Telenursing in mental health: effect on anxiety symptoms and alcohol consumption during the COVID-19 pandemic

Objective: to investigate the effect of a remote intervention on anxiety symptoms and alcohol use in users of the Primary Health Care service. Method: a quasi-experimental study conducted with 1,270 participants who answered the Alcohol Use Disorders Identification Test and the State-Trait Anxiety Inventory-6. Of these, 1,033 interviewees scored for moderate/severe anxiety symptoms (STAI-6 > 3) and moderate/severe risk alcohol use (AUDIT-C > 3), and received the interventions via telephone calls with follow-up periods lasting seven and 180 days. For data analysis, a mixed-effects regression model was used. Results: the effect of the intervention performed was positive in reducing anxiety symptoms between T0 and T1 (µ=1.6, p<0.001) and in reducing the alcohol use pattern between T1 and T3 (µ=1.57, p<0.001) Conclusion: the follow-up results suggest a positive effect of the intervention in reducing anxiety and the alcohol use pattern, which tends to be maintained over time. There is diverse evidence that the intervention proposed can be an alternative for preventive care in mental health, in situations where accessibility of the user or the professional is compromised.


Introduction
The COVID-19 (Coronavirus disease 2019) pandemic was declared in Brazil on March 11 th , 2020, forcing millions of people into extended isolation and social distancing periods and to live with fear, loss of loved ones and social issues such as unemployment and loss of income (1) .
Concomitantly with progression of the pandemic, mental health problems such as anxiety, depression and substance abuse symptoms also advanced, aggravating a problem that had already been progressively occurring in Brazil, mainly among the most vulnerable population that already lived with high violence, racism and poverty rates, which contribute to mental illness (2) .
The results of studies carried out in the country during the COVID-19 pandemic showed that more than 50% of the population had high levels of anxiety and depressive symptoms, as well as increased alcohol consumption during the first year (3)(4) , suggesting an increase in the deterioration of Brazilians' mental health during this period. According to experts, the potential long-term effects on mental health that will emerge after the health crisis can result in the emergence of severe psychiatric pathologies and in an increased need to receive specialized medical care (5) .
This phenomenon can represent a major challenge for governments, health professionals and researchers from low-income countries, including Brazil, given its political and socioeconomic conditions and the deficit of mental health care services available to the population even before the pandemic period (5-7) . Thus, the search for preventive strategies and mental health support quickly and remotely during these periods when face-to-face care is not possible should be considered in order to mitigate the possible repercussions of the pandemic on the mental health of the population.
Thus, in order to provide continuity to health services during the pandemic scenario, the use of digital platforms such as Telehealth was adopted. "Tele" is a prefix meaning "at a distance", and is used in terms such as "telescope" or "telemetry". When combined with the term "scope", the prefix "tele" means an instrument to see phenomena from a distance (8) . Therefore, Telehealth is intrinsically associated with the incorporation of information and communication technologies into health systems (9) , with the use of telecommunication technologies to support remote health care, as well as education for patients and professionals (8) . Telenursing is a subset of Telehealth in which the focus is on the specific Nursing practice (9) .
Although technology use changes the means of providing Nursing care and may require skills related to its use, the Nursing Process and the practice scope do not differ in Telenursing. Nurses continue to evaluate, plan, intervene and reassess the Nursing care results, using lowtech (telephones) and high-tech technologies (computers, videoconferences, Internet, telemonitoring devices) (10)(11) , and, more recently, resorting to communication apps such as Instagram, WhatsApp and Telegram to enable care continuity and provide services continuously (12) .
Although Telenursing has been used for some time in different care areas in various parts of the world, the emergence of the COVID-19 pandemic boosted use of this technology and its leverage by nurses (13) , who needed to employ this strategy in order to maintain continuity of the care provided, mainly to people with chronic conditions (10,12) , when social distancing resulted in the closure of several health services and in the reallocation of services and teams to face the demands of the pandemic, proving to be capable of mitigating these difficulties by redesigning health practices and improving the quality of care provision during this period (14) .

Telenursing can be an important tool to provide
Nursing care in mental health, both mitigating the effects of the pandemic in preventing worsening of conditions and symptoms triggered by it and in monitoring the mental health of the population after the pandemic period.
Although Telenursing can make use of the various so-called high-tech tools currently available, such as video calls that require using a computer with a camera and Internet access or smartphones, telephone calls using lowtech (telephone device) constitute a valuable resource, mainly in places with a high digital poverty level, as is the case in Brazil, where one out of four people does not have Internet access. This represents nearly 30% of the Brazilians living in large cities and 60% in rural areas that do not access the network. On the other hand, mobile phone access is found in 93.2% of the households in urban areas and 70% in rural areas of the country (15) .
A number of studies have indicated a positive effect of Telenursing using telephone calls in various mental health conditions such as smoking cessation, anxiety reduction, improvements in depression, reduction of alcohol use and medication adherence among individuals diagnosed with schizophrenia (16)(17) . However, studies reporting preventive approaches in the mental health area are scarce in the literature. This study was based on studies using Telenursing technologies (16)(17) , on the intervention program for anxiety (18) , and on the application of the Brief Intervention (BI) (19)(20) .
Telenursing was used to screen and perform an intervention to prevent mental health problems caused by situations of vulnerability such as those resulting from Vargas D, Ramirez EGL, Pereira CF, Oliveira SR.
the COVID-19 pandemic, including anxiety symptoms and increased alcohol consumption. The anxiety management program applied in person, in a specialized mental health service, obtained good results in reducing anxiety (18) , showing itself as a feasible possibility based on a Nursing theory of adaptation for use through technology, in order to meet the reality of the moment and reach a highly vulnerable population group. With regard to application of the BI, it has been used by Brazilian nurses with similar populations in face-to-face contexts, observing good results (19)(20) .
The leading role of nurses and Nursing and their importance in coping with disorders related to the use of psychoactive substances has been highlighted by their broad performance in health education, early identification, treatment and rehabilitation of individuals suffering from such disorders (21) . These professionals have been pointed out as a key element to face this problem in health systems around the world (19,22) , leading the World Health with a transition from a model focused on treating the disorders to focusing on the prevention and identification of harmful substance use. In this context, nurses assume a prominent position mainly in the prevention (19) of disorders related to substance use, highlighting the actions of early identification and brief interventions (24) .
Regarding nurses' performance in the face of anxiety symptoms, a number of systematic reviews (25)(26)(27) have shown nurses' potential to help their patients manage their anxiety symptoms more effectively in different care settings and using multiple approaches (28) . With the emergence of COVID-19, the interventions that had already been used by nurses, such as teaching relaxation techniques and breathing exercises among others, had to be reinvented and innovative measures had to be implemented together with the traditional care model (28)(29) . A recent review pointed out that using in health care services around the world. Also according to this review (29) the interventions applied by these professionals, although multiple, showed good results in reducing anxiety symptoms in several populations.
Given the above, this study aimed at investigating the effect of a remote intervention carried out through telephone consultations on anxiety symptoms and alcohol use in users of Primary Health Care (PHC) services during the COVID-19 pandemic.

Method Study design and sample
This is a quasi-experimental study of the beforeand-after non-randomized type, conducted with users undergoing or having undergone psychotherapy in the last 30 days, counseling for anxiety and/or depression, or having participated in mental health interventions, were also considered exclusion criteria.

Instruments
In order to screen the anxiety symptoms, the State-Trait Anxiety Inventory-6 (STAI-6) scale was employed, validated for use in Brazil (30) in populations from various health contexts and showing good reliability indices (a=0.90). STAI-6 aims at identifying the presence of anxiety symptoms through six statements with multiple answer options from "Certainly not" (1) to "Very much" (4), indicating scores between 6 and 24, with the following cutoff points to classify anxiety: from 6 to 10 = Mild; from 11 to 15 = Moderate; and from 16 to 24 = Severe.
To screen the consumption pattern of alcoholic beverages, the brief version of AUDIT (AUDIT-C) was applied in the participating population. This is a simplified instrument validated for use in the Brazilian population (31) , with adequate reliability indices (a=0.83) and already applied in different health contexts in Brazil. It has three questions containing five answer options, which allow classifying the use pattern according to gender. For women, scores from 0 to 2 indicates low risk use, while for men this rating corresponds to scores from 0 to 3. Moderate risk use for women is defined by scores between 3 and 5 points and, for men, from 4 to 5; high risk use from 6 to 7 for both women and men and, likewise, severe risk use between 8 and 12 points (31) . Finally, a sociodemographic data form was applied containing questions about gender, race/skin color, income, schooling, reason for consultation, having been diagnosed with COVID-19 or having lost someone close with that diagnosis.  behaviors that the individual could be using; identification of the triggers that generated anxiety; and guidance on a menu of healthy anxiety relief behaviors (18) .

Data collection
The data were collected among users who sought health care regardless of the reason, in the study scenarios. Each of the interventions was delivered immediately after identifying moderate/severe anxiety symptoms or moderate/severe risk alcohol use with a mean duration of 25 minutes in each intervention. In the cases where the participants presented concurrence of Vargas D, Ramirez EGL, Pereira CF, Oliveira SR. moderate/severe anxiety symptoms and moderate/ severe risk alcohol use, the intervention for the anxiety symptoms was prioritized and the Brief Intervention (BI) was carried out later on with one-week intervals between them ( Figure 1).
Follow-up for those who received the IRA (Interpersonal Relationships in Anxiety), it was initiated immediately at the end of the intervention (T 1 ) and the second follow-up (T 2 ) was carried out 7 days after its application. For the participants who received the BI, the follow-up was carried out through a new telephone contact with AUDIT-C reapplication after 90 (T 1 ) and 180 (T 2 ) days of the initial screening and/or application of the brief intervention. Figure 1 illustrates the study data collection and follow-up process. In order to minimize the response biases, in all cases, the follow-up was performed by an individual different from that one in charge of screening and the intervention.  (Table 1). These results are consistent with those presented in Table 2, which indicate that the difference between the study moments was significantly higher between T 0 and T 1 , which is not observed in the comparison to T 2 .
Individuals invited to participate in the study (n*=1444) Did not accept to take part in the study (n*=174) Screening (n*=1270) -Met the eligibility criteria (n*=1033)  Table 3 shows the measurements performed T 0 , T 1 and T 2 in order to evaluate the effect of the brief intervention in reducing the alcohol use pattern. There is a reduction between the mean of T 0 and T 1 , equivalent to 1.57 points in the AUDIT-C score. In the two-by-two comparison, there is evidence of a new reduction between T 1 and T 2 , suggesting that the effect of the intervention in reducing alcohol use takes longer to happen.

Discussion
The COVID-19 pandemic has imposed multiple consequences, not only to the physical health but also to the mental health of the population, which has been documented by several authors (33)(34)(35)(36) who claim an increase in depression (23) , anxiety, obsessive-compulsive and posttraumatic (37) symptoms related to a variety of negative emotions, such as fear of dying and panic of being or remaining locked in the house, among others that have not been adequately processed by the population (37) .  (38) when talking about the use of psychoactive substances and, considering that the sample was mostly female, it is likely that the female users did not feel confident to provide data more consistent with the reality of alcohol consumption. On the other hand, the research was developed via telephone calls, which makes it a challenge to establish the link between researcher and users, as well as an environment where the individual feels truly welcomed (39) .
Faced with this situation, creativity and the search for remote care strategies to overcome such challenges imposed by the distancing measures began to occupy the agenda of health systems in different care contexts.
Technology use allowed providing necessary and fair care services to the patients who were at their homes and did not have access to some specific services (37) ; however, health professionals had to develop innovative skills/competencies to ensure care quality, safety and efficiency through technology (40) . The current study meets this proposal, aiming to evaluate two psychosocial interventions applied remotely by Nursing professionals in the Primary Health Care context.
The interventions proposed in this study proved to be initially effective in reducing anxiety symptoms and risk alcohol use, also pointing out that they can be employed by nurses and that they have the potential to reach a large percentage of the population, overcoming the digital poverty barrier and being useful in situations where accessibility of the users or professionals is compromised (3) .
There is evidence (11) for the use of health services, through basic low-cost tools such as telephone and Internet connections (12) , rendering the intervention feasible for most patients.  (41)(42) documenting its use in Brazilian Nursing in the last two years, due to the health contingency (43) .
The published studies that correspond to this period are mostly related to respiratory care and physiological complications of COVID-19 (44)(45) , care for older adults (46) or maternal and child health (42) , which makes our study innovative when exploring a useful tool for mental health Nursing care in the post-pandemic period.

Conclusion
The results suggest a positive effect of our intervention in reducing anxiety and the alcohol use pattern. In addition to the benefits of the Nursing intervention to prevent worsening of mental health conditions, the intervention suggested is an alternative to reach even those with fewer digital resources and without Internet access, as a large part of the country's population does not have access to the network. In these cases, telephone calls can offer a low-cost, convenient and methodologically simple service for delivering information on health, education and psychosocial support to different population groups and strata.