Perceptions of adults with obesity about multiprofessional remote monitoring at the beginning of the COVID-19 pandemic

Objective: To understand the perception of adults with obesity about remote monitoring at the beginning of the pandemic of COVID-19. Methods : A descriptive-exploratory, qualitative study with participants in remote monitoring of a multi-professional treatment program in southern Brazil. Data was collected through digital platforms with interviews in written or audio-recorded records. The results were submitted to content analysis, thematic modality. Results : 26 women participated, emerging the thematic category “Difficulties and potentialities in adherence to lifestyle changes during the pandemic. Among the difficulties are the change of routine and increased anxiety; and, among the potentialities are the multi-professional accompaniment, decreased tension, and weight control. Final considerations : The participants’ perception showed considerable weaknesses in adhering to the program, caused by social distance. Studies with remote interventions are essential to improve the quality of this type of health care.


INTRODUCTION
In December 2019, following the Wuhan, China outbreak, the coronavirus for the current Pandemic scenario of COVID-19 was discovered. COVID-19 is known as an infectious disease affecting humans that is highly contagious, rapidly transmitted, and usually affects, generally mildly, children and young adults. However, about one in five infected persons require hospital care (1) ; and the disease can cause severe conditions, with complicated outcomes and mortality, especially in the elderly population and in individuals with chronic diseases (2) .
It is common for people to worry about the impact of the COVID-19 outbreak on everyone's lives, causing unfavorable biological, psychosocial, and economic consequences for the population. Therefore, basic personal and community hygiene, mask-wearing, and social distancing have been essential strategies imposed to control the transmission network of SARS-CoV-2 (1)(2) .
Given the need for social distance, remote monitoring becomes an option to follow-up individuals in treatment. It is known that people with chronic diseases such as obesity currently occupy a possible delicate position in the context of the pandemic since such diseases are one of the aggravating factors of COVID-19 (2) . In this context, the Care Model for Chronic Conditions (MACC) provides an approach in the co-participation of care, according to each individual's limitations, to make available resources capable of favoring health services and recommending innovative technologies of care (3) . The model is applicable in the context of supported self-care, and it has been used as a theoretical reference in other chronic conditions, such as in a study on diabetes (4) .
That said, the use of technology and innovative means of providing health care for chronic conditions represents promising options, especially for individuals with overweight and mild to moderate obesity (5) . In this sense, as part of the healthcare team, nurses can implement programs to assess and monitor chronic conditions and help people self-manage their health problems (6) . The use of technologies to monitor patients has already been addressed in the study known as mHealth; it has been used to assist in managing several diseases, such as HIV/AIDS, malaria, tuberculosis, diabetes, asthma, and smoking (7)(8)(9)(10) .
In telehealth, remote monitoring is an innovative technology with the possibility of helping people suffering from chronic health conditions. That can result in empowerment, better disease management, and treatment adherence. Researches using this technology have mainly involved people with other chronic health conditions such as chronic obstructive pulmonary disease (COPD), congestive heart failure, and diabetes mellitus (11)(12)(13) , but little is known about its benefits in managing weight loss and weight control.
In a study conducted in the United States, obese participants received counseling on eating habits and physical activity via telephone, text messages, and access to study materials on a website about healthy habits and lifestyle. Patients showed significant weight change after 24 months, with an estimated average weight loss of 3.5 kg in the enhanced intervention group and 5.9 kg in the standard intervention group. Despite that, the study concludes that effective long-term treatments are still needed to combat obesity. Numerous specific technologies for physical activity and diet are available, but it is unclear whether they effectively improve the weight loss process (14) .
Until now nobody has found studies that report the exclusive use of remote monitoring in the treatment of obesity in the context of the need for social isolation; therefore, this study advances the production of knowledge on the subject because the methodological approach adopted allows the recognition of subjective factors that interfere with behavior change, especially in the period of social isolation. In this sense, this study sought to answer the following research question: What is the perception of obese individuals about the use of remote monitoring in the treatment of obesity at the beginning of the pandemic of COVID 19?

OBJECTIVE
To understand the perception of adults with obesity about remote monitoring at the beginning of the COVID-19 pandemic.

Ethical aspects
The project was approved by the National Commission for Ethics in Research with Human Beings and followed the ethical precepts of anonymity, right to information, and participation in the research.
All participants were informed about the research and signed the informed consent form, which was the formalization of their agreement to participate in the study, sent online before the remote interview, and after signing, the participants received their copy. The study replaced the names with the letter I (individual), followed by two Arabic numerals. The first number refers to the order of the interview, and the second, to the age of the interviewee (e.g., I1, 42 years old) to ensure confidentiality and anonymity.

Theoretical-methodological framework
The study adopted the MACC (3) as the theoretical basis; and used the content analysis (15) , the thematic modality for data treatment.

Type of study
A descriptive-exploratory study with a qualitative approach, which used the Consolidated Criteria for Reporting Qualitative Research (COREQ) (16) .

Study setting
The study was conducted based on the Multiprofessional Program of Obesity Treatment (PMTO) in a southern Brazilian city. The program comprises a multidisciplinary team including nurses, physical educators, nutritionists, and psychologists. It is part of a research project funded by the Araucária Foundation, linked to the State University of Maringá and the University Hospital of Maringá, which provides free care to obese individuals.

Data source
The study participants were obese individuals participating in PMTO.
For the approach, the primary author -with previous experience in developing and guiding qualitative research conducted through interviews -conducted individual interviews with the participants. Before starting the interviews, the researcher already had contact with the participants through a study group belonging to the Multiprofessional Obesity Study Center (NEMO) held in two public universities in southern Brazil which have this PMTO (17) .
At selection, 38 individuals with body mass index (BMI) above 30, age between 18 and 50 years old, and access to the WhatsApp application, who were in PMTO follow-up, were invited to participate in the research, and twelve of them refused. Consequently, the sample consisted of 26 participants.
They were aware that the interview aimed to understand better how they felt about obesity treatment at this time of social isolation.

Study protocol
The multi-professional intervention model for the treatment of overweight and reduction of metabolic syndrome risk factors plus the nursing intervention using telenursing were carried out with the participants through orientations and interventions, three times a week, by professionals from the fields of nursing, physical education, psychology, and nutrition. They organized the interventions as follows: on Mondays, Wednesdays, and Fridays, the participants received guidance from physical educators; on Mondays, they also received psychological guidance; on Wednesdays, nutritional guidance; and on Fridays, nursing guidance.
The participants were included in two groups of the WhatsApp ® application: the first group, named "Notifications, " where only the group administrators (the team professionals) had access to send messages; this group facilitated that the orientations passed on by the multi-professional team were not lost among the participants' conversations. The second group, named "Participants, " allowed everyone to forward messages, facilitating the interaction between them.

Collection and organization of data
The access to the participants and the application of the research procedures occurred through the WhatsApp® application, using the cell phone numbers listed in May 2020 in the registration form for the PMTO.
The study collected information on age, social class (18) , race, gender, and anthropometric data through the participants' registration form in the PMTO. After gathering this data, the individuals were interviewed via WhatsApp®; the questions were sent via audio recorded on the application and answered in typed texts or recorded audios, according to the participant's preference. Afterward, the researcher read or listened to the answers and, if necessary, forwarded support questions.
The following question guided the interview: Tell us about your experience with multiprofessional monitoring via WhatsApp® during social isolation due to the COVID-19 pandemic. Other supporting questions tried to encourage more participation from the respondents, such as: Do you feel that the activities have the desired effect while done this way? Do you feel motivated to do the activities with distance guidance? How does the social distance affect your activity routine and make you achieve the goal? How do you feel physically about doing these activities at a distance?

Data analysis
The interview data was fully transcribed and submitted to content analysis (15) , thematic modality, followed by the phases of pre-analysis, material exploration, treatment of results, and interpretation. In this aspect, readings were performed for the corpus organization, mapping of common themes, and systematic reduction. The thematic category "Difficulties and potentialities in adherence to lifestyle changes during the pandemic" was extracted, which was illustrated by excerpts/excerpts of the participants' writings.

Category: Difficulties and potentialities in adhering to lifestyle changes during the pandemic
It was analyzed that the social distancing due to the pandemic reflected negatively on the exercises' performance at home: [ The participants emphasized factors that directly influence habits and adherence to a healthy lifestyle, such as increased anxiety: Thus, it was also pointed out the follow-up by the different professionals: The nutritionist, the psychologist and the people attending us, everything is in favor of helping us. (I24, 20 years old)

DISCUSSION
The attention to chronic conditions, when stimulating supported self-care, can prepare and empower people to manage their own health and the actions of assistance provided. For this, it is necessary to use support strategies for the co-participation of individuals in care, including assessing health status, establishing goals to be achieved, evaluating the results obtained and recognizing that the effects of behavior change occur in the long term (3) .
Thus, we emphasize the importance of encouraging selfcare supported by the maintenance of healthy habits in obese individuals, especially during the period of social isolation due to COVID-19, since severe obesity is a clinical condition that worsens the infectious condition. Individuals with obesity present an alteration in different stages of the innate and adaptive immune response, characterized by a state of chronic and low-grade inflammation, contributing to the worsening of the condition. The difference between obese and thin individuals is adopting unhealthy habits, such as sedentarism or physical inactivity. Reduced physical activity is known to impair the immune response against microbial agents in several steps, including macrophage activation and inhibition of pro-inflammatory cytokines (19) .
Among the determining factors for not performing or reducing the frequency of the activities proposed by the PMTO during the social isolation, the participants reported change in routine, accumulating tasks since many people are doing home office due to the COVID-19 pandemic, in addition to family demands. This difficulty meets the profile of the female participants, and this corroborates other studies that presented the history of women's role in society as wives, mothers, and caregivers, and the fact that they do not exercise due to the second shift they face almost daily (20)(21) .
It is noteworthy that the accumulation of activities and social distancing favor the increase of anxiety, directly related to the outbreak of a new coronavirus infection (COVID-19). The increasing and excessive supply of information and concerns are beginning to impact global mental health. All the time, information from various sources is released, with recommendations and updates released minute by minute about the spread and lethality of CO-VID-19. However, today, this infection's burden on global mental health is neglected, even though it may challenge patients, the general population, policymakers, organizations, and health care teams (22) .
Prevention measures for COVID-19 consist mainly of distancing large segments of the population. Distancing or isolation may be protective in many circumstances, but healthcare professionals should be aware of the neurological system's functional disorders after stressful community events, particularly in individuals with a previous psychiatric diagnosis (22)(23) . In this sense, a telephone follow-up is a valuable tool for monitoring individuals with chronic conditions, especially to reinforce the orientations aimed at health education and adopting healthy habits.
Although a period of social distancing is the best option and recommendation to stop the rapid spread of COVID-19, this can have side effects on other dimensions of isolated individuals' health, especially on those mentioned as most at risk. Initiating a sudden state of social distancing implies a radical change in the population's lifestyle. These lifestyles and behaviors, in many cases, include a certain level of physical activity and exercise to maintain a good state of health (24) in order to counteract the negative consequences of certain diseases. Furthermore, as a psychological impact of social isolation, adverse psychological effects have been reported, including post-traumatic stress symptoms, confusion, and anger (25) . Therefore, identifying individuals' protective factors and their families favors the planning of care actions that are more likely to be developed and maintained by that individual, which is in line with the stimulation of individual autonomy and supported self-care.
Participants often mentioned the increase in anxiety in their answers. Another study analyzed the impact of social isolation in obese individuals and identified increased anxiety in 72.8% and depression in 83.6% of participants during that survey. Thus, the PHC health team must develop actions to prevent adverse outcomes for this vulnerable population while there is a need for social isolation and to collaborate in recovery efforts after COVID-19 (26) .
Among the reasons for participating in PMTO activities remotely, participants reported focusing on the initial goal, which is the loss of 20% of body weight at the end of 16 weeks of follow-up. Internal motivational factors (pleasure, prevention of health problems, and adherence) significantly influence physical activity performance (27) . Therefore, the remote monitoring strategy is also an alternative that encourages individuals to maintain activities even in social distance.
One of the participants mentioned difficulty performing the PMTO activities because they are carried out through technological devices. It is important to note that new strategies for obesity treatment, such as using technology and innovative means of providing health care dependent on healthcare professionals other than physicians, represent promising options, especially for overweight and mild to moderate obesity patients (5) . In this sense, it is essential to individualize care and solve difficulties presented by people in the use of technologies and, if necessary, reorganize the individual's care. Moreover, as a relatively new strategy, it is understandable that individuals have difficulties initially, but they need to be encouraged by the possible benefits of using it.
In this context, the MACC can contribute to the collaborative management of care, in which healthcare professionals are not only prescribers but also partners of these patients in health care. That means including the regular use of support programs that can provide information, emotional support, and strategies, in addition to encouraging these people to recognize their role in their health (3) . Because the condition involves a chronic condition, self-care measures for health need to be maintained, and professionals should reinforce that the results, in most cases, are long-term. Nurses can implement programs to evaluate and monitor chronic health problems and help people self-manage their health problems (6) . Health care must encompass a practical attitude mediated by the interaction of different sets of knowledge, based on a humanized relationship between the actors involved in situations that demand a necessary therapeutic action, aiming at the best possible outcome (28) . Although telephone monitoring is not a routine practice in health services, it constitutes a valuable strategy incorporated into the monitoring practice, especially for those stratified as low risk.
Social factors and norms also affect physical activity and the adoption of healthy habits. Some are critical social events, such as economic crises, civil unrest, or natural disasters (29) . In this sense, some participants reported that they became discouraged to perform the PMTO activities as the days in social distance increased.
Not interrupting or completely altering people's lifestyles during social isolation and maintaining an active lifestyle at home is very important for the general population's health. Although outdoor activities are typically more available, varied, and there are more facilities and infrastructure to perform any physical exercise, there are still many possibilities to exercise at home during social isolation to maintain healthy habits. Some examples of physical activities performed at home are resistance training through exercises with body weights, such as squats holding a chair, sitting down and getting up from a chair or going up and down a ladder, carrying items with light and moderate weights (vegetables, rice, water), aerobic exercises such as walking indoors, dancing, balance exercises, such as walking in a line on the floor, walking on tiptoes or heels, walking evenly, and stepping over obstacles (30) . The participants in this research received videos with workouts that could be done at home, including items available in any household or with their body weight.
The fact that participants consider that face-to-face exercise is related to greater motivation to perform the activities proposed by PMTO goes in the direction of creating a bond with the user, considered fundamental to the control and prevention of obesity. Group work allows better stimulation of adherence and generates a better quality of life for patients. The World Health Organization defines adherence to treating chronic diseases as a multidimensional phenomenon determined by the combination of five sets of factors, called dimensions: health system, disease, treatment, patient, and caregiver-related factors. This classification clarifies that the belief that patients are solely responsible for their treatment is misleading (31) .
So, changes in people's behavior, especially with obesity, involve articulated health services, which, through available resources, allow individuals to be informed and become active, with a relationship supported by the community and the health team. To this end, healthcare professionals need to be prepared and proactive to provide functional health outcomes for the population (3) .
In this way, it will be possible to strengthen the pillars of PHC, which has the Basic Health Unit (BHU) as the entry point to users, which takes on and treats the overweight individual -it is the care organizer and communication center among the other points of the Healthcare Network, ensuring comprehensive care, seeking interdisciplinarity and intersectionality (32) .

Study limitations
The study's possible limitations may be linked to the use of online questions, as they may exclude digitally illiterate people, make it difficult to help the participant when they do not understand some question, make it impossible to know the circumstances under which the questionnaire was answered. Nevertheless, it is believed that solutions to the limitations of online surveys will be increasingly analyzed and developed in the future due to the benefits of this type of data collection.

Contributions to the fields of Nursing, Health or Public Policy
This study is relevant for nurses and multi-professional teams because its results provided an understanding of the factors that hinder adherence to PMTO. Based on this, the nurse and the team can develop innovative strategies that can be effective remotely. In turn, this allows stimulating health practices directed to the assistance of overweight individuals, because besides being a public vulnerable to complications for having this chronic condition, the fact that they need social distancing and at the same time there is a self-blame in continuing in weight loss and control can lead them to a picture of psychological symptoms and social consequences for their lives. Therefore, this study can promote health care for this population, with appropriate planning for self-care supported by the health team.

FINAL CONSIDERATIONS
The perception of obese individuals during remote monitoring performed by nursing, nutrition, psychology, and physical education professionals, through a PMTO, showed weaknesses in adherence to the program due to social distance and changes in lifestyle during the pandemic. The statements pointed out that the social distance due to the pandemic reflected negatively on home exercises' performance and the difficulties to control food and weight, routine changes, and increased anxiety. As a potentiality, we emphasize the support and follow-up by different professionals at this moment, and some patients felt less tension and perceived weight control.
In this sense, self-care supported by digital technologies brings co-responsibility with the treatment and multidisciplinary monitoring of the obesity treatment program. However, for better results, innovative strategies and interventions are needed for greater and better adherence of this population to the program remotely. Future studies are imperative to understand how to reverse the overweight population and modify the various views of society about food, physical activity, body, and health, with the support of remote technologies.

FUNDING
This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior -Brasil (CAPES) -Finance Code 001.