We conducted a mixed-method situation analysis study with our main aim to explore the post–COVID-19 management landscape by assessing the needs, preferences, challenges, and existing interventions and strategies for patients with post–COVID-19 complications in Johannesburg, South Africa.

We conducted this study at the Chris Hani Baragwanath Academic Hospital (CHBAH) and Tembisa Provincial Tertiary Hospital (Tembisa), Johannesburg, South Africa. These health care facilities are located in townships in the City of Johannesburg and Ekurhuleni districts and cater to the general population. They are public health care facilities funded by the Gauteng Department of Health. Participants were recruited from outpatient medical and rehabilitation departments at the respective facilities, where patients who had COVID-19 disease were invited to participate, and health care workers who had managed patients with COVID-19 were invited to participate. Potential participants were approached in the waiting areas of clinics, where prescreening procedures assessing COVID-19 history were done followed by full informed consent if potential participants were willing. The study was conducted between December 2022 and February 2023, which was 11-months after the last clear reported COVID-19 wave in South Africa [26].

We collected quantitative data through a cross-sectional standardized questionnaire-based interview (see Multimedia Appendix 1) administered by the research staff with individuals who were previously diagnosed with COVID-19. The questionnaire covered topics on post–COVID-19 symptoms, experience with rehabilitation programs, challenges, preferences, and suggestions for potential interventions. A total of 2 research assistants (male and female) and a research nurse (female) were trained and collected the survey data. We used descriptive statistics to summarize the data in frequencies, mean and median, using Microsoft Excel.

The qualitative study included semistructured in-depth interviews with health care workers who manage COVID-19 patients and focus group discussions (FGDs) with individuals who had post–COVID-19 symptoms. Separate interviews were used with health care workers to allow in-depth conversation on each discipline, and FGDs were used with patients to allow a broad conversation flow of COVID-19 reflection and to encourage group sharing (see Multimedia Appendices 2 and 3). Interviews and FGDs were facilitated by the research team (3 females and 1 male), in English, except 2 FGD’s conducted in a combination of English, isiZulu, and Sepedi. The duration of the interviews and FGDs ranged from 10-minutes to 90-minutes depending on participant availability and willingness to engage in the content of the questions. A guide was used for the interviews focusing on health care worker reflection on managing COVID-19 patients, challenges and perceived need for rehabilitation; and a guide was used in the FGDs to discuss patient post–COVID-19 experiences and rehabilitation needs and challenges. Both guides allowed for flexibility of the discussion. Interviews and FGDs were recorded, transcribed, coded, and deductive thematic analysis was carried out focusing on main concepts for the intervention development.

Quantitative and qualitative data were triangulated through an iterative process to ensure the coherence of findings and obtain more insights on the desirable content and format of the intervention.

The creation of the intervention followed the steps described in the Group Intervention framework [27]. We ensured a suitable context and setting for the intervention. Following this, we designed the group intervention addressing outcomes and measurements, sampling into groups, quantity of groups, and structure of the intervention. Finally, during the delivery of the intervention, we introduced team briefings and group notes to describe and reflect on the dynamics within each group and session, position of group participants and leaders, and communication.

The data collected in the situation analysis and available evidence in post–COVID-19 rehabilitation fed into the content and delivery format of the intervention. The design process, implementation, and evaluation plan for the intervention are described in more detail in the Results section. The outcomes of the intervention are being analyzed and will be presented in a separate paper.

We obtained ethical approval for the situation analysis from Wits Human Research Ethics Committee (230405), and the 2 facilities, CHBAH and Tembisa Hospital. All participants gave written informed consent before participation. The study data are deidentified to protect participant confidentiality. Participants received R 300 (US $16.85) cash reimbursement for each study visit covering costs for travel and time.

Using the information obtained from the situation analysis and existing evidence on post–COVID-19 rehabilitation, we developed an in-person support group program for people with post–COVID-19 complications titled CoPilot. The main study objective was to assess the change in physical and psychological well-being in patients with post–COVID-19 sequelae before and after the pilot intervention. To guide the program and evaluation we present a theory of change (Figure 1). The main intended impact of the intervention is to improve the overall health and well-being of COVID-19 survivors.

The target population for the intervention was individuals who had been diagnosed with COVID-19 and were experiencing ongoing post–COVID-19 complications according to the WHO post–COVID-19 condition definition [3]. The participants were recruited from out-patient medical and rehabilitation departments at the health care facility, including both patients and health care providers, and further participants were recruited by snowball sampling. Eligibility criteria included: self-reported or diagnosed previous COVID-19; adults aged 18-years and older; reporting at least one symptom lasting for more than 2 months, at least 3 months since COVID-19, which could not otherwise be explained by another condition; and willingness to provide written informed consent and to follow study procedures. Reported symptoms could include, but were not limited to, fatigue, breathlessness, pain or discomfort, impaired sleep, or impaired usual activity [2]. Participants with known severe medical or psychiatric conditions which affected ability to consent or participate, or required a higher level of care were excluded.

Group formats in rehabilitation have been shown to strengthen curative factors like universality and altruism, to provide peer and social support, to share coping strategies, and to practice gratitude [28,29]. Taking this into account, with the strong findings for group support in post–COVID-19 rehabilitation from our situation analysis, we designed and conducted a group-based intervention. The program consisted of weekly in-person group sessions over eight-weeks complimented by home-tasks and self-management exercises, with the option to adapt tasks to each person’s abilities. We had 7 groups where each group consisted of 8 to 10 participants. Our target sample size was 60, which was informed by evidence that sample sizes of 24‐50 are sufficient to estimate the key parameters of an efficacy and feasibility trial [30]. Sessions were guided by the predesigned schedule and a duration of one-hour, but with flexibility for participant experiences and needs. The core of the sessions involved research staff facilitating discussion around participants’ post–COVID-19 experiences, challenges and self-management strategies whilst encouraging group support and education on post–COVID-19 complications. Select sessions included invited rehabilitation specialists (eg, psychologist, physiotherapist, and dietician) for additional expertise. If any participant missed a session, they were contacted telephonically to explain the weekly tasks. If participants missed a session and were not contactable, they were regarded as lost-to-follow-up.

The content of the intervention was guided by the findings from our situation analysis, the WHO Brochure “Support for rehabilitation: self-management after COVID-19-related illness [31] and from the HOPE intervention for people with post–Covid-19 conducted by Wright et al [21]. The detailed description of the session’s content, weekly themes, evidence that informed the themes are shown in Table 2 along with the planned duration of the session and home-tasks.

Monitoring of the intervention was done using a participant registry, discussions at each session to review understanding of the content and tasks, and completion of a questionnaire to assess adherence to tasks and subjective progress.

The evaluation of the intervention was performed by measuring effectiveness (pre-and postintervention assessment) and a process evaluation (including feasibility and acceptability) of the group intervention. The main effectiveness outcomes included: (1) lung function, (2) mental well-being, and (3) quality of life. Data collection included baseline information on demographics and knowledge of COVID-19 and sequelae. The pre-post-intervention assessments included questionnaires on COVID-19 symptoms, fatigue and sleepiness scales [21,32,33], quality of life using the EuroQoL 5-Dimension 5-Level (EQ-5D-5L) [34], short Warwick-Edinburgh Mental Wellbeing Scale to describe mental well-being [35], lung function testing by means of spirometry, and functional capacity by 1-minute sit-to-stand test [36]. The process evaluation was guided by the Medical Research Council framework to assess both the implementation process (how the project is delivered), what is delivered (fidelity, dose, adaptations, or reach) and contextual factors influencing the implementation and acceptability of the intervention [37]. We used mixed methods to assess feasibility and acceptability of the intervention through a questionnaire and semistructured interviews with participants to elaborate on the design of the intervention, the potential barriers, and facilitators. Data from the intervention will be analyzed using descriptive statistics producing frequencies, means, and proportions of the different variables of interest. Outcomes will be analyzed using paired sample t tests. Qualitative process evaluation data will be transcribed and analyzed by thematic analysis.

To the best of our knowledge, this is the first study to develop and implement a context-adapted group intervention for post–COVID-19 survivors in South Africa. It was aimed to address debilitating consequences of COVID-19 and provide people with the tools to manage their symptoms to improve every-day quality of life and potentially health outcomes including mental and lung health. This situation analysis and intervention development highlighted 2 main points: first, engaging with patients and health care workers on their perspectives on post–COVID-19 care is an integral component in developing management strategies for post–COVID-19 complications, and second, that mental health support should strongly be considered in rehabilitation guidelines post–COVID-19 while considering support groups as a component.

Engaging with health care providers and patients’ perspectives on post–COVID-19 complications and the management thereof is a crucial step in guideline development. The cornerstone to this is understanding the patient experience of post–COVID-19 complications and leveraging on existing and innovative strategies for care [21,25]. Fatigue is a common symptom reported post–COVID-19; however, it has been described by patients to have physical, mental, and emotional components [6,21], thereby illustrating that understanding the problem on a deeper level can help direct health services toward patient needs, as well as develop suitable assessment measures for patient-reported outcomes [9]. Understanding patient and health care provider perspectives and communication between them has been shown to be important in HIV care, specifically relating to social, mental health, and health care system challenges [38]. In addition, coworking and partnership with shared responsibility in care between health care provider and patient with a focus on self-management principles were recognized as key features in the management process of other chronic lung diseases [24]. Taking into account the health resource limitations in LMICs and the strain on insufficient rehabilitation services poses another challenge to the management of post–COVID-19 complications, emphasizing the need for context-adapted guidelines [39].

The importance of the need for mental health support was a major theme that came through during our situation analysis. Mental health symptoms have been reported in up to 21% of people post–COVID-19 and can include anxiety, depression, sleep disorders, and neurocognitive disorders [4,6]. In a study by Rofail et al [9], it was reported that despite no clear psychological diagnosis, most impacts on daily life were not attributed to any singular symptom, but rather to the holistic experience of COVID-19 infection, further supporting the need to support psychological processing in recovery. Findings from our situation analysis clearly showed the gaps in psychological support for patients and health care providers post–COVID-19 and that these services are sought after as an adjunct to post–COVID-19 care. More specifically, support groups were suggested as helpful platforms to engage in psychological support, facilitating connection and shared experiences. This focus in care has been shown to be valued and helpful in support of patients with other chronic lung conditions [24].

One limitation is that this was a narrow population, where participants were only recruited from 2 facilities; however, to overcome this we recruited from multiple departments and recruited both health care providers and patients in order to increase variation. Another limitation was the heterogeneity of the post–COVID-19 sequelae definition, where interpretation conducted by the study team was to meet the WHO post–COVID-19 condition definition. This could result in bias of either overestimating or underestimating post–COVID-19 consequences, depending on alternate definitions used in other contexts. Despite this, consistency was maintained throughout recruitment for the situation analysis and planned intervention, and symptoms were clearly documented.

The strengths of the study include the context and population of the study where post–COVID-19 rehabilitation has not been studied previously. Another strength includes the mixed-methods approach for both the situation analysis and intervention in order to obtain deeper insight into the rehabilitation post–COVID-19.

Understanding the characteristics and burden of post–COVID-19 complications, particularly from the patient and health care provider perspectives, helps to direct post–COVID-19 management principles to ensure a more holistic recovery. As more people recover from COVID-19, it becomes crucial to maximize on the opportunity to better understand postviral complications and adapted health service allocation, particularly in LMICs. We believe that our group intervention holds a potential to improve health and well-being of people living with post–COVID-19 complications in Johannesburg, and its effectiveness and feasibility will be analyzed in the next steps.