Using Mixed-methods Approach to Explore the Long-term Effects of COVID-19: Presentations, Associating Factors, and Survivor Experience
Conditions: Covid19
Sponsor: National Taiwan University Hospital

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Using mixed-methods approach to explore the long-term 
effects of COVID-19: presentations, associating factors, and 
survivor experience 
 
 
 
NCT ID:____ not yet assigned _______ 
Last update:12/02/2021 Version5 
 
 
 
 
 
 
 
 
 
 
 

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Abstract 
Background. When the COVID-19 pandemic sustains for more than a year, 
a growing number of COVID-19 survivors have returned to their community. 
However, researchers warned that up to 80% of the survivors may experience multiple 
and severe long-term symptoms, sometimes called Long COVID, even they were 
asymptomatic or only had mild symptoms at diagnosis. These Long COVID can 
persist for longer than three months and cause profound distress and life interferences. 
Findings from studies and patient reports on social media suggest that various 
symptoms may be experienced, including fatigue, neurological symptoms, respiratory 
symptoms, and cardiovascular symptoms. With that being said, more areas, such as 
how Long COVID evolved after diagnosis, how we identify risk groups, and what are 
these survivors’ needs, remain unclear. Aim. The overarching goal of this research 
project is to investigate the presentations and associating factors regarding Long 
COVID, and to explore survivor experience. The specific aims are to (1) integrate the 
state of science of Long COVID, (2) describe the changes of various symptoms and 
HRQOL after 3, 6, 9, and 12 months of COVID-19 diagnosis, (3) explore predicting 
factors of the existence and severity of Long COVID, and (4) explore how patient 
experienced COVID-19 symptoms. Design. It is a mixed-methods research project 
with embedded design. Among the three research stages, a systematical review will be 
conducted first to address aim one. In stage two, a longitudinal cohort study will be 
carried out to recruit and follow up with individuals diagnosed with COVID-19 for a 
year. During the follow-up, the participants will need to report their symptoms via 
online questionnaire, phone or video interviews (aim 2 and 3). Those who did 
experience COVID-19 symptoms will be invited to join stage three study. Stage three 
is a qualitative descriptive study addressing aim 4. Participants and recruitment. 
For stage two, the inclusion criteria are individuals who (1) are at least 20 years-old 
and (2) were diagnosed with COVID-19 within six months. Individuals who have 
cognitive impairment or other issues that prevents them from doing self-ratings of 
symptoms will be excluded. Potential participants will be identified through 
recruitment messages posting on social media and referrals from collaborating 
healthcare providers. Expecting outcomes. It is expected that Long COVID will pose 
huge burden on survivors and their families. This project can provide a solid reference 
to foresee possible problems in this population and formulate strategies for early 
detection and management. It is one of the few, if there is any, longitudinal study 
following up with COVID-19 survivors and including patients’ perspectives.  
關鍵詞 (Keywords)：COVID-19, Long COVID, long-term effects, mixed-methods, 
health-related quality of life, longitudinal cohort study 

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Aims 
The overarching goal of this proposed project is to explore the Long 
COVID and associating factors in Taiwan. In the proposed research project, we intend 
to investigate both ongoing and post-COVID-19 syndrome defined by NICE guideline 
and referred these symptoms as Long COVID. Building upon the overarching goal, 
the specific aims of this research project are to (1) integrate the state of science of 
Long COVID, (2) describe the changes of various symptoms and HRQOL after 3, 6, 9, 
and 12 months of COVID-19 diagnosis, (3) explore predicting factors of the existence 
and severity of Long COVID, and (4) explore how patient experienced COVID-19 
symptoms. 
Introduction 
Starting from the beginning of 2020, the COVID-19 pandemic has already 
affected more than one billion people with over three million deaths globally [1]. In 
Taiwan, about ten thousands covid-19 cases were confirmed in mid-June, 2021, and 
the case number continues to grow [2]. While a lot of individuals diagnosed with 
COVID-19 completed the treatment course of the acute phase and returned to their 
community, a considerable portion of COVID-19 survivors continuously experienced 
complicated, distressing, and multiple long-term symptoms weeks to months after 
COVID-19 diagnosis [3, 4]. These long-term symptoms sometimes may be labeled as 
Long COVID, post-COVID symptoms, or ongoing symptoms and have profound 
impact on individuals health, function, and quality of life [5, 6]. Thus developed 
guidelines stress the importance of monitoring and managing Long COVID 
continuously [7]. However, the symptom profile is still vague and the guideline is left 
to be scrutinized.  
Symptom profile of Long COVID 
Although it is expected that the acute symptoms of COVID-19 last about a 
week [8], researchers have warned that more than 50 long-term symptoms or signs 
can be experienced by COVID-19 survivors weeks after diagnosis [3].  
Rather than just respiratory or localized symptoms, Long COVID seem to 
be more systematic [3, 4, 6]. The most frequent reported long-term symptoms across 
studies include fatigue (22-72%), respiratory symptoms (19-65.6%), neurological 
symptoms (7.2-44%), joint pain (15-19%), and psychological symptoms (4.4-46.9%) 
[3, 4, 6, 9]. Cardiovascular symptoms and GI symptoms were also reported [3, 4]. As 
studies surveyed Long COVID at different time points (from 3 weeks to 6 months) in 
various populations (e.g., hospitalized patients, individuals with mild, moderate, or 
severe acute symptoms), the incidence rate of Long COVID is between 20%-80% [3, 
4, 6, 9].  
While it seems that the symptoms gradually subsided over time [10], as 

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high as 30-40% of COVID survivors still experienced multiple symptoms at 6 months 
after diagnosis [4]. More importantly, these symptoms can be very frustrating. 
Although there is very little qualitative study described these survivors’ experience or 
studies measured the intensity or distressing level of the persistent symptoms, some 
survivors have shared their horrible experience on internet [11, 12]. A 31-year-old 
female survivor commented that “nearly 12 months after I was first ill…I wanted to 
get out but I stood up and was so dizzy and breathless and so I couldn’t even get 
dressed. [11]” Among few studies addressed health-related quality of life (HRQOL) in 
this population, their findings showed a significant drop in HRQOL, including 
impaired ability to perform daily activities, for a considerable number of COVID 
survivors [5, 6, 13]. 
In addition to the symptoms, findings from studies showed objective 
evidence of organ damage weeks to months after diagnosis. For example, abnormal 
chest x-ray, echocardiograms, elevated d-dimer, raised CRP, and lymphopenia were 
found and suggested lung and heart damage, clotting disorder, continuous 
inflammation, and reduced immunity [3, 14]. 
Predictors of Long COVID? 
These evidence of long-term organ damage, symptom burden, and 
functional impairment lead healthcare providers to wonder if it is possible to predict 
who will develop Long COVID. While results from some studies showed that the 
severity of acute COVID-19 symptoms associate with Long COVID [6, 15], a study 
pointed out that there is no relationship between disease severity and chronic fatigue 
post COVID recovery [9]. Instead, female and history of psychological distress may 
associate with prolonged fatigue [9]. Another study recruited more than four thousand 
patients in UK found that older age, increasing BMI, female sex, and experiencing 
more than five symptoms during the first week of illness were associated with Long 
COVID [16]. In a similar vein, female sex and overweight/obesity were found to be 
related to lower HRQOL in survivors [13]. In short, the severity of acute symptoms, 
preexisting comorbidity, female gender, and BMI or weight are all potential predictors 
of Long COVID [6, 9, 13, 15, 16]. With that being said, current evidence is premature 
to determine what can predict the existence or severity of Long COVID at different 
stage of survivorship. 
-Guideline for Current Practice 
In order to managing Long COVID, National Institute for Health and Care 
Excellence (NICE), the Scottish Intercollegiate Guidelines Network (SIGN), and the 
Royal College of General Practitioners (RCGP) published a rapid guideline in 
December, 2020 [17]. In this NICE guideline, symptoms of COVID-19 are 
categorized as acute (i.e., signs and symptoms for up to 4 weeks), ongoing (i.e., signs 

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and symptoms from 4 to 12weeks), and post-COVID-19 syndrome (i.e., signs and 
symptoms continue for more than 12 weeks and are not explained by an alternative 
diagnosis). It recommends that healthcare providers should be aware of possible 
symptoms, actively discuss with survivors in terms of their symptom experience and 
how symptoms affect their function and life, offer chest X-ray by 12weeks after acute 
covid-19, offer an exercise tolerance test, and consider referring survivors to an 
integrated multidisciplinary assessment. It also stressed the importance of long-term 
follow-up with symptom changes. However, upon the time of guideline development, 
accessible evidence was still scarce and of poor quality [7]. Furthermore, while the 
guideline repeatedly mentioned the needs to discuss symptom impacts on function 
and life, relevant reference is even less available.  
The Knowledge Gap 
Taken it together, evidence has strongly supported the profound impact of 
Long COVID. However, there is still a huge knowledge gap regarding the trajectory, 
impacts, predictors, and interventions of Long COVID. For example, with regard to 
the symptom trajectory, most studies measured Long COVID at one time point, 
ranged from 14 to 180 days without defining ongoing and post-COVID-19 syndrome 
clearly [3, 4]. Less study observed symptom trajectory overtime. No evidence of 
symptom profile after 6 months of diagnosis is available. The way to identify 
symptoms also varies. Researchers selected various instruments or pre-determined 
lists of symptoms without clear rationale. Some research used chart review to identify 
symptoms. It is possible that some symptoms were ignored if they were not on the 
lists or does not documented in the medical record.  
While emerging studies addressed the impacts of Long COVID on HRQOL 
and function, relevant data is still insufficient, including the HRQOL and function 
changes over time. To our knowledge, there is no qualitative studies describing 
symptom experience from survivors’ perspectives. The changes of HRQOL and 
function is an important information for decision making of selecting palliative care 
and assessing rehabilitation needs. Lastly, most studies were completed in certain 
areas, such as US, UK, and other regions of Europe. 
When “a worrying new wave of COVID-19 is hitting South-East Asia”[18], including 
Taiwan, it is imperative to follow up with these patients’ symptom trajectory and 
experience comprehensively in order to monitor symptom burdens, identify needs, 
and manage symptoms early. 
Methods 
This is a three-phase, mixed-methods research project with embedded 
design (Figure 1.). Mixed-methods design is selected because it allows us to 

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comprehend the phenomenon from multiple aspects─ the lack of information 
regarding longitudinal aspects and survivors’ aspects is identified in the previous 
paragraphs. The following bulletin points describe the embedded design according to 
the six key characteristics which are used to categorize and understand different 
mixed-methods designs [19]. 
1. 
Number of study phases, type of implementation process, and stage of 
integration of approaches: The proposed project include three phases. 
Following the first phase of preparation, phase two (quantitative strand) 
and three (qualitative strand) are conducted concurrently. The 
integration of quantitative and qualitative findings happens in the end of the 
whole projects to triangulate qualitative and quantitative findings. 
2. 
Theoretical perspective: The embedded design includes dealing with both 
quantitative and qualitative data and is supported by the pragmatism 
worldview. The pragmatism perspective appreciates both singular and 
multiple realities and emphasizes practicality. Pragmatism embraces 
abduative logic and is research question centered [20]. 
3. 
Function of the research study: The embedded design allow us to enhance 
the overall design of the quantitative, cohort study by adding qualitative 
approach. It is an important strategy as the interested phenomenon is not 
clearly understood and may be missed if we only use quantitative methods 
to explore.  
4. 
Priority of methodological approach: Quantitative method is the primary 
part of this study. 
Study procedure 
In the first phase, a systematical review will be conducted to address 
research aim one. The second and third phase will cover quantitative strand and 
qualitative strand, respectively. The quantitative strand will employ cohort study 
design to follow up with COVID-19 survivors regularly for a year (aim 2 and 3). The 
qualitative design will explore their symptom experience (aim 4). 
-Phase two: Quantitative strand 
The independent variables for the cohort study of the quantitative strand are 
demographic variables (e.g., age, sex, chronic disease, smoking, BMI) and symptom 
severity at COVID-19 diagnosis. The dependent variables are existence and severity 
of Long COVID symptoms and several indicators of health status, including known 
infection episodes, fever, SpO2 level, hospital or emergency room admissions, and 
any new diagnosis. 

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Phase 1: systematical review 
Phase 2 & 3: mixed methods research 
with embedded design 
Systematical review: 
study aim 1  
Quantitative strand─ Cohort, observational 
study：study aim 2 &3 
 
 
 
 
Qualitative strand─ Descriptive 
qualitative study: study aim 4 
Interpretation  
Figure 1. Two Phases Mixed Methods Research Design 

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Sampling and Recruitments. Inclusion criteria are individuals who are (1) 
at least 20 years-old and (2) diagnosed with COVID-19 within six months. Exclusion 
criteria are individuals who (1) are still in the active phase of COVID-19 infection 
(i.e., diagnosed within 4 weeks) and (2) have cognitive impairment or other issues that 
prevents them from doing self-ratings of symptoms via phone interviews. The 
estimated sample size is about 98 subjects based on G*Power 3.1.9.4 calculation 
(effect size f2=0.15,α=0.05,β=0.2, 6 predictors). Considering the loss of follow-up rate 
of 20%, 118 subjects are needed.  
Potential subjects will be identified through the following strategies: (1) 
searching the intranet of participating medical institutions (e.g., National Taiwan 
University Hospital, National Yang Ming Chiao Tung University Hospital and 
Min-Sheng General Hospital), (2) recruitment messages posting on social media, and 
(3) referrals from collaborating healthcare providers. After participants fill out the 
online questionnaire, research assistant will approach potential subjects via phone to 
explain the research, explore their willingness, and screen for eligibility. Individuals 
who are eligible and agree to participate in the study will receive documents of study 
information and consent form by mail. Participants are required to mail back the 
signed inform consents.  
Upon the receiving the signed inform consents, the subjects will be 
followed immediately to confirm participation and collect demographic data. They 
will then be regular followed up at 3 (for those who are participated within 3 months 
of COVID diagnosis), 6, 9, and 12 months (T1-4) from the diagnosis of COVID-19. 
During these regular follow-ups, subjects will need to report health status indicators 
and rate their symptom severity and HRQOL based on selected instruments. Subjects 
will have access to a line group managed by the research team. They can 
communicate with the research team regarding any issues of research or symptoms 
through line group. All data collection will be occurred via online questionnaire, 
phone or video call interview (e.g., +Google meet or line video call). Paper 
documents, such as inform consents, will be stored in the locked cabin located at 
National Taiwan University School of Nursing. Electrical data will be managed and 
stored using Redcap and encrypted Dropbox.         
Instruments: assessing Long COVID symptoms. While there is no 
symptom or HRQOL instruments designed for COVID-19 survivors or patients with 
infectious disease, some HRQOL instruments designed for cancer patients may be an 
alternative choice. Specifically, as it is mentioned earlier in this proposal, in addition 
to respiratory symptoms, Long COVID seems to be systematical─ just like symptoms 
caused by cancer and its treatment. Thus we propose to use European Organization 
for Research and Treatment of Cancer Quality of Life questionnaire (EORCT-QLQ 

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C30, Taiwan Chinese version) and lung cancer model (EORTC QLQ-LC29, Taiwan 
Chinese version) to measure Long COVID. In fact, among the 36 Long COVID 
self-perceived symptoms reported by Lopez-Leon’s systematical review and 
Romero-Duarte’s 6 months follow-up, these two questionnaires covered 29 of them 
(about 81%), including the most frequently reported ones (table 1). Three missing 
symptoms that are not covered by EORTC-QLQ-C30 or LC29 are anosmia, ageusia, 
and palpitation. These symptoms will be checked for existence separately during the 
follow-ups. 
Both EORTC-QLQ C30 and LC29 are widely used by medical research and 
show good validity and reliability. EORCT-QLQ C30 consists of 30 items and 
measures patients’ functions and symptoms by 4-point Likert scales. EORCT-QLQ 
C30 also measures quality-of-life (QoL) by 7-point Likert scales. While LC29 
consists of 29 items, the subscales of ‘fear of progression (2 items)’ and 
‘surgery-related problems (5 items)’ will not be used as they are related to cancer 
progression and treatment. The remanding 22 items will be rated by 4-point Likert 
scales in this study to measure additional symptoms. The Cronbach’s alpha coefficient 
are above 0.70 and 0.73 for all items in EORCT-QLQ C30 and LC29 Taiwan Chinese 
version, respectively [21-23]. Higher scores for symptom scales represent more 
intense symptoms while higher scores for function scales and QoL means better 
function and QoL level. Example questionnaires are provided in appendix A and B.   
Statically methods. In addition to use descriptive statistics to describe the 
characteristics of participants and symptoms, one-way repeated measures analysis of 
variance (ANOVA) will be employed to determine whether there are any differences 
of symptom severity along the four time points (aim 2). Binominal logistic regression 
will be selected to predict a dichotomous dependent variable (i.e., existence of Long 
COVID) given multiple independent variables. Multiple linear regression will be used 
to predict continuous dependent variable (i.e., symptom severity) given multiple 
independent variables (aim 3). 

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Table 1. Long COVID Symptoms Mentioned by Example Studies and Instruments 
First Author of the Studies or Instrument   
Lopez-Leon 
 
Romero-Duarte EORTC-QLQ30 LC29 
Fatigue 
58% 
22-34% 
V 
- 
Pain 
11% 
- 
V 
V 
Joint pain/ muscular pain 
19% 
15.3% 
- 
V 
Muscle weakness 
- 
3.8% 
- 
V* 
Weight loss  
17% 
- 
- 
V 
Alopecia 
25% 
3% 
- 
V 
Red eyes 
6% 
- 
- 
V 
Cutaneous signs 
12% 
1.5-3.1% 
- 
V 
Dyspnea 
24% 
28% 
V 
V 
Polypnea 
21% 
- 
- 
V 
Cough 
19% 
19.2% 
- 
V 
Throat pain 
3% 
8.4% 
- 
V 
Chest discomfort 
16% 
6.6% 
- 
V 
Rib pain 
- 
4.5% 
- 
V 
Headache  
44% 
5.3% 
- 
V* 
Anosmia/ loss of the sense of smell 
21% 
- 
- 
- 
Ageusia/ loss of the sense of taste/ dysgeusia 
23% 
7.2% 
- 
- 
Paresthesia 
- 
3.4% 
- 
V 
Attention disorder 
27% 
- 
V 
- 
Memory loss 
16% 
- 
V 
- 
Dizziness 
3% 
1.9% 
- 
V 
Depression 
12% 
4.4% 
V 
- 
Anxiety 
13% 
6.8% 
V 
- 
Mood disorder 
2% 
- 
V 
- 
Dysphoria 
2% 
- 
- 
- 
Sleep disorder 
11% 
4.9% 
V 
- 
Palpitation 
11% 
3.1% 
- 
- 
Diarrhea 
- 
10.3% 
V  
 
Constipation 
- 
1.8% 
V  
- 
Abdomen pain 
16% 
5.4% 
- 
V* 
N/v 
58% 
2% 
V 
- 
Anorexia 
11% 
1% 
V 
- 
Note. Table 1 compares the Long COVID symptoms mentioned by example studies and selected instruments. The 
percentage represents how many people have reported specific symptoms in the study. The check mark represents 
symptoms addressed in the instrument. Grey shading highlights symptoms that are not covered by EORTC QLQ30 or 
LC29. The instrument uses different terminology to describe the symptom.   

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Qualitative strand 
Recruitment. The approach of the qualitative strand is based on qualitative 
descriptive design because we want to provide a fundamental and straightforward 
description regarding the survivors’ symptom experience. Participants who reported 
considerable symptoms at three-months follow-ups in phase two will be recruited 
purposively. Agreed participants will be offered inform consent forms to sign by mail 
and arranged a 40-50 minutes phone interview. According to the rule of thumb of 
qualitative study, approximately 30 participants are needed for the qualitative strand 
[24].  
Data collection and analysis. All phone interviews are carried out by a 
trained research assistant who has relevant background (medical, nursing, or 
psychological). Field notes will be documented after each interviews. All recorded 
interviews will be transcribed verbatim.  
Content analysis which is the common analytic strategy for qualitative 
descriptive studies will be used for data analysis in the qualitative strand. Content 
analysis is “a research technique for making replicable and valid inferences from text 
or other meaningful matter to the contexts of their use.[25]” Content analysis is 
flexible in terms of its approach and focus of analysis [26, 27]. The major process of 
content analysis generally includes the following processes: (1) deciding on the 
content to be analyzed, (2) selection of the unit of analysis, (3) condensation (i.e., 
reducing data while preserving the core), and (4) abstraction (i.e., creating codes and 
then grouping them into a hierarchy of categories based on their similarity) [26, 28]. 
Rather than following a linear direction, the process is interactive and is constantly 
modified based on the data [29]. The researcher will analyze the transcript data step 
by step:   
Step 1: Transcript Review. The researcher will read through all transcripts 
several times to become immersed in the data and obtain a thorough understanding of 
the nature of the interactions that occur during the office visits.  The researcher will 
construct memos about my impressions of each encounter and write a brief case 
description of each visit. 
Step 2: Extraction of Text Units. In all of the transcripts, the researcher will 
highlight each text unit (e.g., phrase, sentence, story) related to symptom discussions. 
To aid in later organization of the data, the researcher will highlight data related to 
each major symptom (e.g., pain, fatigue, depression) with a different color or shading.  
Step 3: Coding. The researcher will code each text unit. A code is “a word 
or short phrase that symbolically assigns a summative, salient, essence-capturing, 
and/or evocative attribute for a portion of language-based or visual data [30].”   
Step 4: Data display. These codes will be placed into a cross-case construct 

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table as described by Miles, Huberman, and Saldaña (2013) – see Table 3. A 
cross-case construct table is structured so that the cases are presented on the vertical 
axis and variables of interest are presented on the horizontal axis. This descriptive 
table is used to organize, condense and display codes [31]. In this study, the rows will 
be organized according to each case. The columns will be organized according to 
different dimensions of symptoms and symptom management.  
Step 5: Categorization. To meet aim 4, the researcher will categorize and 
summarize the codes in the columns.  
Step 6: Narrative summary. A narrative description of each column, with 
the use of exemplars taking from the transcripts, will be constructed The computer 
programs NVivo qualitative data analysis software (version 10; QSR International Pty 
Ltd, 2012) and Microsoft Word will be used to aid the analysis. the researcher will 
write memos through the research process to facilitate and document analytic and 
methodological decisions [30]. 

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Table 3. Example of Data Display Using Cross-Case Construct Table 
Cases  
Symptoms  Intensity  
Timing   
Quality  
Suffering   
Self-Management 
Medical advice 
#1 
Pain  
 
Severe  
Continuous  
Muscle aching  
Cannot go out 
Purchase 
over-counter pain 
killers 
 
Does not respond 
or advise 
 
Diarrhea  
Mild  
Periodical during 
the first 6 months 
With abdomen cramping  
Cannot eat favorite 
spicy food 
Eat less spicy food 
Never seek medical 
help 
#2 
Dyspnea  
Moderate  
Periodical 
Mostly after exercise  
feel awful 
Nothing to do 
Follow up with 
Chest x-ray 
#3 
Fatigue 
Severe  
Continuous  
Stays in bed all day 
Loss of 
independency  
Family moved in to 
provide care 
Never seek medical 
help 
Note. Adapted from Qualitative Data Analysis: A Methods Sourcebook, p. 170, by M. B. Miles, A. M. Huberman, & J.  Saldaña, 2013, SAGE Publications, 
Incorporated.  

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Trustworthiness. To ensure the quality of study results and conclusions, 
five standards outlined by Miles and colleagues (2013) will serve as an evaluative 
framework. The standards are confirmability, reliability, credibility, transferability, 
and application.  
Confirmability is the extent to which the findings are neutral, that is free of 
researcher bias, and thus can be confirmed by others. The strategies that will be used 
to ensure confirmability for the current study include the following: 1) The study 
processes, especially the analysis plan, will be explicitly described and documented, 
and 2) The research team will meet regularly to monitor the analytic processes and 
confirm study findings.  
Reliability is whether the study processes remains consistent and stable 
over time and across researchers. Reliability is based on whether the researcher has 
taken care to ensure the quality and integrity of the research process. The strategies 
that will be used to ensure reliability are as follows: (1) Clear study aims have been 
established and the study design is explicit and consistent with the aims, and (2) The 
PI will ensure that all study procedures as outlined in this proposal are closely 
followed.  
Credibility is the “truth value” of the findings – that is whether the study 
findings are authentic and thus make sense to people we study and to readers. The 
strategies that will be used to ensure credibility are as follows: 1) the PI will obtain 
feedback on all codes and categories as they emerge from research team members and 
(2) checking the credibility of the study findings by mailing the preliminary report to 
the 3-5 original participants for feedback.  
Transferability is whether the study results can be generalized or transferred 
to other contexts, populations, or settings [32]. Although it is similar to external 
validity or generalization in quantitative studies, they are different in that 
transferability invites the readers of the study to determine if the findings can apply or 
inform their understanding of the phenomenon by describing the participants and the 
study context fully. The strategy that will be used to ensure transferability is to clearly 
describe the study context, population, and settings 
Utilization describes the pragmatic value of the study. It is determined 
based on whether the study results can be applied to real world and advance the 
knowledge [33]. The strategy that will be used to ensure utilization is sending the 
completed findings to 3-5 agreed healthcare providers for feedback regarding the 
potential usefulness of the study results in their practice. 
Limitations 
There are some limitations of this projects. As a predetermined list of 
symptoms will be used to document Long COVID, it is possible that symptoms that 

15 
 
are not listed will be ignored. The qualitative strand is thus designed and hopefully to 
close the gap between experienced symptoms and reported symptoms. The 
recruitment will occur in certain hospitals and through online platform which may 
overlook some population, such as older age groups. The one-year longitudinal design 
also pose challenges to participant retention. Several strategies, such as convenient 
communication channel (e.g., line group) and participant compensation, will be 
employed to retain sufficient sample size.        
Expecting outcomes 
Results of this project will inform future practice, education, and research 
regarding managing Long COVID, which requires immediate attention and calls for 
evidence-based guideline. Specifically, based on the research aims, a systematical and 
comprehensive understanding of Long COVID will first outlined. This information 
can be used to advance practice guideline, stimulate intervention studies, and 
empower patients by helping them foreseeing possible symptoms. Secondly, by 
exploring the predicting factors, individuals with high-risk of developing severe Long 
COVID can be identified and targeted early. Lastly, the qualitative findings will 
enhance our understanding toward patient experience and can be used to design more 
patient- or family-centered care. While the NICE guideline recommends to track Long 
COVID regularly, it also mentioned that it is still too early to make recommendation 
of tracing methods based on insufficient evidence. Our quantitative results based on 
particular instruments and qualitative results based on patient perspectives may 
provide a reference of selecting appropriate strategies of observing and documenting 
Long COVID. Table 4 demonstrate the timeline of conducting this research project.       
Conclusion 
This project will be the first to address long-term effects of COVID-19 
from both subjective and objective aspects. In addition to its innovation, this project 
responds to real time issues as a growing number of COVID-19 survivors emerged in 
Taiwan. The society, health system, families, and survivors will soon encounter the 
challenges and burden of managing Long COVID. This research project can help 
monitor long-term effects and serves as a base for early identification and timely 
interventions. It also provide important reference for relevant policy-making.

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Table 4. Timeline of the Proposed Research Project 
                              Year/ 
months 
Process 
2021 
 
2022 
2023 
8-9 
10-12 
1-3 
4-6 
7-9 
10-12 
1-3 
4-6 
7 
Phase 1: preparation and systematical review 
Preparation: formulating research team  
X 
 
 
 
 
 
 
 
 
Preparation: IRB 
X 
 
 
 
 
 
 
 
 
Systematical review: literature search and 
analysis 
X  
X 
 
 
 
 
 
 
 
Systematical review: manuscript writing  
 
 
X 
 
 
 
 
 
 
Phase 2: quantitative strand  
Quantitative strand: recruitment  
 
X  
X  
 
 
 
 
 
 
Quantitative strand: data collection 
 
X  
X  
X  
X  
X  
X  
 
 
Quantitative strand: data analysis 
 
 
 
 
 
X  
X  
X  
 
Quantitative strand: preliminary report  
 
 
 
 
 
 
 
X  
 
Phase 3: qualitative strand 
 
 
 
 
 
 
 
 
 
Qualitative strand: recruitment  
 
X  
X  
X  
X  
 
 
 
 
Qualitative strand: data collection  
 
X  
X  
X  
X  
X  
 
 
 
Qualitative strand: data analysis 
 
 
X  
X  
X  
X  
X  
X  
 
Qualitative strand: preliminary report 
 
 
 
 
 
 
 
X  
 
Mixed-methods: interpretation and final report  
 
 
 
 
 
 
 
 
X  

[在此鍵入] 
 
Reference 
1. 
WHO. Coronavirus disease (COVID-19) pandemic. 2021; Available from: 
https://www.who.int/emergencies/diseases/novel-coronavirus-2019. 
2. 
Center, T.D.C. 2021  [cited 2021 6/16]; Available from: https://www.cdc.gov.tw/. 
3. 
Lopez-Leon, S., et al., More than 50 Long-term effects of COVID-19: a systematic review and 
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