ABSTRACT

Objective:

This study aimed to analyze the existence of an association between the biopsychosocial profile of people affected and the number of self-reported clinical complications from COVID-19 in a Brazilian city.

Methods:

This is a cross-sectional (baseline) study, nested in a cohort study, carried out with 217 confirmed cases of COVID-19, interviewed from January to October 2021, during home visits, in a city in the south of Minas Gerais, Brazil. A structured questionnaire with the KoboToolbox resource was used. The independent variables were sociodemographic and clinical profile (comorbidities), quality of life, post-traumatic stress, anxiety, depression, and social support. The dependent variable was the number of self-reported clinical complications from COVID-19. The multivariate linear regression technique was adopted for the analyses.

Results:

The participants reported multiple clinical complications from COVID-19. There were “four or more” complications in 94.6% of the cases. Having a history of high blood pressure was associated with more complications post-SARS-CoV-2 infection, whereas having a caregiver and presenting with post-traumatic stress were associated with fewer COVID-19 complications.

Conclusion:

The multisystemic nature of the complications caused by COVID-19 and the associations identified emphasizes the need for an integrated approach to patients and for studies that monitor the effects of the disease on the demands placed on health systems, aiming to better understand and address them.

Keywords:
COVID-19; Hypertension; Caregivers; Stress disorders; post-traumatic; Regression analysis

RESUMO

Objetivo:

Este estudo teve como objetivo analisar a existência de associação entre o número de complicações clínicas por COVID-19 autorreferidas e as características biopsicossociais de pessoas acometidas em um município brasileiro.

Métodos:

Tratou-se de um estudo transversal (primeira visita de seguimento), aninhado em uma coorte com 217 casos confirmados de COVID-19, entrevistados de janeiro a outubro de 2021, durante visitas domiciliares, em um município ao sul de Minas Gerais, Brasil. Foi utilizado um questionário estruturado com o recurso KoboToolbox. Características sociodemográficas, clínicas (comorbidades), qualidade de vida, estresse pós-traumático, ansiedade, depressão e apoio social compuseram o elenco de variáveis independentes. A variável dependente foi expressa pelo número de complicações clínicas autorreferidas decorrentes da COVID-19. Para as análises, utilizou-se técnica de regressão linear multivariada.

Resultados:

Os participantes referiram múltiplas complicações clínicas por COVID-19. Em 94,6% dos casos houve “quatro ou mais” complicações relatadas. Ter hipertensão arterial prévia esteve associado a maior número de complicações pós-infecção pelo SARS-CoV-2, enquanto ter um cuidador e apresentar estresse pós-traumático se associaram a menor número de complicações por COVID-19.

Conclusão:

Depreende-se que o caráter multissistêmico das multicomplicações por COVID-19 e que as associações identificadas reforçam a necessidade de uma abordagem integral às pessoas acometidas, bem como de estudos que acompanhem os efeitos da doença sobre as demandas dos sistemas de saúde, a fim de melhor compreendê-los e melhor enfrentá-los.

Palavras-chave:
COVID-19; Hipertensão; Cuidadores; Transtornos de estresse pós-traumáticos; Análise de regressão

INTRODUCTION

During the coronavirus pandemic, millions of people were infected with the SARS-CoV-2 virus and were affected by its clinical and social implications¹1 Matta GC, Rego S, Souto EP, Segata J, editors. Os impactos sociais da Covid-19 no Brasil: populações vulnerabilizadas e respostas à pandemia. Rio de Janeiro: Fiocruz; 2021 [Internet]. 2021 [cited on Jul 5, 2022]. Available at: http://books.scielo.org/id/r3hc2
http://books.scielo.org/id/r3hc2... ,²2 Campos MR, Schramm JMA, Emmerick ICM, Rodrigues JM, Avelar FG, Pimentel TG. Carga de doença da COVID-19 e de suas complicações agudas e crônicas: reflexões sobre a mensuração (DALY) e perspectivas no Sistema Único de Saúde. Cad Saúde Pública 2020; 36(11): e00148920. https://doi.org/10.1590/0102-311X00148920
https://doi.org/10.1590/0102-311X0014892... . The natural history of the COVID-19 has proven to be highly variable, sometimes sparing elderly centenarians who do not even present with major respiratory symptoms, and sometimes claiming the lives of young people who develop severe clinical complications³3 Bastard P. Why do people die from COVID-19? Science 2022; 375(6583): 829-30. https://doi.org/10.1126/science.abn9649
https://doi.org/10.1126/science.abn9649... . As knowledge about this disease expands, the post-infection clinical complications of the novel coronavirus have been recorded in the literature and represent a relevant contemporary public health problem, as they can lead to significant sequelae and/or death²2 Campos MR, Schramm JMA, Emmerick ICM, Rodrigues JM, Avelar FG, Pimentel TG. Carga de doença da COVID-19 e de suas complicações agudas e crônicas: reflexões sobre a mensuração (DALY) e perspectivas no Sistema Único de Saúde. Cad Saúde Pública 2020; 36(11): e00148920. https://doi.org/10.1590/0102-311X00148920
https://doi.org/10.1590/0102-311X0014892... ,⁴4 Galvão MHR, Roncalli AG. Fatores associados a maior risco de ocorrência de óbito por COVID-19: análise de sobrevivência com base em casos confirmados. Rev Bras Epidemiol 2020; 23: E200106. https://doi.org/10.1590/1980-549720200106
https://doi.org/10.1590/1980-54972020010... ,⁵5 Silva Júnior FJG, Sales JCS, Vieira CPB, Costa APC, Campos LRB, Miranda PIG, et al. Fatores associados à infecção em grupos com condições clínicas de risco para complicações por COVID-19. Reme Rev Min Enferm 2021; 25: e-1406. https://doi.org/10.5935/1415-2762-20210054
https://doi.org/10.5935/1415-2762-202100... .

Among the major COVID-19 complications previously described are either respiratory failure or acute respiratory distress syndrome (ARDS)⁶6 Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020; 323(11): 1061-9. https://doi.org/10.1001/jama.2020.1585
https://doi.org/10.1001/jama.2020.1585... –⁸8 Petrilli CM, Jones SA, Yang J, Rajagopalan H, O’Donnell L, Chernyak Y, et al. Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study. BMJ 2020; 369: m1966. https://doi.org/10.1136/bmj.m1966
https://doi.org/10.1136/bmj.m1966... , cardiac and cardiovascular complications⁶6 Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020; 323(11): 1061-9. https://doi.org/10.1001/jama.2020.1585
https://doi.org/10.1001/jama.2020.1585... ,⁹9 Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ 2020; 368: m1091. https://doi.org/10.1136/bmj.m1091
https://doi.org/10.1136/bmj.m1091... –¹¹11 Cao J, Tu WJ, Cheng W, Yu L, Liu YK, Hu X, et al. Clinical features and short-term outcomes of 102 patients with coronavirus disease 2019 in Wuhan, China. Clin Infect Dis 2020; 71(15): 748-55. https://doi.org/10.1093/cid/ciaa243
https://doi.org/10.1093/cid/ciaa243... , thromboembolic¹²12 Katsoularis I, Fonseca-Rodríguez O, Farrington P, Jerndal H, Lundevaller EH, Sund M, et al. Risks of deep vein thrombosis, pulmonary embolism, and bleeding after covid-19: nationwide self-controlled cases series and matched cohort study. BMJ 2022; 376: e069590. https://doi.org/10.1136/bmj-2021-069590
https://doi.org/10.1136/bmj-2021-069590... –¹⁴14 Helms J, Tacquard C, Severac F, Leonard-Lorant I, Ohana M, Delabranche X, et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med 2020; 46(6): 1089-98. https://doi.org/10.1007/s00134-020-06062-x
https://doi.org/10.1007/s00134-020-06062... , neurological¹⁵15 Liotta EM, Batra A, Clark JR, Shlobin NA, Hoffman SC, Orban ZS, et al. Frequent neurologic manifestations and encephalopathy-associated morbidity in Covid-19 patients. Annals of Clinical and Translational Neurology 2020; 7(11): 2221-30. https://doi.org/10.1002/acn3.51210
https://doi.org/10.1002/acn3.51210... ,¹⁶16 Nath A, Smith B. Neurological complications of COVID-19: from bridesmaid to bride. Arq Neuropsiquiatr 2020; 78(8): 459-60. https://doi.org/10.1590/0004-282X20200121
https://doi.org/10.1590/0004-282X2020012... , and inflammatory complications¹⁷17 Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395(10223): 497-506. https://doi.org/10.1016/S0140-6736(20)30183-5
https://doi.org/10.1016/S0140-6736(20)30... ,¹⁸18 Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ, et al. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet 2020; 395(10229): 1033-4. https://doi.org/10.1016/S0140-6736(20)30628-0
https://doi.org/10.1016/S0140-6736(20)30... . Such a body of evidence endorses, in this sense, that the factors that compose the health-disease process related to infections by the novel coronavirus SARS-CoV-2 and its impact on populations are diverse and multifaceted¹1 Matta GC, Rego S, Souto EP, Segata J, editors. Os impactos sociais da Covid-19 no Brasil: populações vulnerabilizadas e respostas à pandemia. Rio de Janeiro: Fiocruz; 2021 [Internet]. 2021 [cited on Jul 5, 2022]. Available at: http://books.scielo.org/id/r3hc2
http://books.scielo.org/id/r3hc2... ,¹⁹19 Shadmi E, Chen Y, Dourado I, Faran-Perach I, Furler J, Hangoma P, et al. Health equity and COVID-19: global perspectives. Int J Equity Health 2020; 19(1): 104. https://doi.org/10.1186/s12939-020-01218-z
https://doi.org/10.1186/s12939-020-01218... .

Therefore, there is a considerable registry of publications on systemic, organic, cellular, emotional, and mental health alterations, mostly in the hospital, educational, and work environments. However, the gap that has drawn attention is the fact that studies addressing jointly the relationship between COVID-19 clinical complications and the biopsychosocial profile of people in the community still need to be further expanded in the literature. Thus, for this work, the biopsychosocial profile was considered to be the set of sociodemographic and clinical traits (comorbidities), quality of life²⁰20 Fleck MPA, Louzada S, Xavier M, Chachamovich E, Vieira G, Santos L, et al. Aplicação da versão em português do instrumento abreviado de avaliação da qualidade de vida “WHOQOL-bref.” Rev Saúde Pública 2000; 34(2): 178-83. https://doi.org/10.1590/S0034-89102000000200012
https://doi.org/10.1590/S0034-8910200000... ,²¹21 The World Health Organization Quality of Life Assessment (WHOQOL): development and general psychometric properties. Soc Sci Med 1998; 46(12): 1569-85. https://doi.org/10.1016/s0277-9536(98)00009-4
https://doi.org/10.1016/s0277-9536(98)00... , post-traumatic stress²²22 Creamer M, Bell R, Failla S. Psychometric properties of the impact of event scale - revised. Behav Res Ther 2003; 41(12): 1489-96. https://doi.org/10.1016/j.brat.2003.07.010
https://doi.org/10.1016/j.brat.2003.07.0... , anxiety²³23 Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol 1988; 56(6): 893-7. https://doi.org/10.1037/0022-006x.56.6.893
https://doi.org/10.1037/0022-006x.56.6.8... –²⁵25 Cunha JA. Manual da versão em português das Escalas Beck. São Paulo: Casa do Psicólogo; 2001., depression²⁴24 Beck AT, Steer RA, Brown GK. BDI-II: beck depression inventory manual. San Antonio: Psychological Corporation; 1996.,²⁶26 Gorenstein C, Pang WY, Argimon IL, Werlang BSG. Inventário Beck de Depressão-II. Manual. São Paulo: Casa do Psicólogo; 2011., and social support²⁷27 Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med 1991; 32(6): 705-14. https://doi.org/10.1016/0277-9536(91)90150-b
https://doi.org/10.1016/0277-9536(91)901... –²⁹29 Zanini DS, Verolla-Moura A, Queiroz IPAR. Apoio social: aspectos da validade de constructo em estudantes universitários. Psicol Estud 2009; 14(1): 195-202..

This study aimed to analyze the existence of an association between the biopsychosocial profile of people affected and the number of self-reported COVID-19 clinical complications in a Brazilian city.

METHODS

This is a cross-sectional study (first recruitment visit), nested in the cohort study entitled “Longitudinal study of confirmed COVID-19 cases in Minas Gerais”.

The city where the study was carried out has an area of 850.446 km²2 Campos MR, Schramm JMA, Emmerick ICM, Rodrigues JM, Avelar FG, Pimentel TG. Carga de doença da COVID-19 e de suas complicações agudas e crônicas: reflexões sobre a mensuração (DALY) e perspectivas no Sistema Único de Saúde. Cad Saúde Pública 2020; 36(11): e00148920. https://doi.org/10.1590/0102-311X00148920
https://doi.org/10.1590/0102-311X0014892... and an estimated population of 80,973 inhabitants in 2021. The prevalent age group is 20–24 years, with a similar distribution between males and females. In 2020, the average monthly income was equivalent to 2.4 times the minimum wage³⁰30 Brasil. Instituto Brasileiro de Geografia e Estatística. Cidades. Alfenas [Internet]. 2022 [cited 2022 Sep 12]. Available from: https://cidades.ibge.gov.br/brasil/mg/alfenas/panorama
https://cidades.ibge.gov.br/brasil/mg/al... .

The reference population consisted of the first 1,923 confirmed COVID-19 cases residing in a Brazilian city located in the south of the state of Minas Gerais, diagnosed with COVID-19 between March 15 and October 26, 2020, and found in the compulsory notification registry of the City Health Department.

The following inclusion criteria were considered: an adult or elderly (aged 20 years or older), living in that city, confirmed COVID-19 cases through laboratory tests, not residing in a nursing home, and not deceased. Following the exclusion of 357 people for several reasons, a total of 1,566 people remained eligible.

The sampling process was developed by considering two strata, namely, hospitalized and community cases. For the sample calculation, stratified and proportional random sampling was considered, with the stratum based on the age group and admission (n=107) of patients hospitalized in the period and adding cases from the community who had not been admitted to a hospital in a ratio of 2.5:1. Thus, from the 1,566 eligible people, a sample size of 428 participants was estimated, already considering a 20% increase due to the possibility of losses by refusal or other causes. The estimated sample power (1−β) was equivalent to 88%.

Among all 428 cases of COVID-19, which were allocated for interviews, 211 were lost for different reasons. Considering only the “refusals” (n=71) and “three or more unsuccessful attempts” (n=38), the nonresponse rate was equivalent to 25.5% (71+38)/428, discarding registration errors (n=80) in the database used for the source of allocation of the study population, false positives (n=09), deaths (n=10), and others (n=03). Thus, the response rate was 74.5%, corresponding to 217 participants aged 20 years or older.

In this study, the sample was not divided into community or inpatient cases.

Due to the pandemic, careful preparation was required for the fieldwork, with a series of training sessions involving 27 professors, undergraduate students, scientific initiation students, and graduate students who participated as interviewers. Pretesting of the instrument and a pilot study were also carried out before starting data collection. The pilot study was carried out between November and December 2020 with 23 interviews. The people interviewed in the pilot study were approached by the undergraduate and graduate students during home visits and invited to participate in the study. The respondents were kept as research participants, as there were no content modifications in the collection instrument.

Data collection was carried out between January 11 and October 5, 2021, i.e., 6 months after the COVID-19 diagnoses, and the following strategies were adopted for the application of questionnaires:

1. Home visits for face-to-face interviews and

2. Telephone calls and WhatsApp messages due to the circulation restrictions socially imposed within the state.

The interviewers used tablets and smartphones during home visits and laptops or desktop computers to collect data remotely. Consent to participate in the study was obtained using a printed and signed informed consent form, as well as by audio recording and screenshots during phone calls and WhatsApp messaging.

An electronic questionnaire was developed by the executive team using the KoboToolbox, which is a free toolkit for collecting and managing field research data. The questionnaire included the informed consent form as well as the following instruments: sociodemographic and clinical profiling instrument (26 questions); quality of life assessment instrument (WHOQOL-Bref) — 26 items²⁰20 Fleck MPA, Louzada S, Xavier M, Chachamovich E, Vieira G, Santos L, et al. Aplicação da versão em português do instrumento abreviado de avaliação da qualidade de vida “WHOQOL-bref.” Rev Saúde Pública 2000; 34(2): 178-83. https://doi.org/10.1590/S0034-89102000000200012
https://doi.org/10.1590/S0034-8910200000... ,²¹21 The World Health Organization Quality of Life Assessment (WHOQOL): development and general psychometric properties. Soc Sci Med 1998; 46(12): 1569-85. https://doi.org/10.1016/s0277-9536(98)00009-4
https://doi.org/10.1016/s0277-9536(98)00... ; Impact of Event Scale-Revised (IES-R) — 22 items²²22 Creamer M, Bell R, Failla S. Psychometric properties of the impact of event scale - revised. Behav Res Ther 2003; 41(12): 1489-96. https://doi.org/10.1016/j.brat.2003.07.010
https://doi.org/10.1016/j.brat.2003.07.0... ; Beck’s Anxiety Inventory (BAI) — 21 items²³23 Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol 1988; 56(6): 893-7. https://doi.org/10.1037/0022-006x.56.6.893
https://doi.org/10.1037/0022-006x.56.6.8... –²⁵25 Cunha JA. Manual da versão em português das Escalas Beck. São Paulo: Casa do Psicólogo; 2001.; Beck’s Depression Inventory (BDI-II) — 21 items²⁴24 Beck AT, Steer RA, Brown GK. BDI-II: beck depression inventory manual. San Antonio: Psychological Corporation; 1996.,²⁶26 Gorenstein C, Pang WY, Argimon IL, Werlang BSG. Inventário Beck de Depressão-II. Manual. São Paulo: Casa do Psicólogo; 2011.; and the Medical Outcomes Study (MOS), Social Support Scale (SSS) — 19 items and 5 factors²⁷27 Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med 1991; 32(6): 705-14. https://doi.org/10.1016/0277-9536(91)90150-b
https://doi.org/10.1016/0277-9536(91)901... –²⁹29 Zanini DS, Verolla-Moura A, Queiroz IPAR. Apoio social: aspectos da validade de constructo em estudantes universitários. Psicol Estud 2009; 14(1): 195-202..

Dependent variables were the number of self-reported COVID-19 clinical complications, related to 6 months after diagnosis. The clinical complications caused by COVID-19 were previously codified (yes/no) into six categories, namely, respiratory, cardiac, neurological, hematological, vascular, and others. This variable was a result of a sum of positive responses for those categories, numerical and discrete nature, and was treated in its original form without the application of any cutoff point. The “PNorm” graph test was used to assess adherence to the Gaussian curve.

Independent variables were grouped into three blocks, namely, sociodemographic; comorbidities, health service access, and caregiver assistance; and biopsychosocial profile (quality of life, post-traumatic stress, anxiety, depression, and social support).

Sociodemographic variables: Male and female participants who were ≥20 years of age were included. Age in completed years was grouped into six categories by 10 years. Education was regarded as the number of completed years of formal education. Marital status was defined according to the presence or absence of a partner, regardless of formal union. Household density was calculated by the number of people/number of rooms (living, diner, and bedroom). Per capita income was calculated by total family income/number of people and classified into three categories according to the cutoff points defined by tertiles of the distribution.

Comorbidities, health service access, and caregiver assistance: The number of diseases reported by the participants (diabetes, obesity, high blood pressure, heart failure, asthma/bronchitis, respiratory failure, and others) was treated by the sum of positive responses for those comorbidities; becoming sick with dengue fever in the past 2 years (yes/no); sought health services for the treatment of preexisting diseases (yes/no); and sought health services to treat COVID-19 complications (yes/no).

Biopsychosocial profile: This includes WHOQOL-Bref (26 items)²⁰20 Fleck MPA, Louzada S, Xavier M, Chachamovich E, Vieira G, Santos L, et al. Aplicação da versão em português do instrumento abreviado de avaliação da qualidade de vida “WHOQOL-bref.” Rev Saúde Pública 2000; 34(2): 178-83. https://doi.org/10.1590/S0034-89102000000200012
https://doi.org/10.1590/S0034-8910200000... ,²¹21 The World Health Organization Quality of Life Assessment (WHOQOL): development and general psychometric properties. Soc Sci Med 1998; 46(12): 1569-85. https://doi.org/10.1016/s0277-9536(98)00009-4
https://doi.org/10.1016/s0277-9536(98)00... (global score and four domain scores: physical, psychological, social relationships, and environment); IES-R (22 items)²²22 Creamer M, Bell R, Failla S. Psychometric properties of the impact of event scale - revised. Behav Res Ther 2003; 41(12): 1489-96. https://doi.org/10.1016/j.brat.2003.07.010
https://doi.org/10.1016/j.brat.2003.07.0... (global scores and three domains scores: intrusion, avoidance, and hyperstimulation); BAI (21 items)²³23 Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol 1988; 56(6): 893-7. https://doi.org/10.1037/0022-006x.56.6.893
https://doi.org/10.1037/0022-006x.56.6.8... –²⁵25 Cunha JA. Manual da versão em português das Escalas Beck. São Paulo: Casa do Psicólogo; 2001.; BDI-II (21 items)²⁴24 Beck AT, Steer RA, Brown GK. BDI-II: beck depression inventory manual. San Antonio: Psychological Corporation; 1996.,²⁶26 Gorenstein C, Pang WY, Argimon IL, Werlang BSG. Inventário Beck de Depressão-II. Manual. São Paulo: Casa do Psicólogo; 2011. (global scores and two classifications according to Beck²⁴24 Beck AT, Steer RA, Brown GK. BDI-II: beck depression inventory manual. San Antonio: Psychological Corporation; 1996.: mild, moderate, and severe; and Gorenstein²⁶26 Gorenstein C, Pang WY, Argimon IL, Werlang BSG. Inventário Beck de Depressão-II. Manual. São Paulo: Casa do Psicólogo; 2011.: dysphoria and depression); and the MOS, SSS (19 items and 5 factors)²⁷27 Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med 1991; 32(6): 705-14. https://doi.org/10.1016/0277-9536(91)90150-b
https://doi.org/10.1016/0277-9536(91)901... –²⁹29 Zanini DS, Verolla-Moura A, Queiroz IPAR. Apoio social: aspectos da validade de constructo em estudantes universitários. Psicol Estud 2009; 14(1): 195-202. (five domain scores: material, affective, emotional, information, and positive social interaction).

Data processing

The information collected during the face-to-face and remote interviews was automatically transferred via electronic questionnaire to the KoboToolbox platform, where it was stored. Subsequently, the data were exported to a spreadsheet in Excel format and then transferred to Stata, version 13.1. At each batch of 50/100 records, the database was submitted to internal consistency tests (evaluation of the quality of information and missing data pattern). Once this phase was concluded, the final stage of data management was dedicated to the definitive categorization of the original variables and the generation of new variables.

Statistical analysis

Descriptive phase: Estimated frequencies were used for the characterization of the sample according to variables related to sociodemographic aspects; comorbidities, health service access, and caregiver assistance; biopsychosocial profile; and the number of self-reported COVID-19 complications.

Analytical phase: In this phase, all participants were considered, regardless of their stratum classification. To identify associated factors with the number of self-reported COVID-19 complications, crude and adjusted models were developed using multivariate linear regression. First, univariate analyses were run, according to each block of independent variables, excluding those that presented p-value >0.15 for Wald statistics. In the sequence, partially adjusted models, intra block, were run excluding those variables that presented p-value >0.10. The final model was run, and the variables with p-value <0.05 were retained. The final model was submitted to the goodness-of-fit test. All independent variables classified into more than two categories were treated as indicators (dummy variables). All analyses were run using Stata, version 13.1.

Ethical considerations

This study was approved by the Research Ethics Committee of the proposing institution, under CAAE number 34746620.6.0000.5142 and Legal Opinion number 4.317.149, on October 2, 2020. All participants registered their agreement to participate in the study, either physically or electronically, by signing the Informed Consent Form. The procedures used in this research were complied with the Ethics Criteria for Research with Human Beings.

RESULTS

This study’s response rate was 74.5%, excluding filling errors in the registration of patients, deaths, addresses located in rural areas of the city, and others.

The median time elapsed between the COVID-19 diagnosis and the interview was 6.2 months (IQR=5.0) and the mean was 6.7 months (SD=2.9).

Regarding the main sociodemographic traits of the 217 participants, the mean age was 58.3 years (SD=14.8), with the youngest being 20 years and the oldest being 91 years. The most frequent age group was 60–69 years, with 65 (30.0%) participants, and the least expressive was 20–29 years, with 9 (4.1%) respondents. Among the participants, 121 (55.8%) respondents were female, 150 (69.1%) lived with a partner, 74 (34.2%) reported having an education of 4–7 years, and the average individual income was 1637.33 BRL (mean values and their respective SD are not shown). The participants reported multiple clinical complications from COVID-19. There were “four or more” complications in 94.6% of the cases (Table 1).

Regarding the association analysis, multiple linear regression and partial adjustment models were applied to help identify the role that biopsychosocial factors played in increasing or decreasing the mean of self-reported clinical complications among the positive cases of COVID-19. The evolution of the models with the contribution of sociodemographic, health, psychosocial, and care factors associated is presented in Tables 2–4.

The final model with the contribution of the three correlated factors with the modulation of the mean number of self-reported COVID-19 complications is presented in Table 5.

No associations were identified among sociodemographic factors, quality of life, anxiety, depression, social support, and the number of self-reported COVID-19 clinical complications in the final model. However, association was noted with the factors such as having a caregiver, a history of high blood pressure, and post-traumatic stress.

Regarding the types of associations identified, having a caregiver influences the reduction of the mean of these unfavorable outcomes by -0.66 points. Having a high blood pressure can increase the mean number of clinical complications among the participants by 0.23 points. As for post-traumatic stress, each point lower in the post-traumatic stress score contributes -0.01 points to the mean post-COVID-19 clinical complications score.

DISCUSSION

The COVID-19 clinical complications have emerged as an important health problem³¹31 Pontes L, Danski MTR, Piubello SMN, Pereira JFG, Jantsch LB, Costa LB, et al. Perfil clínico e fatores associados ao óbito de pacientes COVID-19 nos primeiros meses da pandemia. Esc Anna Nery 2022; 26: e20210203. https://doi.org/10.1590/2177-9465-EAN-2021-0203
https://doi.org/10.1590/2177-9465-EAN-20... that needs to be studied in light of biopsychosocial determinants to be better understood and addressed. This study’s main findings were that having a history of high blood pressure was associated with more self-reported post-SARS-CoV-2 infection complications and that both post-traumatic stress and having a caregiver were associated with fewer (self-reported) COVID-19 clinical complications.

Having a high blood pressure was positively associated with the number of (self-reported) coronavirus disease complications, indicating that high blood pressure could increase the average number of clinical complications among participants by 0.23 points. To date, the SARS-CoV-2 virus can directly infect target cells by coupling to the angiotensin-converting enzyme 2 (ACE 2) receptor and that such binding decreases the activity of this type of receptor, generating increased vascular permeability³²32 Almeida-Pititto B, Dualib PM, Zajdenverg L, Dantas JR, Souza FD, Rodacki M, et al. Severity and mortality of COVID 19 in patients with diabetes, hypertension and cardiovascular disease: a meta-analysis. Diabetol Metab Syndr 2020; 12: 75. https://doi.org/10.1186/s13098-020-00586-4
https://doi.org/10.1186/s13098-020-00586... . This receptor has a higher expression in the lungs and heart, which is vital for the functionality of these systems³³33 Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system. Nat Rev Cardiol 2020; 17(5): 259-60. https://doi.org/10.1038/s41569-020-0360-5
https://doi.org/10.1038/s41569-020-0360-... . Despite these findings, according to a review study published in November 2021, questions remain regarding the actual mechanism by which a high blood pressure leads to unfavorable outcomes in patients with COVID-19³⁴34 Peng M, He J, Xue Y, Yang X, Liu S, Gong Z. Role of hypertension on the severity of COVID-19: a review. J Cardiovasc Pharmacol 2021; 78(5): e648-55. https://doi.org/10.1097/FJC.0000000000001116
https://doi.org/10.1097/FJC.000000000000... . Thus, attention is still needed for future studies to evaluate the mechanisms responsible for the hypertension-related worsening of cases and mortality from COVID-19.

It was also found that having caregiver assistance, meanwhile, represented a -0.66 point reduction in the mean number of (self-reported) COVID-19 complications. A previous study with 16 patients and 25 caregivers, conducted between May and June 2020, pointed out that caregivers played an important role in protecting patients at risk of COVID-19 by ensuring patient self-care through direct and indirect interventions³⁵35 De Maria M, Ferro F, Vellone E, Ausili D, Luciani M, Matarese M. Self-care of patients with multiple chronic conditions and their caregivers during the COVID-19 pandemic: a qualitative descriptive study. J Adv Nurs 2022; 78(5): 1431-47. https://doi.org/10.1111/jan.15115
https://doi.org/10.1111/jan.15115... . However, in a study with 139 caregivers with dementia during the pandemic, it was found that only a few of them knew of atypical presentations and how to recognize the warning signs of COVID-19 emergencies³⁶36 Remoli G, Canevelli M, Robertazzo UM, Nuti F, Bacigalupo I, Salvi E, et al. Supporting and protecting people with dementia in the COVID-19 pandemic. J Alzheimers Dis 2021; 83(1): 43-9. https://doi.org/10.3233/JAD-210264
https://doi.org/10.3233/JAD-210264... .

This study results indicate that having a caregiver can be a protective factor for COVID-19 complications, which refers to the importance of this social/caregiver factor in the current pandemic context. People who depend on the care of others are particularly more vulnerable to risk exposure due to the frailty of their care, the breaking of bonds, exclusion, abandonment, and worsening of survival, especially in moments of greater social frailty aggravated by the COVID-19 pandemic. Therefore, the caregiver can be a protective factor, as protection is indissociable from care and covers initiatives that support, welcome, provide help, and take actions that are intended to prevent something from happening³⁷37 Brasil. Ministério do Desenvolvimento Social. Secretaria Nacional de Assistênvia Social. Departamento de Proteção Social Básica. Orientações técnicas sobre o service de proteção social básica no domicílio para pessoas com deficiência e idosas. Brasília: Ministério do Desenvolvimento Social, Secretaria Nacional de Assistência Social; [Internet] 2017. [cited on Abr 11, 2022]. Available at: http://www.mds.gov.br/webarquivos/assistencia_social/caderno_PSB_idoso_pcd_1.pdf
http://www.mds.gov.br/webarquivos/assist... ,³⁸38 Boff L. Saber cuidar: ética do humano, compaixão pela terra. 6ᵃ ed. Petrópolis: Vozes; 1999., which contributes to reducing vulnerability to COVID-19 complications³⁹39 Dias BC. Pandemia da Covid-19 e um Brasil de desigualdades: populações vulneráveis e o risco de um genocídio relacionado à idade [Internet]. 2020 [cited on Jun 22, 2022]. Available at: https://www.abrasco.org.br/site/gtenvelhecimentoesaudecoletiva/2020/03/31/pandemia-do-covid-19-e-um-brasil-de-desigualdades-populacoes-vulneraveis-e-o-risco-de-um-genocidio-relacionado-a-idade/
https://www.abrasco.org.br/site/gtenvelh... .

Another important aspect regarding the association between having a caregiver and the reduction in the mean number of complications self-reported by COVID-19 is that the variable “having a caregiver” can also be a proxy for other sociodemographic and clinical factors, such as age, income, and multimorbidity, among other characteristics not controlled in the study. Therefore, as this control and/or adjustment were not performed, this hypothesis needs to be further investigated in future studies.

The overall score related to the impact of the event “sick with COVID-19” also had a negative association with the number of complications (self-reported) by the disease, indicating that each point in the post-traumatic stress classification would have contributed to -0.01 points in the mean of post-COVID-19 clinical complications. Regarding the development of post-traumatic stress disorder (PTSD), such a condition is not just related to traumatic events, but it also requires a combination of factors such as personality traits, inadequate social support, the presence of traumatic experiences in childhood, gender, genetic vulnerability to psychiatric illnesses, or recent stressful experiences that lead to life changes⁴⁰40 Sherin JE, Nemeroff CB. Post-traumatic stress disorder: the neurobiological impact of psychological trauma. Dialogues Clin Neurosci 2011; 13(3): 263-78. https://doi.org/10.31887/DCNS.2011.13.2/jsherin
https://doi.org/10.31887/DCNS.2011.13.2/... .

Studies carried out in China have shown that the prevalence of PTSD symptoms ranges between 3 and 7 percent of adults⁴¹41 Tang W, Hu T, Hu B, Jin C, Wang G, Xie C, et al. Prevalence and correlates of PTSD and depressive symptoms one month after the outbreak of the COVID-19 epidemic in a sample of home-quarantined Chinese university students. J Affect Disord 2020; 274: 1-7. https://doi.org/10.1016/j.jad.2020.05.009
https://doi.org/10.1016/j.jad.2020.05.00... ,⁴²42 Liu N, Zhang F, Wei C, Jia Y, Shang Z, Sun L, et al. Prevalence and predictors of PTSS during COVID-19 outbreak in China hardest-hit areas: gender differences matter. Psychiatry Res 2020; 287: 112921. https://doi.org/10.1016/j.psychres.2020.112921
https://doi.org/10.1016/j.psychres.2020.... , being reported symptoms of intrusion, avoidance, negative changes in mood and cognition, and hyperexcitation⁴²42 Liu N, Zhang F, Wei C, Jia Y, Shang Z, Sun L, et al. Prevalence and predictors of PTSS during COVID-19 outbreak in China hardest-hit areas: gender differences matter. Psychiatry Res 2020; 287: 112921. https://doi.org/10.1016/j.psychres.2020.112921
https://doi.org/10.1016/j.psychres.2020.... . Studies on the neurobiology of PTSD show that gaps to be clarified still exist, but there is an activation of the hypothalamic-pituitary-adrenal axis and, consequently, the release of glucocorticoids, in particular cortisol, which play an important role in the stress response. Glucocorticoids modulate stress-related physiological patterns, such as metabolic, brain, and immune functions, as their main function of regulation and restoration of the autonomic response to stress, assisting in the restoration of organ functions⁴⁰40 Sherin JE, Nemeroff CB. Post-traumatic stress disorder: the neurobiological impact of psychological trauma. Dialogues Clin Neurosci 2011; 13(3): 263-78. https://doi.org/10.31887/DCNS.2011.13.2/jsherin
https://doi.org/10.31887/DCNS.2011.13.2/... ,⁴³43 Yehuda R. Advances in understanding neuroendocrine alterations in PTSD and their therapeutic implications. Ann N Y Acad Sci 2006; 1071(1): 137-66. https://doi.org/10.1196/annals.1364.012
https://doi.org/10.1196/annals.1364.012... .

It is known that comorbidity rates are high in PTSD patients⁴⁴44 Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995; 52(12): 1048-60. https://doi.org/10.1001/archpsyc.1995.03950240066012
https://doi.org/10.1001/archpsyc.1995.03... –⁴⁶46 Koenen KC, Moffitt TE, Caspi A, Gregory A, Harrington H, Poulton R. The developmental mental-disorder histories of adults with posttraumatic stress disorder: a prospective longitudinal birth cohort study. J Abnorm Psychol 2008; 117(2): 460-6. https://doi.org/10.1037/0021-843X.117.2.460
https://doi.org/10.1037/0021-843X.117.2.... , with approximately two-thirds of those affected by post-traumatic stress experiencing at least two other illnesses⁴⁴44 Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995; 52(12): 1048-60. https://doi.org/10.1001/archpsyc.1995.03950240066012
https://doi.org/10.1001/archpsyc.1995.03... . In addition, studies have also shown that other conditions can increase vulnerability to PTSD⁴⁷47 Silver E, Arseneault L, Langley J, Caspi A, Moffitt TE. Mental disorder and violent victimization in a total birth cohort. Am J Public Health 2005; 95(11): 2015-21. https://doi.org/10.2105/AJPH.2003.021436
https://doi.org/10.2105/AJPH.2003.021436... . In light of this evidence, the result found in this research that post-traumatic stress was associated with fewer clinical complications is not supported in the literature, especially considering that individuals with PTSD are more susceptible to chronic diseases.

It is believed that the instrument’s questions, whose content refers to people’s attention to “getting sick with COVID-19 as a stressing event” may have contributed to a situation where the individuals who were more attentive and concerned about the disease may have been people who performed self-care more often or sought care early, which is a hypothesis for their having experienced fewer complications after SARS-CoV-2 infection. However, without these answers, it is inferred that such an association may also have occurred by reverse causality or that the other health conditions of those with PTSD symptoms may have been uncontrolled confounding factors in this research, constituting a methodological limitation to be considered.

The movement restrictions carefully targeted as preventive measures in the context of the COVID-19 pandemic contributed significantly to the challenges inherent to advancing fieldwork. During the research period, there were losses, refusals, and problems with the location data of positive cases of COVID-19 used to access and invite the target audience of interest. Such conditions and situations meant that the total number of participants was lower than what had been originally expected.

The use of self-reported variables and the number of complications as dependent variables were also limitations of this study. It should be noted that the pandemic context contributes to justifying the adoption of questions developed by the project execution team, rather than a set of previously validated questions. In the first scenario of a health emergency triggered by the global spread of SARS-CoV-2, there were no published studies with the specific approach of interest, which rendered impossible in the selection of a validated instrument that could meet the objective of characterizing the clinical complications resulting from COVID-19 at that moment.

Therefore, by recognizing and discussing such limitations that hinder a more detailed understanding of the severity of the clinical conditions experienced by the participants and that may eventually compromise the generalization of the results, it is suggested to address the external validity of the findings and to develop other sequential research aiming to contemplate the aspects that were not possible to address in this study.

This study advances knowledge by concluding that among the biopsychosocial aspects analyzed, having a history of high blood pressure was associated with more self-reported clinical complications, while having a caregiver and presenting post-traumatic stress were associated with fewer unfavorable implications by COVID-19. The multisystemic nature with which the disease was presented among this study’s participants emphasizes that the attention to this disease and to the people affected must also be based on a systemic approach, centered on the individual, from the perspective of integral care. Considering COVID-19 potential to generate persistent symptoms as well as acute and chronic complications, it is still necessary to move forward with studies on the effects of the disease, as these aspects tend to increase and modify the demands on health systems.

ACKNOWLEDGMENT:

We would like to thank Isabel Cristina Martins de Freitas, PhD, for the methodological and statistical support.

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