{"paper_id":"2d3f9936-84f0-40d7-be49-39f41dbd290e","body_text":"Relevance of a physical activity rehabilitation care pathway based on the experience and commitment of people suffering of obesity | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Relevance of a physical activity rehabilitation care pathway based on the experience and commitment of people suffering of obesity Elise Bourgeois, Béatrice Lognos, Ariane Sultan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5973776/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Jul, 2025 Read the published version in BMC Public Health → Version 1 posted 8 You are reading this latest preprint version Abstract Context : Despite the benefits of physical activity, people suffering from obesity face a number of obstacles and often give up. The proposed care pathway integrates multidisciplinary management of people suffering from obesity. It aims to assess the impact of adapted physical activity: a supervised practice tailored to each individual's state of health, abilities and needs. It was offered to eighty people during their day hospitalization at Montpellier University Hospital; forty-six started and eight stopped during the three-month course. Eligibility criteria included a body mass index (BMI) greater than 30 kg/m² and the presence of musculoskeletal pain requiring physiotherapy. Our main aim was to identify the factors structuring patients' involvement, by collecting their experiences and views. Method : The study is based on a qualitative analysis of data from semi-structured interviews conducted with all participants. The comments collected from each participant were organized into units of meaning. These data were then reprocessed in a matrix of conceptual groupings, enabling cross-cutting themes to emerge. The inductive approach we adopted led us, in the first instance, to stay as close as possible to what we heard, avoiding any premature interpretation. Inscribed in a constructivist posture and a reflexive logic, this initial phase formed the basis for a more in-depth analysis in a second phase. Results : Analysis of the thirty-five interviews carried out revealed the following determinants: The interpersonal relationship between the professional and the patient, which must lead the former to value the latter and build mutual trust; - The question of patient autonomy, through the difficulty they express in taking charge of their own care, or in the need they express to benefit from additional follow-up at the end of the care pathway; - The need for flexibility on the part of patients, who conversely wish to become actors in their own care pathway; - Coordination and communication, notably with the necessary sharing of patient information, and the integration of relatives into the care pathway. These results lead to the formulation of several proposals with practical implications for the deployment of a care pathway. Conclusion: These relational, organizational and personal determinants structure patient involvement, and need to be taken into account right from the design phase. The success of a healthcare program depends on the stakeholders' ability to identify them and ensure that the objectives set are achievable. A care pathway that takes these factors into account increases the likelihood of successful patient outcomes. obesity care pathway lived experience commitment relevance Figures Figure 1 Introduction The number of people suffering from obesity worldwide doubled between 1990 and 2022 ( 1 ). A study published in The Lancet in 2024 shows that obesity affects almost 16% of the world's population, or more than one billion people ( 2 ). Faced with this alarming increase, there is now a broad scientific consensus in favor of physical activity adapted to each individual's health conditions and capacities as a means of combating obesity. Physical activity helps improve anthropometric and biological parameters ( 3 ), as well as quality of life ( 4 ). In addition, several studies have shown that physical activity, even in the absence of caloric restriction, contributes significantly to reducing abdominal and visceral fat, as well as total body fat. It increases energy expenditure while limiting the loss of lean body mass ( 5 ). However, people suffering from obesity face various obstacles to practicing and maintaining physical activity. Among the most common are self-deprecation, fatigue and fear of injury ( 6 ). A study of obese women and women with a so-called “normal” BMI also highlighted specific barriers linked to overweight, whether physical (breathlessness, body discomfort) or emotional (discomfort with appearance). What's more, 46.5% of obese women feel that their weight makes physical exercise difficult, compared with just 7.3% of non-obese women, due in particular to muscular pain ( 7 ). These obstacles are not insurmountable. They can be overcome by setting up a structured care pathway focused on adapted physical activity. To this end, current recommendations encourage the development of multi-disciplinary, multi-factorial lifestyle programs, combining both dietary behavior modification and gradual increases in physical activity ( 8 ). The adapted physical activity pathway, which we coordinated at Montpellier University Hospital, is based on a city-hospital collaboration involving multidisciplinary care (doctors, physiotherapists, psychologists, dieticians) for people suffering from obesity. It is also based on a therapeutic education program for patients, designed to enable them to acquire the skills they need to manage their disease independently, while encouraging them to modify their lifestyle habits to reduce their weight and improve their quality of life. It is therefore essential to understand what enables a patient to go beyond a simple medical prescription and become truly involved in a care program. In other words, it's a question of identifying the conditions that encourage the transition from a multidisciplinary prescription to an active and lasting commitment on the part of the patient. This is the issue we wish to address, using a qualitative approach to understand the mechanisms involved. As Karstens et al. point out, qualitative studies provide an understanding of patients' experiences and the logic underlying their commitment to a care pathway ( 9 ). For their part, Valyi et al (2021) stress the need for healthcare establishments to collect and analyze patient experience in order to improve the quality of care ( 10 ). Finally, Boyle et al advocate an approach in which the patient becomes a fully-fledged player in the evaluation of care pathways ( 11 ). Our thinking is thus in line with the Patient Experience movement, a concept developed in the UK, USA and Canada in the early 2000s. This approach invites us to consider the patient's word not as a mere testimony, but as an essential element in the evaluation and improvement of care systems. Although a number of studies have taken patients' voices into account, they remain in the minority when compared with approaches focusing on the biomedical effects of adapted physical activity. By focusing on patients' appropriation of the pathway and the conditions that encourage or hinder their involvement, this study crosses lived experience and the organization of the care pathway. In this context, our aim is to gain a better understanding of how patients experience the adapted physical activity pathway, as implemented at Montpellier University Hospital, and what elements of this pathway encourage or hinder their involvement. The research question guiding our study can therefore be formulated as follows: How do patients suffering from obesity appropriate a course of adapted physical activity, and what determinants encourage their involvement? 1. Method In order to obtain the regulatory approvals required to carry out the study, we drew up an Institutional Review Board protocol whose admissibility and ethical nature were confirmed (IRB: IRB-MTP_2022_03_202201067). 1.1 Patient recruitment Patients with obesity requiring treatment were referred to the Nutrition-Diabetes team at Montpellier University Hospital by their GP, as part of a day hospitalization. They could also seek such care on their own initiative. During this day hospitalization, the protocol was proposed to them according to the following selection criteria: Inclusion criteria : - Obesity (BMI > 30 kg/m²); - Age between 18 and 70 years; - Residence in the Montpellier metropolitan area; - Explicit request for weight management; - Presence of at least one comorbidity justifying physiotherapy treatment (musculoskeletal disorders, whatever their location: lumbago, cervicalgia, gonalgia, ankle pain, shoulder pain, etc.); - Stable treatment for at least one year. ); - Stable treatment for at least three months with a GLP-1 analogue or SGLT2 inhibitor. Exclusion criteria : - Persons already undergoing bariatric surgery; - Contraindication to physical activity; - Initiation of GLP-1 or SGLT2 treatment for less than three months. This dual mode of entry by the physician or at the patient's initiative, combined with well-defined clinical criteria, helped to limit selection bias while ensuring a diversity of profiles and consistency in the medical situations analyzed. 1.2 Course of treatment As part of the program, patients were first admitted to a day hospital, where they were cared for by a multidisciplinary team comprising a doctor, a dietician, a nurse, a psychologist and an adapted physical activity teacher. Their clinical and biological data were collected, and they completed a food diary and quality-of-life questionnaires. At the end of the day, they were given a prescription for a three-month course of adapted physical activity by a physiotherapist. Each participant benefited from two weekly sessions supervised by this health professional. These sessions were part of a protocol drawn up in collaboration with the URPS for physiotherapy, in line with the recommendations of the Haute Autorité de Santé, and distributed to all physiotherapists involved in the study. The protocol included a weekly LipoxMax-type session, focusing on low-intensity endurance, and an intermittent muscle-strengthening session. At three months, semi-directive interviews were carried out to gather participants' feelings on the progress of their course, a stage on which our analysis focused. Finally, a new day hospitalization took place at six months to renew the collection of initial clinical and biological data. 1.3 Methodological approach We carried out a qualitative analysis in order to interpret the patients' point of view, expressed in words through interviews ( 12 ). These interviews, lasting an average of 40 minutes, yielded data of varying richness, depending on the availability and commitment of the respondents. With this in mind, we opted for a semi-structured interview to explore respondents' lived experience ( 13 ). The interviews were conducted by us, either remotely or at the Montpellier University Hospital, in a calm and confidential setting to ensure a better match between data collection and research objectives. As a result, no control groups or outside contributors were mobilized, which is in keeping with the exploratory nature of the study, focused on in-depth understanding of the phenomena observed. Permission to record was systematically requested from each respondent. All interviews were recorded and transcribed in full. To guarantee confidentiality, each participant was given an alphanumeric identifier (letter A followed by a number). The interview guide presented in the appendix served as a common framework for all respondents, while allowing for flexible adaptation according to the situation, in order to encourage free expression. It was also designed to facilitate follow-ups and encourage the development of responses. It is based on the literature on the relevance of a care pathway, and on contributions from the sociology of organizations. Indeed, we consider that a care pathway is similar to the contexts experienced in organizations insofar as it is constrained by the same imperatives of task allocation, coordination and results. The sections of the interview guide are organized around concepts such as patient adherence and involvement, trust, change management, relevance indicators, coordination and cooperation. It was reviewed and validated by healthcare professionals and a researcher in the humanities and social sciences, to ensure its relevance, clarity and suitability for the issues explored. Initially, we chose to remain as close as possible to the comments we received, by proposing a descriptive reading, avoiding any hasty interpretation. This first phase, based on a constructivist and reflective approach, forms the basis for a more in-depth analysis at a later stage. The comments collected from each respondent were grouped into units of meaning. The interview data were then condensed into a conceptual grouping matrix ( 14 ). The thematic analysis, conducted using an inductive approach, is based on the emergence of categories from the discourse gathered during semi-structured interviews. Themes were identified on the basis of units of meaning, contextualized to ensure consistency, and then restructured into four main categories. This process guarantees fidelity to lived experience. In this way, we were able to overcome the initial limitations of the interview guide and better reflect the complexity of care journeys. To reinforce the validity of the qualitative data analysis, we triangulated with an experienced qualitative researcher. 2. Results Forty-six patients were included in the study, but eight dropped out within the first three months. We chose to conduct interviews with all patients still involved in the program, although three did not ultimately participate. Processing the verbatims collected enabled us to identify several units of meaning, each reflecting the comments of at least 25% of the thirty-five respondents. For each unit of meaning, we present examples of verbatim that illustrate its effectiveness or, conversely, its absence. Initially, the analysis was based on three headings taken from the interview guide: - Adherence factors; - Relevance indicators; - Patient-healthcare professional coordination. These headings were used to structure the data collected. The interviews conducted were condensed and organized within a matrix of conceptual groupings. However, analysis showed that these headings, while relevant, were not sufficient to capture all the experiences expressed by patients. Certain cross-cutting themes, such as the notion of autonomy or the tension between the need for support and personal initiative, were not satisfactorily taken into account. To overcome these limitations, an inductive approach was adopted. Each unit of meaning was placed in its initial context, in order to verify its coherence with newly emerging categories. This interpretive work made it possible to reorganize the data beyond pre-existing frameworks, in line with the recommendations of Attride-Stirling ( 15 ) and the thematic approach of Braun and Clarke ( 16 ). Four categories thus emerge from the reprocessing of the data collected. Table 1 highlights this process. Table 1 Process for deriving categories from empirical data Initial headings in the interview guide Examples of content partially covered Emerging categories from the inductive analysis Support factors Desire to be listened to, feeling of being valued 1 Interpersonal relationship : quality of the link, recognition and trust between professional and patient Indicators of relevance Sense of dependence, need for prolonged support 2. Patient autonomy : ability to take responsibility for themselves, request for additional follow-up Patient-professional coordination Desire for personal initiative, frustration with rigidities 3 Need for flexibility : patients' desire to shape their care pathway and play an active role in it Patient-professional coordination Lack of shared information, non-involvement of relatives 4 Coordination and communication : circulation of information and inclusion of relatives in the care process 2.1 Patient-professional interpersonal relations a) The quality of the relationship between patient and carer: appreciation, trust and listening Involvement in the treatment process depends on the feeling that the efforts made are appreciated. This is all the more important given that the majority of obesity sufferers have developed a lack of self-esteem over the course of their lives. A17 confides: \"As someone who doubts myself, I felt important to the people at the hospital and the physio. That's one of the reasons why I succeeded in the course\". A17's testimony highlights the importance of the caregivers' positive regard for patients who often lose self-confidence. From the very first interviews, this dimension came to the fore, leading us to identify recurring factors: stigmatization from childhood, devaluing remarks in the school, family or medical spheres, and a persistent feeling of not being recognized for their efforts. Confidence in those involved in the treatment process is also a key factor in patient adherence. A9 says: \"I think what helped me was the kindness I encountered in your department, the idea that there was no judgment. I don't feel obliged to get results\". On the other hand, A28, whose clinical results are not conclusive, declares: \"I would have liked more supervision. I didn't like the way the physio behaved\". Respondents attest to the fact that taking their views into account is a key factor in the success of their care pathways. For example, A18 expresses his satisfaction: \"I especially appreciated being able to give my point of view on the exercises, some of which I didn't like and which hurt me. I was listened to and that's new for me\". On the other hand, a number of respondents expressed frustration, such as A23: \"I need to be heard. I've missed that. By expressing myself and listening to me, I think I would have been more involved in the process\". b) The influence of previous medical experience Satisfactory previous medical care seems to facilitate participants' integration into the program, by making them more receptive to the advice and support offered by professionals. A18 points out: \"In 1990, I had a sleeve operation, followed by a bypass in 1992. In 1993, I had my thyroid removed. These were not easy times, but they gave me confidence in the medical world\". On the other hand, medical treatment that has led to dissatisfaction calls for increased vigilance in support. As A27 explains: \"I had a sleeve, but there was no follow-up. I was let go\". c) Preparing the patient: understanding, anticipation and appropriation All the participants stressed the importance of the efforts involved. That's why preparing patients before they enter the program is a prerequisite for their involvement and for the relationship they'll have with those involved. For example, as A4 confides: “I did some psychological work which helped me and made me aware of the benefits of devoting myself to physical activity”. Knowing what is at stake is also a determining factor. A19, who didn't get any convincing results, says: \"At first, I didn't know what I was doing there. I saw a lot of people. I didn't know what their role was\". Getting to grips with the tools of a system is essential if you want to feel part of it. The main tool used during the course was the Aviitam database, which is used to collect all patient data and prepare consultations by means of various questionnaires. It is fed by both patients and healthcare professionals. It can be consulted by anyone involved in the treatment process, enabling information to be pooled and strengthening the relationship between patients and practitioners. In the words of A8: \"I really understand the value of the questionnaires and the Aviitam tool. It has enabled me to know where I stand and to share my data with the various professionals\". On the other hand, A3, who has not been entirely successful with the pathway, comments: “I haven't logged on to Aviitam, because I don't see the point of it and I find it hard to understand”. d) Unexpected benefits of the pathway: detection of associated pathologies The value of the care pathway also lies in what it has indirectly brought to participants; they express their gratitude and confidence in practitioners because of the detection of pathologies that were not targeted by the pathway. For example, A13 states: \"The course enabled me to detect my diabetes. I owe you a debt of gratitude\". 2.2 Patient autonomy in question a) Difficulty in taking charge and decisive support Half of all respondents stressed their difficulty in taking charge and being autonomous. This is compensated for by the support provided during the course of the treatment, which strongly influences their feelings. For example, A30 states: \"I couldn't have done it on my own. I couldn't have done it on my own. I needed this multiple care\". On the other hand, A5 adds: \"The doctor who saw me didn't know my file. That demotivated me, because I need to be supervised to get involved\". b) Complementary care or follow-up Respondents are looking for a complementary service to reinforce their commitment. A2, for example, points out that: \"Being in this program enabled me to be taken in for sleep recordings. Since then, I've been fitted with a device and my sleep has improved. I'd never thought of doing it before\". A16, on the other hand, points to her lack of investment, saying: “I didn't have a dietetic follow-up to complement the physical activity sessions”. However, patients had received advice and benefited from dietary workshops at the start of the protocol as part of their therapeutic education. c) Expectation of collective follow-up after the program More than a third of respondents regretted the end of support at the end of the program, and said they were unable to continue what had been started on their own. For example, A10 confides: \"I suggest that there should be a follow-up to all this. I may be demanding, but I need to be followed beyond the protocol, otherwise I wouldn't be able to do all this on my own\". 2.3 Patients, actors in their own care a) Motivation to take care of their own health Ownership of the care pathway is correlated with the patient's motivation to take care of themselves. As A23 points out: \"I didn't like the way I looked at myself and my image. I wanted to lose weight and work on my self-confidence\". On the other hand, A23 justifies her lack of success in the course as follows: \"I have to admit that I wasn't involved in the program at first, because I was very busy professionally. I wasn't ready to take care of my body. b) Accessibility and geographical proximity Proximity, in particular of the physiotherapy practice to the patient's home or workplace, is certainly a factor in success, as the patient feels he or she is not subject to the material constraints associated with the course. As A21 put it: “I live in a village; I work in the same village; I do everything on foot and taking my car is a chore for me... so the proximity of the physiotherapist motivated me”. c) Need for flexibility in the organization of the treatment The need for flexibility was expressed by half of the respondents, and reflects their desire to have some control over the treatment. It is expressed first and foremost in their satisfaction with the program's adaptation to their pathologies. For example, A8 declares: \"There are things I can't do. But my physio has adapted the exercises for me. I have cartilage injections. We compensate by doing things differently\". This need for flexibility also manifests itself in the adjustment of the protocol to patients' life constraints. A9 explains: \"I followed the program, but it was a bit hard to do it twice a week with a professional activity. It was complicated to find the time slots, but the physiotherapist adapted\". On the other hand, A29 expressed her disappointment: \"I couldn't do any workshops at the hospital, because we couldn't find time slots compatible with my schedule. That put a bit of a brake on the project\". d) Pain-related concerns The suitability of the course also depends on the patient's perception of his or her pain and ability to regain control of sensations. For example, A12 explains: \"Having followed this program makes me think less about my back pain. I find myself doing activities without fear of pain\". On the contrary, A4 warns us: \"I'm always worried about my back pain. I know it's partly in my head, but I haven't managed to get rid of it\". e) Persistence of physical activity at the end of the pathway This theme, shared by three quarters of respondents, is consubstantial with the adapted physical activity pathway. It demonstrates the patient's ability to take responsibility over the long term, and is therefore an essential indicator of relevance. As A6 puts it: \"I'm going to take up rowing again, and I'm trying to reproduce at home the physical exercises I used to do with the physiotherapist. I've become a sportswoman again\". 2.4 Coordination between practitioners and communication with patients' relatives a) Interest in alternating hospital and city care Echoing the recommendations made by the health authorities, 45% of respondents expressed their attachment to the sharing of healthcare skills and missions between private practitioners and hospitals. As A18 explains: “The physiotherapist's office is more familiar. That makes it more attractive to go there, even though I've had my appointments at the hospital. Being in a program with both forces us to give our best. b) Involvement of professionals in the program According to respondents, feeling that healthcare professionals are involved in the care pathway contributes to the feeling that it is properly coordinated. For example, A17 states: “Every professional I met did their utmost to support and motivate me. I went home with the desire to excel”. On the other hand, A5 points out that “the doctor was supposed to see me again in June, but he rescheduled my appointment, and when I arrived for my consultation it wasn't him”. c) Patient requests: remote consultations and information sharing A third of respondents regretted the absence of remote consultations carried out by several professionals simultaneously. A2 said: “I would have liked to have remote consultations during which I could have exchanged information with my physiotherapist and the hospital at the same time. There's a lack of coordination between the practitioners.\" Similarly, the sharing of patient information between the different practitioners is an important area of focus in implementing the pathway. For example, A11 states: \"It would be good to have an intermediary point with the different practitioners. I feel that information about my situation doesn't circulate well between the hospital and the physiotherapist.\" d) Support and Integration of Family and Friends in the Pathway Support from family and friends plays an essential role in patient adherence to the pathway, strengthening patient involvement and facilitating the implementation of the expected changes. For example, A1 states: \"My husband, my children, my sisters, they walk with me, they make me do exercises.\" A31, who did not obtain satisfactory clinical results, specifies: “No, I am not accompanied, I am alone because the course is a subject of dispute with my husband.” Furthermore, the importance of loved ones in the rehabilitation process, highlighted by many patients, leads some to regret the lack of communication from practitioners towards them. They express a wish for them to be more involved. For example, A29 emphasizes: \"It would be good to inform them from the start with a meeting with all participants. My partner would better understand what is expected of me.\" Ultimately, the inductive analysis revealed four major categories structuring patients' engagement in their rehabilitation journey. The relationships between these categories, as well as their contribution to the relevance of a care pathway, are summarized in Fig. 1 . 3. Discussion The results are analyzed in two stages. First, we compare the units of meaning derived from our survey with the National Health Service classification. Secondly, we put them into perspective in relation to existing literature, based on the four categories identified in the discourse analysis (interpersonal patient-professional relationship, patient autonomy, patient as actor in his or her care pathway, coordination between practitioners and communication with relatives), and make proposals for improving practices in the care pathway. 3.1 Correspondence with National Health Service (NHS) classification The UK is one of the pioneers of the “Patient Experience”, and the classification established by the National Health Service (NHS) in 2011 is a major reference in the field ( 17 ). This classification organizes the “Patient Experience” around nine fundamental criteria. In our study, we propose a correspondence test between seven of these nine criteria and the units of meaning derived from the analysis of our interviews (Table 2 ). This approach enables us to make a new classification of the units of meaning that have emerged, validating our data collection through this theoretical framework. The seven criteria selected: respect for patient needs and preferences; coordination and integration of services; information, communication and education; physical comfort; emotional support; involvement of family and friends; continuity and transition of care are those that correspond to the testimonies collected. On the other hand, two NHS criteria - access to care and hospital environment - did not emerge from our analysis of the interviews and were therefore not retained. Participants placed more emphasis on the quality of follow-up, the personalization of care and human support than on structural or administrative aspects. Table 2 Correspondence between National Health Service classification and subcategories Classification du National Health Service Subcategories determining the relevance of the course Respect for patient needs and preferences • Proximity to the health establishment • Adjusting the protocol according to patient constraints • Possibility of teleconsultation • Taking the patient's voice into account Service Coordination and Integration • Sharing patient information • Interest in alternating care between hospitals and town centres Information, communication et education • Preparing the patient before the journey • Appropriation of tools and procedures relating to the route • Communication with relatives and carers Physicial confort • Motivation to take care of your body • Improvement in the patient’s general condition • Adapting the patient pathway to the patient's pathologies Emotional support • Valuation by the healthcare professional • Difficulty in taking charge of one's life - decisive support • Adjusting the protocol according to patient constraints • Reduced concern about pain and health • Taking the patient's voice into account Involving families and friends • Accompaniment by a close friend or family member as a factor in adherence • Communication with relatives and carers Continuity and transition of care • Previous medical treatment favourable • Providing care or follow-up that complements the programme • Detection of other pathologies • Collective follow-up after the course Cross-referencing our results with the “Patient Experience” criteria defined by the NHS reveals a high degree of consistency, reinforcing the validity of our study. • Respect for the patient's needs and preferences This criterion is illustrated by different units of significance found in the interviews. The proximity of the healthcare facility, the possibility of teleconsultation, the adjustment of the protocol to personal constraints and the explicit recognition of the patient's voice all testify to an expectation in favor of personalization and adaptability of the care pathway. • Coordination and integration of services Our results also highlight the importance of good coordination between care providers. The sharing of information between professionals, as well as the alternation between hospital and outpatient care, confirm the importance of continuity and integration of services, in line with NHS principles. • Information, communication and education The interviews emphasized the need for patients to be prepared in advance, for tools and procedures linked to the care pathway to be appropriated, and for exchanges with family and friends to flow smoothly. These elements are in line with the importance attached to information and education in the care experience. • Physical comfort The improvement in general condition, the adaptation of the care pathway to specific pathologies, and the motivation of patients to take care of themselves all reflect high expectations in terms of physical well-being, echoing the criteria for physical comfort established by the NHS. • Emotional support Emotional and psychological support are also key factors. The importance of emotional support for patients is illustrated by the fact that they are valued by healthcare professionals, helped in situations where they lack autonomy, and less worried about pain. • Involvement of family and friends The presence and involvement of family and friends appear to be essential to patients' adherence to the care pathway. This support is often mentioned in interviews, confirming the alignment with the NHS criterion dedicated to the involvement of family and friends. • Continuity and transition of care Finally, careful consideration of medical history, the provision of complementary care and the detection of other pathologies testify to a concern for continuity and fluidity in the transitions of the care pathway, in line with the expectations set by the NHS. This analysis confirms the validity of our study, demonstrating that the expectations and experiences formulated by our participants are in line with the dimensions of the “Patient Experience” as defined by the NHS. 3.2 The interpersonal patient-professional relationship The first category of our model focuses on the interpersonal relationships between patients and healthcare professionals, which are essential to the success of the care journey. According to Kobeissi and Aubert, the patient experience is based on factors that transcend the expertise of healthcare professionals, and are founded on subjective factors ( 18 ). Our study first shows that the quality of previous medical experiences influences patient engagement. Positive experiences promote adherence and trust, while negative memories, marked by a communication deficit or a feeling of neglect, generate mistrust and less involvement ( 19 ). Hence the importance of implementing corrective actions to restore trust after such experiences ( proposal 1) . Patient preparation prior to the treatment also appears to be a determining factor. Structured preparation, combining clear information and effective coordination, reduces anxiety and strengthens patient involvement ( 20 ). With this in mind, personalized preparation is needed to optimize adherence to the care pathway ( proposal 2 ). Moreover, when patients' efforts are recognized, their motivation and commitment are reinforced. Conversely, poor communication increases the risk of non-adherence ( 21 ). Thus, patient trust in their practitioner leads to convincing results by promoting ownership of the protocol's objectives ( 22 ). It is therefore essential to value their words and reinforce this trust ( proposal 3 ). The appropriation of tools relating to the pathway is also a fundamental lever. While these tools make it possible to better coordinate care and make patients actors in their own health, their perceived complexity or insufficient support can hinder their adoption ( 23 ). Fostering personalized appropriation, by providing appropriate explanations, helps to reinforce patient autonomy ( proposal 4 ). Finally, our study reveals that the care pathway can be an opportunity to detect other pathologies not initially anticipated, thanks to the vigilance of professionals or the complementary examinations carried out. Patients testified to their satisfaction following the discovery and management of pathologies such as sleep apnea or diabetes. This secondary benefit, highlighted by the HAS (2023), contributes to improving patient health and increasing patient involvement ( 24 ). It would therefore be a good idea to systematically integrate an early detection system into the care pathway ( proposal 5 ). 3.3 Patient autonomy Our study highlights the fact that, although patient autonomy is now a principle in healthcare policies, aimed at promoting participation and empowerment, it remains difficult to achieve in practice ( 25 ). Many participants describe their inability to manage their chronic illness on their own. Without the support they received, they would not have been able to complete their protocol. These observations concur with those of Anderson and Funnell, for whom lack of self-confidence and psychosocial barriers hinder empowerment, necessitating reinforced support ( 26 ). From this perspective, it seems essential to reinforce support throughout the care process to promote autonomy ( proposal 6 ). In addition, our research reveals a high level of expectation concerning the provision of complementary follow-up care, particularly dietary advice. Although patients were given advice at the start of the care pathway, the absence of regular support hampered the long-term anchoring of good practices. These results corroborate the analyses of Chambouleyron et al, who recommend ongoing support through therapeutic education or appropriate psychological follow-up ( 27 ). Providing additional follow-up throughout the course of the treatment would reinforce patients' adaptation and self-care skills ( proposal 7 ). Similarly, the question of maintaining good practices after the end of the program is a central one. Many participants expressed their difficulty in maintaining regular physical activity without a structured framework, citing loss of motivation and isolation. These findings are in line with the study by Maledon, which shows that starting a physical activity program too early leads to a loss of motivation, as participants do not feel sufficiently autonomous ( 28 ). More broadly, Vielle et al stress the importance of gradual support to help people become more autonomous ( 29 ). With this in mind, it would seem appropriate to organize collective support after the course has been completed, in order to consolidate what has been learned and encourage the perpetuation of best practices ( proposal 8 ). 3.4 Patients as actors in their own care We have shown that, although patient autonomy remains elusive, many patients express their desire to become active players in their own care. The concept of the patient as actor in his or her own care pathway has been developing for several years. For example, according to Laude, “the legislator wanted to draw the consequences of developments in the healthcare relationship by making the patient an actor in his or her own health” ( 30 ). Similarly, according to Remillieux, “personalized treatment is the cornerstone of success” ( 31 ). This observation echoes that of Gros, for whom engagement is based on the perception of concrete benefits ( 32 ). It therefore seems essential to support patient involvement by linking their efforts to tangible results ( proposal 9 ). The proximity of care facilities is also a determining factor in patient adherence. As indicated by the Institut national de santé publique du Québec (2018), easier access encourages regular participation, whereas remoteness is a hindrance ( 33 ). The development of teleconsultation, recommended by DREES, offers solutions to overcome these obstacles ( 34 ). Guaranteeing physical or digital accessibility to care thus seems essential to reinforce patient commitment ( proposal 10 ). Adjusting the protocol to specific needs and constraints also appears crucial. Racodon and Masson show that organizational flexibility promotes autonomy and involvement ( 35 ). Adapting the frequency, intensity and schedules of care is therefore necessary to maintain adherence to the pathway ( proposal 11 ). Lastly, the persistence of physical activity after the course is completed is a source of ownership. Work by Inserm and the Look AHEAD Research Group shows that it improves the long-term management of chronic diseases ( 36 ) ( 37 ). It is therefore important to support the continuity of physical activity beyond the protocol. ( proposal 12 ). 3.5 Coordination and communication with family and friends 3.5.1 Information sharing between healthcare professionals Sharing information between healthcare professionals emerged as a strong expectation in our interviews. Several respondents expressed the wish to benefit from remote consultations involving several practitioners, reflecting their attachment to the sharing of skills and better coordination. This need is in line with the work of Brémond and Fieschi, who believe that information exchange promotes efficiency and collective performance ( 38 ). Jacobs et al confirm that multidisciplinary teams enable more personalized care, and significantly improve patient health, engagement and satisfaction ( 39 ). Consequently, structuring care paths around reinforced coordination within multidisciplinary teams appears to be an essential lever for improving the quality of care ( proposal 13 ). 3.5.2 Communication and coordination with family and friends We emphasize the importance that patients attach to communication with their loved ones, and to their active involvement in the care process. For many, engaging in a therapeutic approach is a shared decision, made in agreement with those around them. This finding echoes that of Reblin and Uchino, who highlight the importance of emotional and logistical support from loved ones in helping patients overcome psychological challenges, such as stigmatization and declining motivation ( 40 ). Furthermore, Bigossi and Laborde point out that relatives help to lighten patients' mental load, by participating in the day-to-day management of tasks and following medical recommendations ( 41 ). This daily involvement promotes regularity in the application of therapeutic advice. Funnell et al. confirm that the presence of family and friends acts as an additional motivational lever to comply with treatment, thus reinforcing adherence ( 42 ). Finally, our analysis is also in line with the work of Buthion and Godé, for whom loved ones, in certain situations, become veritable “life assistants” and “caregivers”, their participation being considered indispensable to the effective coordination of care pathways ( 43 ). With this in mind, it seems essential to systematically involve family members in the care pathway, in order to strengthen their understanding of the pathology and encourage patients' long-term adherence to treatment recommendations ( proposal 14 ). The results we have obtained suggest that the success of a care pathway for patients depends on integrating the fourteen proposals formulated upstream and throughout the pathway. Upstream, we need to restore trust (proposal 1), personalize preparation (Proposal 2), involve family and friends (Proposal 14), support intrinsic motivation (Proposal 9) and anticipate accessibility to care (Proposal 10). During the course of the treatment, the patient's commitment must be reinforced by high-quality communication (Proposal 3), the development of autonomy (Proposal 4), the adaptation of care to individual constraints (Proposal 11) and effective multidisciplinary coordination (Proposal 13). Downstream, the aim is to consolidate gains through collective follow-up (Proposal 8), support the pursuit of physical activity (Proposal 12), accompany adaptation to new needs (Proposal 7) and prevent any associated pathologies (Proposal 5), while maintaining the involvement of family and friends (Proposal 14). Implementing these proposals means overcoming a number of challenges: limited medical time, insufficient coordination, inequalities in access to care, variable involvement of family and friends, and a growing administrative burden. It requires the development of flexible educational systems, regular coordination time, simplified procedures for patients and healthcare professionals, and a culture of partnership with patients and their families. Conclusion Assessing the appropriateness of a care pathway cannot, of course, be limited to patient experience; it must also take into account the expertise of professionals, compliance with protocols and the clinical benefits observed. This study set out to understand how patients suffering from obesity appropriate a course of adapted physical activity, and what factors encourage their commitment. The results show that appropriation is based on several levers: the quality of the care-giver-patient relationship, personalization of the pathway, recognition of the patient's active role, and flexibility in the organization of care and exercise. The commitment of patients is built through a human approach centered on listening, trust and individualized support, but also through the progressive development of their autonomy. Continuity of support also helps to prevent breakdowns, consolidate achievements and ensure a gradual transition to more autonomous health management. This work is not without its difficulties, as a care pathway is often a real challenge for healthcare professionals, requiring them to persevere in coordinating actions and providing long-term support for patients. With a view to enriching this research, a number of avenues need to be explored. Firstly, it would be appropriate to extend the evaluation of the model to other chronic pathologies, such as type 2 diabetes, cardiovascular disease or musculoskeletal disorders, in order to test the transferability of the factors identified and propose a generalization of the model, regardless of the specificity of the pathway. Secondly, a longitudinal follow-up of patients would enable us to observe the evolution of their commitment, the effective integration of recommendations and the impact on their quality of life and long-term health behaviours. Finally, a sociological approach could be envisaged to analyze the obstacles and levers influencing patients' adherence to the recommendations in their care pathway. This study would integrate the psychosocial, cultural and economic dimensions that condition their commitment. It would also involve healthcare professionals, whose expertise would make it possible to identify obstacles and propose adjustments to medical and propose adjustments to medical practices and organization, as well as other aids, where your contribution will allow you to understand the family and social aspects that influence patient adherence. Declarations Ethics approval and consent to participate : The IRB (Institutional Review Board) protocol, the admissibility and ethical nature of which were confirmed under number IRB- MTP_2022_03_202201067. Permission to register was requested from all respondents Informed consent to participate has been obtained from all study participants Our study complied with the Declaration of Helsinki. Consent for publication : Not applicable Availability of data and materials : The datasets generated and/or analysed during the current study are not publicly available due to the confidentiality of the information collected during the interviews but are available from the corresponding author on reasonable request. Competing interests : A.S : Servier, Viatris, Amgen, Sanofi. These interests are not related to the article submitted. Funding : this study did not receive any specific funding Authors' contributions : E.B created the interview guide, conducted the interviews and wrote the main text; B.L checked the interviews and transcriptions. A.S and E.B contributed to the creation of the protocol. B.L and A.S proofread the manuscript. All authors read and approved the final manuscript. Acknowledgements : Not applicable References OMS, Obesity and overweight, 1 march 2024. 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L'Expansion Management Review 2014/3 (No. 154), pages 51 to 57. Chandra S, Mohammadnezhad M, Ward PR. (2018). Trust and communication in a doctor-patient relationship: A literature review. Journal of Healthcare Communications .Vol. July 19 2018. Rodde-Dunet M-H, Mounic V. 2016. Le parcours du patient selon la Haute Autorité de santé. Journal des Maladies Vasculaires Volume 41, mars 2016, Page 100. Haskard Zolnierek KB, Dimatteo MR. (2009). Physician’s communication and patient’s adherence to treatment. Medical Care August 2009. Leske S, Strodl E, Hou X-Y. (2012). Patient-practitioner relationships desired by overweight/obese adults. Patient Education and Counselling 4 July 2012 . Rasmussen SR, Jensen H, Pedersen KM, Andersen JS. (2017). The effect of eHealth tools on patient activation and empowerment: A systematic review. Journal of Medical Internet Research, 19(3). Haute Autorité de Santé. (2023). Recommandations sur les parcours de soins intégrés. Bacqué M-H, Biewener C. (2013). L'empowerment, une pratique émancipatrice - La Découverte. Anderson RM, Funnell MM. (2005). Patient empowerment: Reflections on the challenge of fostering the adoption of a new paradigm. Patient Educ Couns. 2005;57(2):153-7 . Chambouleyron M, et al. Éducation thérapeutique du patient obèse, une approche de la complexité. Obésité. 2012;7:199–204. Maledon L. (2018). Evaluation and impact of a Physical Activity, Health and Well-Being (APSBE) programme carried out at the CREPS Antilles-Guyane health centre on a population with chronic diseases. Medical Thesis University of the Indies . Vielle P, Pochet P, Cassiers I. (2006). L'État social actif - P.I.E-Peter Lang S.A. Éditions Scientifiques Internationales. Laude A. (2007). Le patient, nouvel acteur de santé ? Recueil Dalloz. Remillieux M. (2018). Respecting the autonomy of the cared-for person. journal Soins April 2018. Gros C. Patient autonome ou autonome patient ? Santé publique. 2017;29(5):685–92. Institut national de santé publique du Québec. (2018). L’accessibilité aux services de santé: défis et pistes d'action . DREES. Les pratiques de téléconsultation en France en 2020. Direction de la recherche, des études, de l’évaluation et des statistiques; 2021. Racodon C, et, Masson D. (2015). Flexibilité organisationnelle et autonomie du patient dans les parcours de soins. Revue française des affaires sociales, 2, 123 . Inserm. Activité physique: prévention et traitement des maladies chroniques. Expertise collective; 2020. Look AHEAD, Research Group. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: Four-year results of the Look AHEAD trial. Arch Intern Med. 2013;170(17):1566–75. Brémond M, Marius Fieschi M. (2008). Information sharing in the healthcare system. Les Tribunes de la santé 2008/4 (n° 21). Jacobs J, Dougherty A, McCarn B, Saiyed NS, Ignoffo S, Wagener C, San Miguel C, Martinez L. Impact of a multi-disciplinary team-based care model for patients living with diabetes on health outcomes: a mixed-methods study. BMC Health Serv Res. 2024;24(1):746. Reblin M, Uchino BN. Social and emotional support and its implication for health. Curr Opin Psychiatry. 2016;29(2):135–40. Bigossi M, Laborde C. Le rôle des proches dans la gestion des maladies chroniques: soutien psychologique et organisation pratique. Revue Française de Médecine Générale. 2021;15(183):56–61. Funnell MM, Anderson RM et al. (2008). Empowerment and self-management of diabetes: Educating patients to take control. BMJ, 336(7652), 1030–1031 . Buthion V, Godé C. (2014). Les proches aidants, quels rôles dans la coordination du parcours de soins des personnes malades? Journal de gestion et d'économie médicales 2014/7–8 (Vol. 32), pages 501 to 519. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-5973776\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":446832775,\"identity\":\"37bfac3f-4e59-43bd-8c49-dab12f6f8075\",\"order_by\":0,\"name\":\"Elise Bourgeois\",\"email\":\"data:image/png;base64,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\",\"orcid\":\"\",\"institution\":\"University Hospital Center of Montpellier\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Elise\",\"middleName\":\"\",\"lastName\":\"Bourgeois\",\"suffix\":\"\"},{\"id\":446832776,\"identity\":\"6af87bd5-a46b-42c8-9abb-25e4f96368ed\",\"order_by\":1,\"name\":\"Béatrice Lognos\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"UMR INSERM - University of Montpellier\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Béatrice\",\"middleName\":\"\",\"lastName\":\"Lognos\",\"suffix\":\"\"},{\"id\":446832777,\"identity\":\"7776d434-bab3-47c4-905c-bc5d377c0df0\",\"order_by\":2,\"name\":\"Ariane Sultan\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University Hospital Center of Montpellier\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ariane\",\"middleName\":\"\",\"lastName\":\"Sultan\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-02-06 13:08:13\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-5973776/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-5973776/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1186/s12889-025-23357-0\",\"type\":\"published\",\"date\":\"2025-07-02T15:57:57+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":81542992,\"identity\":\"2dc2a068-59ca-4cfe-952a-d9d338060c61\",\"added_by\":\"auto\",\"created_at\":\"2025-04-28 11:23:23\",\"extension\":\"jpeg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":901909,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eDeterminants of the relevance of a care pathway and patient engagement\\u003c/strong\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5973776/v1/e2a774a7e2379728132b8862.jpeg\"},{\"id\":86179107,\"identity\":\"962c5c03-fcd3-49af-998b-b0e30c4ebdf1\",\"added_by\":\"auto\",\"created_at\":\"2025-07-07 16:15:47\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":2401693,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5973776/v1/940f6add-1d4b-4ad6-b15e-4c40a74e8011.pdf\"},{\"id\":81542983,\"identity\":\"fff1358b-1077-4e28-b09f-09c2127befad\",\"added_by\":\"auto\",\"created_at\":\"2025-04-28 11:23:21\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":19832,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Appendix1.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5973776/v1/32a0eb9f9602afc74ce8978d.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Relevance of a physical activity rehabilitation care pathway based on the experience and commitment of people suffering of obesity\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eThe number of people suffering from obesity worldwide doubled between 1990 and 2022 (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eA study published in The Lancet in 2024 shows that obesity affects almost 16% of the world's population, or more than one billion people (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eFaced with this alarming increase, there is now a broad scientific consensus in favor of physical activity adapted to each individual's health conditions and capacities as a means of combating obesity. Physical activity helps improve anthropometric and biological parameters (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e), as well as quality of life (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eIn addition, several studies have shown that physical activity, even in the absence of caloric restriction, contributes significantly to reducing abdominal and visceral fat, as well as total body fat. It increases energy expenditure while limiting the loss of lean body mass (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eHowever, people suffering from obesity face various obstacles to practicing and maintaining physical activity. Among the most common are self-deprecation, fatigue and fear of injury (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e). A study of obese women and women with a so-called \\u0026ldquo;normal\\u0026rdquo; BMI also highlighted specific barriers linked to overweight, whether physical (breathlessness, body discomfort) or emotional (discomfort with appearance).\\u003c/p\\u003e \\u003cp\\u003eWhat's more, 46.5% of obese women feel that their weight makes physical exercise difficult, compared with just 7.3% of non-obese women, due in particular to muscular pain (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThese obstacles are not insurmountable. They can be overcome by setting up a structured care pathway focused on adapted physical activity.\\u003c/p\\u003e \\u003cp\\u003eTo this end, current recommendations encourage the development of multi-disciplinary, multi-factorial lifestyle programs, combining both dietary behavior modification and gradual increases in physical activity (\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e The adapted physical activity pathway, which we coordinated at Montpellier University Hospital, is based on a city-hospital collaboration involving multidisciplinary care (doctors, physiotherapists, psychologists, dieticians) for people suffering from obesity. It is also based on a therapeutic education program for patients, designed to enable them to acquire the skills they need to manage their disease independently, while encouraging them to modify their lifestyle habits to reduce their weight and improve their quality of life.\\u003c/p\\u003e \\u003cp\\u003eIt is therefore essential to understand what enables a patient to go beyond a simple medical prescription and become truly involved in a care program. In other words, it's a question of identifying the conditions that encourage the transition from a multidisciplinary prescription to an active and lasting commitment on the part of the patient.\\u003c/p\\u003e \\u003cp\\u003eThis is the issue we wish to address, using a qualitative approach to understand the mechanisms involved. As Karstens et al. point out, qualitative studies provide an understanding of patients' experiences and the logic underlying their commitment to a care pathway (\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). For their part, Valyi et al (2021) stress the need for healthcare establishments to collect and analyze patient experience in order to improve the quality of care (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). Finally, Boyle et al advocate an approach in which the patient becomes a fully-fledged player in the evaluation of care pathways (\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eOur thinking is thus in line with the Patient Experience movement, a concept developed in the UK, USA and Canada in the early 2000s. This approach invites us to consider the patient's word not as a mere testimony, but as an essential element in the evaluation and improvement of care systems.\\u003c/p\\u003e \\u003cp\\u003eAlthough a number of studies have taken patients' voices into account, they remain in the minority when compared with approaches focusing on the biomedical effects of adapted physical activity. By focusing on patients' appropriation of the pathway and the conditions that encourage or hinder their involvement, this study crosses lived experience and the organization of the care pathway.\\u003c/p\\u003e \\u003cp\\u003eIn this context, our aim is to gain a better understanding of how patients experience the adapted physical activity pathway, as implemented at Montpellier University Hospital, and what elements of this pathway encourage or hinder their involvement. The research question guiding our study can therefore be formulated as follows:\\u003c/p\\u003e \\u003cp\\u003eHow do patients suffering from obesity appropriate a course of adapted physical activity, and what determinants encourage their involvement?\\u003c/p\\u003e\"},{\"header\":\"1. Method\",\"content\":\"\\u003cp\\u003e In order to obtain the regulatory approvals required to carry out the study, we drew up an Institutional Review Board protocol whose admissibility and ethical nature were confirmed (IRB: IRB-MTP_2022_03_202201067).\\u003c/p\\u003e \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e1.1 Patient recruitment\\u003c/h2\\u003e \\u003cp\\u003ePatients with obesity requiring treatment were referred to the Nutrition-Diabetes team at Montpellier University Hospital by their GP, as part of a day hospitalization. They could also seek such care on their own initiative.\\u003c/p\\u003e \\u003cp\\u003eDuring this day hospitalization, the protocol was proposed to them according to the following selection criteria:\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eInclusion criteria\\u003c/b\\u003e :\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003e- Obesity (BMI\\u0026thinsp;\\u0026gt;\\u0026thinsp;30 kg/m\\u0026sup2;);\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e- Age between 18 and 70 years;\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e- Residence in the Montpellier metropolitan area;\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e- Explicit request for weight management;\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e- Presence of at least one comorbidity justifying physiotherapy treatment (musculoskeletal disorders, whatever their location: lumbago, cervicalgia, gonalgia, ankle pain, shoulder pain, etc.); - Stable treatment for at least one year. );\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e- Stable treatment for at least three months with a GLP-1 analogue or SGLT2 inhibitor.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eExclusion criteria\\u003c/b\\u003e :\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003e- Persons already undergoing bariatric surgery;\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e- Contraindication to physical activity;\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e- Initiation of GLP-1 or SGLT2 treatment for less than three months.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003eThis dual mode of entry by the physician or at the patient's initiative, combined with well-defined clinical criteria, helped to limit selection bias while ensuring a diversity of profiles and consistency in the medical situations analyzed.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003e1.2 Course of treatment\\u003c/h3\\u003e\\n\\u003cp\\u003eAs part of the program, patients were first admitted to a day hospital, where they were cared for by a multidisciplinary team comprising a doctor, a dietician, a nurse, a psychologist and an adapted physical activity teacher. Their clinical and biological data were collected, and they completed a food diary and quality-of-life questionnaires.\\u003c/p\\u003e \\u003cp\\u003eAt the end of the day, they were given a prescription for a three-month course of adapted physical activity by a physiotherapist. Each participant benefited from two weekly sessions supervised by this health professional. These sessions were part of a protocol drawn up in collaboration with the URPS for physiotherapy, in line with the recommendations of the Haute Autorit\\u0026eacute; de Sant\\u0026eacute;, and distributed to all physiotherapists involved in the study. The protocol included a weekly LipoxMax-type session, focusing on low-intensity endurance, and an intermittent muscle-strengthening session.\\u003c/p\\u003e \\u003cp\\u003eAt three months, semi-directive interviews were carried out to gather participants' feelings on the progress of their course, a stage on which our analysis focused. Finally, a new day hospitalization took place at six months to renew the collection of initial clinical and biological data.\\u003c/p\\u003e\\n\\u003ch3\\u003e1.3 Methodological approach\\u003c/h3\\u003e\\n\\u003cp\\u003eWe carried out a qualitative analysis in order to interpret the patients' point of view, expressed in words through interviews (\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). These interviews, lasting an average of 40 minutes, yielded data of varying richness, depending on the availability and commitment of the respondents. With this in mind, we opted for a semi-structured interview to explore respondents' lived experience (\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThe interviews were conducted by us, either remotely or at the Montpellier University Hospital, in a calm and confidential setting to ensure a better match between data collection and research objectives. As a result, no control groups or outside contributors were mobilized, which is in keeping with the exploratory nature of the study, focused on in-depth understanding of the phenomena observed.\\u003c/p\\u003e \\u003cp\\u003ePermission to record was systematically requested from each respondent. All interviews were recorded and transcribed in full. To guarantee confidentiality, each participant was given an alphanumeric identifier (letter A followed by a number).\\u003c/p\\u003e \\u003cp\\u003eThe interview guide presented in the appendix served as a common framework for all respondents, while allowing for flexible adaptation according to the situation, in order to encourage free expression. It was also designed to facilitate follow-ups and encourage the development of responses. It is based on the literature on the relevance of a care pathway, and on contributions from the sociology of organizations. Indeed, we consider that a care pathway is similar to the contexts experienced in organizations insofar as it is constrained by the same imperatives of task allocation, coordination and results.\\u003c/p\\u003e \\u003cp\\u003eThe sections of the interview guide are organized around concepts such as patient adherence and involvement, trust, change management, relevance indicators, coordination and cooperation. It was reviewed and validated by healthcare professionals and a researcher in the humanities and social sciences, to ensure its relevance, clarity and suitability for the issues explored.\\u003c/p\\u003e \\u003cp\\u003eInitially, we chose to remain as close as possible to the comments we received, by proposing a descriptive reading, avoiding any hasty interpretation. This first phase, based on a constructivist and reflective approach, forms the basis for a more in-depth analysis at a later stage.\\u003c/p\\u003e \\u003cp\\u003eThe comments collected from each respondent were grouped into units of meaning. The interview data were then condensed into a conceptual grouping matrix (\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThe thematic analysis, conducted using an inductive approach, is based on the emergence of categories from the discourse gathered during semi-structured interviews. Themes were identified on the basis of units of meaning, contextualized to ensure consistency, and then restructured into four main categories. This process guarantees fidelity to lived experience. In this way, we were able to overcome the initial limitations of the interview guide and better reflect the complexity of care journeys.\\u003c/p\\u003e \\u003cp\\u003eTo reinforce the validity of the qualitative data analysis, we triangulated with an experienced qualitative researcher.\\u003c/p\\u003e\"},{\"header\":\"2. Results\",\"content\":\"\\u003cp\\u003eForty-six patients were included in the study, but eight dropped out within the first three months. We chose to conduct interviews with all patients still involved in the program, although three did not ultimately participate. Processing the verbatims collected enabled us to identify several units of meaning, each reflecting the comments of at least 25% of the thirty-five respondents. For each unit of meaning, we present examples of verbatim that illustrate its effectiveness or, conversely, its absence.\\u003c/p\\u003e \\u003cp\\u003eInitially, the analysis was based on three headings taken from the interview guide:\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003e- Adherence factors;\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e- Relevance indicators;\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e- Patient-healthcare professional coordination.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003eThese headings were used to structure the data collected. The interviews conducted were condensed and organized within a matrix of conceptual groupings. However, analysis showed that these headings, while relevant, were not sufficient to capture all the experiences expressed by patients. Certain cross-cutting themes, such as the notion of autonomy or the tension between the need for support and personal initiative, were not satisfactorily taken into account.\\u003c/p\\u003e \\u003cp\\u003eTo overcome these limitations, an inductive approach was adopted. Each unit of meaning was placed in its initial context, in order to verify its coherence with newly emerging categories. This interpretive work made it possible to reorganize the data beyond pre-existing frameworks, in line with the recommendations of Attride-Stirling (\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e) and the thematic approach of Braun and Clarke (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eFour categories thus emerge from the reprocessing of the data collected. Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e highlights this process.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eProcess for deriving categories from empirical data\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"3\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInitial headings in the interview guide\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eExamples of content partially covered\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eEmerging categories from the inductive analysis\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSupport factors\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eDesire to be listened to, feeling of being valued\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e1 Interpersonal relationship\\u003c/b\\u003e: quality of the link, recognition and trust between professional and patient\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIndicators of relevance\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSense of dependence, need for prolonged support\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e2. Patient autonomy\\u003c/b\\u003e: ability to take responsibility for themselves, request for additional follow-up\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient-professional coordination\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eDesire for personal initiative, frustration with rigidities\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e3 Need for flexibility\\u003c/b\\u003e: patients' desire to shape their care pathway and play an active role in it\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient-professional coordination\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eLack of shared information, non-involvement of relatives\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e4 Coordination and communication\\u003c/b\\u003e: circulation of information and inclusion of relatives in the care process\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003e2.1 Patient-professional interpersonal relations\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003col\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003e \\u003cb\\u003ea) The quality of the relationship between patient and carer: appreciation, trust and listening\\u003c/b\\u003e \\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003c/ol\\u003e \\u003c/p\\u003e \\u003cp\\u003eInvolvement in the treatment process depends on the feeling that the efforts made are appreciated. This is all the more important given that the majority of obesity sufferers have developed a lack of self-esteem over the course of their lives. A17 confides: \\\"As someone who doubts myself, I felt important to the people at the hospital and the physio. That's one of the reasons why I succeeded in the course\\\".\\u003c/p\\u003e \\u003cp\\u003eA17's testimony highlights the importance of the caregivers' positive regard for patients who often lose self-confidence. From the very first interviews, this dimension came to the fore, leading us to identify recurring factors: stigmatization from childhood, devaluing remarks in the school, family or medical spheres, and a persistent feeling of not being recognized for their efforts.\\u003c/p\\u003e \\u003cp\\u003eConfidence in those involved in the treatment process is also a key factor in patient adherence. A9 says: \\\"I think what helped me was the kindness I encountered in your department, the idea that there was no judgment. I don't feel obliged to get results\\\".\\u003c/p\\u003e \\u003cp\\u003eOn the other hand, A28, whose clinical results are not conclusive, declares: \\\"I would have liked more supervision. I didn't like the way the physio behaved\\\".\\u003c/p\\u003e \\u003cp\\u003eRespondents attest to the fact that taking their views into account is a key factor in the success of their care pathways. For example, A18 expresses his satisfaction: \\\"I especially appreciated being able to give my point of view on the exercises, some of which I didn't like and which hurt me. I was listened to and that's new for me\\\".\\u003c/p\\u003e \\u003cp\\u003eOn the other hand, a number of respondents expressed frustration, such as A23:\\u003c/p\\u003e \\u003cp\\u003e\\\"I need to be heard. I've missed that. By expressing myself and listening to me, I think I would have been more involved in the process\\\".\\u003c/p\\u003e \\u003cdiv id=\\\"Sec7\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eb) The influence of previous medical experience\\u003c/h2\\u003e \\u003cp\\u003eSatisfactory previous medical care seems to facilitate participants' integration into the program, by making them more receptive to the advice and support offered by professionals. A18 points out: \\\"In 1990, I had a sleeve operation, followed by a bypass in 1992. In 1993, I had my thyroid removed. These were not easy times, but they gave me confidence in the medical world\\\".\\u003c/p\\u003e \\u003cp\\u003eOn the other hand, medical treatment that has led to dissatisfaction calls for increased vigilance in support. As A27 explains: \\\"I had a sleeve, but there was no follow-up. I was let go\\\".\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003ec) Preparing the patient: understanding, anticipation and appropriation\\u003c/h3\\u003e\\n\\u003cp\\u003eAll the participants stressed the importance of the efforts involved. That's why preparing patients before they enter the program is a prerequisite for their involvement and for the relationship they'll have with those involved. For example, as A4 confides: \\u0026ldquo;I did some psychological work which helped me and made me aware of the benefits of devoting myself to physical activity\\u0026rdquo;.\\u003c/p\\u003e \\u003cp\\u003eKnowing what is at stake is also a determining factor. A19, who didn't get any convincing results, says: \\\"At first, I didn't know what I was doing there. I saw a lot of people. I didn't know what their role was\\\".\\u003c/p\\u003e \\u003cp\\u003eGetting to grips with the tools of a system is essential if you want to feel part of it. The main tool used during the course was the Aviitam database, which is used to collect all patient data and prepare consultations by means of various questionnaires. It is fed by both patients and healthcare professionals. It can be consulted by anyone involved in the treatment process, enabling information to be pooled and strengthening the relationship between patients and practitioners. In the words of A8: \\\"I really understand the value of the questionnaires and the Aviitam tool. It has enabled me to know where I stand and to share my data with the various professionals\\\".\\u003c/p\\u003e \\u003cp\\u003eOn the other hand, A3, who has not been entirely successful with the pathway, comments:\\u003c/p\\u003e \\u003cp\\u003e\\u0026ldquo;I haven't logged on to Aviitam, because I don't see the point of it and I find it hard to understand\\u0026rdquo;.\\u003c/p\\u003e\\n\\u003ch3\\u003ed) Unexpected benefits of the pathway: detection of associated pathologies\\u003c/h3\\u003e\\n\\u003cp\\u003eThe value of the care pathway also lies in what it has indirectly brought to participants; they express their gratitude and confidence in practitioners because of the detection of pathologies that were not targeted by the pathway. For example, A13 states: \\\"The course enabled me to detect my diabetes. I owe you a debt of gratitude\\\".\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003e2.2 Patient autonomy in question\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003ea) Difficulty in taking charge and decisive support\\u003c/b\\u003e \\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003c/ol\\u003e \\u003c/p\\u003e \\u003cp\\u003eHalf of all respondents stressed their difficulty in taking charge and being autonomous. This is compensated for by the support provided during the course of the treatment, which strongly influences their feelings. For example, A30 states: \\\"I couldn't have done it on my own. I couldn't have done it on my own. I needed this multiple care\\\".\\u003c/p\\u003e \\u003cp\\u003eOn the other hand, A5 adds: \\\"The doctor who saw me didn't know my file. That demotivated me, because I need to be supervised to get involved\\\".\\u003c/p\\u003e \\u003cdiv id=\\\"Sec10\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eb) Complementary care or follow-up\\u003c/h2\\u003e \\u003cp\\u003eRespondents are looking for a complementary service to reinforce their commitment. A2, for example, points out that: \\\"Being in this program enabled me to be taken in for sleep recordings. Since then, I've been fitted with a device and my sleep has improved. I'd never thought of doing it before\\\".\\u003c/p\\u003e \\u003cp\\u003eA16, on the other hand, points to her lack of investment, saying: \\u0026ldquo;I didn't have a dietetic follow-up to complement the physical activity sessions\\u0026rdquo;. However, patients had received advice and benefited from dietary workshops at the start of the protocol as part of their therapeutic education.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ec) Expectation of collective follow-up after the program\\u003c/h2\\u003e \\u003cp\\u003eMore than a third of respondents regretted the end of support at the end of the program, and said they were unable to continue what had been started on their own. For example, A10 confides: \\\"I suggest that there should be a follow-up to all this. I may be demanding, but I need to be followed beyond the protocol, otherwise I wouldn't be able to do all this on my own\\\".\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003e2.3 Patients, actors in their own care\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cp\\u003e \\u003cb\\u003ea) Motivation to take care of their own health\\u003c/b\\u003e \\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003c/ol\\u003e \\u003c/p\\u003e \\u003cp\\u003eOwnership of the care pathway is correlated with the patient's motivation to take care of themselves. As A23 points out: \\\"I didn't like the way I looked at myself and my image. I wanted to lose weight and work on my self-confidence\\\".\\u003c/p\\u003e \\u003cp\\u003eOn the other hand, A23 justifies her lack of success in the course as follows: \\\"I have to admit that I wasn't involved in the program at first, because I was very busy professionally. I wasn't ready to take care of my body.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eb) Accessibility and geographical proximity\\u003c/h2\\u003e \\u003cp\\u003eProximity, in particular of the physiotherapy practice to the patient's home or workplace, is certainly a factor in success, as the patient feels he or she is not subject to the material constraints associated with the course. As A21 put it: \\u0026ldquo;I live in a village; I work in the same village; I do everything on foot and taking my car is a chore for me... so the proximity of the physiotherapist motivated me\\u0026rdquo;.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ec) Need for flexibility in the organization of the treatment\\u003c/h2\\u003e \\u003cp\\u003eThe need for flexibility was expressed by half of the respondents, and reflects their desire to have some control over the treatment. It is expressed first and foremost in their satisfaction with the program's adaptation to their pathologies. For example, A8 declares: \\\"There are things I can't do. But my physio has adapted the exercises for me. I have cartilage injections. We compensate by doing things differently\\\".\\u003c/p\\u003e \\u003cp\\u003eThis need for flexibility also manifests itself in the adjustment of the protocol to patients' life constraints. A9 explains: \\\"I followed the program, but it was a bit hard to do it twice a week with a professional activity. It was complicated to find the time slots, but the physiotherapist adapted\\\". On the other hand, A29 expressed her disappointment: \\\"I couldn't do any workshops at the hospital, because we couldn't find time slots compatible with my schedule. That put a bit of a brake on the project\\\".\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ed) Pain-related concerns\\u003c/h2\\u003e \\u003cp\\u003eThe suitability of the course also depends on the patient's perception of his or her pain and ability to regain control of sensations. For example, A12 explains: \\\"Having followed this program makes me think less about my back pain. I find myself doing activities without fear of pain\\\".\\u003c/p\\u003e \\u003cp\\u003eOn the contrary, A4 warns us: \\\"I'm always worried about my back pain. I know it's partly in my head, but I haven't managed to get rid of it\\\".\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ee) Persistence of physical activity at the end of the pathway\\u003c/h2\\u003e \\u003cp\\u003eThis theme, shared by three quarters of respondents, is consubstantial with the adapted physical activity pathway. It demonstrates the patient's ability to take responsibility over the long term, and is therefore an essential indicator of relevance. As A6 puts it: \\\"I'm going to take up rowing again, and I'm trying to reproduce at home the physical exercises I used to do with the physiotherapist. I've become a sportswoman again\\\".\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003e2.4 Coordination between practitioners and communication with patients' relatives\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003ea) Interest in alternating hospital and city care\\u003c/b\\u003e \\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003c/ol\\u003e \\u003c/p\\u003e \\u003cp\\u003eEchoing the recommendations made by the health authorities, 45% of respondents expressed their attachment to the sharing of healthcare skills and missions between private practitioners and hospitals. As A18 explains: \\u0026ldquo;The physiotherapist's office is more familiar. That makes it more attractive to go there, even though I've had my appointments at the hospital. Being in a program with both forces us to give our best.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eb) Involvement of professionals in the program\\u003c/h2\\u003e \\u003cp\\u003eAccording to respondents, feeling that healthcare professionals are involved in the care pathway contributes to the feeling that it is properly coordinated.\\u003c/p\\u003e \\u003cp\\u003eFor example, A17 states: \\u0026ldquo;Every professional I met did their utmost to support and motivate me. I went home with the desire to excel\\u0026rdquo;.\\u003c/p\\u003e \\u003cp\\u003eOn the other hand, A5 points out that \\u0026ldquo;the doctor was supposed to see me again in June, but he rescheduled my appointment, and when I arrived for my consultation it wasn't him\\u0026rdquo;.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec17\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ec) Patient requests: remote consultations and information sharing\\u003c/h2\\u003e \\u003cp\\u003eA third of respondents regretted the absence of remote consultations carried out by several professionals simultaneously. A2 said: \\u0026ldquo;I would have liked to have remote consultations during which I could have exchanged information with my physiotherapist and the hospital at the same time. There's a lack of coordination between the practitioners.\\\"\\u003c/p\\u003e \\u003cp\\u003eSimilarly, the sharing of patient information between the different practitioners is an important area of focus in implementing the pathway. For example, A11 states: \\\"It would be good to have an intermediary point with the different practitioners. I feel that information about my situation doesn't circulate well between the hospital and the physiotherapist.\\\"\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec18\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ed) Support and Integration of Family and Friends in the Pathway\\u003c/h2\\u003e \\u003cp\\u003eSupport from family and friends plays an essential role in patient adherence to the pathway, strengthening patient involvement and facilitating the implementation of the expected changes. For example, A1 states: \\\"My husband, my children, my sisters, they walk with me, they make me do exercises.\\\" A31, who did not obtain satisfactory clinical results, specifies: \\u0026ldquo;No, I am not accompanied, I am alone because the course is a subject of dispute with my husband.\\u0026rdquo;\\u003c/p\\u003e \\u003cp\\u003eFurthermore, the importance of loved ones in the rehabilitation process, highlighted by many patients, leads some to regret the lack of communication from practitioners towards them. They express a wish for them to be more involved. For example, A29 emphasizes: \\\"It would be good to inform them from the start with a meeting with all participants. My partner would better understand what is expected of me.\\\"\\u003c/p\\u003e \\u003cp\\u003eUltimately, the inductive analysis revealed four major categories structuring patients' engagement in their rehabilitation journey. The relationships between these categories, as well as their contribution to the relevance of a care pathway, are summarized in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \"},{\"header\":\"3. Discussion\",\"content\":\"\\u003cdiv id=\\\"Sec19\\\" class=\\\"Section3\\\"\\u003e \\u003cp\\u003eThe results are analyzed in two stages. First, we compare the units of meaning derived from our survey with the National Health Service classification. Secondly, we put them into perspective in relation to existing literature, based on the four categories identified in the discourse analysis (interpersonal patient-professional relationship, patient autonomy, patient as actor in his or her care pathway, coordination between practitioners and communication with relatives), and make proposals for improving practices in the care pathway.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec20\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.1 Correspondence with National Health Service (NHS) classification\\u003c/h2\\u003e \\u003cp\\u003eThe UK is one of the pioneers of the \\u0026ldquo;Patient Experience\\u0026rdquo;, and the classification established by the National Health Service (NHS) in 2011 is a major reference in the field (\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e). This classification organizes the \\u0026ldquo;Patient Experience\\u0026rdquo; around nine fundamental criteria. In our study, we propose a correspondence test between seven of these nine criteria and the units of meaning derived from the analysis of our interviews (Table \\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). This approach enables us to make a new classification of the units of meaning that have emerged, validating our data collection through this theoretical framework.\\u003c/p\\u003e \\u003cp\\u003eThe seven criteria selected: respect for patient needs and preferences; coordination and integration of services; information, communication and education; physical comfort; emotional support; involvement of family and friends; continuity and transition of care are those that correspond to the testimonies collected.\\u003c/p\\u003e \\u003cp\\u003e On the other hand, two NHS criteria - access to care and hospital environment - did not emerge from our analysis of the interviews and were therefore not retained. Participants placed more emphasis on the quality of follow-up, the personalization of care and human support than on structural or administrative aspects.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eCorrespondence between National Health Service classification and subcategories\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eClassification du National Health Service\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSubcategories determining the relevance of the course\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eRespect for patient needs and preferences\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u0026bull; Proximity to the health establishment\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; Adjusting the protocol according to patient constraints\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; Possibility of teleconsultation\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; Taking the patient's voice into account\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eService Coordination and Integration\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u0026bull; Sharing patient information\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; Interest in alternating care between hospitals and town centres\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInformation, communication et education\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u0026bull; Preparing the patient before the journey\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; Appropriation of tools and procedures relating to the route\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; Communication with relatives and carers\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePhysicial confort\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u0026bull; Motivation to take care of your body\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; Improvement in the patient\\u0026rsquo;s general condition\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; Adapting the patient pathway to the patient's pathologies\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEmotional support\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u0026bull; Valuation by the healthcare professional\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; Difficulty in taking charge of one's life - decisive support\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; Adjusting the protocol according to patient constraints\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; Reduced concern about pain and health\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; Taking the patient's voice into account\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInvolving families and friends\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u0026bull; Accompaniment by a close friend or family member as a factor in adherence\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; Communication with relatives and carers\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eContinuity and transition of care\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u0026bull; Previous medical treatment favourable\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; Providing care or follow-up that complements the programme\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; Detection of other pathologies\\u003c/p\\u003e \\u003cp\\u003e\\u0026bull; Collective follow-up after the course\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eCross-referencing our results with the \\u0026ldquo;Patient Experience\\u0026rdquo; criteria defined by the NHS reveals a high degree of consistency, reinforcing the validity of our study.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec21\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003e\\u0026bull; Respect for the patient's needs and preferences\\u003c/h2\\u003e \\u003cp\\u003eThis criterion is illustrated by different units of significance found in the interviews. The proximity of the healthcare facility, the possibility of teleconsultation, the adjustment of the protocol to personal constraints and the explicit recognition of the patient's voice all testify to an expectation in favor of personalization and adaptability of the care pathway.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec22\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003e\\u0026bull; Coordination and integration of services\\u003c/h2\\u003e \\u003cp\\u003eOur results also highlight the importance of good coordination between care providers. The sharing of information between professionals, as well as the alternation between hospital and outpatient care, confirm the importance of continuity and integration of services, in line with NHS principles.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec23\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003e\\u0026bull; Information, communication and education\\u003c/h2\\u003e \\u003cp\\u003eThe interviews emphasized the need for patients to be prepared in advance, for tools and procedures linked to the care pathway to be appropriated, and for exchanges with family and friends to flow smoothly. These elements are in line with the importance attached to information and education in the care experience.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec24\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e\\u0026bull; Physical comfort\\u003c/h2\\u003e \\u003cp\\u003eThe improvement in general condition, the adaptation of the care pathway to specific pathologies, and the motivation of patients to take care of themselves all reflect high expectations in terms of physical well-being, echoing the criteria for physical comfort established by the NHS.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec25\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e\\u0026bull; Emotional support\\u003c/h2\\u003e \\u003cp\\u003eEmotional and psychological support are also key factors. The importance of emotional support for patients is illustrated by the fact that they are valued by healthcare professionals, helped in situations where they lack autonomy, and less worried about pain.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003e• Involvement of family and friends\\u003c/h3\\u003e\\n\\u003cp\\u003eThe presence and involvement of family and friends appear to be essential to patients' adherence to the care pathway. This support is often mentioned in interviews, confirming the alignment with the NHS criterion dedicated to the involvement of family and friends.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec27\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e\\u0026bull; Continuity and transition of care\\u003c/h2\\u003e \\u003cp\\u003eFinally, careful consideration of medical history, the provision of complementary care and the detection of other pathologies testify to a concern for continuity and fluidity in the transitions of the care pathway, in line with the expectations set by the NHS.\\u003c/p\\u003e \\u003cp\\u003eThis analysis confirms the validity of our study, demonstrating that the expectations and experiences formulated by our participants are in line with the dimensions of the \\u0026ldquo;Patient Experience\\u0026rdquo; as defined by the NHS.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec28\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.2 The interpersonal patient-professional relationship\\u003c/h2\\u003e \\u003cp\\u003eThe first category of our model focuses on the interpersonal relationships between patients and healthcare professionals, which are essential to the success of the care journey. According to Kobeissi and Aubert, the patient experience is based on factors that transcend the expertise of healthcare professionals, and are founded on subjective factors (\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eOur study first shows that the quality of previous medical experiences influences patient engagement. Positive experiences promote adherence and trust, while negative memories, marked by a communication deficit or a feeling of neglect, generate mistrust and less involvement (\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e). Hence the importance of implementing corrective actions to restore trust after such experiences (\\u003cb\\u003eproposal 1)\\u003c/b\\u003e.\\u003c/p\\u003e \\u003cp\\u003ePatient preparation prior to the treatment also appears to be a determining factor. Structured preparation, combining clear information and effective coordination, reduces anxiety and strengthens patient involvement (\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e). With this in mind, personalized preparation is needed to optimize adherence to the care pathway (\\u003cb\\u003eproposal 2\\u003c/b\\u003e).\\u003c/p\\u003e \\u003cp\\u003eMoreover, when patients' efforts are recognized, their motivation and commitment are reinforced. Conversely, poor communication increases the risk of non-adherence (\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e). Thus, patient trust in their practitioner leads to convincing results by promoting ownership of the protocol's objectives (\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e). It is therefore essential to value their words and reinforce this trust (\\u003cb\\u003eproposal 3\\u003c/b\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThe appropriation of tools relating to the pathway is also a fundamental lever. While these tools make it possible to better coordinate care and make patients actors in their own health, their perceived complexity or insufficient support can hinder their adoption (\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e). Fostering personalized appropriation, by providing appropriate explanations, helps to reinforce patient autonomy (\\u003cb\\u003eproposal 4\\u003c/b\\u003e).\\u003c/p\\u003e \\u003cp\\u003eFinally, our study reveals that the care pathway can be an opportunity to detect other pathologies not initially anticipated, thanks to the vigilance of professionals or the complementary examinations carried out. Patients testified to their satisfaction following the discovery and management of pathologies such as sleep apnea or diabetes. This secondary benefit, highlighted by the HAS (2023), contributes to improving patient health and increasing patient involvement (\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eIt would therefore be a good idea to systematically integrate an early detection system into the care pathway (\\u003cb\\u003eproposal 5\\u003c/b\\u003e).\\u003c/p\\u003e \\u003cdiv id=\\\"Sec29\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003e3.3 Patient autonomy\\u003c/h2\\u003e \\u003cp\\u003eOur study highlights the fact that, although patient autonomy is now a principle in healthcare policies, aimed at promoting participation and empowerment, it remains difficult to achieve in practice (\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e). Many participants describe their inability to manage their chronic illness on their own. Without the support they received, they would not have been able to complete their protocol. These observations concur with those of Anderson and Funnell, for whom lack of self-confidence and psychosocial barriers hinder empowerment, necessitating reinforced support (\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e). From this perspective, it seems essential to reinforce support throughout the care process to promote autonomy (\\u003cb\\u003eproposal 6\\u003c/b\\u003e).\\u003c/p\\u003e \\u003cp\\u003eIn addition, our research reveals a high level of expectation concerning the provision of complementary follow-up care, particularly dietary advice. Although patients were given advice at the start of the care pathway, the absence of regular support hampered the long-term anchoring of good practices. These results corroborate the analyses of Chambouleyron et al, who recommend ongoing support through therapeutic education or appropriate psychological follow-up (\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e). Providing additional follow-up throughout the course of the treatment would reinforce patients' adaptation and self-care skills (\\u003cb\\u003eproposal 7\\u003c/b\\u003e).\\u003c/p\\u003e \\u003cp\\u003eSimilarly, the question of maintaining good practices after the end of the program is a central one. Many participants expressed their difficulty in maintaining regular physical activity without a structured framework, citing loss of motivation and isolation. These findings are in line with the study by Maledon, which shows that starting a physical activity program too early leads to a loss of motivation, as participants do not feel sufficiently autonomous (\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e). More broadly, Vielle et al stress the importance of gradual support to help people become more autonomous (\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eWith this in mind, it would seem appropriate to organize collective support after the course has been completed, in order to consolidate what has been learned and encourage the perpetuation of best practices (\\u003cb\\u003eproposal 8\\u003c/b\\u003e).\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec30\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003e3.4 Patients as actors in their own care\\u003c/h2\\u003e \\u003cp\\u003eWe have shown that, although patient autonomy remains elusive, many patients express their desire to become active players in their own care. The concept of the patient as actor in his or her own care pathway has been developing for several years. For example, according to Laude, \\u0026ldquo;the legislator wanted to draw the consequences of developments in the healthcare relationship by making the patient an actor in his or her own health\\u0026rdquo; (\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e). Similarly, according to Remillieux, \\u0026ldquo;personalized treatment is the cornerstone of success\\u0026rdquo; (\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e). This observation echoes that of Gros, for whom engagement is based on the perception of concrete benefits (\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e). It therefore seems essential to support patient involvement by linking their efforts to tangible results (\\u003cb\\u003eproposal 9\\u003c/b\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThe proximity of care facilities is also a determining factor in patient adherence. As indicated by the Institut national de sant\\u0026eacute; publique du Qu\\u0026eacute;bec (2018), easier access encourages regular participation, whereas remoteness is a hindrance (\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e). The development of teleconsultation, recommended by DREES, offers solutions to overcome these obstacles (\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e). Guaranteeing physical or digital accessibility to care thus seems essential to reinforce patient commitment (\\u003cb\\u003eproposal 10\\u003c/b\\u003e).\\u003c/p\\u003e \\u003cp\\u003eAdjusting the protocol to specific needs and constraints also appears crucial. Racodon and Masson show that organizational flexibility promotes autonomy and involvement (\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e). Adapting the frequency, intensity and schedules of care is therefore necessary to maintain adherence to the pathway (\\u003cb\\u003eproposal 11\\u003c/b\\u003e).\\u003c/p\\u003e \\u003cp\\u003eLastly, the persistence of physical activity after the course is completed is a source of ownership.\\u003c/p\\u003e \\u003cp\\u003eWork by Inserm and the Look AHEAD Research Group shows that it improves the long-term management of chronic diseases (\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e) (\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e). It is therefore important to support the continuity of physical activity beyond the protocol. (\\u003cb\\u003eproposal 12\\u003c/b\\u003e).\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003e3.5 Coordination and communication with family and friends\\u003c/h3\\u003e\\n\\u003cdiv id=\\\"Sec32\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.5.1 Information sharing between healthcare professionals\\u003c/h2\\u003e \\u003cp\\u003eSharing information between healthcare professionals emerged as a strong expectation in our interviews. Several respondents expressed the wish to benefit from remote consultations involving several practitioners, reflecting their attachment to the sharing of skills and better coordination. This need is in line with the work of Br\\u0026eacute;mond and Fieschi, who believe that information exchange promotes efficiency and collective performance (\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e). Jacobs et al confirm that multidisciplinary teams enable more personalized care, and significantly improve patient health, engagement and satisfaction (\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e). Consequently, structuring care paths around reinforced coordination within multidisciplinary teams appears to be an essential lever for improving the quality of care (\\u003cb\\u003eproposal 13\\u003c/b\\u003e).\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec33\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.5.2 Communication and coordination with family and friends\\u003c/h2\\u003e \\u003cp\\u003eWe emphasize the importance that patients attach to communication with their loved ones, and to their active involvement in the care process.\\u003c/p\\u003e \\u003cp\\u003e For many, engaging in a therapeutic approach is a shared decision, made in agreement with those around them. This finding echoes that of Reblin and Uchino, who highlight the importance of emotional and logistical support from loved ones in helping patients overcome psychological challenges, such as stigmatization and declining motivation (\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eFurthermore, Bigossi and Laborde point out that relatives help to lighten patients' mental load, by participating in the day-to-day management of tasks and following medical recommendations (\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e). This daily involvement promotes regularity in the application of therapeutic advice. Funnell et al. confirm that the presence of family and friends acts as an additional motivational lever to comply with treatment, thus reinforcing adherence (\\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eFinally, our analysis is also in line with the work of Buthion and God\\u0026eacute;, for whom loved ones, in certain situations, become veritable \\u0026ldquo;life assistants\\u0026rdquo; and \\u0026ldquo;caregivers\\u0026rdquo;, their participation being considered indispensable to the effective coordination of care pathways (\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eWith this in mind, it seems essential to systematically involve family members in the care pathway, in order to strengthen their understanding of the pathology and encourage patients' long-term adherence to treatment recommendations (\\u003cb\\u003eproposal 14\\u003c/b\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThe results we have obtained suggest that the success of a care pathway for patients depends on integrating the fourteen proposals formulated upstream and throughout the pathway.\\u003c/p\\u003e \\u003cp\\u003eUpstream, we need to restore trust (proposal 1), personalize preparation (Proposal 2), involve family and friends (Proposal 14), support intrinsic motivation (Proposal 9) and anticipate accessibility to care (Proposal 10).\\u003c/p\\u003e \\u003cp\\u003eDuring the course of the treatment, the patient's commitment must be reinforced by high-quality communication (Proposal 3), the development of autonomy (Proposal 4), the adaptation of care to individual constraints (Proposal 11) and effective multidisciplinary coordination (Proposal 13).\\u003c/p\\u003e \\u003cp\\u003eDownstream, the aim is to consolidate gains through collective follow-up (Proposal 8), support the pursuit of physical activity (Proposal 12), accompany adaptation to new needs (Proposal 7) and prevent any associated pathologies (Proposal 5), while maintaining the involvement of family and friends (Proposal 14).\\u003c/p\\u003e \\u003cp\\u003eImplementing these proposals means overcoming a number of challenges: limited medical time, insufficient coordination, inequalities in access to care, variable involvement of family and friends, and a growing administrative burden.\\u003c/p\\u003e \\u003cp\\u003eIt requires the development of flexible educational systems, regular coordination time, simplified procedures for patients and healthcare professionals, and a culture of partnership with patients and their families.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eAssessing the appropriateness of a care pathway cannot, of course, be limited to patient experience; it must also take into account the expertise of professionals, compliance with protocols and the clinical benefits observed. This study set out to understand how patients suffering from obesity appropriate a course of adapted physical activity, and what factors encourage their commitment.\\u003c/p\\u003e \\u003cp\\u003eThe results show that appropriation is based on several levers: the quality of the care-giver-patient relationship, personalization of the pathway, recognition of the patient's active role, and flexibility in the organization of care and exercise. The commitment of patients is built through a human approach centered on listening, trust and individualized support, but also through the progressive development of their autonomy. Continuity of support also helps to prevent breakdowns, consolidate achievements and ensure a gradual transition to more autonomous health management.\\u003c/p\\u003e \\u003cp\\u003eThis work is not without its difficulties, as a care pathway is often a real challenge for healthcare professionals, requiring them to persevere in coordinating actions and providing long-term support for patients. With a view to enriching this research, a number of avenues need to be explored.\\u003c/p\\u003e \\u003cp\\u003eFirstly, it would be appropriate to extend the evaluation of the model to other chronic pathologies, such as type 2 diabetes, cardiovascular disease or musculoskeletal disorders, in order to test the transferability of the factors identified and propose a generalization of the model, regardless of the specificity of the pathway.\\u003c/p\\u003e \\u003cp\\u003eSecondly, a longitudinal follow-up of patients would enable us to observe the evolution of their commitment, the effective integration of recommendations and the impact on their quality of life and long-term health behaviours.\\u003c/p\\u003e \\u003cp\\u003eFinally, a sociological approach could be envisaged to analyze the obstacles and levers influencing patients' adherence to the recommendations in their care pathway. This study would integrate the psychosocial, cultural and economic dimensions that condition their commitment.\\u003c/p\\u003e \\u003cp\\u003eIt would also involve healthcare professionals, whose expertise would make it possible to identify obstacles and propose adjustments to medical and propose adjustments to medical practices and organization, as well as other aids, where your contribution will allow you to understand the family and social aspects that influence patient adherence.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eEthics approval and consent to participate : The IRB (Institutional Review Board) protocol, the admissibility and ethical nature of which were confirmed under number IRB- MTP_2022_03_202201067. Permission to register was requested from all respondents\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eInformed consent to participate has been obtained from all study participants\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eOur study complied with the Declaration of Helsinki.\\u003c/p\\u003e\\n\\u003cp\\u003eConsent for publication : Not applicable\\u003c/p\\u003e\\n\\u003cp\\u003eAvailability of data and materials : The datasets generated and/or analysed during the current study are not publicly available due to the confidentiality of the information collected during the interviews but are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;Competing interests : A.S : Servier, Viatris, Amgen, Sanofi. These interests are not related to the article submitted.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eFunding : this study did not receive any specific funding\\u003c/p\\u003e\\n\\u003cp\\u003eAuthors' contributions : E.B created the interview guide, conducted the interviews and wrote the main text; B.L checked the interviews and transcriptions. A.S and E.B contributed to the creation of the protocol. B.L and A.S proofread the manuscript. All authors read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003eAcknowledgements : Not applicable\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eOMS, Obesity and overweight, 1 march 2024.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNCD \\u003cem\\u003eRisk Factor Collaboration (NCD-RisC), 2024\\u003c/em\\u003e Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population- representative studies with 222 million children, adolescents, and adults. \\u003cem\\u003eLancet\\u003c/em\\u003e 2024: 403: 1027\\u0026ndash;50.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJelleyman C, Yates T, O'Donovan G, Gray LJ, King JA, Khunti K, Davies MJ. (2015). 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(2011). \\u003cem\\u003eNHS patient experience framewor\\u003c/em\\u003e k \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment\\u003c/span\\u003e\\u003cspan address=\\\"https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKobeissi K, Aubert B. (2014). Le patient, un client presque comme les autres. \\u003cem\\u003eL'Expansion Management Review\\u003c/em\\u003e 2014/3 (No. 154), pages 51 to 57.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChandra S, Mohammadnezhad M, Ward PR. (2018). 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Patient-practitioner relationships desired by overweight/obese adults. \\u003cem\\u003ePatient Education and Counselling 4 July 2012\\u003c/em\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRasmussen SR, Jensen H, Pedersen KM, Andersen JS. (2017). The effect of eHealth tools on patient activation and empowerment: A systematic review. \\u003cem\\u003eJournal of Medical Internet Research, 19(3).\\u003c/em\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHaute Autorit\\u0026eacute; de Sant\\u0026eacute;. (2023). Recommandations sur les parcours de soins int\\u0026eacute;gr\\u0026eacute;s.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBacqu\\u0026eacute; M-H, Biewener C. (2013). \\u003cem\\u003eL'empowerment, une pratique \\u0026eacute;mancipatrice\\u003c/em\\u003e - La D\\u0026eacute;couverte.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAnderson RM, Funnell MM. (2005). Patient empowerment: Reflections on the challenge of fostering the adoption of a new paradigm. \\u003cem\\u003ePatient Educ Couns. 2005;57(2):153-7\\u003c/em\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChambouleyron M, et al. \\u0026Eacute;ducation th\\u0026eacute;rapeutique du patient ob\\u0026egrave;se, une approche de la complexit\\u0026eacute;. Ob\\u0026eacute;sit\\u0026eacute;. 2012;7:199\\u0026ndash;204.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMaledon L. (2018). Evaluation and impact of a Physical Activity, Health and Well-Being (APSBE) programme carried out at the CREPS Antilles-Guyane health centre on a population with chronic diseases. \\u003cem\\u003eMedical Thesis University of the Indies\\u003c/em\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eVielle P, Pochet P, Cassiers I. (2006). \\u003cem\\u003eL'\\u0026Eacute;tat social actif\\u003c/em\\u003e - P.I.E-Peter Lang S.A. \\u0026Eacute;ditions Scientifiques Internationales.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLaude A. (2007). \\u003cem\\u003eLe patient, nouvel acteur de sant\\u0026eacute; ?\\u003c/em\\u003e Recueil Dalloz.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRemillieux M. (2018). Respecting the autonomy of the cared-for person. \\u003cem\\u003ejournal Soins April 2018.\\u003c/em\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGros C. Patient autonome ou autonome patient ? Sant\\u0026eacute; publique. 2017;29(5):685\\u0026ndash;92.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eInstitut national de sant\\u0026eacute; publique du Qu\\u0026eacute;bec. (2018). \\u003cem\\u003eL\\u0026rsquo;accessibilit\\u0026eacute; aux services de sant\\u0026eacute;: d\\u0026eacute;fis et pistes d'action\\u003c/em\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDREES. Les pratiques de t\\u0026eacute;l\\u0026eacute;consultation en France en 2020. Direction de la recherche, des \\u0026eacute;tudes, de l\\u0026rsquo;\\u0026eacute;valuation et des statistiques; 2021.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRacodon C, et, Masson D. (2015). Flexibilit\\u0026eacute; organisationnelle et autonomie du patient dans les parcours de soins. \\u003cem\\u003eRevue fran\\u0026ccedil;aise des affaires sociales, 2, 123\\u003c/em\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eInserm. Activit\\u0026eacute; physique: pr\\u0026eacute;vention et traitement des maladies chroniques. Expertise collective; 2020.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLook AHEAD, Research Group. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: Four-year results of the Look AHEAD trial. Arch Intern Med. 2013;170(17):1566\\u0026ndash;75.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBr\\u0026eacute;mond M, Marius Fieschi M. (2008). Information sharing in the healthcare system. \\u003cem\\u003eLes Tribunes de la sant\\u0026eacute; 2008/4\\u003c/em\\u003e (n\\u0026deg; 21).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJacobs J, Dougherty A, McCarn B, Saiyed NS, Ignoffo S, Wagener C, San Miguel C, Martinez L. Impact of a multi-disciplinary team-based care model for patients living with diabetes on health outcomes: a mixed-methods study. BMC Health Serv Res. 2024;24(1):746.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eReblin M, Uchino BN. Social and emotional support and its implication for health. Curr Opin Psychiatry. 2016;29(2):135\\u0026ndash;40.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBigossi M, Laborde C. Le r\\u0026ocirc;le des proches dans la gestion des maladies chroniques: soutien psychologique et organisation pratique. Revue Fran\\u0026ccedil;aise de M\\u0026eacute;decine G\\u0026eacute;n\\u0026eacute;rale. 2021;15(183):56\\u0026ndash;61.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFunnell MM, Anderson RM et al. (2008). Empowerment and self-management of diabetes: Educating patients to take control. \\u003cem\\u003eBMJ, 336(7652), 1030\\u0026ndash;1031\\u003c/em\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eButhion V, God\\u0026eacute; C. (2014). Les proches aidants, quels r\\u0026ocirc;les dans la coordination du parcours de soins des personnes malades? \\u003cem\\u003eJournal de gestion et d'\\u0026eacute;conomie m\\u0026eacute;dicales 2014/7\\u0026ndash;8 (Vol. 32), pages 501 to 519.\\u003c/em\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-public-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"pubh\",\"sideBox\":\"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/pubh/default.aspx\",\"title\":\"BMC Public Health\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"obesity, care pathway, lived experience, commitment, relevance\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-5973776/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-5973776/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eContext\\u003c/strong\\u003e: Despite the benefits of physical activity, people suffering from obesity face a number of obstacles and often give up.\\u003c/p\\u003e\\n\\u003cp\\u003eThe proposed care pathway integrates multidisciplinary management of people suffering from obesity. It aims to assess the impact of adapted physical activity: a supervised practice tailored to each individual's state of health, abilities and needs. It was offered to eighty people during their day hospitalization at Montpellier University Hospital; forty-six started and eight stopped during the three-month course. Eligibility criteria included a body mass index (BMI) greater than 30 kg/m² and the presence of musculoskeletal pain requiring physiotherapy.\\u003c/p\\u003e\\n\\u003cp\\u003eOur main aim was to identify the factors structuring patients' involvement, by collecting their experiences and views.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethod\\u003c/strong\\u003e: The study is based on a qualitative analysis of data from semi-structured interviews conducted with all participants. The comments collected from each participant were organized into units of meaning. These data were then reprocessed in a matrix of conceptual groupings, enabling cross-cutting themes to emerge.\\u003c/p\\u003e\\n\\u003cp\\u003eThe inductive approach we adopted led us, in the first instance, to stay as close as possible to what we heard, avoiding any premature interpretation. Inscribed in a constructivist posture and a reflexive logic, this initial phase formed the basis for a more in-depth analysis in a second phase.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e: Analysis of the thirty-five interviews carried out revealed the following determinants:\\u003c/p\\u003e\\n\\u003cp\\u003eThe interpersonal relationship between the professional and the patient, which must lead the former to value the latter and build mutual trust;\\u003c/p\\u003e\\n\\u003cp\\u003e- The question of patient autonomy, through the difficulty they express in taking charge of their own care, or in the need they express to benefit from additional follow-up at the end of the care pathway;\\u003c/p\\u003e\\n\\u003cp\\u003e- The need for flexibility on the part of patients, who conversely wish to become actors in their own care pathway;\\u003c/p\\u003e\\n\\u003cp\\u003e- Coordination and communication, notably with the necessary sharing of patient information, and the integration of relatives into the care pathway.\\u003c/p\\u003e\\n\\u003cp\\u003eThese results lead to the formulation of several proposals with practical implications for the deployment of a care pathway.\\u003c/p\\u003e\\n\\u003cp\\u003eConclusion: These relational, organizational and personal determinants structure patient involvement, and need to be taken into account right from the design phase. The success of a healthcare program depends on the stakeholders' ability to identify them and ensure that the objectives set are achievable. 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