Our study utilised a phenomenological qualitative design using semi-structured interviews, allowing personal accounts to be shared about the common phenomenon and providing valuable insight into participants’ first-hand experiences (Creswell 2014). Open-ended questions explored the lived experiences of PLWLC on the influence of long-COVID on physical activities. This encouraged participants to construct meaning and create discussions about their sickness trajectory, physical activity experiences and course of recovery.

Data were collected during the COVID-19 pandemic in 2022 and conducted in an outpatient private healthcare facility in a lower-to-middle income area in the eThekwini district, South Africa. This facility provided follow-up consultation services to PLWLC and services residents within a 5-km radius. Depending on the patient’s financial status, the facility consults at discounted rates or free.

Our study population included males and females living with long-COVID in a low-to-middle income area from diverse ethnic groups and aged from 24 to 80 years.

Purposive maximum variation sampling was used by selecting participants over 18 years old who accessed care at our study site, experienced persistent COVID-19 symptoms for 4 weeks post-diagnosis that affected their pre-COVID physical activity levels, were not dependent on assistance to carry out ADLs pre-COVID and did not have underlying cognitive disorders that would hinder comprehension and communication abilities. These cognitive disorders were screened by the facility’s doctors and psychologists. At the time of recruitment, the facility’s staff contacted long-COVID patients who were diagnosed with COVID-19 between 2020 and 2022 from their medical records and acquired permission for the authors’ involvement for further screening. Of the 42 patients contacted, 10 did not meet all the inclusion criteria, nine did not respond and six did not consent. Only 17 participants were included in our study.

Within 48 h following the interviews, audio recordings were transcribed verbatim using the software REV (2022). The accuracy of the transcription was verified by the authors listening to the audio recording while reading the transcript for each participant. Participants verified their transcripts and approved the information without changes, and this ensured trustworthiness (Lim 2025). An inductive conventional thematic data analysis was performed, using a step-wise approach (familiarisation; coding; initial theme generation; theme review; defining and naming themes) to produce the report (Nowell et al. 2017). Digital transcripts were read repeatedly to obtain an overall impression of the material collected, and subsequently, initial codes were identified and ideas were extracted into themes through an inductive process. Dependability was achieved by peer evaluation of the authors’ generated themes and quotes by research supervisors (Lim 2025). The authors discussed and deliberated until a consensus on final themes was reached. Transferability was attained by documenting our study’s process and methodology (Lim 2025).

Ethical approval was obtained from the University of KwaZulu-Natal’s Research Ethics Committee (reference number: HSSREC/00004323/2022). All processes adhered to the approved ethics guidelines. Participants completed and signed a written information sheet with an informed consent form detailing the intent and purpose of our study, its voluntary nature, the right to withdraw at any moment and permission to be audiotaped in the interviews. Pseudonyms were used to ensure anonymity in the data. The data were kept in encrypted electronic devices, accessible to the authors only, to ensure confidentiality.

From the data collected, four major themes emerged: perceptions of pre-COVID and post-COVID physical activities in daily life, approaches to coping strategies with physical activity limitations, perceptions of physical activity’s influence on recovery and progressive informal exercise therapy.

The greatest challenge related to long-COVID is its extensive and crippling symptom profile (Hayes, Ingram & Sculthorpe 2021; Thomas et al. 2023). Joint pains, muscle weakness, dizziness, PEM and exacerbation of underlying conditions were examples of some of the debilitating symptom profiles that our study’s participants experienced, leading to reduced exercise capacity and impaired mobility. These symptoms are aligned with the long-COVID symptom profiles, recognised in global and national studies (Davis et al. 2023; Jassat et al. 2023; Tziolos et al. 2023). Participants described fatigue and dyspnoea as the most common debilitating symptoms, which reinforce findings by Jassat et al. (2023) and Hossain et al. (2023). In support of recommendations to create long-COVID-specific rehabilitation strategies, our study highlights the need for interventions by rehabilitation regimes specifically targeted for fatigue and dyspnoea in PLWLC (Hawke et al. 2023; Vélez-Santamaría et al. 2023).

Impaired communication, mobility and essential work skills resulted in fewer work targets being reached, meeting absenteeism and reduced engagement with clients post-COVID. Participants attributed their poor work performance to long-COVID symptoms (e.g. breathlessness), challenging structural environments (e.g. stairs and long corridors) and functional impairments (e.g. inability to sew and communicate). This is concerning as those who could not meet pre-COVID productivity levels experienced a poor return to work and faced a threat to their financial stability, such as reduced income, early retirement or job losses, especially to those who did not have formalised job protection (Faghy et al. 2022; McNabb et al. 2023). Ottiger et al. (2024) assert that approximately 60.9% of PLWLC successfully return to work post-COVID. This draws attention to the need for modifications to PLWLC’s workspace and a review of their working hours to aid recovery and occupational reintegration.

To live independently, ADLs are essential skills needed and commonly used to evaluate physical functioning (Humphreys et al. 2021). As reflected in our study population, all participants pre-COVID were independent and could carry out their daily activities timeously. Most participants described themselves as highly involved in leisure activities pre-COVID, participating in sports, walking to work or shops or physical engagement in family activities and social events. However, post-COVID, participants expressed challenges and frustration when undertaking these activities. Consequently, individuals utilised assistive devices or required assistance from loved ones to complete the rest of their duties. This is similar to Hawke et al. (2023), Vélez-Santamaría et al. (2023) and Faghy et al. (2022), where PLWLC relied on others when executing ADLs, and some required canes or wheelchairs for mobility. Pre-COVID activities that were once considered low intensity were now activities that exacerbated symptoms and led to prolonged resting periods. Thus, participants did not take up ADLs, leisure activities or work activities that consumed too much energy or time. Likewise, in Humphreys et al. (2021), participants found self-care and domestic duties difficult, with formal exercise inconceivable, resulting in house confinement for months. These findings reflect the profound and lasting impact of long-COVID on functional independence and suggest a pattern consistent with the limitations observed in our study.

Humphreys et al. (2021) indicate that psychological and physical impacts of long-COVID were interconnected. On the one hand, stress triggered physical symptoms; on the other hand, the prolonged and unanticipated physical impairments led to frustration, lowered self-esteem and shame for not fulfilling daily responsibilities. Our study reinforces the interlinking effects of psychological and physical impacts on physical activity, leading to fear-avoidance, depression, despondency and withdrawal from family roles and community engagements. This demonstrates the significance of ADLs and leisure activities to PLWLC’s sense of identity, family roles and mental health.

Our study indicated prolonged morbidity and reduced daily activities as a result of, or in an attempt to avoid, PEM, leading to a decline in QoL and an increase in SB (Vélez-Santamaría et al. 2023; Wright et al. 2022). Sedentary behaviour and physical inactivity are both independent contributors to various adverse health conditions, including depression, cardiovascular disease, reduced QoL and, ultimately, mortality (Cunningham et al. 2020; Wright et al. 2022). Given the results of our study, PLWLC are exposed to the detrimental effects of prolonged SB and physical inactivity, and therefore there is a need to advocate for their safe return to physical activity. Their return to independence should be of paramount concern to healthcare practitioners and future rehabilitation initiatives to avoid secondary complications because of the loss of physical activity (Lippi, Mattiuzzi & Sanchis-Gomar 2024; Wright et al. 2022).

Wright et al. (2022) suggest that because of risks from physical inactivity and a sedentary lifestyle, physical activity levels did not improve through the course of long-COVID. This was deduced by PLWLC not reaching their pre-COVID activity levels. However, despite the current participants’ inability to reach pre-COVID levels, most expressed significant physical activity improvements, particularly between 3 and 6 months post-COVID, and in those who engaged with physical activity earlier in the recovery phase. This is similar to findings by Chuang et al. (2024), where PLWLC also experienced a downward trend of long-COVID symptoms over time. This should be interpreted with caution, as long-COVID is multifaceted, and recovery is influenced by long-COVID phenotypes and participants’ mental states (Baz et al. 2021; Thomas et al. 2023).

The idea of recovery, and attitudes to physical activity uptake, differed between participants, despite all experiencing similar debilitating symptoms and the inability to reach pre-COVID physical levels.

Participants who experienced prolonged recuperation periods, relapses, fluctuating or stagnant outcomes after physical activity, and who had lived more sedentary lives pre-COVID, were overwhelmed and uncertain. They tended not to attempt physical activity to improve their function. Their perception of the adverse effects outweighed their perception of its benefits. Those who had mixed or negative perceptions of the uptake of physical activity to improve recovery emphasised their reliance on rest and assistance from others, working within their comfort zone and waiting for their bodies to heal. Participants who were not certain of long-COVID’s unpredictable nature and patterns, and who had not regained control over their symptoms, perceived stagnation in their recovery, together with loss of purpose, self-identity and worsening of mental health, which if not resolved could lead to a negative reinforcing loop (Skilbeck, Spanton & Paton 2023).

Skilbeck et al. (2023) report that positive attitudes to physical activity uptake occur once PLWLC gain an understanding of their symptom patterns, mastery over relapses and control over their lives and the condition. In our study, participants who lived active lifestyles pre-COVID, whether through sport or occupation, perceived the uptake of physical activity more positively. These participants were more likely to be experimental and were disciplined to use physical activity to achieve physical goals, despite the risk of exertion. They exhibited positive mindsets, resilience and survival instincts when dealing with long-COVID repercussions and perceived improvements in physical and mental health. Individuals who used physical activity to self-rehabilitate understood how far they could exert their bodies and therefore established boundaries. This is congruent with the findings of Humphreys et al. (2021), where participants whose physical activity formed part of their core-identity pre-COVID are more likely to take up physical activity, risk relapses and view symptom exacerbation as constructive. Moreover, PLWLC who viewed physical activity uptake as positive, as Skilbeck et al. (2023) describe, redefined their sense of recovery in terms of fulfilling duties and roles, and accepting that recovery may require more time and help. It is therefore recommended that PLWLC should fully understand symptoms, goals and management as better knowledge may assist with more positive perceptions. In addition, education on the benefits of physical activity, understanding an individual’s body and contributing conditions should be addressed by physiotherapists to support PLWLC to manage their symptoms independently.

Almost all participants resorted to energy conservation strategies to prevent exertion and fatigue. Although studies commonly indicate pacing as a self-rehabilitation strategy to preserve energy in PLWLC (Humphreys et al. 2021; McNabb et al. 2023; Wright et al. 2022), arguably ‘ineffective outcomes’ of pacing are reported by Thomas et al. (2023) because of limited tolerance in which pacing can help in certain activities (p. 6). This necessitates more research into interventions used by PLWLC in relation to various symptom profiles, versus the intensity and capacity of activity, for better energy conservation advice.

Participants described low-to-moderate intensity exercises or ADLs, containing elements of aerobic, anaerobic and gradually progressive loading, which improved their perceived respiration, balance, muscle strength, mobility, endurance and fatigue levels, especially in the first 6 months post-COVID. While GET had been discouraged in past studies because of damaging outcomes from unpredictable physical, cognitive and emotional triggers of post-exertional malaise or relapse (Décary et al. 2021; D’Souza 2021; Vink & Vink-Niese 2022), our study’s participants perceived improvements with informal graded activities, which warrants investigation on how PLWLC can cautiously engage in physical activity with gradual increasing intensities.

Pouliopoulou et al. (2023) indicate that exercise-based rehabilitation and respiratory training interventions were more effective on functional exercise capacity in PLWLC than physical activity in home settings, suggesting close monitoring by clinicians to ensure safe treatment. This raises concerns, considering South Africa’s overburdened clinical facilities and the low levels of general health service availability and affordability in poor and rural settings (Burger & Christian 2020; Jassat et al. 2023), However, a key limitation to the finding of Pouliopoulou et al. (2023) is that treatment not contextualised to a person’s particular setting can face the risk of rejection (Thomas et al. 2023). Therefore, it would be more feasible and appropriate for physiotherapists in South Africa to incorporate PLWLC’s daily activities and lifestyle as a rehabilitation starting point to improve physical activity levels in low- middle-income communities. Encouraging family activities and the initiation of community exercise and support groups to increase social interaction and QoL can be included, which may also reduce fear-avoidance. Therefore, intervention studies developed in the future need to incorporate personal accounts of PEM, coping and self-monitoring strategies within a patient’s setting, to reduce the risk of rejection and promote sustainability and safety. Our study advocates patient involvement, experience and personalised approaches, which are lacking in previous studies that seek to develop rehabilitation regimes.

Our study may be subject to response bias, as the participants were likely those with a particular interest in physical activity, potentially influencing the findings. Consequently, the results may not be generalisable to the broader population of PLWLC, particularly those who are less inclined towards physical activity or who face greater barriers to participation. Additionally, our study was conducted within a single healthcare facility in KwaZulu-Natal, South Africa, which presents a unique context and set of characteristics that may not reflect other settings or populations.

Furthermore, most interviews were conducted via Zoom, which, while practical during times of restricted in-person contact, may have limited the ability to capture non-verbal cues. This could have affected the depth and richness of the qualitative data, potentially constraining the interpretation of participants’ experiences and perspectives.

Further research is needed to explore the impact of long-COVID on physical activity among PLWLC in the South African context. This would enhance the generalisability of findings and contribute to a more comprehensive understanding of the condition’s implications within diverse local populations. Future studies should consider incorporating more face-to-face interviews, which may enrich data collection through the observation of non-verbal cues and facilitate deeper engagement with participants.

It is also recommended that a pilot study be conducted to evaluate the effectiveness and clarity of the interview questionnaire, ensuring that it is well-suited to capturing the complex experiences of PLWLC. Moreover, expanding the scope of future research to include interviews with medical practitioners and key stakeholders such as employers and caregivers would provide a broader perspective. This could inform the development of more effective, multisectoral rehabilitation and support plans tailored to the needs of PLWLC in South Africa.