ARTICLE

https://doi.org/10.1057/s41599-024-03906-5 OPEN

Lived experiences of South African bariatric

patients during the COVID-19 pandemic: a
qualitative study
Chereé Davidson1 ✉, Caroll Hermann 2 & Vusi Mathe1
1234567890():,;

Patients having bariatric surgery require comprehensive support both socially and pro-
fessionally for successful surgery outcomes. With the outbreak of Coronavirus disease 2019
(COVID-19), many bariatric patients were negatively impacted due to stay-at-home orders
and social distancing practices. This study used a qualitative research design using a phe-
nomenological approach to gain a better understanding of bariatric patients’ difficulties and
lifestyle challenges between 3 months and 6 years after having bariatric surgery, and to
determine the impact that COVID-19 had on patients’ daily lives. A sample of 17 adults were
recruited from three hospitals in the Western Cape Province of South Africa. In-depth
interviews were conducted with open-ended questions that allowed participants to express
their feelings and describe their lived experiences during the pandemic. The interviews were
audio recorded and transcribed verbatim. The research data were analysed using inductive
content analysis. Most participants were women (88.2%) and married (64.7%). The study
identified five main categories: (1) physical impact; (2) psychological impact; (3) social
impact; (4) medical and follow-up care; and (5) financial impact. The study yielded results
that were in support of existing COVID-19 bariatric surgery literature. Many participants in
the study regained weight during the pandemic due to stress and the disruption of physical
routines and healthy eating habits. Many experienced an increased anxiety of contracting the
virus due to a compromised immune system. The need for professional support during this
time was emphasised. All follow-up appointments were cancelled due to the pandemic.
Virtual support groups were not favoured above in-person support groups. This research
study concluded that bariatric patients regained weight due to the pandemic because of their
healthy routines being disrupted. Bariatric patients are reliant on social and professional
support for successful outcomes. In-person support group meetings are highly favoured
amongst these patients.

1 Department of Psychology, University of Zululand, Private Bag X10001, KwaDlangezwa 3886, South Africa. 2 Department of Psychology, School of

Psychosocial Health, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa. ✉email: chereeschorn@gmail.com

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T
Introduction
he World Health Organisation (WHO) declared COVID- Background of the study
19 a pandemic on March 11, 2020. The pandemic pro- This article stems from a doctoral study on the lived experiences
foundly affected healthcare services worldwide. South of bariatric surgery patients initiated prior to the outbreak of
Africa reported its first confirmed case on March 5, 2020, and Coronavirus Disease 2019 (COVID-19). During the data collec-
declared a State of National Disaster only ten days later tion process between 2020 and 2021, it became evident that the
(Heywood, 2020). The pandemic impacted all individuals, espe- pandemic had significantly impacted the participants, an effect
cially those with obesity and other comorbidities, who faced unforeseen at the study’s onset. This emerged as a sub-theme
higher risks of hospitalisation, mechanical ventilation and from the participants’ narratives and was an unsolicited response
increased mortality due to compromised pulmonary function deemed significant by the authors.
(Dietz and Santos-Burgoa, 2020).
More than 890 million people worldwide are classified as
having obesity (WHO, 2024). In South Africa, 31% of adult men Research methodology
and 68% of adult women are considered to have obesity (Western This qualitative study was conducted in South Africa and
Cape Government, 2022). Bariatric surgery is increasingly employed a phenomenological approach to explore the lived
recognised as an effective treatment for obesity, though its psy- experiences of bariatric surgery patients during the COVID-19
chosocial impacts and the lifestyle challenges post-surgery are less pandemic. The aim was to understand the difficulties and lifestyle
understood (Coulman et al. 2017). The COVID-19 pandemic challenges these patients faced post-surgery. Phenomenology was
further complicated these challenges for South African bariatric chosen as it is well-suited to capturing and describing lived
patients. experiences from the individuals’ perspectives (Given, 2008).
Effective bariatric surgery requires patients to maintain sig- Two complimentary research methods were used. The phe-
nificant long-term behaviour changes supported by ongoing nomenological approach guided the overall design, while induc-
social and professional assistance (ASMBS, 2021; Sharman et al. tive content analysis provided a structured method for analysing
2015). The South African government enforced a national lock and interpreting the data. Grounded in an interpretivist para-
down due to COVID-19, which began on March 27, 2020. Stay- digm, the study aimed to understand participants’ subjective
at-home orders were given and social distancing practices became experiences. This approach facilitated detailed descriptions of
mandatory by law to reduce transmission. This impacted indi- how individuals made sense of their realities during the pandemic
viduals’ physical and psychological health, particularly among the (Guest et al. 2011), making it ideal for exploring complex lived
bariatric population (Heywood, 2020; Ahmed, 2020; Athanasiadis experiences.
et al. 2021). The sample was obtained through a purposeful sampling
Research has highlighted various factors influencing weight technique from three hospitals in the Western Cape province in
regain during the pandemic, including decreased physical South Africa, with additional participants recruited via snowball
activity and loss of access to nutritional support (de Luis et al. sampling. The participants were from both suburban and rural
2021; Athanasiadis et al. 2021; Conceição et al. 2021; Durão areas. The study protocol was approved by the University of
et al., 2021). An American study that identified risk factors for Zululand Research Ethics Committee (UZREC Number: 171110-
weight gain found that the bariatric patient population were 030 PGM 2020/17). After receiving ethics approval, the Centre of
more vulnerable to crisis situations and required additional Excellence for Metabolic Medicine and Surgery in South Africa
intervention (Athanasiadis et al. 2021). Studies also noted the (CEMMSSA) was contacted to obtain authorisation for partici-
increased rate of anxiety and depression among individuals pant recruitment. Participants were recruited from CEMMSSA
with obesity during this period (Almandoz et al. 2020; Sisto centres, specifically Netcare N1 City Hospital and Medi-Clinic
et al. 2021). Conceição et al. (2021) and Sisto et al. (2021) Vergelegen Hospital, two private hospitals in the Cape Town area,
reported disordered eating and psychological distress associated as well as from Tygerberg Hospital, a tertiary government-funded
with the lockdown period. Youseff et al., (2021) described the facility.
impact of the pandemic on patients’ obesity self-management Each centre in the Western Cape was individually contacted.
ability and mental health and Sockalingam et al. (2020) All patient information is confidentially kept at the centres. The
implemented psychosocial interventions to support mental study overview was discussed with the psychologist of each centre
health and bariatric care. to gain access to their patient cohorts.
While many studies focused on the medical treatment and A total of 50 patient details were provided to the researcher.
procedural impacts on bariatric patients during the pandemic Each patient was contacted telephonically, a study overview given,
(Azran et al. 2020; Moradpour, et al, 2021; Dudek et al. 2021; and oral consent gained to provide additional information via
Singhal et al. 2021; Daigle et al. 2020; Lazaridis et al. 2020), less email. This included the researcher’s credentials, study overview
have explored the psychosocial impact. and letter of informed consent.
Van Vollenstee and van der Merwe (2021) conducted a South Those willing to partake in the study were required to sign and
African study on bariatric patients that focused on obesity and return the informed consent form. Participants were assured of
its implications during COVID-19 pandemic from a purely confidentiality and the right to withdraw from the study at any
medical standpoint. No other studies were found on the psy- time without prejudice. In cases of discomfort during the inter-
chosocial impact that the pandemic had on South African views, participants were offered counselling. Upon receiving the
bariatric patients. There is a lack of research describing the requested, the researcher then arranged a suitable time and venue
specific experiences of South African bariatric patients during to meet participants.
the COVID-19 pandemic. The main author conducted 17 individual, semi-structured
The aim of this study is to describe and understand the lived interviews, each lasting on average 31 min. These interviews
experiences of South African bariatric patients during the pan- explored patients’ experiences and perspectives after bariatric
demic, shedding light on their unique challenges they faced. surgery and their lifestyle challenges. Due to the COVID-19
These findings will be discussed from a Social Cognitive Theory pandemic and related restrictions, only four interviews were
perspective through the concepts of self-efficacy, self-regulation, conducted in person, with the remaining 13 interviews conducted
and environmental influences (Bandura, 1997). via a virtual platform (Zoom). A research assistant transcribed the

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interviews verbatim, and the researcher audited the transcriptions An Excel pivot table was created to systematically organise the
for accuracy against the recordings. The inclusion criteria were various codes, categories and subcategories. The frequency of each
patients who had undergone bariatric surgery between 3 months code word was recorded. This quantification provided a clear
and 6 years prior to the study and were willing to share their indication of the prevalence of different categories and subcategories
experiences. in the data (see Table 1 below). The summarised data was then used
to create a chart, visually representing the distribution and
prominence of the categories and subcategories, allowing for an easy
Data analysis procedure. An inductive content analysis was understanding of the key findings (see Fig. 1 below).
performed, allowing categories to emerge naturally from the data Through this process, five main categories and five subcate-
without imposing preconceived categories (Kyngäs et al. 2020). gories were identified. Specific quotations from the transcripts
The researcher conducted the primary coding by reviewing the were extracted to illustrate the categories and subcategories. By
interview transcripts line-by-line, reading and re-reading to gain a using inductive content analysis within a phenomenological
deep understanding of the content, identifying significant state- framework, the analysis remained grounded in the data, ensuring
ments and developing initial codes. These codes were system- the findings accurately reflected the participants’ lived experiences
atically organised as the content was examined. Categories and (Kyngäs et al. 2020).
subcategories were derived from the codes and explored to assess
their relevance to the study’s research objectives. Results
To ensure the credibility of the coding process, the supervisor Socio-Demographics. The participants age varied from 30 to 62
independently reviewed the code words and categories for years old with a mean age of 44.5 years. There was an imbalance in
consensus. This review served as a form of triangulation, adding the representation of gender. Women represented 88.2% (15) and
an additional layer of validation to confirm the consistency and men 11.2% (2). A third of participants were single (29.4%) and the
accuracy of the identified categories (Bhandari, 2022). majority married (64.7%). Most participants were employed (88.3%)
at the time of the study. The sample had diverse socioeconomic
backgrounds. A little more than half (52.6%) reportedly earned an
Table 1 Values of categories and subcategories.
income over R25,000 per month. Less than a third (29.4%) earned
between R5,000 and R15,000 per month.
Row Labels Sum of Value Demographic characteristics of the sample are shown in Table 2.
Financial Impact 5
Medical and Follow-up Care 12 Qualitative results
Physical Impact 22
Main Category 1: Physical Impact. The COVID-19 pandemic and
Exercise and Fitness 10
Group Exercise 4
the nationwide lockdown in South Africa significantly affected the
Weight Regain 8 physical activities of participants, restricting outdoor movements
Psychological Impact 20 and forcing individuals to remain indoors.
Emotional Impact 12 ● Subcategory 1.1: Exercise and Fitness
Routine Changes 8
Maintaining exercise routines was a significant issue for 10
Social Impact 8
Grand Total 67
participants who faced challenges in maintaining their
exercise routines due to the closure of gyms and fear of
The table indicates the prevalence of different categories and subcategories that emerged from contracting the virus.
the data.

Financial Impact

Medical and
Follow-up care Physical Impact

Social Impact

Psychological
Impact

Fig. 1 Impact of COVID-19 on bariatric patients. The chart visually represents the distribution and prominence of categories and subcategories.

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Table 2 Demographic information. P2: “I think the weight that I gained over the last
2 months has contributed to my mental breakdown
building up and me finding comfort in food. I think it
(n) % (n) %
correlates to my Bipolar, because I’m an emotional
(N = 17) (N = 17)
eater. So when my mental health is healthy, I’m
Age Economic Status healthy. So as soon as my mental health takes a dip so
20–29 0 0 R 5,000-R15,000 5 29.4
do I.”
30–39 5 29.4 R15,000-R25,000 1 5.8
40–49 8 47 R25,000-R35,000 6 35.2
50–59 3 17.6 R35,000-R45,000 1 5.8 P5: “Oh, I get a little bit depressed and then I start by: I
60–69 1 5.8 R45,000-R55,000 1 5.8 have to watch my meals more carefully.”
Gender Above R55,000 1 5.8
Male 2 11.7 Unemployed 2 11.7 P10: “… Being at home during COVID, and the financial
Female 15 88.2 impact COVID has had, so that transported into my diet”.
Marital Status
Married 11 64.7 P16: “I think with the whole stress around COVID…”
Living together 1 5.8
Divorced 0 0
● Subcategory 2.2: Routine Changes
Widowed 0 0 The pandemic disrupted the daily routines of 8 participants
Single 5 29.4 making it difficult to maintain their usual activities.
The table displays the socio-demographic information of participants in the study. P1: “Let’s pretend COVID never happened. Before it
happened, I was going regularly to the gym 4 or 5 times a
week.”
P1: “I haven’t been exercising, I don’t want to pick up the
weight again … before it happened I was going to the gym 4 P3: “… obviously through lockdown it was a bit difficult and
or 5 times a week … but no one is going to the gym.” I was also working from home and I am a bored eater …”

P16: “I think with the whole stress around COVID, I think P10: “… one minute you’re at the office, the next minute you
it makes it a lot more difficult to get your mind into it, get sent home. You’re sitting at home, my gym membership
because when you go to the gym there are queues and is in town and I live in the northern suburbs … then you go
queues standing. I don’t want to go stand in those queues ” back for two weeks again, then you’re home again for a
month … my routine is out … there’s no routine, there’s no
P17: “I’m still very rarely going to gyms with COVID, and set thing. So it’s difficult.”
with exposure there, although we have been vaccinated, but
you know, we rather air on the side of caution.”
Main Category 3: Social Impact. Social support in patient recovery
● Subcategory 1.2: Group Exercise and management was shown to impact 8 participants. The can-
The cancellation of structured group exercise activities cellation or shift to online platforms from in-person support
during lockdown impacted 4 participants. This was less groups due to social distancing regulations had a notable impact
critical in comparison to personal fitness routines. on these participants.
P1: “I used to join the spin classes every second day and go P1: “The last support group was in January. With COVID,
spinning.” this was all cancelled in March. I have put on 8 kilos.”
P11: “When the Parkruns are back, I would love to go do P10: “We had one last month over Zoom, it just doesn’t
the Parkruns. I’ve done 13 already, so that’s nice, it keeps work. People miss people. We’re trying to see if we could
me going.” get a physical venue together and then the third wave hit, so
it’s difficult, but we’re working on it.”
P13: “I’m playing netball again as well, but it will stop
now because of COVID, but I love it …” P12: “Not at the moment due to COVID. I speak to some of
● Subcategory 1.3: Weight Regain the people on the bariatric group on WhatsApp and we
Participants experienced weight regain due to changes in support one another through that means. I think it’s
their lifestyle and routines, as highlighted by 8 participants. important, especially for people that have got other
problems, especially mental problems, that they feel they
P1: “In 4 months to pick up 8 kilos …” can’t cope with this operation.”
P4: “… I won’t say I ate more per session but instead of
eating my four (meals), I might have chosen the wrong Main Category 4: Medical and Follow-up Care. Many scheduled
thing and I picked up almost 7 kgs…” follow-up practitioner appointments were cancelled or post-
poned, increasing anxiety among some participants who relied on
P10: “I’ve gained weight due to COVID…I have gained these for reassurance. This impacted 12 participants.
about 11.” P4: “… with COVID we did miss a few … they first want to
Main Category 2: Psychological Impact.
try and sort out all the backlog … the last one was the 22nd
● Subcategory 2.1: Emotional Impact of April.”
Significant psychological stress and challenges were faced
by 12 participants during the pandemic, which impacted P7: “I haven’t had a follow-up because of COVID … they
their diets and physical activity. just cancelled all the appointments.”

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P13: “I would have definitely stuck to my appointments in this study. However, this impact was mostly relevant for
were it not for COVID, yes, because I’m so worried and I’m individuals who preferred gym facilities. Those who preferred
a bit paranoid that anything could go wrong …” running or walking outdoors were less affected, although these
activities were also curtailed by the nationwide lockdown (Sallis
Main Category 5: Financial Impact. The COVID-19 pandemic et al. 1990).
had a significant financial impact on 5 participants. Bariatric patients are often advised to establish an exercise
routine before surgery to enhance post-operative recovery and
P10: “… the supplements, and ja (yes), eating healthy costs long-term outcomes (Sherwood and Jeffrey, 2000; King and
a lot of money. I think that’s also why during COVID and Bond, 2013). The closure of gyms and restricted movements likely
the financial impact from COVID and trying to recover hindered participants’ ability to maintain these routines, under-
from that, I’m just not there yet.” scoring the importance of self-efficacy and self-regulation in
adhering to exercise (Bandura, 1997; Anderson et al. 2006). Self-
P13: “I changed for about 10 months during the COVID efficacy, a key component of Social Cognitive Theory, is regarded
time, but that was the only reason I changed. I’m a bond as the most significant predictor of exercise behaviour. It refers to
consultant, a home owner specialist, and the deeds office an individual’s belief in their ability to exert control and persevere
was closed and the estate agents couldn’t show properties so in the face of challenges, thereby increasing the likelihood of
we literally just had our basic salaries and I couldn’t cope maintaining an exercise routine (Sherwood et al. 2001; Bandura,
on that. So I left the company …” 1997). Self-efficacy fosters resilience, enabling individuals to
regulate their motivation and behaviour (Bandura, 1997). In this
P15: “They asked me to come back and assist in COVID context, higher self-efficacy supports better exercise adherence, as
ICU and I’ve actually been working for more than a year. I individuals are more likely to maintain routines despite external
actually was on pension for 3 months and I’m still working. challenges.
It is fantastic in terms of having more money.” Anderson et al. (2006) examined a social-cognitive model of
physical activity, identifying self-efficacy, self-regulation, and
social support as key determinants of physical activity, with self-
Summary. The analysis revealed several key themes and pat- regulation having the strongest influence. This suggests that
terns. The COVID-19 pandemic had a significant impact on individuals lacking self-efficacy and self-regulation may rely more
emotional and physical health of participants. It affected heavily on external motivators for behaviour change.
exercise and fitness, weight regain, and routine changes. Roessler (2016) identified significant factors influencing
Medical support and access to follow-up appointments were exercise behaviour, including the supportive effect of structured
disrupted. Social support groups were also significantly environments, group support and the positive feelings experi-
impacted. Additionally, the pandemic had a financial impact enced during and after exercise. This study found that
on participants. participants preferred a fixed structure and relied on external
institutions to manage their physical activity. The lack of
Discussion structured environments, such as gyms and organised classes
The results of this study reveal that many participants experi- during the pandemic, disrupted participants’ engagement in
enced negative impacts due to the COVID-19 pandemic across physical activity, further highlighting their reliance on external
physical, psychological, social and financial domains. Participants motivators for behaviour change.
were generally unprepared to cope with the various challenges Additionally, the cancellation of group exercise activities,
posed by the pandemic. These findings are consistent with pre- which some participants noted as a significant loss, emphasises
vious research indicating that individuals with obesity were dis- the importance of social support in maintaining physical activity.
proportionally more affected by the pandemic (Flanagan et al. Social cognitive theory suggests that observational learning and
2021; Glazer and Vallis, 2022; Athanasiadis et al. 2021; Youssef modelling behaviour in a group setting can enhance motivation
et al. 2021; Almandoz et al. 2020). and adherence to exercise routines (Bandura, 1986). Although no
current studies conducted during COVID-19 specifically
Physical Impact. During the COVID-19 pandemic in South addressed the impact of group exercise cancellations, it is well
Africa, restrictions on outdoor movements initially forced indi- known that social support and exercising with others can boost
viduals to remain indoors, limiting their physical activity (Gon- physical activity levels, especially among women (Sherwood and
zalez and Maina, 2020). Jeffrey, 2000). The prohibition of group gatherings during the
Participants reported being unable to attend gyms due to pandemic removed a critical source of motivation, particularly for
closures and fears of contracting the virus, which led to increased those who thrived on group support, leading to a decrease in
anxiety, as they could not maintain their regular exercise routines. physical activity.
A recent study of bariatric patients in the United States similarly Several participants reported weight regain during the
found that the pandemic disrupted dietary and exercise routines pandemic, consistent with other bariatric studies (Glazer and
due to facility closures and fear of virus exposure (Murtha et al. Vallis, 2022; Athanasiadis et al. 2021; Flanagan et al. 2021). For
2023). These findings align with the current study, particularly instance, Glazer and Vallis, (2022) found that 60% of patients
among female participants. regained weight during the social distancing period, while
This is consistent with research by Athanasiadis et al. (2021), Athanasiadis et al. (2022) reported 43.6% weight regain.
which reported a 55.2% reduction in exercise activity among Additionally, more than half of the patients experienced increased
bariatric patients during the pandemic. Although the current anxiety, more frequent snacking and reduced physical activity
study did not measure the amount of time spent on physical (Athanasiadis et al. 2021), findings echoed in this study.
exercise, most participants reported a reduction in their activity Research by de Luis et al. (2021), noted that increased body
levels. weight was linked to decreased physical activity. Similar trends
Access to exercise facilities plays a significant role in were observed in a large-scale study across multiple countries,
influencing physical activity levels (Sherwood and Jeffrey, 2000), where weight gain was prevalent among individuals with obesity
and the enforced lockdown disrupted this access, as highlighted during lockdown (Flanagan et al. 2021).

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The weight regain during the COVID-19 pandemic likely consistently engage in health behaviours. This includes regular
resulted from increased sedentary behaviour, disrupted routines, physical activity, meal patterns, eating breakfast, following a low-
and poor dietary choices, compounded by the psychological stress calorie and low-fat diet, and monitoring their weight. However,
of the pandemic. According to Social Cognitive Theory, these during the pandemic, many participants struggled to maintain
findings underscore the need for continued self-monitoring and these routines, including their diets and exercise habits. Flanagan
the maintenance of healthy habits, even in challenging times et al. (2021) found that individuals with obesity were significantly
(Bandura, 1997; Kruger et al. 2006; Odom et al. 2010). more affected by these disruptions, and Glazer and Villis (2022)
noted that the lack of routine was a common barrier to
maintaining healthy eating habits.
Psychological Impact. The psychological toll of the pandemic
was clear in the increased stress, emotional eating and sedentary
Social Impact. The social impact of the pandemic was significant,
behaviour reported by participants. This supports earlier research
particularly due to the disruption of in-person support groups.
showing that stress negatively affects diet and physical activity,
While the shift to virtual support has been well documented
particularly in individuals with obesity (Murtha et al. 2023;
(Youssef et al. 2021; Athanasiadis et al. 2022; Yeo et al. 2020), this
Almandoz et al. 2020). Similarly, a study found that bariatric
transition was not equally effective for all participants, despite
patients often face unique psychological challenges, using emo-
evidence of its potential benefits (Athanasiadis et al. 2022; Youssef
tional eating to cope with anxiety or boredom (Youssef et al.
et al. 2021).
2021).
Research by Beck et al. (2012) found that attending post-
According to Social Cognitive Theory, stress can reduce self-
operative bariatric support groups is associated with increased
regulation, leading to unhealthy habits like emotional eating,
weight loss. Recognising the importance of social support, the
especially in those with low self-efficacy (Bandura, 1997).
American Society for Metabolic and Bariatric Surgery includes
Research also found that 40% to 50% of participants showed a
organised and supervised support groups as part of the treatment
negative correlation between stress and exercise; as stress
plan (Pratt et al. 2006; Sogg et al. 2016; LeMont et al. 2004).
increased, exercise decreased, which contributed to weight gain
The cancellation of in-person support groups during the
(Munekawa et al. 2021). Richardson et al. (2015) found similar
pandemic negatively impacted participants’ ability to share
results linking stress to emotional eating, poor diet quality and
experiences, gain peer support, and adhere to their health plans.
severe obesity. Many participants in this study faced heightened
Social Cognitive Theory emphasises the role of social support in
stress during the pandemic, with limited access to social and
behaviour change, particularly through vicarious experiences and
healthcare support due to appointment cancellations and social
observational learning (Bandura, 1986). The lack of face-to-face
distancing.
interaction likely reduced the effectiveness of these support
The emotional eating observed, can be explained by Social
groups, as the opportunities for social learning in in-person
Cognitive Theory, which suggests behaviour is influenced by
meetings were diminished.
personal, behavioural, and environmental factors (Bandura,
Some participants may have relied heavily on the established
1986). The pandemic heightened stress, which led participants
friendships and face-to-face interactions within the bariatric
to use emotional eating as a coping mechanism. Additionally,
groups (Azizi et al. 2020), as well as direct support from
disruptions to daily routines made it harder to maintain healthy
healthcare professionals. The importance of such support from
habits, worsening psychological distress.
healthcare professionals is well documented (Torrente-Sánchez
Stults-Kolehmainen and Sinha (2014) noted that people with a
et al. 2021). This suggests that while virtual support can
history of being active are more likely to exercise during stressful
complement in-person interactions, it may not fully replace the
periods, while those new to exercise tend to stop. Most
benefits of direct human connection.
participants in this study had been sedentary for years before
surgery. The combination of increased stress, poor diet and a lack
of exercise during the pandemic, likely contributed to weight gain. Medical and Follow-up Care. The cancellation or postponement
A global study by Flanagan et al. (2021) also found that weight of medical follow-up appointments increased anxiety among
gain was linked to declines in mental health, with those having participants who relied on reassurance from their doctors about
obesity reporting significantly higher anxiety levels. their health. Global research on COVID-19 health behaviours
The pandemic disrupted participants’ daily routines, indicated that patients with obesity were particularly affected,
forcing them to spend more time at home and face new experiencing increased anxiety levels and weight gain (Flanagan
challenges, like working from home. Without regular routines et al. 2021). Several studies recommended that bariatric patients
of commuting, exercising, and planning meals, many receive additional comprehensive support and mental health
struggled to maintain healthy habits. Youssef et al. (2021) screenings during the pandemic, emphasising the importance of
found similar results, noting that disruptions to daily routines maintaining connections through telehealth and remote medicine
increased stress and reduced adherence to dietary guidelines. (Flanagan et al. 2021; Ray et al. 2022).
Social Cognitive Theory suggests that routines are sustained A United States study by Murtha et al. (2023) reported that
through self-regulation and habit; both of which were follow-up appointments for bariatric patients transitioned from
disrupted by the pandemic, leading to poor health outcomes in-person to telemedicine. This study also highlighted the
(Bandura, 1986). vulnerability of bariatric patients and the importance of ongoing
International studies found that lockdown and stay-at-home professional support. In other countries, telemedicine and phone
orders reduced healthy eating, increased sedentary behaviour, calls were commonly used to maintain communication with
decreased physical activity, and led to weight gain (Flanagan et al. bariatric patients during the pandemic, emphasising the impor-
2021). Almandoz et al. (2020) also reported that nearly 70% of tance of continued care (Mikami and Noria, 2020; Glazer and
patients found it harder to reach weight loss goals during the Vallis, 2022). The value of virtual care in boosting patients’ self-
lockdown. efficacy was also reported by Youssef et al. (2021). However,
Building a healthy routine takes time and has many benefits telemedicine was not an option for participants in this study, likely
(Arlinghaus and Johnston, 2018). Wing and Phelan (2005) due to limited availability in South Africa (Pillay et al. 2021).
highlighted that individuals who successfully maintain weigh loss Social Cognitive Theory suggests that self-efficacy in managing

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HUMANITIES AND SOCIAL SCIENCES COMMUNICATIONS | https://doi.org/10.1057/s41599-024-03906-5 ARTICLE

one’s health is strengthened by regular feedback and support from The significant psychological impact found in this study
healthcare providers (Bandura, 1997). The absence of such emphasises the need for integrated psychological support within
support likely reduced participants’ confidence in managing their bariatric care. Mental health professionals should be more
post-operative care, underscoring the need for accessible tele- involved in bariatric patients’ treatment plans, offering counsel-
medicine services to ensure continuity of care during crises. ling and support to address stress and emotional eating. The
psychological support that patients require was also suggested by
Mikami and Noria, (2020) in their study on bariatric surgery
Financial Impact. The pandemic caused significant financial strain
practice and patient care during the pandemic.
on participants, which was exacerbated by the need to maintain a
The disruption of support groups highlights the importance in
healthy lifestyle and afford lifelong vitamin and mineral supple-
patient recovery. This is consistent with the American Society for
ments (van Vollenstee and van der Merwe, 2021). These supple-
Metabolic and Bariatric Surgery guidelines, recognising the
ments, not covered by medical health schemes, can be costly. The
effectiveness of bariatric support groups (Pratt et al. 2006; Sogg
financial challenges faced by participants are consistent with global
et al. 2016; LeMont et al. 2004) and has also been supported by
trends (Euart et al. 2020). South Africa reportedly experienced some
other recent COVID-19 research (Athanasiadis et al. 2022; Yeo
of the most drastic income reductions, with 50% of South Africans
et al, 2020). Healthcare systems should ensure that virtual support
reporting job insecurity and savings covering less than four months
groups are effective and accessible, possibly enhancing them with
expenses (Euart et al. 2020). No specific studies were found on the
interactive features to mimic in-person meetings. In addition,
financial impact of COVID-19 on bariatric patients.
virtual support groups should be included regularly as part of the
Some participants experienced employment changes as a result
support group programme so when there are times of crisis,
of COVID-19, further affecting them financially. A study reported
individuals are used to a virtual platform.
that the pandemic negatively impacted families in South Africa,
Highlighting an important area of concern, the findings
with many businesses closing, leading to temporary or permanent
indicate the need for telehealth services to ensure continuity of
unemployment for main income earners. This, in turn, affected
care. Remote monitoring tools and regular virtual consultations
families’ food security and their ability to afford basic necessities
should be implemented to maintain the necessary medical care
(Adebiyi et al. 2021).
for bariatric patients (Youseff, et al., 2021; Mikami and Noria,
According to a survey conducted by Stats South Africa on
2020; Glazer and Vallis, 2022).
2,688 respondents, 70% of those who lost their jobs did so due to
The financial impact of the pandemic presents a barrier that
business closures. Two-thirds of participants expressed concern
should be addressed. Healthcare providers should be aware of the
about the long-term financial impact of the pandemic (Stats
financial constraints patients face and offer resources or guidance
South Africa, 2020).
on affordable healthy living options.
The financial impact on bariatric patients, though not
These findings should inform public health policies to ensure
extensively studied, reflects the broader socio-economic challenges
that during future pandemics or crisis, there are clear guidelines
faced during the pandemic. Social Cognitive Theory suggests that
and support systems for maintaining physical and mental health
financial stress can reduce self-efficacy, making it harder for
of bariatric patients in South Africa.
individuals to engage in health-promoting behaviours (Bandura,
Future research should focus on longitudinal studies to
1986). This highlights the need to address financial barriers in
understand the long-term impacts of COVID-19 on bariatric
healthcare, especially for bariatric patients during crises.
patients, especially concerning weight regain and mental health.
Perhaps future studies may investigate the effectiveness of
Relevance of the Study. Obesity is increasing worldwide (WHO, different virtual intervention programmes to maintain physical
2024). Improved long-term outcomes of bariatric surgery are activity, emotional well-being and social support in bariatric
important for individuals (ASMBS, 2021). patients.
The COVID-19 pandemic challenged all healthcare systems. In The findings from this study are highly relevant as they provide
South Africa, bariatric patients’ lives were also affected. This important insights into the multifaceted impacts of the COVID-
study highlighted clinical practice implications. It could influence 19 pandemic on bariatric patients within a South African context.
future public policy and possible areas of future research, to
improve surgical outcomes during times of crises.
From a clinical practice standpoint, the study highlighted Strengths and Weaknesses of the Study. The study provides
important areas of concern for bariatric patients. The disruption valuable insights into the challenges faced by bariatric patients
in exercise routines highlighted the need for healthcare providers during the COVID-19 pandemic, highlighting the multifaceted
to develop home-based alternative exercise programmes. To help impacts on physical, psychological, social, and financial domains.
patients maintain their physical health, virtual fitness classes and As this is a qualitative study, our results should not be general-
personalised home workout plans can be introduced. Recent ised. However, the study’s demographic limitations, pre-
studies have reported virtual exercise classes have produced dominantly involving white, affluent, female participants from
positive outcomes in patients after bariatric surgery (Ali et al. the Western Cape, can establish that participants’ opinions and
2022; Jassil et al. 2022; Yeo et al. 2020). experiences exist within this population. Future research should
Emphasising the role of group activities in motivation for aim for a more inclusive sample to better represent the diverse
exercise, clinicians might consider arranging small, safer, in- South African population.
person group activities or virtual group exercise sessions to The short duration of the interviews may have impacted the
maintain patient physical activity. amount of data obtained in that participants possibly did not fully
The study findings underline the need for continuous support elaborate on their experiences. Although participants were given
in maintaining healthy routines. Healthcare providers should the time to freely express themselves when answering the
provide regular check-ins via telehealth to help patients stay on questions, this may have lead to less detailed responses and
track with their weight management goals. This has been potentially impacting the studies overall insights. Future research
implemented in other countries and has shown effectiveness in should aim for longer interviews.
patient management (Mikami and Noria, 2020; Glazer and Vallis, Additionally, the study’s reliance on self-reported data may
2022). introduce bias. Future research should involve a more diverse

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ARTICLE HUMANITIES AND SOCIAL SCIENCES COMMUNICATIONS | https://doi.org/10.1057/s41599-024-03906-5

sample and explore the long-term impacts of the pandemic on and recommendations. Open Public Health J. 233–238. https://doi.org/10.
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Ahmed HO (2020) The impact of social distancing and self-isolation in the last
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