How a long COVID rehabilitation intervention works: refining its programme theory through a realist-informed qualitative study, 2025, Nielsen et al.

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How a long COVID rehabilitation intervention works: refining its programme theory through a realist-informed qualitative study

Spoiler: Authors

Nielsen, Trine Brøns; Oestergaard, Lisa Gregersen; Hawkins, Jemma; Nielsen, Claus Vinther; Leth, Steffen; Laursen, Cecilia Hee; Sørensen, Dorthe

BACKGROUND
Although the majority of individuals infected with SARS-CoV-2 recover without treatment, some individuals experience persistent symptoms (long COVID), which may negatively affect their activities and roles of everyday life, leaving them with a profound rehabilitation need. In response to the emergence of long COVID patients, a Danish municipality developed and implemented a structured, out-patient long COVID rehabilitation intervention (The Long COVID Rehabilitation Intervention). To understand how, why and for whom the intervention works, and its functioning, an exploration of the underlying programme theory is required. We thus aimed to explore the interactions between the intervention mechanisms of change, the implementation context and the expected outcomes of The Long COVID Rehabilitation Intervention to confirm or refine the initial programme theory.

METHODS
We conducted a qualitative study from a realist perspective. Data comprised 12 individual interviews with patients participating in the intervention, a focus group interview with the health professionals delivering the intervention, and an individual interview with the manager of the rehabilitation centre. Transcripts were coded and analysed using a realist analytical approach, enabling for refinement of the initial programme theory expressed with context-mechanism-outcome configurations.

RESULTS
We demonstrated a close interconnectedness among the context-mechanism-outcome configurations, with identity transformation as central to the intervention functioning supported by a person-centred rehabilitation approach, patient education, and peer support. Moreover, we identified acceptance as an overarching mechanism across all context-mechanism-outcome configurations, facilitating a reconceptualisation of beliefs, values, and roles. This empowered the patients to navigate and participate in daily life despite ongoing long COVID symptoms.

CONCLUSION
Overall, the initial programme theory was confirmed but required refinement to contexts and mechanisms. The theorisation of The Long COVID Intervention clarified how, why, and for whom it worked, informing the development of future long COVID and post-viral rehabilitation interventions.

Web | DOI | PDF | BMC Health Services Research | Open Access

 

[SNT Gatchaman]

Realist evaluations are found promising in exploring the underlying programme theories and context-mechanism-outcome configurations (CMOCs) to understand the functioning of the interventions.

To our knowledge, this is the first study to explore the programme theory and CMOCs of a long COVID rehabilitation intervention.

Patients received psychoeducation on long COVID and were introduced to principles of energy management, which was expected to equip them with necessary skills, empower them, and increase their self-efficacy to implement the strategies and participate in meaningful activities at home, work or leisure.

According to the manager of the rehabilitation centre, having to navigate in the context of a new disease resulted in a situation where “[W]e were all out of our depth. But we were out of our depth together”.

Based on the analysis, the CMOC on person-centred rehabilitation approach is refined as follows:

• If patients with long COVID participate in The Long COVID Rehabilitation Intervention, delivered by a multidisciplinary team using a biopsychosocial and patient-centred approach, with whom they share a trustful relationship, and if the intervention is implemented in an organisational setting supporting the person-centred approach (C), then the patients will experience a feeling of being met, taken seriously and acknowledged, and an acceptance of their situation (M). This will lead to a more coherent rehabilitation course and strengthened commitment and engagement in the rehabilitation intervention (O).

Generally, the patients described how they gained new knowledge on breathing techniques, taking breaks and planning and prioritising daily activities, which enabled them to get through a whole day and perform more activities at home, at work and during leisure time throughout the day without or with fewer symptom relapses, supporting the outcomes described in the initial programme theory on patient education.

Thus, if the patients experienced severe fatigue, it made it difficult for them to engage and interact with the other patients in the group. Additionally, having more physical-related symptoms instead of fatigue also seem to influence the mechanisms behind the peer support. […] The quotes illustrate that when the patients perceived symptoms other than fatigue as their primary or most severe symptom, such as more physically related symptoms, the content and discussions with the other patients in the energy management group felt less relevant to them.