQ-VAS was 92.14 ± 0.39. The symptomatic group, older age group, female gender and those with comorbidity had persistent symptoms, had relatively low utility score for HRQoL
Gupta et al[32], 2022	Kota, Rajasthan, India	Cross-sectional, semi-structured and questionnaire-based study	173	EQ-5D-5 L	Anemia, pre-eclampsia, antepartum eclampsia, hypothyroidism	4 months (from March 2021 to June 2021)	26.3 ± 6.6	-	100%	Post-COVID, 82.56% were asymptomatic, while 1744% had symptoms. Using EQ-5D-5 L, most reported no problems in any dimension, with some issues in mobility (3.46%), usual activities (5.2%), pain/discomfort (7.52%), and anxiety/depression (8.1%). Anxiety/depression reached level 2 in 1.73% of subjects
Hegde et al[27], 2022	Karnataka, India	Retrospective observational study	118	EQ-5D-5 L	-	7 months (from June 2020 to December 2020)	45.28 ± 17.76	58.5%	41.5%	Anxiety/depression scores changed significantly over time (at discharge, 4 weeks, and 8 weeks). Scores improved notably between discharge and 8 weeks. At 4 weeks, age was linked to higher anxiety/depression. Overall health index scores also showed significant differences across the three time points
Jain et al[29], 2023	Jhansi	Multicentric cross sectional	491	EUROHIS-QOL 8, GAD-7, and MDI	-	3 months (from July 2020 to September 2020)	52.23 ± 7.31	62%	38%	The mean EUROHIS-QOL score was found to be 328 ± 0.98. New-onset psychological disorders and sleep disturbances were observed in severe COVID-19 survivors. Long term quality of life and work ability remained poor for survivors who had prolong ICU admission. GAD-7 Scale: The mean score was 18.63 ± 3.28, reflecting moderate to severe anxiety levels. MDI: The mean score was 4.12 ± 1.45, indicative of mild to moderate depressive symptoms
Neelima and Chivukula[31], 2023	Andhra Pradesh	Cross-sectional study	107	EQ-5D-5 L	DM, HTN, asthma, thyroid	5 months (from August 2022 to January 2023)	55.24 ± 9.94	66.6%	33.4%	The mean EQ-5D-5 L utility score was 0.51 ± 0.43 and EQ-VAS was 68.97 ± 22.27. Patients with comorbidities had lower EQ-5D-5 L scores. A significant negative correlation between ICU stay duration and EQ-5D-5 L score was noted. COVID-19 patients with comorbidities had a significantly poorer quality of life
Revathishree et al[25], 2022	Thandalam, Chennai, Tamil Nadu, India	Prospective cross-sectional study	250	FCV-19S (fear/anxiety of COVID-19 individuals)	DM, HTN, asthma, thyroid, CAD	1 month (from June 1, 2020 to June 30, 2020)	41.13 ± 9.93	70.8%	29.2%	High the clinical category score, higher FCV-19S. Post treatment score suggested COVID-19 survivors had a definite improvement in their quality of life, but still had mental stress even after full recovery. Survivors also faced social discrimination
Sarda et al[33], 2022	Delhi	Cross-sectional study	251	Fatigue Severity Scale, WHOQOL-BREF	Musculoskeletal disorders, RD, fatigue, GID, ND, SD	3 month (from May 2020 to July 2020)	35.8 ± 12.5	67.3%	32.7%	Long COVID-19 patients showed higher fatigue severity and lower WHOQOL-BREF scores than those without, with males having higher WHOQOL-BREF scores than females, and a negative correlation between WHOQOL-BREF scores and symptom duration
Shah et al[26], 2023	Unclear	Prospective cross-sectional study	388	EQ-5D-3 L scale	DM, HTN, CVD, Thrombosis	5 months (from February 2021 to June 2021)	48 (36-59)	62.6%	37.4%	EQ-5D-3 L showed significant improvement in quality of life at 3 months compared to 1 month, especially in non-ICU patients. The mean EQ-VAS score also improved at 3 months. Illness severity correlated with quality of life. The study showed ongoing improvement in quality of life
Wasim and Kuriakose[28], 2024	Bangaluru, Karnataka	Observational study	264	Short Form-36 Health Survey (RAND 36-Item Health Survey Instrument) questionnaire	Not reported	-	22.37 ± 3.11	44%	56%	Long COVID symptoms were found in 43.2% of subjects. The duration of symptoms ranged from less than one month (46.6%) to more than five months (10.2%). In the quality of life, mental health was the most affected domain. The overall averages for the physical component were 7111 ± 8.24 and 64.20 ± 10.73 for the mental component

CAD: Coronary artery disease; COVID-19: Coronavirus disease 2019; CVD: Cardiovascular disease; DM: Diabetes mellitus; EQ-VAS: EuroQol Visual Analogue Scale; EQ-5D-5 L: 5-level EuroQol 5-Dimensional questionnaire; EUROHIS-QOL: European Health Interview Survey-Quality of Life; FCV-19S: Fear of Coronavirus Disease 2019 Scale; GAD-7: Generalized Anxiety Disorder-7 item Scale; GID: Gastrointestinal disease; HRQoL: Health-related quality of life; HTN: Hypertension; ICU: Intensive care unit; MDI: Major depression inventory; ND: Neurological disease; RD: Respiratory disease; SD: Sleep disturbances; SGRQ: St. George’s Respiratory Questionnaire; WHOQOL-BREF: World Health Organization Quality of Life-Brief Version.

Continuous HRQoL scores were extracted from all eligible studies; however, due to substantial variation in measurement instruments and incomplete reporting of mean ± SD values, these outcomes were summarised descriptively. A meta-analysis of continuous outcomes was conducted only for studies reporting EuroQol instruments, with the 5-level EuroQol 5-Dimensional questionnaire (EQ-5D-5 L) utility scores, since this was the only HRQoL metric consistently reported with comparable scaling across studies. Three studies contributed to this pooled utility analysis.

All other HRQoL instruments [EuroQol Visual Analogue Scale (EQ-VAS), Short Form-36 Health Survey (SF-36), World Health Organization Quality of Life-Brief Version (WHOQOL-BREF), European Health Interview Survey-Quality of Life (EUROHIS-QOL)] were not pooled quantitatively because of heterogeneity in scoring systems.

For binary outcomes, effect estimates and their 95%CI. Determinants included age (≥ 60 years), sex, vaccination status, comorbidity (≥ 1 chronic condition), and indicators of disease severity (e.g., ICU admission, mechanical ventilation, abnormal pulmonary function). We performed random-effects meta-analyses using the inverse-variance method to pool log-transformed odds ratios (ORs). When a study reported more than one HRQoL-related OR for the same determinant [e.g., multiple EuroQol 5-Dimensional questionnaire (EQ-5D) domains], domain-specific log(OR) values were combined using inverse-variance weighting to generate a single study-level estimate and avoid double counting. Heterogeneity was assessed using τ² and I² statistics.

Statistical analysis

Statistical heterogeneity was assessed using the I² statistic and interpreted according to Cochrane recommendations, with I² > 50% indicating substantial heterogeneity. τ² values were computed to quantify between-study variance. Funnel plots were visually inspected to assess publication bias; Egger’s test was performed when at least ten studies were available. All analyses were conducted using R under a random-effects framework to generate conservative, generalizable effect estimates.

Quality assessment

The methodological quality of the included studies was assessed. Two authors utilised JBI critical evaluation techniques to independently assess the methodological quality and risk of bias in included research[36]. A third author resolved potential disagreements. We rated research based on their JBI ratings and classified them as low, moderate, or high risk of bias[36].

RESULTS

A total of 11 studies, comprising more than 3600 participants, were retained in the systematic review and included in the meta-analysis. Nine studies contributed extractable mean and standard deviation values for pooled analysis of HRQoL, while additional studies were included in subgroup analyses of predictors. The study sample sizes ranged from 107 participants to 1047 participants (Table 3) while the study duration in the different studies varied from one month to seven months post-discharge[25-35].

Table 3 summarizes the selected studies that assessed HRQoL following COVID-19[25-35]. Among these, eight were cross-sectional observational studies, including one multicentric study, with sample sizes ranging from 107 participants to 1047 participants. Two studies adopted a prospective follow-up observational design, with sample sizes of 250 and 388 participants[25,26]. One retrospective observational study included 118 participants, while another community-based cross-sectional study focused on 264 participants[27,28]. Collectively, these studies contribute to understanding HRQoL variations in diverse populations, with sample sizes ranging from 107 participants to 1047 participants.

HRQoL measurement tools

Across the 11 included studies, a range of instruments were employed to assess HRQoL. The most widely applied tools were the EQ-5D-5 L used in 4 studies and the EQ-VAS in 2 studies. Other validated scales included the SF-36 in 1 study, WHOQOL-BREF in 1 study, EUROHIS-QOL in 1 study, and the St. George’s Respiratory Questionnaire (SGRQ) in 1 study. Additional domain-specific instruments were also used, such as the Fatigue Severity Scale in 1 study and the Fear of COVID-19 Scale (FCV-19S) in 1 study. While all instruments assessed multiple domains of HRQoL, the EQ-5D-5 L and EQ-VAS were the most consistently applied (Table 3)[25-35].

Age and gender characteristics

Ten studies across different Indian states reported varied impacts of COVID-19 on HRQoL. Comorbidities, prolonged hospital stays, older age, and female sex were consistently associated with lower EQ-5D utility scores and poorer outcomes. Several studies noted psychological disorders, fatigue, anxiety, and social stigma as persistent challenges, while others observed gradual improvements in mental health and quality of life over time. Severe disease and ICU admission were negatively correlated with HRQoL, whereas male participants generally reported higher scores. The prevalence of long COVID symptoms ranged from 17% to 43%, with mental health domains being particularly affected. These findings highlight the multifactorial determinants of post-COVID HRQoL in India, effected by demographic, clinical, and regional factors. The detailed sociodemographic characteristics of the participants are reported in Table 3[25-35].

The studies presented in Table 3 shows disparities in HRQoL outcomes stratified by gender and age among COVID-19 patients in India[25-35]. Male participants were overrepresented in most studies, accounting for a higher percentage of the sample populations, ranging from 57.5% to 70.8%, like Barani et al[30], where men had a higher EQ-5D-5 L utility score than women. Regarding age, younger patients generally showed better HRQoL outcomes compared to older adults. For example, in Neelima and Chivukula[31] which had a relatively higher mean age (55.24 years), HRQoL scores were notably lower, with a mean EQ-5D-5 L utility score of 0.51. In contrast, studies involving younger populations, such as Gupta et al[32] with a mean age of 26.3 years, showed higher HRQoL outcomes, with over 90% of participants reporting normal HRQoL dimensions like mobility and self-care. Additionally, older age was associated with persistent symptoms and slower HRQoL recovery in studies such as Hegde et al[27], where anxiety and depression scores were particularly high among older participants. Age emerged as a key factor, with older adults consistently reporting lower utility scores and delayed recovery. These findings suggest that older age, particularly beyond 50 years, is associated with greater deterioration in HRQoL, with comorbidities, disease severity, and female sex acting as additional determinants. Recovery duration varied, with studies such as Shah et al[26] noting improved EQ-VAS scores from one to three months post-discharge. Moreover, long COVID symptoms – particularly fatigue, breathlessness, and psychological distress – were prevalent and contributed to lower HRQoL, as highlighted by Wasim and Kuriakose[28], Sarda et al[33], and Christopher et al[34].

Quality of life measures

The spectrum of HRQoL outcomes reported in the selected studies. Considerable methodological heterogeneity was observed due to the use of different HRQoL assessment tools and scales. In the survey conducted by Barani et al[30], a mean ± SD EQ-5D-5 L utility score of 0.925 ± 0.150 (range from 0 to 1) and an EQ-VAS score of 90.68 ± 11.81 (ranges from 0 to 100) were reported that indicated strong recovery among the COVID patients. Similarly, a mean EQ-5D-5 L utility score of 0.98 ± 0.05 and an EQ-VAS score of 92.14 ± 0.39 were reported in the study conducted by Elumalai et al[35], indicating good recovery. In contrast, the survey conducted by Neelima and Chivukula[31] reported a low HRQoL mean utility score of 0.51 ± 0.43 and an EQ-VAS score of 68.97 ± 22.27, which was indicative of possible impairments post-recovery. In another study, Christopher et al[34] used the SGRQ (0-100, higher scores indicating worse respiratory health) and discovered that 41.0% of participants reported having persistent respiratory symptoms with SGRQ scores ≥ 25.90%. Using the EQ-5D-5 L, Gupta et al[32] found that over 90% of participants did not report any problems with mobility, self-care, or usual activities other than a few minor issues in mobility (3.46%), pain/discomfort (7.52%), and usual activities (5.2%). Hegde et al[27] used the EuroQol-5D-5 L to assess HRQOL scores at three-time points: At discharge, 4 weeks, and 8 weeks post-discharge. Mobility issues decreased from 9.8% at discharge to 4.9% at 8 weeks. Similarly, self-care problems reduced from 4.9% to 1.6%, and pain/discomfort dropped from 12.2% to 4.1%. The most significant improvement was seen in anxiety/depression scores, decreasing from 31.7% at discharge to 0.8% at 8 weeks. Jain et al[29] showed a moderate recovery with a score of 3.28 ± 0.98 on the EUROHIS-QOL 8 (1-5, higher scores indicating better quality of life). The study used the Generalized Anxiety Disorder-7 and reported a mean score of 18.63 ± 3.28, suggesting moderate to severe anxiety levels, highlighting the significant prevalence of anxiety even 18 months post-recovery. The major depression inventory (MDI) score of 4.12 ± 1.45, suggesting moderate but persistent depression in the participants. Revathishree et al[25], used the FCV-19S scale (7-35, with higher scores indicating more FCV-19S) obtained a score of 12.32 ± 3.64, which was indicative of moderate depression and anxiety among the recovered individuals. Sarda et al[33] reported a mean HRQOL score of 68.5 ± 10.6 using the WHOQOL-BREF (0-100, higher scores assessed at least 28 days after diagnosis indicating better quality of life), which was reflective of physical challenges and fatigue, especially in the long COVID-19 group. Shah et al[26] similarly employed the EQ-5D-3 L reporting EQ-VAS scale, of 80.34 ± 12.77 at 1 month and 91.69 ± 12.34 at 3 months, indicating a remarkable improvement in quality of life among the patients. Significant differences in quality of life were also reported between ICU and non-ICU patients (P = 0.007), with non-ICU patients showing better recovery. Finally, using the SF-36 scale (0-100, higher scores indicating better health), Wasim and Kuriakose[28] reported a score of 67.65 ± 4.88, suggesting moderate recovery with persistent physical and mental challenges (Supplementary material)[25-35].

Comorbidities

The most common comorbidities reported in the included studies were diabetes mellitus and hypertension (HTN) with prevalence estimates of diabetes mellitus ranging from 3.09% to 52.3%, and for HTN were 9.8% to 39%. Less common, comorbidities include chronic kidney disease (CKD), cancer, ischemic heart disease, and musculoskeletal disorders. CKD prevalence was reported at 6.5% by Neelima and Chivukula[31] and 1.9% by Christopher et al[34], while cancer appeared with rates of 0.3% in Barani et al[30] and 4.3% in Christopher et al[34]. Additionally, ischemic heart disease was identified at a prevalence of 8.2% in Christopher et al[34]. These lower frequencies suggest that while these conditions are less common than diabetes and HTN, they still represent significant health risks for COVID-19 patients.

Certain comorbidities appeared distinctly in specific studies, such as anaemia, pre-eclampsia, and antepartum eclampsia, which were exclusively reported by Gupta et al[32] with prevalence rates of 7.5%, 6.35%, and 3.47%, respectively. Similarly, thrombosis, with a low occurrence rate of 0.25%, was only noted in the study by Shah et al[26] (Supplementary material).

Meta analysis results

Three studies (n = 1526) reported EQ-5D utility scores. The pooled utility was 0.83 (95%CI: 0.75-0.92); however, heterogeneity was high (I² = 98.9%), reflecting substantial differences in study populations. Elumalai et al[35] reported near-normal utility among mostly mild and moderate cases (0.98), Barani et al[30] showed moderately reduced utility (0.93), whereas Neelima et al[31] documented markedly impaired HRQoL among ICU survivors (0.51) (Figure 2).

Figure 2  Forest plot of pooled mean post-coronavirus disease health-related quality of life utility scores using 5-level EuroQol 5-Dimensional questionnaire.

Age emerged as another key determinant. Participants aged ≥ 60 years had approximately twice the odds of persistent symptoms or reduced EQ-5D utility scores (pooled OR = 1.83, 95%CI: 1.43-2.35; I² = 0%) (Figure 3A)[26,27,30,31,33]. Sex-stratified analyses revealed an explicit gender disparity: Females were more than twice as likely to experience impaired HRQoL (pooled OR = 1.74, 95%CI: 1.44-2.10; I² < 30%), whereas males had a significantly lower risk (pooled OR = 0.58, 95%CI: 0.48-0.70), indicating a protective effect (Figure 3B and C)[26,28,30-33].

Figure 3 Forest plots of pooled odds ratio for predictors of impaired health-related quality of life and persistent symptoms among coronavirus disease 2019 survivors. A: Forest plot of pooled odds ratio (OR) for age ≥ 60 years as a predictor of poor health-related quality of life (HRQoL) or persistent symptoms after coronavirus disease 2019 (COVID-19); B: Forest plot of pooled ORs for male sex as a predictor of post-COVID HRQoL impairment and persistent symptoms; C: Forest plot of pooled ORs for female sex as a predictor of impaired HRQoL and persistent symptoms after COVID-19; D: Forest plot of pooled ORs for Non vaccinated status as a predictor of long-COVID and persistent symptoms after COVID-19; E: Forest plot of pooled ORs for severe COVID-19 or intensive care unit-level illness as a predictor of impaired HRQoL after recovery. COVID: Coronavirus disease; EQ-VAS: EuroQol Visual Analogue Scale; EQ-5D: EuroQol 5-Dimensional questionnaire; OR: Odds ratio.

Vaccination status was also a significant predictor of outcomes. Across three studies, being unvaccinated was associated with 60% higher odds of lower HRQoL in long COVID (pooled OR = 1.60, 95%CI: 1.21-2.14; I² = 0%), underscoring the protective benefit of vaccination (Figure 3D)[26,28,33].

Several consistent determinants of impaired HRQoL were identified. Comorbidity was strongly associated with poor HRQoL, with a nearly two-fold higher risk compared with those without chronic conditions (pooled OR = 1.94, 95%CI: 1.43-2.63; I² = 0%). Disease severity demonstrated stronger effect: Across five studies, severe COVID-19 or ICU admission nearly tripled the odds of poor HRQoL (pooled OR = 2.77, 95%CI: 2.13-3.59; I² = 0%), with highly consistent findings (Figure 3E)[26,29,31,34,35].

Quality assessment of the included studies

The quality of the studies was assessed using the JBI Critical Appraisal tool[36] with most studies receiving a rating of "good". A total of 10 (90.9%) studies met all eight quality criteria, including clearly defined sample inclusion, detailed subject descriptions, reliable measurement of exposure and outcomes, and appropriate statistical analysis (Supplementary material)[25-35].

DISCUSSION

This systematic review and meta-analysis demonstrate that COVID-19 has a substantial and lasting impact on HRQoL among people with a history of COVID-19 in India. The evidence consistently shows deterioration across physical, psychological, and social domains, particularly among individuals with advanced age, comorbidities, severe acute illness, or intensive care admission. Female participants were more likely to experience impaired HRQoL, while male sex appeared protective. Unvaccinated individuals also demonstrated worse recovery outcomes, underscoring the role of preventive measures.

The use of diverse but validated instruments including EQ-5D-5 L, EQ-VAS, SF-36, WHOQOL-BREF, and EUROHIS-QOL – adds strength to these findings by capturing multidimensional aspects of post-COVID well-being. Despite differences in tools and follow-up periods, a consistent pattern emerged: Patients with pre-existing conditions such as diabetes, HTN, and CKD, as well as those experiencing long-term fatigue, psychological stress, or social stigma, reported markedly lower HRQoL.

Extensive global research strongly corroborates these findings, indicating that the HRQoL repercussions of COVID-19 represent a significant and enduring challenge[37,38]. A study from Bangladesh observed that the participant’s physical health scores remained significantly lower than pre-infection levels even 12 months post-recovery[14]. Those who experienced severe COVID-19 or had pre-existing conditions faced considerable physical health limitations, particularly regarding mobility and daily activities, even 12 months after recovery[14]. This observation aligns with the current study's findings, which also indicate that in India, recovery of physical health and overall HRQoL is delayed by 25 days, ranges from 16 days to 34 days, particularly among individuals with chronic conditions whereas long COVID patients reported a median recovery time of approximately 7.9 months[39].

Similar findings have been reported in Europe, where research has examined the long-term effects of COVID-19 on quality of life across various health domains. Pooled results from Italian studies indicated that older adults, women, and patients with severe COVID-19 outcomes experienced poorer HRQoL, particularly in mental health and social interaction areas[16]. Individuals with more severe COVID-19 symptoms requiring hospitalization or intensive care had significantly lower HRQoL scores, emphasizing the correlation between disease severity and reduced post-recovery quality of life. Another national study from Italy based on analysis of death certificates, observed that COVID-19 was the underlying cause of death in 46.0% of cases associated with post-COVID conditions (n = 4752)[40].

The impact of comorbidities on HRQoL among people with a history of COVID-19 has also been investigated in other global contexts. A study conducted in Brazil a nationwide cross-sectional study found that comorbidities such as diabetes, cardiovascular disease, and obesity were significant predictors of decreased HRQoL following COVID-19[41]. Similar findings were observed in this review wherein patients with chronic diseases experienced inferior HRQoL during recovery post-COVID-19 since the pre-existing conditions exacerbated both physical and psychological symptoms associated with long COVID. The chronic conditions particularly diabetes and HTN often involve underlying immune system dysregulation, which is further accentuated by COVID-19, leading to prolonged inflammation and delayed recovery. Additionally, endothelial dysfunction, a common factor in both COVID-19 and chronic diseases, impairs vascular health and reduces oxygen delivery to tissues, contributing to persistent fatigue and diminished physical well-being[42]. Metabolic imbalances, frequently observed in conditions like diabetes, are also worsened by COVID-19, disrupting homeostasis and intensifying symptoms such as fatigue and muscle weakness, further impacting overall HRQoL[43]. In India, a parallel trend was observed, linking chronic conditions like diabetes and HTN to lower HRQoL scores. For instance, patients with diabetes and respiratory disorders reported ongoing symptoms such as fatigue and anxiety, further diminishing their quality-of-life weeks and months after their recovery from the infection.

Furthermore, gender-specific differences in HRQoL post-COVID-19 have been identified across various studies worldwide, with female patients often reporting lower quality of life reflected in higher levels of persistent fatigue, anxiety, and depressive symptoms compared to males[44,45]. A Prospective study conducted in India involving long COVID patients revealed that women's HRQoL scores, particularly in mental health and social domains were significantly lower than those of men, likely due to the additional psychological burdens and societal roles typically assumed by women[46]. Evidence from this systematic review including Indian studies also suggests that female patients tend to report higher burden of poorer mental health and increased anxiety compared to male patients. Although male participants were overrepresented in most included studies and generally reported higher HRQoL scores, the smaller proportion of female participants consistently demonstrated poorer outcomes, indicating a disproportionate burden of long-COVID among women.

The global studies on the social and psychological repercussions of COVID-19 indicated a widespread sense of isolation, stigma, and anxiety among survivors especially in the initial months after the pandemic[47-49]. A UK study emphasized the psychological toll on those affected by COVID-19, particularly among ethnic minorities who frequently encounter additional social discrimination and reduced access to quality healthcare services[50]. Similarly, this review found that studies employing the FCV-19S reported elevated levels of anxiety and psychological stress among those with a history of COVID-19 in India, some of whom also experienced social discrimination[25,33]. Addressing these psychological and social challenges is essential as they can impede recovery and intensify long-term mental health issues for survivors, especially in resource-limited settings.

Given the global consistency in challenges associated with long COVID, evidence strongly indicates that a multidisciplinary, patient-centred approach to post-COVID rehabilitation is crucial. Health systems worldwide are beginning to establish comprehensive post-COVID clinics and multidisciplinary rehabilitation programs that address physical, psychological, and social needs. For instance, Spain has launched a nationwide initiative offering tailored care for long COVID patients that includes physical rehabilitation, psychological counselling, and support for managing chronic comorbidities[51]. This model has shown promising results with improved HRQoL outcomes reported among participating patients. Implementing similar programs in India could prove highly beneficial due to the diverse range of post-COVID symptoms necessitating a holistic approach to care[52]. In addition to demographic and clinical determinants, post-COVID pulmonary sequelae such as lung fibrosis, reported in approximately 7% of survivors, represent an important factor that may further compromise HRQoL. The absence of high-resolution computed tomography-based assessment in most included studies limits our ability to directly evaluate this association, but it remains a critical area for future research. Specifically, targeted rehabilitation services for high-risk groups including older adults, women, and individuals with comorbidities – could help bridge gaps in long-term recovery from COVID-19.

Strengths and limitations

This study offers several strengths that enhance its contributions to understanding the long-term impacts of COVID-19 on HRQoL. Firstly, it employed a comprehensive data collection approach using a variety of validated HRQoL assessment tools, such as the EQ-5D-5 L, SF-36, and WHOQOL-BREF, which allowed for a robust analysis of different dimensions of HRQoL among people with a history of COVID-19. The inclusion of a diverse patient population from various demographics and clinical backgrounds further strengthens the generalizability of the findings, providing valuable insights into how factors like comorbidities and disease severity influence HRQoL outcomes.

The study acknowledges certain limitations. Interpretation of the pooled EQ-5D utility score requires caution due to the limited number of included studies (n = 3). Given the significant clinical diversity among these populations, the random-effects pooling serves primarily as a descriptive summary rather than a reliable prediction of the true post-COVID utility distribution. The sample size was limited in certain subgroups, potentially affecting the statistical power and generalizability of the results. The reliance on self-reported measures may introduce bias due to subjective interpretations of health status, with participants possibly overestimating or underestimating their symptoms. The findings may also be influenced by regional healthcare disparities and cultural factors specific to India, which might not be applicable to other contexts or countries. It is estimated that 7% of patients with COVID-19 develop persistent lung fibrosis[53]. However, the evaluation of COVID-19 related lung fibrosis in patients with respiratory symptoms using high-resolution computed tomography was not assessed in any of the studies which precluded assessment of this condition which is known to severely compromise HRQoL.

CONCLUSION

This systematic review and meta-analysis demonstrate that post-COVID HRQoL is suboptimal among people with a history of COVID-19 in India. Recovery outcomes are influenced by multiple determinants, with older age, female sex, comorbidities, severe disease, and lack of vaccination consistently associated with poorer HRQoL due to persistent impairment. These findings highlight the disproportionate burden faced by vulnerable groups and underscore the need for targeted interventions, including long-term follow-up, rehabilitation services, and integration of mental health support into post-COVID care. From a public health perspective, the evidence reinforces the importance of vaccination and proactive chronic disease management in mitigating the long-term consequences of COVID-19 in India.