Effect of online peer support on mental health among patients of post-acute sequelae of SARS-CoV-2 infection: A systematic review

doi:10.21203/rs.3.rs-4200253/v1

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Systematic Review

Effect of online peer support on mental health among patients of post-acute sequelae of SARS-CoV-2 infection: A systematic review

https://doi.org/10.21203/rs.3.rs-4200253/v1

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Background

Psychosocial burdens of the post-acute sequelae of SARS-CoV-2 infection (PASC) are an emerging public health concern. Online peer support is expected to be effective in improving the mental health of PASC patients. However, the effectiveness of these treatments remains unclear. This study investigated the effectiveness of online peer support for improving the mental health of PASC patients.

Methods

We searched the MEDLINE, PsycINFO/PsycArticles, and Japan Medical Abstracts Society electronic databases for studies on June 12, 2023. The inclusion criteria for studies were as follows: 1) patients with post-COVID-19 conditions over 18 years of age; 2) conducted online peer support exposure or intervention; 3) measured mental health-related outcomes using quantity scales; and 4) peer-reviewed original articles written in English or Japanese. We excluded qualitative studies that did not use quantitative scales to measure outcomes and original peer-reviewed articles. We conducted risk of bias assessments with the Risk of Bias Assessment instrument designed for non-randomized studies (RoBANS).

Results

A total of 157 studies were retrieved, and two met the inclusion criteria. The total numbers of participants in the two studies were 239 and 47, respectively. One was a cohort study, and the other was a pre-post study; neither had a control group. Most participants in both studies were middle-aged women or female from high-income European countries. Exposure or intervention included sharing sources of support (e.g., experiences, knowledge, and expertise) and peer support combined with workshops for the self-management of physical and mental health facilitated by trained medical experts. The effectiveness of online peer support on mental health outcomes was also assessed. Two studies reported significant improvements in work productivity, functional status, quality of life, self-efficacy, and well-being. Both studies were rated as high or unclear in most risk-of-bias domains. No meta-analysis was performed because of the small number of included studies.

Conclusions

Few studies examine online peer support for improving mental health-related outcomes among PASC patients, and evidence of its effectiveness is unclear. Well-designed studies are required to conduct meta-analyses to evaluate the effectiveness of online peer support for PASC patients.

Psychiatry

Psychology

Psychosocial burdens arising from the post-acute sequelae of SARS-CoV-2 infection (PASC) are an emerging public health concern. PASC is defined as “the continuation or development of new symptoms 3 months after the initial SARS-CoV-2 infection, with these symptoms lasting for at least 2 months with no other explanation” (1), and is reported to have over 200 different symptoms, including the most common symptoms—fatigue, shortness of breath, loss of smell, and muscle aches (1, 2).Approximately 50% of COVID-19 survivors experience some form of long-term effects up to a year post-infection (3–5), with 41.7% still displaying unresolved symptoms after two years, as revealed by systematic reviews and meta-analyses (6). Previous studies show that PASCs is associated with mental health (7). The diverse nature of PASC, its complex and unpredictable paths of symptom recovery, and the wide fluctuations in symptoms highlight the complexities involved in making accurate diagnoses (8, 9), leading to misunderstandings and barriers in communication between patients and healthcare professionals (10). These challenges may lead to stigma from healthcare providers and close associates, affecting their work capabilities, potentially resulting in a loss of identity, and consequently affecting patients’ mental health (11–13). Few effective treatments are available for these mental health problems and they could lead to an economic burden (14–16).

Online peer support is gaining attention as a response to mental health issues in PASC (17). Peer support refers to empathetic assistance in relationships between people with shared experiences (12). Sharing knowledge and experiences with others with the same disease can improve self-efficacy, mental health, and the quality of life (QOL). Previous meta-analyses show peer support has an effective or positive impact on the mental health of patients with chronic conditions such as PASC (e.g., perinatal depression (18, 19), psychiatric disorders (20, 21), and cancer (22)). Specifically, online peer support is expected to overcome PASC patients’ barriers to service access (e.g., living in an area with poor access to medical care or having problems going out of the house because of symptoms). Hence, peer support is effective if conducted properly and with caution in unmoderated and unstructured groups or without peer training (23). However, a previous scoping review revealed that evidence regarding the effectiveness of online peer support is insubstantial, although some studies showed positive results for mental health-related outcomes among patients with chronic conditions (24). A previous qualitative study also indicated that online peer support may have a negative effect when the support required in a situation is more than they can manage (25). Therefore, further evaluation of the effectiveness of online peer support for PASC patients is necessary, as few comprehensive reviews are currently available.

This review analyzes recent studies on the effects of online peer support interventions on the PASC patients’ mental health. It assesses the included papers for risk of bias, applies meta-analysis where data uniformity and volume permit, and otherwise employs narrative reviews. The outcomes of this review will contribute to improving mental health care for PASC patients and deepen our understanding of broader public health challenges.

Design

This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 (PRISMA-2020) statement (26). The study protocol is registered in the UMIN registry (registration number: UMIN000050901).

Search strategy

First, we searched PROSPERO, PubMed, and the Cochrane Database of Systematic Reviews; no systematic review protocols or published systematic reviews on this topic were found. Subsequently, we used our search strategy to retrieve peer-reviewed articles published in English or Japanese. We excluded gray literature from the search criteria. The search terms used in the study are listed in Appendix 1. Three authors (MK, MH, and DN) agreed on the search terms included in the search strategy. Words for search terms related to outcomes were included to ensure that all relevant articles were included. We searched three electronic databases (MEDLINE, PsycINFO/PsycArticles, and Japan Medical Abstracts Society electronic databases) on June 12, 2023.

Eligibility

We included the following participants, interventions/exposures, comparisons, and outcomes (P[I/E]CO) of the studies as eligible for the review.

(P) Patients over 20 years old with post-COVID-19 conditions.

(I/E) Intervention or exposure to online peer support.

(O) Mental health-related outcomes

The inclusion criteria were as follows: 1) inclusion of patients with post-COVID-19 conditions (diagnosed by a physician or self-reported) aged 18 years or older; 2) online peer support exposure or intervention; 3) measured mental health-related outcomes using quantity scales; and 4) peer-reviewed original articles written in English or Japanese. After reviewing the median and mean age of each study participant and the interquartile range and standard deviation, we determined that most participants were 20 years of age or older. We included studies that measured outcomes such as QOL, which may be related to mental health. We excluded qualitative studies that did not use quantitative scales to measure outcomes as well as any studies that were not original peer-reviewed articles.

We used Microsoft Excel (Washington, USA) to integrate and manage all records extracted through the database search before screening the studies, and MK removed duplicate entries from the Excel files. Next, two authors (MK and MH) independently screened all titles and abstracts. Subsequently, MK and MH independently reviewed the full text of studies whose eligibility could not be confirmed through the title and abstract. We recorded reasons for exclusion during the full-text screening process. Two authors (MK and MH) discussed disagreements between results of the first and full-text screening. Conflicts were resolved through discussion with a supervisor (DN) to reach a consensus. The PRISMA flowchart summarizes the selection process (Fig. 1).

Data extraction

Two authors (MK and MH) independently extracted the following information from the selected studies: (1) characteristics of the study setting [author, year of publication, country, and sociodemographic characteristics of participants]; (2) characteristics of the exposure or intervention [details of the exposure or intervention program, control condition, mechanism, duration of the exposure or intervention, and follow-up period]; (and 3) outcome measurements [instruments and outcome scores]). We did not request any missing information from the authors. Two authors (MK and MH) discussed disagreements regarding the information extraction results and resolved conflicts.

Risk of bias assessment of individual studies

MK and MH independently conducted a risk of bias assessment using the risk of bias assessment instrument (RoBANS) specifically designed for nonrandomized studies (27).

Statistical methods

Owing to the small number of included studies and the need for uniformity in exposure types, interventions, and outcome measures, integrating the included articles was inappropriate. Therefore, no meta-analysis was performed and the results were reported in narrative form.

Database searching

The search yielded 157 studies (MEDLINE n = 77, PsycINFO/PsycArticles n = 65, Japan Medical Abstracts Society n = 13, Other methods n = 2). After removing duplicate studies (n = 31), we included 126 studies in the first screening. Subsequently, 122 were excluded and four studies proceeded to full-text screening. The kappa score for the first screening was 0.66. Two studies that did not meet the article type criteria were excluded (not using quantitative scales to measure outcomes (25), n = 1; not peer-reviewed original articles (28), n = 1). Finally, two studies were included in this systematic review (29, 30). The study selection flowchart is presented in Fig. 1.

Study description

The included studies are summarized in Table 1. One study was conducted in the Netherlands (NLD) and Belgium (BE) in 2021 (29), and the other in the UK (United Kingdom) in 2022 (30). The NLD and BE study was a cohort study (29), and The UK study was a pre-post study without a control group and included a mixed-method approach (30).

There were 239 participants in the NLD and BE study (29, 30), and 47 in the UK study (29, 30). Participants self-reported post-COVID-19 symptoms in both studies (29, 30). The participants were largely middle-aged women or female (the NLD and BE study: median 50.0 age years [interquartile range 39.0–56.0], women 82.8%, the UK study: mean 48.8 age years [Standard Deviation (SD) 11.0], female 83.0%) (29, 30). Sixty two (26.0%) and two (4.3%) participants were hospitalized in the NLD and BE and UK studies, respectively, and only the NLD and BE study provided information about admission to the Intensive Care Unit (ICU). None of the participants was admitted to the ICU (29). In the NLD and BE study, participants’ had experienced COVID-19-related symptoms for six months; in the UK study, participants had experienced PASC for an average of 377.3 days (SD = 171.8).

The exposure of the NLD and BE study was registration in a Facebook group of peers or online COVID-19 panels (29). The intervention in the UK study was 8 weeks of peer support combined with workshops for self-management of physical and mental health, facilitated by trained medical experts using positive psychology approaches for self-management. Patients and healthcare professionals developed content using co-design methods. The interventions included content and self-management techniques. Optionally, weekly online interactions with peers through virtual communication (Zoom), discussion forums, and email were provided (30).

The outcomes in the NLD and BE study were work productivity and activity impairment (absenteeism, presenteeism, work productivity, and activity impairment), functional status, and QOL, using the Work Productivity, Activity Impairment Questionnaire and the 5-level EuroQol-5 Dimensions version (EQ-5D-5L) (29). In the UK study, the outcomes were positive mental well-being, self-efficacy for managing conditions, and loneliness using the (short form) Warwick-Edinburgh Mental Well-being Scale (SWEMWBS and WEMWBS), the 6-item Self-Efficacy for Managing Chronic Disease Scale (SEMCD6), and The University of California, Los Angeles (UCLA) Loneliness Scale, Version 3 (30). Both studies used validated scales. The follow-up periods were between 3 and 6 months after the onset of COVID-19-related symptoms in the NLD and BE study (29) and at the end of the 8-week intervention in the UK study (30). Only short form of Positive Mental Well-being scores were measured across the program at three time points (week 1, 4, and 7) in the UK study (30).

Results of individual studies

The NLD and BE study showed a statistically significant improvement between the time points in all outcomes (absenteeism: p < 0.001; presenteeism: p < 0.001, work productivity: p < 0.001, activity impairment: p < 0.001, functional status: p < 0.001, EQ-5D [index: p < 0.001, index < percentile five values: p < 0.001, Today’s health status: p < 0.001]) (29). The UK study showed a statistically significant improvement, except for loneliness (WEMWBS: p < 0.001, Cohen’s d = 0.8; SEMCD6: p = 0.01, Cohen’s d = 0.5; Loneliness p = 0.60, Cohen’s d = 0.1; and SWEMWBS: p < 0.001). The SWEMWBS scores increased between weeks 1 and 4 (p < 0.001) and between weeks 1 and 7 (p = 0.001); however, scores between weeks 4 and 7 did not differ (p = 0.25) (30).

Risk of bias assessment

The risk of bias assessment result is shown in Table 2. The NLD and BE study recruited participants consecutively (29) and data were collected prospectively. Therefore, we rated them low for the selection of participants. Neither study had control and self-reported participation in the exposure or intervention (29, 30). Both studies measured the outcomes using self-report questionnaires (29, 30). Therefore, we rated the confounding variables, exposure measurements, and blinding of outcome assessments as high. Details of the rationale for the risk of bias assessment for each study are provided in Appendix 2.

Results of individual exposure or intervention

Table 3 presents the form, approach, and content of each exposure or intervention. Both studies provided group peer support (29, 30). The NLD and BE study contained no detailed explanation of exposure in the article (29); we retrieved the contents from the explanation of the Facebook group or panel. According to this description, a group or panel provides a place to share experiences and information about post-COVID-19 symptoms (31, 32). The panel included a medical professional as a board member (33). The UK study provided an intervention combining peer support and online workshop content. Each content involved self-management tools for weekly goal setting, exercises, and activities (30). The NLD and BE study did not report the frequency of participation in online peer support groups (29); the UK study described the frequency of sessions but not the frequency of participation (30).

To the best of our knowledge, this is the first systematic review to investigate the effectiveness of online peer support for improving PASC patients’ mental health. The effectiveness is still uncertain because the studies included in this review had no control group or heterogeneity among exposure, intervention, and outcome, and the available evidence was insufficient to draw conclusions. This field of research is expected to grow in the future because the problem of PASC-related psychosocial burdens has emerged relatively recently, which may explain the paucity of research. Further studies are necessary in this regard. The present study provides new insights into online peer support exposure or interventions for PASC patients’ mental health and suggests further research directions to integrate effectiveness.

Excluding loneliness, work productivity, functional status, QOL, self-efficacy, and well-being significantly improved after the exposure or intervention. The small sample size was reported as the reason for no significant change in loneliness (30). In addition to being an evidence-based approach, the presence of a facilitator in a UK study may have positively impacted the intervention’s outcomes, as a previous systematic review suggested that group interventions with facilitators may contribute to effectiveness (34). However, the NLD and BE study did not describe the presence of facilitators. This suggests that online peer support may be effective for PASC patients whose symptoms are new and are still under study, simply by sharing experiences and knowledge. However, since neither study had a control group, it is unclear whether this was an effect of exposure or intervention, or just a natural course of outcomes (29, 30). Further studies with a control group and sufficient sample size are thus necessary. Moreover, core outcomes across studies should be measured to integrate the effects of online peer support, because the high heterogeneity of outcomes can make it difficult to integrate results (23, 35). A Delphi consensus study proposed core outcome sets for PASC study (36). Measuring these core outcomes using validated instruments in future studies may help clarify the effectiveness of online peer support.

Both studies were conducted in high-income European countries, and the participants were mostly middle-aged women who were not hospitalized when infected with the virus. Further studies are required to investigate whether similar results can be obtained in other populations to provide comprehensive care equally to all people. Males and females have different support needs provided by peer support (37), and people may have difficulty accessing online services in low- and middle-income countries (38). These differences in support needs by gender and challenges in accessing online services in low- and middle-income countries may affect the motivation and barriers to participation and the effectiveness of online peer support. Hospitalization, especially ICU admission, may be associated with psychiatric disabilities after treatment (39). Therefore, mental health and QOL issues may be more severe among such patients, and may influence the effectiveness of online peer support through difficulty in participation owing to the severity of symptoms. Further studies are necessary to confirm the effectiveness of online peer support for males, in low- and middle-income countries, or among patients with more severe symptoms in the acute phase of infection.

Both studies included in this review used group intervention or exposure (29, 30). Future research should ascertain which is most effective: group, one-on-one, or a combination of the two, because prior meta-analyses show that outcome results differ depending on the forms of peer support (e.g., the combined support form of individual and group was the most effective for perinatal depression (18), group may had limited effect (40) but one-to-one positively affected empowerment with mental health conditions (41)). Studies indicate that among PASC patients with individual differences in symptoms and trajectories, participants may become irritated if the severity differs among participants in peer support group sessions (25). Therefore, interventions that include one-to-one peer support for people with similar symptoms may help prevent irritation.

The UK study used text and virtual communication (30), whereas the NLD and BE study used text-based communication and no information about virtual communication (29). Whether the effect on outcomes differed between text- and virtual-based communication was not reported in the UK study and remains unclear. Virtual peer support for pandemic and PASC patients may help improve accessibility and availability issues (42), provide a comfortable and safe place for participants, and help create a supportive environment for each other (43). In the future, determining whether text- or virtual-based interventions lead to better effects on mental health may help clarify better intervention content.

Since neither study reported the frequency of participation in exposure or interventions (29, 30), we could not investigate the association between frequency of participation and outcomes. Previous studies suggest the effect of an intervention could change with the frequency of participation. A meta-analysis of perinatal depression revealed that attending a peer support group once a week is sufficient to reduce the risk of depression (19). A cross-sectional study of patients with cancer showed that those with higher levels of loneliness attended peer support groups less than once per week (44). Future research may need to clarify the minimum participation frequency necessary for adequate online peer support, because being asked to participate frequently may be a burden depending on the severity of the patient’s symptoms or work and personal schedules.

This study has some limitations. Only two studies with 286 participants were included in this review. We could not conduct a meta-analysis because of the limitations and heterogeneity of the study design, interventions, and outcomes. None of the studies included a control group; therefore, it was difficult to evaluate their effectiveness. Finally, the language of the included studies was restricted to English and Japanese.

Online peer support is expected to be an effective way to address psychosocial burdens caused by PASC symptoms. However, its efficacy remains unclear. Well-designed studies should be conducted to clarify its effectiveness.

BE: Belgium

EQ-5D-5L: 5-level EuroQol-5 Dimensions version

ICU: Intensive Care Unit

NCNP: National Center of Neurology and Psychiatry

NLD: Netherlands

PASC: post-acute sequelae of SARS-CoV-2 infection

PRISMA-2020: Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020

QOL: Quality of Life

RoBANS: Risk of Bias Assessment instrument designed for non-randomized studies

SD: Standard Deviation

SEMCD6: 6-item Self-Efficacy for Managing Chronic Disease Scale

SWEMWBS: short form Warwick-Edinburgh Mental Well-being Scale

UCLA: The University of California, Los Angeles

UK: United Kingdom

WEMWBS: Warwick-Edinburgh Mental Well-being Scale

Ethics approval and consent to participate

The systematic review was not reviewed by ethics board because the study was on previously published literature.

Registry and the Registration: UMIN registry (registration number: UMIN000050901)

Consent for publication

Not applicable.

Availability of data and materials

The data that support the findings of the current study are available from the corresponding author on reasonable request.

Competing Interests

Daisuke Nishi reports personal fees from Startia, Inc., en-Power, Inc., MD.net, and Takeda Pharmaceutical Company, Ltd. outside the submitted work. The other authors declare no conflicts of interest.

Funding

Intramural Research Grant for Neurological and Psychiatric Disorders was received from the NCNP (4-3)

Authors’ Contributions

MK was in charge of this study design and wrote the first draft. MK and MH conducted the literature screening. All authors contributed to the critical revision and the finalization of the manuscript.

Acknowledgments

Not applicable.

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Table 1. Characteristics of included studies

No.	Study	Design	Country	Participants	Exporsure or intervention	Mechanisms of exporsure or intervention	Duration of exporsure or intervention	Control	Follow-up periods	Outcomes
1	Vaes et al. (2021)	Cohort	Netherlands and Belgium	Median age (years): 50.0 (interquartile range:39.0-56.0) N=239 %women: 82.8 Hospitalized: 26.0% Diagnosis: self-reported post-COVID-19 symptoms Symptomatic period: 6 months	Online peer support group on facebook	N/A	6 months	N/A	between 3 and 6 months	Absenteeism (The Work Productivity and Activity Impairment questionnaire): T1 = 72.9 ± 35.2, T2 = 52.4 ± 38.4 (p < 0.001) Presenteeism (The Work Productivity and Activity Impairment questionnaire): T1 = 66.1 ± 25.8, T2 = 59.7 ± 24.0 (p < 0.001) Work productivity loss (The Work Productivity and Activity Impairment questionnaire): T1 = 89.3 ± 19.4, T2 = 78.6 ± 26.0 (p < 0.001) Activity impairment (The Work Productivity and Activity Impairment questionnaire): T1=71.4 ± 21.7, T2 = 59.7 ± 22.8 (p < 0.001) Functional Status (The Post-COVID-19 Functional Status): T1 = 2.4 ± 0.9, T2 = 2.2 ± 1.0 (p < 0.001) Quality of life (EQ-5D index): T1 = 0.645 ± 0.181, T2 = 0.694 ± 0.165 (p < 0.001) Quality of life (EQ-5D index <percentile five values): T1= 36.8, T2 = 26.8 (p < 0.001) Quality of life (EQ-5D Today's health status [visual analoque scale] point): T1 = 49 ± 19, T2 = 56 ± 18 (p < 0.001)
2	Wright et al. (2022)	Pre-post	UK	Mean age (years): 48.8 (SD:11.0) N=47 %female: 83.0 Hospitalized: 4.3% Diagnosis: self-reported post-COVID-19 symptoms Symptomatic period: 377.3 days (mean), 171.8 (SD)	Digital intervention combining peer support with evidence-based behavior change techniques for self-managing the physical, emotional, psychological, and cognitive challenges associated with long COVID facilitated by trained medical experts (Patients and health care professionals developed the contents through codesign methods) .	positive psychology approaches for self-management	8 week	N/A	End of the intervention (only short form of Positive Mental Well-being scores were measured across the program at 3 time point: week 1, 4, and 7)	Positive Mental Well-being (The Warwick-Edinburgh Mental Wellbeing Scale [WEMWBS]):Mean difference (SD)＝6.5 (8.5), p < 0.001, Cohens'd=0.8 Self-efficacy (The 6-item Self-Efficacy for Managing Chronic Disease scale [SEMCD6]):Mean difference (SD)＝1.1 (1.9), p = 0.01, Cohens'd = 0.5 Loneliness (The University of California, Los Angeles [UCLA] Loneliness Scale, Version 3):Mean difference (SD)＝0.2 (1.8), p = 0.60, Cohens'd=0.1 Positive Mental Well-being (Short-Form Warwick-Edinburgh Mental Wellbeing Scale [SWEMWBS]): F1.4,22.1value =20.2, p < 0.001. Week 1: Mean (SD)＝19.5 (4.5), Week 4; Mean (SD)＝22.6 (4.9), Week 7; Mean (SD)＝21.4 (4.6) Bonferroni-corrected comparisons; between week 1 and week 4 = p < 0.001(increase in scores) , between week 1 and week 7= p = 0.001(increase in scores) , between week 4 and week 7 = p = 0.25(no difference in scores).

Note. Absenteeism, Presenteeism, Work productivity, Activity impairment, Functional Status, and EQ-5D index <percentile five values; a lower percentage or score indicates good health.

Table 3. Details of exposure or intervention

No.	Study	Form	Approach	Contents of exposure or intervention
1	Vaes et al. (2021)	Group	Social networking service (Facebook)	Serve as a source of support through shared experiences, knowledge, and expertise.
2	Wright et al. (2022)	Group	Website (include video), virtual communication (Zoom), and discussion forums and email with trained facilitators (medical professionals)	1. Online workshop (8-weeks) with following content. Each content involved self-management tools for weekly goal setting, exercises, and activities.
				Contents	Self-management tools
				Week 1: Introduction ・Positive emotions, gratitude, self-compassion ・Goal setting (How to set achievable goals)	Week 1: ・Interactive gratitude diary, goal setting and goal feedback ・Breathing exercise ・Self test about feeling
				Week 2: Long COVID Symptoms ・Fatique and brain fog management ・Sharing experiences of managing fatigue and brain fog(Forum topic) ・Resources of Long COVID information and support	Week 2: ・Interactive gratitude diary, goal setting, and goal feedback ・Activity and fatigue diary ・Pacing planner
				Week 3: Managing Stress ・Coping with thinking patterns, managing stress, self-compassion and acceptance, mindfulness for stress management and meditation ・Resources of self-compassion, mindfulness, and stress management ・How to be kind oneself (video)	Week 3: ・Interactive gratitude diary, goal setting and goal feedback ・Breathing exercise ・Self-care checklist
				Week 4: Communication ・Communication skills (tips for talking with health professionals, employer, and family, preparing for difficult conversations, asking for and accepting help, compassion for worries) ・Resources of Long COVID support groups	Week 4: ・Interactive gratitude diary, goal setting and goal feedback ・Live session to Ask the expert ・Self test about feeling
				Week 5: Sleep and Mindfulness ・How to affect COVID－19 to sleep ・Tips for sleeping better and aiding relaxation ・Introduction to mindfulness, meditation, and relaxation	Week 5: ・Interactive gratitude diary, goal setting and goal feedback ・Raisin meditation ・Breathing exercises ・Live mindfulness meditation session (via Zoom)
				Week 6: Move Better, Feel Better ・Keeping active with LC ・Postexertional malaise ・Tips for getting active ・Eating well for physical and mental health ・Managing changes to taste and smell after COVID-19	Week 6: ・Interactive gratitude diary, goal setting and goal feedback ・ What contributes to happiness? (Quiz) ・Gentle stretches and exercises (Activity)
				Week 7: Happiness and Strengths ・Long COVID and effects on mood, Happiness and hope ・Identifying ones character strengths and Understanding how using it can lead to a more fulfilling life ・The science of character strengths ・Managing setbacks ・Tips for authentic happiness, managing setbacks, and keeping going	Week 7: ・Interactive gratitude diary, goal setting and goal feedback ・Guided meditation activity (Video)
				Week 8: Moving Forward With Hope ・Hopes and dreams ・Doing something for oneself, planning pleasant activities, and keeping in touch with peers ・Review of the program ・Feedback ・Staying hopeful	Week 8: ・Interactive gratitude diary, goal setting and goal feedback ・Self test about feeling
				2. Weekly online interaction with peers through Zoom or discussion forums and email (optional).

Table 2 is available in the Supplementary Files section.

The authors declare no competing interests.

Table2.Resultofriskofbiasassessment.pptx
Table2. Result of risk of bias assessment
Appendix1.searchterms1.docx
Appendix1. search terms
Appendix2.therationalefortheriskofbiasassessment1.xlsx
Appendix2. The rationale for the risk of bias assessment
PRISMA2020abstractchecklist1.docx
PRISMA2020 abstract checklist
PRISMA2020checklist2.docx
PRISMA2020 checklist

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Effect of online peer support on mental health among patients of post-acute sequelae of SARS-CoV-2 infection: A systematic review

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