In our study 79.5% of physicians said that they practice PA of which 49.3% report reaching WHO recommendations with regard to regular PA, that is 150 min/week of moderate-intensity PA or 75 min/week of high-intensity PA12. The results are close to the French national average of 42,5% regular PA according to the nutrition health barometer 20086, but lies just above that of the inhabitants of French Guiana according to the DOM health barometer 2014 where 75% practiced PA, of which 36% on a regular basis6. Few data on the practice of PA by GPs are to be found in the literature. A recently published study in 2019 by Alameh and al. described that only 27% of physicians engaged in regular PA13. In our study the physicians who practiced regular PA believed more often than others that their recommendations would have an impact. The review of the Lobelo and al. literature, in 2016 found that the physicians who engage in regular PA are more likely to advise effectively and to prescribe PA to their patients and are more convincing because they themselves exercise14. Several studies support this notion9 15 16 17. Furthermore, the MOBILE study18 19 demonstrates that regular PA by physicians has a strong influence on the glycemic control of their patients by a positive correlation with the level of the patient’s PA. In 2005, Rogers and al. even demonstrated that the introduction of a PA program with medical students was significantly associated with changes in terms of their PA guidance to patients20. The promotion of practicing PA with physicians is also a point for reflection. The second observation is the lack of training in this subject; indeed, two-thirds of physicians were not aware of the French National Authority for Health 2018 guide and frame of reference about the prescription of PA and diabetes, and three-quarters are not aware of the 2016 decree. No significant statistical link was found between the knowledge of recommendations/decree and the characteristics linked to physicians. It was observed in our study that physicians who apply the recommendations responded that they more often felt competent to prescribe PA than those who did not apply the frame of reference, and they also spent more time doing so. The low level of training observed in our study of GPs concerning the fields of sport (5.8%), diabetology (15%) but also in sport-health training (11%) might explain on the one hand this finding of poor knowledge of the recommendations. It is known that physicians having knowledge of the recommendations more often advise and prescribe PA. Thus, Rogers and al., 2006 in the USA demonstrated that greater training and confidence concerning PA recommendations were associated with more frequent advice21. However, Cogneau and al., 2007 asserts in his study that even though physicians were aware of the best practice recommendations for type 2 diabetes, they failed to adhere to them, in particular through a lack of communication with patients, which could be resolved by working closely with other paramedical professionals involved (dieticians, APAT, nurses)22. It also outlined that the recommendations barely addressed the subject of PA, which, in his opinion, explained the gap between the frame of reference and physicians’ practices. The majority of physicians assumed that their recommendations had an impact on their patients, yet almost all estimated that more than 50% of their patients did not follow their advice. And yet, a review of the literature shows that the advice of physicians is associated with an increase in the adherence of patients23. Vallée, and al. in 2017 even demonstrated that a piece of advice, even minimum, addressing PA during a consultation favored the practice of PA24. Its recommendation is logically associated with nutritional advice25. The systematic review of Hébert and al. literature found that physicians were not sure of the effectiveness of their recommendations in view of the barriers that they met26.
Indeed, in our study we found that physicians convinced that their recommendations had an impact prescribed PA more frequently and used it more often as a non-medicinal therapeutic choice. To be persuaded of the value of PA was not found as a strong factor favoring prescription, and yet this factor had an influence on the prescription and the practice of patients. Lanhers and al, 2015 found that the more a GP had barriers to prescription, the more the patient would have barriers to practice and as a consequence would have a lower level of PA27. The interest of PA is now well established in terms of primary, secondary and tertiary prevention as is detailed in prerequisite25 28–31, and yet some physicians may still be sceptical about its utility, as is reported in the qualitative study by Persson and al. in Sweden32. The Mandic and al. study 2018 in the United States found that being convinced of the interest of PA and its practice by physicians, was associated with a better perception of the impact of PA recommendations on their patients33.
Very few physicians were in favor of written prescriptions and yet a review of the literature has demonstrated the effectiveness of this method on the increase in levels of practice of PA34.
Equally, as demonstrated by Little and al. 2004 the association of different means (written prescription, oral advice and delivery of documents) lead to a significant increase in the practice of PA by patients35. Our study shows that the physicians who applied the recommendations hardly ever spent less than two minutes prescribing. In the study of Duclos and al. 2015, 50% of physicians spent less than five minutes to prescribe PA19. On average, a medical consultation lasts 18 minutes (Drees 2012 data36), however there are no precise data concerning the time required to prescribe PA. The French National Authority for Health’s recommendation is for a PA medical consultation to take on average 30 minutes, but it may take place over different consultation times37. More than one-half of respondents said that they evaluate the level of practice and follow-up of PA in their type 2 diabetic patients. The means employed in preference were interview for 97.6 of respondents, as found in Gerin and al9.
The use of other means as movement meters such as the pedometer demonstrated an improvement in the patient’s motivation and practice of PA. Yet also as demonstrated by the Canadian program SMARTER, its association with a simple medical prescription of a number of daily steps increased PA, and had an impact on the insulin sensitivity of type 2 diabetic patients38. Evidence of its direct effectiveness on HbA1C was still not found39. The integration of this mechanism might be possible considering that according to studies it seems to be generally accepted by both the patient and the physician40 41.
The collection of the level of PA by a questionnaire and/or journal and/or activity notebook also has its advantages, indeed its integration as a vital sign recorded in the patient’s medical file around two or three questions, as well as the other parameters during a consultation is considered as an innovative key action. The paper by Sallis and al. explains that different electronic medical software has already integrated this parameter, and have observed an increase in medical advice, and a consequence on weight loss and HbA1c42. In the face of the emergence of connected objects in our societies, new ideas are appearing regarding the utilization of these means to favor the evaluation, monitoring and practice of PA42. Our results concerning the obstacles to the prescription of PA, the adherence of patients and the factors favoring the prescription of PA, are very similar to the data in the literature such as the studies of Duclos and al.19, Gérin and al.9, or the ENTRED study43, aside from one significant point which is “lack of time”. Indeed, this was not found to be one of the main obstacles to the prescription of PA in our study, whereas it was in other works in the literature8 9 15 16 44. A single study has however found a result comparable to ours, that of Oloo M. published in 2019, which found that the time factor was not considered as an obstacle and that the main obstacle was the lack of support/teaching resources in Kenya45. It is assumed that even if the GPs in French Guiana had more time, the prescription of PA would not be more frequent when considering all the other obstacles highlighted including above all the lack of networks and structures, which are the most lacking in our department. According to practically all the physicians in the study, it seems to be important to have a structure to guide type 2 diabetic patients in the context of PA. The lack of structure was the first obstacle to the prescription of PA by GPs, but also an obstacle to the adherence of patients for 68.5% of physicians. The development of sport-health networks was the second measure requested by physicians to help prescription. The structures and sport-health networks provide orientation adapted to the patient, in appropriate places, and thus facilitate the maintaining of and commitment to practicing PA. For physicians it serves as a relay structure, which enables other health professionals to work together. Indeed, in our study, one-half of physicians felt alone in the face of integrating the prescription of PA and the majority of physicians were not aware of structures towards which they could refer their patients.
We do not have a regional sport-health center in French Guiana although some hospital programs exist which we have outlined previously. However, this does not meet all the needs of the territory in order to reach our objectives. As far as the teaching of PA is concerned, just over half of physicians (57.5%) are not aware of the profession of APAT, but nearly all are ready to refer their patients to these actors. The collaboration between health professionals was the first factor favoring prescription of PA voiced by the GPs in our study. Recognition of the APAT is already well established and integrated in the health systems of many countries, such as Europe, the United States and Australia. However, in some countries, like China, it is not yet recognized by the state19. In France, as outlined previously, the APAT is a professional, trained in PAA, accredited and currently at the core of each sports device on developed prescription. The evaluation of different methods has demonstrated the effectiveness of programs in terms of patient adherence and the change towards an active lifestyle, with an increase in their level of experience. A review of the literature by Bullard and al. showed a 77% average rate of adherence to programs46. As an example, the experience of the Biarritz Côte Basque Sport Health program showed that 90% pursued the practice of PA in a sports association after stopping the program47. With the final goal being to empower the patient, few studies have yet been conducted to observe the long-term impact of these methods. The French Society of APA Professionals created an online directory in 2018 identifying private APAT, however no APAT from French Guiana are listed.
Some physicians believe that it is not their role to prescribe PA, as it was reported in the qualitative study of Persson and al. 2013, where Swedish physicians preferred to delegate prescription to other health professionals32. Indeed, in some countries, health professionals other than physicians are authorized to prescribe PA. In Sweden, for example, trained physiotherapists and nurses can prescribe PA. Other countries are discussing the possibility of collaboration with other medical and paramedical professionals to help prescription of PA: with pharmacists in the United States, or with nurses in Canada48 49. Some health professionals are more accessible to the population, and with appropriate training they could increase patients’ awareness to the practice of PA. According to physicians, the first causes listed as obstacles to patient adherence are principally factors intrinsic to the patients: lack of interest/motivation of the patient is the first factor. The patient’s foreseeable lack of compliance was found to be an obstacle to prescription from average to very important by more than 50% of GPs. This demonstrates the difficulty physicians have with the motivational interview. One of the explanations is probably the lack of training in this area of competence. The second factor is the lack of patient knowledge about the correlation between sport and the management of their diabetes. This element illustrates the need to increase training in TPE in order to improve patients’ knowledge and to increase their adherence to care and treatments. The 2007 ENTRED study highlighted the need expressed by patients for information about their condition43. Physicians also identified the presence of physical limitations and comorbidities (4th factor), which was the main barrier identified by GPs in the MOBILE study19. Additional care given by paramedics and APAT, offers exactly a framework of practice supported by trained professionals, authorized to provide APA to patients with functional limitations, even when these limitations are severe. Other intrinsic factors (fear of hypoglycemia, fear of failure/prior failure) or non-intrinsic (absence of family or neighbors, lack of personnel and lack of time) which help patient adherence, were less relevant to physicians. The absence and/or remoteness of structures was the 3rd factor cited by physicians. According to the DOM health barometer 2014, 12% of Guyanese declare having forsaken care or examinations because of transportation issues to access the structures50. To address this obstacle, the French National Authority for Health recommends encouraging the practice of PA outdoors, possibly assisted by the enrichment of sports facilities in communal areas (first aspect of the National Sport-Health Strategy 2019–2024)37. Some countries like Australia are studying the possibility of development of APA programs at home which appear to be accepted by patients51. The ethnocultural aspect considered as a factor of resistance to practice by patients by one third of physicians is to be addressed. As demonstrated by the Quebec study in the dissertation on physical activity by Ouimet I.: “the perception of physical activity and the obstacles to its practice vary depending on ethnocultural origin and sex”. It is therefore necessary to consider this aspect in order to “develop culturally appropriate interventions”52. Reviews of the literature support this aspect by finding ethnocultural differences related to beliefs and perception of the disease, in line with cultural standards, immigration, religion, and bio-anthropological data53 54. This is an important concept in French Guiana, where the population is ethno-culturally very heterogeneous. Finally, the financial cost of PA was mentioned as the 5th obstacle to patient adherence in this study and for 53.4% of physicians the compensation of patient costs appeared to be a very important measure to help prescription.
Indeed, since the implementation of the decree in 2016, reimbursement of patients has not been foreseen when prescribing APA in the context of an LTD, whereas 83.6% of physicians in the study believed that the compensation of costs related to PA on prescription would improve the adherence of patients. Half of them believed that the French social security should take part in its financing in priority, unlike the IFOP survey conducted amongst a representative sample of 603 GPs in 2015, where almost 50% of physicians thought that the patient should finance it in priority and then the French social security 25%8. It has been demonstrated that the socioeconomic context of the patient has an impact on the level of patients’ practice53 54. The DOM health barometer 2014 found that 30.9% of Guyanese had stopped seeking medical care for financial reasons50.
Furthermore, an analysis of the ENTRED study concerning the DOMs observed a prevalence of diabetic patients receiving significantly higher universal health cover (35% in West Indies-French Guiana, versus 12% in mainland France), which is a reflection of a more economically disadvantaged population. This component accentuates our need to think about the costs linked to the practice of PA by patients in French Guiana. The medico-economic study of Da Costa Correia and al., 2008 demonstrated that the responsibility of the TPE network “Auvergne Diabetes on health” resulted in a saving of 1 088 Euros/patient/year of health care expenditure55. The Montpellier study of Brun and al., 2008 also showed lower health care costs during medical rehabilitation prescribed for type 2 diabetic patients56. Future medico-economic studies which will result from recent French sport networks on prescription will support the issue, as does the National Health-Sport Strategy 2019–2024 and will highlight the benefit represented by the practice of financed PA, not only directly impacting the reduction in costs linked to the management of diabetes and its complications, but also improving patients' quality of life.
Since the 2016 decree, no dedicated pricing system has been planned for prescribing physicians. Yet the physicians in our study did not consider that it would be an important aid to favor their prescription, nor was a significant constraint. In some programs physicians even accept voluntary actions, for example in the United States as in the program “Walk with doc”, where the local physician organizes and practices walking sessions in public places, open to all42. However, the results of the study, showing that self-employed physicians were more inclined to view compensation of physicians as a factor supporting prescription, justify reflection on this issue. In the 2007 ENTRED study, 53% of specialist physicians considered the non-remuneration of PA on prescription as an obstacle43. In France, despite the implementation of Public Health Remuneration in line with Objectives, the system of health care payment per consultation is not very indicative according to the report of the French National Authority for Health regarding the prescription of non-medicinal therapies. The Ministry of Health envisages a reform of the French healthcare system and different concepts are to this day under consideration with the aim of enhancing the quality of patient care, whilst improving cooperation between health professionals and empowering the patient. Different models of payment exist elsewhere, however each has its own drawbacks. In Switzerland, medical pricing balances time/cost effectiveness by pricing by capitation (basic charge per 5 minutes of consultation). Several countries have adopted the concept of "disease management" which encourages health insurance funds to better manage the care of patients with long-term diseases. In the United States, it’s a combined pricing system which consecutively associates within the consultation process, a flat fee and profit-sharing. In Germany, exists a main payment by social security contributions, combined with a fixed payment by the health insurance, financial incentives and packages for chronic patients. In England, a performance-pricing system has been introduced57.
Currently, a hybrid model, which combines the different modes of payment appears to be more suitable to satisfy health professionals, patients and the state in a common goal of improving the quality of care of chronic diseases. Although almost all physicians believe that the GP is the main player in the management of PA on prescription in type 2 diabetes patients, it should be noted that nearly half of physicians think they do not have the appropriate skills to comfortably prescribe PA. A possible explanation may be the lack of teaching related to the prescription of PA during the earlier medical curriculum. Moreover, the integration of a sport-health module in general medicine training seems interesting for almost all physicians. Indeed, the New Zealand study of Mandic and al., 2018 showed that access to a PA learning module raised awareness and knowledge among medical students of the current recommendations on PA and improved their confidence and their skill perceived in providing guidance on PA33. A desire for training was also expressed by the majority of the Guyanese physicians. Indeed, only 11% of them were already trained, in accordance with the study by Lesage C., where 8.7% of physicians were trained with 89% expressing a wish for training44. In our study, training was a measure considered as being important to very important to help prescription by half of the physicians (5th factor) and also represented an obstacle to their prescription (5th factor) in the case of its absence. In the 2007 ENTRED study, physicians expressed their willingness to train and to upgrade their knowledge in the management of type 2 diabetic patients43. To meet the demands of medical training and with the goal of promoting and facilitating PA on prescription, the French National Authority for Health produced in September 2018 a guide to promote PA on prescription37, as well as a specific frame of reference for PA on prescription in the context of type 2 diabetes. It would be interesting to develop a scheme in French Guiana adapted to our territory with a list of approved APAT to whom each GP could refer his patients after issuing a prototype prescription, and to set up mobile APAT. These would be located near to patients in this vast territory, which would enable an appropriate professional to evaluate patients by promoting PA outdoors in those isolated communities which have fewer sports infrastructures and thus envisage sport-health collaborations with sports clubs which already exist on the territory. Furthermore, concerning the study, the extension of its duration would probably improve the response rate in order to ensure a better representativeness of the sample on age data. Concerning our study, some questions were subject to social desirability bias leading to an overvaluation of positive responses compared with reality. In order to limit this, responses were anonymous. The method of recruitment by self-administered questionnaire was chosen to reinforce the sense of anonymity thereby limiting social desirability bias and providing the possibility of responding at the most suitable time for GPs.
A response and formulation bias may though appear. The very nature of the data, declarative and, for some, subjective with the absence of standardized definitions of terms employed, might have influenced the outcomes. Furthermore, we did not collect the mixed activity of physicians in the questionnaire, whereas analyses between employed and self-employed physicians were carried out, with a small base of the employed group.