Patients' views and experiences of live supervised tele‐exercise classes following bariatric surgery during the COVID‐19 pandemic: The BARI‐LIFESTYLE qualitative study

Summary The BARI‐LIFESTYLE trial is a randomized controlled trial evaluating the efficacy of a post‐surgery nutritional and behavioural tele‐counselling, and supervised exercise programme to maximize the health benefits of bariatric surgery. Due to the coronavirus disease 2019 (COVID‐19) pandemic, the in‐person supervised exercise component had to be converted to remote tele‐exercise. However, patients' acceptability of this method of exercise provision is unknown. Between 3 and 6 months following bariatric surgery, 13 adults participated in weekly, structured, 60‐min supervised exercise classes delivered via Zoom by a trained exercise therapist. A total of 12 participants (n = 8 female), with a mean age of 46.3 (range 33–63) years, who had undergone either sleeve gastrectomy (n = 8) or Roux‐en‐Y gastric bypass (n = 4) surgery, participated in one‐to‐one semi‐structured interviews following the tele‐exercise classes. Interviews were audio‐recorded, transcribed verbatim and analysed using thematic analysis. Participants described how the tele‐exercise classes helped them to cope with the changes to their lives brought about by the COVID‐19 pandemic. Participants found the tele‐exercise schedule, content and intensity to be acceptable, and were satisfied with the privacy, security and safety of the technology and classes. Professional supervision and guidance from an exercise therapist were described as central to the tele‐exercise provision. Importantly, participation in the tele‐exercise provided physical, emotional and social benefits. Few participants reported barriers to participation. Overall, the tele‐exercise classes were deemed acceptable and compared favourably to in‐person exercise classes.

What is already known about this subject • Exercise provides additional health benefits after bariatric surgery; however, most patients do not meet the recommended level of physical activity.
• Post-surgery supervised exercise programmes have been shown to maximize the health outcomes of bariatric surgery, but low uptake is common due to barriers such as geographical accessibility of exercise facilities and lack of time.
• The imposed restrictions along with limited access to bariatric care service during the COVID-19 pandemic have led to an increased level of anxiety, decreased level of physical activity and weight gain.
• Tele-exercise can increase accessibility to structured exercise programmes; however to date, no study has explored in-depth views and experiences of patients who have undergone bariatric surgery towards a remotely delivered supervised exercise programmes.

What this study adds
• Post-bariatric tele-exercise classes were feasible and acceptable to patients and compared favourably to in-person exercise classes.
• The tele-exercise classes helped patients to cope with the extra challenges associated with the COVID-19 pandemic in adhering to the lifestyle changes recommended following bariatric surgery.
• Useful suggestions were identified to optimize the delivery and safety of, and adherence to, tele-exercise classes, which could be considered when planning and developing future teleexercise programmes for patients pre-and post-bariatric surgery.

| INTRODUCTION
Bariatric surgery is currently the most effective treatment option for people living with severe obesity 1 ; however, approximately 20%-33% of patients experience poor weight loss outcomes and weight regain over the long term. [2][3][4] Exercise provides additional health benefits after bariatric surgery 5 but the majority of patients do not meet the recommended level of physical activity and studies suggest that more than 60% of their waking time is spent in sedentary behaviour. [6][7][8][9][10] Post-bariatric exercise services help patients to adopt and/or maintain exercise behaviours however, access to these is limited. 11 In the United Kingdom, most bariatric centres do not offer exercise programmes as part of standard post-surgery care due to the lack of evidence-based research to support their implementation. 12 Therefore, we conducted the BARI-LIFESTYLE randomized controlled trial (RCT) to evaluate the efficacy of a combined nutritional-behavioural tele-counselling and supervised exercise programme in the first year after bariatric surgery (ClinicalTrials.gov Identifier: NCT03214471).
In March 2020, the UK government imposed a nationwide lockdown to contain the spread of the coronavirus disease 2019 (COVID- 19), 13 which we now know had a negative impact on mental health and health-related behaviours such as physical activity, especially for people living with obesity. 14 All research-related in-person activities were suspended to abide with the restrictions. In order to maintain the integrity of BARI-LIFESTYLE, the supervised exercise component was modified to be delivered remotely via Zoom, a cloudbased video conferencing service (referred to hereafter as tele-exercise). 15 With the advancement in digital communication technology, health systems worldwide are looking to integrate online delivery of services to improve the overall efficiency and effectiveness of care. 16 The acceptability of such technology for patients is essential for the successful implementation and uptake of such services. To date, the use of telehealth to deliver exercise programmes in patients pre-and postbariatric surgery is scarce. 17 In view of this, the present study sought to: (1) explore experiences and views of patients who have undergone bariatric surgery on supervised tele-exercise classes, (2) identify the barriers to, and limitations of such classes, and (3) identify points of intervention that could be targeted to optimize the delivery and safety of, and adherence to, a future tele-exercise programme.

| Study design and participants
This qualitative study is an additional sub-study of the BARI-LIFESTYLE trial that received ethical approval by London-Dulwich Research Ethics Committee (17/LO/0950) as part of a protocol amendment. The use of semi-structured interviews as exploratory method provided a wealth of raw data that is particularly useful in assessing needs and informing the design for future interventions. Semi-structured interviews were selected to ensure that specific research questions were addressed; however, participants were retained the freedom to bring up other topics if they felt they were important to the study. Data were analysed using thematic analysis, which involves identifying and making sense of patterns that emerge from qualitative data by organizing them into meaningful themes. 18 Because thematic analysis adopts an inductive approach, it is particularly useful when studying under-researched areas where there is insufficient knowledge to apply meaningful theories or hypotheses a priori, which is the case in this present study of bariatric surgery patients' perspectives on tele-exercise. This study was carried out by the Centre for Obesity Research, University College London (UCL).
In brief, BARI-LIFESTYE was a multi-site, two-arm, parallel group, single-blinded RCT embedded within an observational cohort. Participants were recruited from University College London Hospitals (UCLH), Whittington Hospital and Homerton University Hospital. A total of 153 participants were enrolled in the BARI-LIFESTYLE observational study since March 2018. 19 On the day of surgery, all participants in this cohort were randomized (1:1 allocation) to either receive post-surgery standard care or standard care plus a lifestyle intervention (BARI-LIFESTYLE intervention study) (Figure 1).
By the time the UK government announced the stay-at-home order, 13 a total of 16 remaining participants in the intervention group were still actively participating in the gym exercise class. Of these, 13 participants agreed to complete the remaining exercise sessions remotely via Zoom (Zoom Video Communications, Inc., California, USA). Two months after the end of the tele-exercise classes, these 13 participants were invited to take part in qualitative interviews via phone call and/or email, or an invitation letter to those who could not be reached. Interested subjects were given a copy of the participants' information sheet for the qualitative study, detailing what the study entails, and encouraged to contact the research team should they have further questions related to the study. To be eligible for inclusion, participants must have had attended at least three tele-exercise classes to ensure they could provide in-depth insights into the teleexercise programme. Of all eligible participants approached, 12 participants agreed to be interviewed ( Figure 2).

| Tele-exercise classes
Participants were invited to attend one of the three weekly tele-exercise classes, delivered via Zoom in a group format (Tuesday at 10:30 AM, Thursday at 5:30 PM and Saturday at 10:30 AM). To assist the organization of the classes, a group messaging app, WhatsApp (Facebook, Inc., California, USA) was set up. The tele-exercise class content (Supporting Information S1) was designed based on our experiences in a previous pilot feasibility study. 20 A total of 45 classes were carried out throughout the lockdown period from April to July 2020. The overall attendance in each class ranged between two to six participants.

| Topic guide
The interview topic guide was developed using the research ques- F I G U R E 1 Schematic representation of BARI-LIFESTYLE trial. The lifestyle intervention programme consisted of a nutritional-behavioural tele-counselling with dietitian and once weekly supervised exercise classes in the hospital gym for 12 weeks

| Data collection
The lead author (FCJ) recruited and conducted 12 individual, indepth, semi-structured interviews with participants, of which seven were conducted in-person, three by telephone, and two by video call using Zoom. All in-person interviews took place at UCLH.
Written informed consent for participation in the study was obtained prior to the face-to-face interviews. Whereas for the telephone and video call interviews, the consent forms were either: (1) posted to the participants' home address and the signed consent forms were returned using a stamped addressed envelope provided or (2) emailed to the participants and the signed consent forms were emailed back, prior to the interviews undertaken. All interviews were audio-recorded and anonymized using the same unique PIN number assigned in the initial RCT, participants consented to the audio-recording when signing the consent form. Interviews were conducted between October and December 2020 with interview lasting between 23 and 46 min (mean of 33 min). All interviews were transcribed verbatim and checked against the recordings for accuracy.

| Data analysis
Transcripts were analysed using an inductive form of thematic analysis 18 using NVivo 12 (QSR International Pty Ltd., version 12, 2014) to provide a detailed and data-driven account of participant's view and experiences. Given the limited knowledge of patients' views and experiences of live supervised tele-exercise classes following bariatric surgery, the aim of the current study was not to test a specific theory, but rather to take an inductive approach that identified points of particular salience in patients' own accounts of their experience.
Reflexivity was maintained by keeping a research journal and by regular discussion among the researchers (FCJ and RR) to help manage pre-assumptions and cross-check that the analysis was reflective of the data. Initially, two researchers (FCJ and RR) independently read four transcripts to familiarize themselves with the data and coded the transcripts line-by-line. Both FCJ and RR met weekly to discuss their preliminary codes and refined them through an iterative process until a consensus was reached. Using this initial framework of codes, FCJ then continued coding the remaining transcripts. FCJ and RR continued to meet weekly to discuss new codes and refine them, until no more new codes were generated from the data. Next, FCJ and RR independently extracted the codes that shared similar ideas and concepts to represent broader level categories that held relevance to the research questions. Both FCJ and RR met to discuss their framework of categories and refined them through an iterative process until a consensus was reached. The reviewed categories were organized into potential themes or sub-themes. Next, the codes and themes were reviewed and refined to ensure that the themes demonstrated a valid, accurate and coherent pattern. When all themes were finalized, the names of the themes were refined to check that they provided a valid account of the data that they represent. Specific quotations were extracted to illustrate the themes and subthemes. FCJ is a dietitian and involved in BARI-LIFESTYLE trial. RR is a health psychologist with training and experience in conducting and analysing qualitative interviews. RR was not involved in the wider BARI-LIFESTYLE trial.

| RESULTS
Participants' characteristics are presented in Table 1 In addition, a few participants anticipated that having to exercise at home, alone, would have been difficult due to having no one to properly guide or monitor them. Furthermore, the lockdown appeared to negatively impact their motivation to stay physically active. As a result, these participants felt that having access to the tele-exercise classes provided them with the much-needed support to engage in physical activity and helped to increase their motivation to keep active during this challenging period.   due to the small screen size. Some participants also experienced a problem with poor internet connection that led to audio and video lagging.
This happened either due to having a low internet bandwidth or when trying to access the classes outdoors (e.g., the yard, balcony).
"When my internet speed gets slower, there was a bit of lagging, but that again improved because all I needed is to get my internet upgraded. It's inevitable.
There will be some tuning issues when you first start One of the advantages of tele-exercise classes that was reported by a few participants was feeling less self-conscious and intimidated by their peers, compared to attending in-person classes at the gym.
These participants did not feel they were being judged because of their physical limitations or feel they were in competition with others in the tele-exercise classes.
"When I was big, I lack a lot of confidence. Although participants appeared aware of the privacy and security risks associated with using any type of virtual platform, they generally felt that the tele-exercise classes did not require any additional security above and beyond other activities that they have had previously performed on a virtual platform. Most participants were also familiar with Zoom software, which they believed to be fairly secure. However, two participants suggested that the use of a hospital-based virtual platform would reassure participants that their privacy is being well protected.
Participants also generally perceived the tele-exercise classes to be physically safe, as they did not feel pressured to do exercises that they deemed as unsuitable for themselves. Additionally, participants appreciated having the instructor therapist guiding their technique and providing alternative exercises when needed, in order to prevent injuries. "I had someone that was a professional that knew about the fact that we all had surgery and so the types of exercises that were given to us was very specific and really tailored towards our own special needs at that particular time." (P4, Female, 42)

| Sub
Participants valued having a therapist who was attentive, able to communicate and give feedback whenever needed. This has helped them boost their level of confidence and motivation in the classes. Conversely, failure to address individualized needs proved to be off putting for participants. For example, one participant explained: "I think the therapist should know each individual capability and what they are fit to do, so that you don't push anyone to a level where they can't do it." (P2, Male, 58) The class size was judged to be acceptable, as many participants felt that in a small class, the therapist would be able to better observe and provide personalized guidance and feedback. Participants believed that having too many attendees in each session would have negatively impacted the level of individual attention from the therapist, which may cause participants to be less inclined to attend.

| Theme 4: Tele-exercise provided physical, emotional and social benefits
Overall, all participants reported to have experienced benefits from participating in the tele-exercise classes including physical, emotional and social benefits. In turn, these perceived benefits appeared to facilitate adherence to the classes and encouraged participants to continue engaging in physical activity beyond the research study. Among . 30 In the present study, the problem associated with the access to the tele-exercise classes and technical setup of software were minimal. This is unsurprising as of 2020, 96% of households in the United Kingdom having internet access. 31 Additionally, 83% of participants in this study were from a higher educational background, with an age below 65 that was deemed to be technology savvy. 32 People living with obesity generally experience a wide range of barriers to engaging in physical activity encompassing both internal barriers, which can be divided into physical (excess weight, poor fitness, health problems, injury) and psychological barriers (weight perception, low mood, lack of enjoyment and motivation/willpower), and also external barriers (lack of time and knowledge, poor weather, competing demands). 33 Despite a significant weight loss following bariatric surgery, the majority of these barriers to exercise continue to persist. 24 Ongoing support from an exercise professional is therefore recommended particularly following bariatric surgery 29  self-efficacy and improve action control skills as they found a strong relationship between these self-regulation factors with both objective and self-reported physical activity after bariatric surgery. 34 To date, a growing number of studies have attempted to elucidate the beneficial effects of exercise programmes following bariatric surgery in order to support a post-surgery exercise recommendation. 5 Although the effect of exercise post-bariatric specifically in enhancing weight loss remains inconclusive due to the paucity of high-quality studies, 35 several other positive outcomes were reported hence favoured recommendation, including preventing excessive loss of fatfree mass, enhancing physical and cardiorespiratory fitness, promoting better health-related quality of life, among other benefits. 36,37 In the present study, participants perceived that the tele-exercise not only benefited them in terms of physical health but also their social and emotional wellbeing were improved. Notwithstanding, high-quality studies of tele-exercise following bariatric surgery that measure these reported outcomes using objective assessment tools are still needed to confirm these early findings.

| Practical considerations for future implementation
To optimize the delivery of tele-exercise, several important aspects should be taken into consideration. Using a hospital-based virtual platform to deliver the tele-exercise would be a better option as this will assure participants of their privacy and safety being well-protected.
Providing participants with clear written guidance such as login instruction will ensure a smooth process of the tele-exercise delivery.
For a clear visual and access, ideally, participants would require a device with a larger screen (e.g., desktop, laptop or tablet) and a minimum internet bandwidth required to access a virtual platform. To ensure tailored and personalized supervision, the class size should be limited ideally between five to eight participants per session. Furthermore, an initial in-person session with an exercise therapist prior to enrolment in tele-exercise is needed to assess participants' exercise capacity for tailored exercise prescription and building rapport.
Recording the tele-exercise classes with availability to access this resource on demands were found to be useful but the copyright of the recordings should be taken into consideration. As per participants' suggestions, consider providing other simple and cheap exercise tools such as a yoga mat and exercise ball which were thought to be suitable and applicable for the tele-exercise. Finally, regarding the scheduling, a mix of weekdays and weekend options covering morning and evening classes would increase the likelihood of attendance. For the evening class, consider a later evening time to provide an opportunity for patients who are working in a daytime to get ready for the tele-exercise.

| Strengths and limitations
The present study captured in-depth views and experiences of patients towards a tele-exercise intervention following bariatric surgery and included a varied sample of male and female participants, with a wide age range and diverse ethnic backgrounds. We assumed that a sample of 12 participants was deemed appropriate because of the early, exploratory nature of this study and the focus was to gain preliminary insights that were useful for the planning and development of future robust teleexercise interventions. However, as the majority of participants in this study were highly educated and employed, the generalisability is somehow limited. Digital exclusion, especially among patients from a lower socio-economic group, may impact the uptake of such programmes. 38 In the current climate of the COVID-19 pandemic and associated restrictions, tele-exercise might be perceived positively, and as beneficial.
Therefore, patients' perceptions towards tele-exercise delivered during a non-pandemic period should be further explored. In addition, the present study did not explore the views and experiences of the exercise therapists, which are important to consider when designing and implementing future tele-exercise interventions. Lastly, although the majority of participants perceived the tele-exercise to be as effective as the in-person classes, we recognize that a quantitative study that objectively compares both methods is required in order to support the present findings.

| CONCLUSIONS
The COVID-19 pandemic has revolutionized the way healthcare is provided through telehealth. The present study suggests that teleexercise, when implemented specifically in patients who have undergone bariatric surgery, is feasible and well-accepted, and potentially as effective and useful as in-person exercise classes. These preliminary findings have provided additional insights into much-needed evidence for the potential use of telehealth in the provision of care following bariatric surgery. 17 In today's technologically advanced society, it is foreseeable that telehealth will eventually become a new norm for future healthcare. Therefore, it is timely and relevant now to undertake more robust research designs to investigate the efficacy and effectiveness of tele-exercise pre-and post-bariatric surgery. The research findings will be not only useful to face the present and future pandemics but can also be translated and integrated into the existing bariatric care pathway to optimize patient outcomes.