Development of a physical activity prescription in Luxembourg

Worth Michael J.^1,2, Delagardelle Charles^2,3,4,5, Urhausen Axel^4,6,7, Theisen Daniel⁸, Lion Alexis^2,3,4
1 General practitioner, L-8010 Strassen, Luxembourg
² Fédération Luxembourgeoise des Associations de Sport de Santé, L-1445 Strassen, Luxembourg
³ Association Luxembourgeoise des Groupes Sportifs pour Cardiaques, L-1445 Strassen, Luxembourg
⁴ Luxembourg Institute of Research in Orthopedics, Sports Medicine and Science, L-1460 Luxembourg, Luxembourg
⁵ Department of Cardiology, Centre Hospitalier de Luxembourg, L-1210 Luxembourg, Luxembourg
⁶ Sports Medicine Research Laboratory, Luxembourg Institute of Health, L-1460 Luxembourg, Luxembourg
⁷ Sports Clinic, Centre Hospitalier de Luxembourg – Clinique d’Eich, L-1460 Luxembourg, Luxembourg
⁸ ALAN – Maladies Rares Luxembourg, L-1896 Kockelscheuer, Luxembourg

Abstract

Background: We aimed to develop a physical activity prescription (PAP) that would help efficiently promote PA by medical practitioners in Luxembourg.

Methods: During a first phase, a PAP model and its user guide were created by 15 experts (medical doctors, sport and exercise scientists, physiotherapists). Second, this PAP and its user guide were evaluated by a panel of medical doctors (different from the 15 experts) who were asked to answer a questionnaire in 2 rounds using 41 questions and 2 questions, respectively.

Results: The panel was composed of 66 medical practitioners. Of the 41 items of the PAP, six did not reach consensus and had to be re-evaluated during a 2nd round in which 50 medical practitioners participated. After this 2nd round, four items did not reach consensus and were subsequently presented as optional. A consensus was found concerning the PAP guide from the first round.

Conclusion: Our study allowed the development of a consensual tool for the prescription of PA by physicians for physicians. The PAP and its guide may help practitioners to promote health-enhancing PA, in conjunction with a systematic policy-level PA promotion to address the public health issue of physical inactivity.

Résumé

Contexte: Nous avions pour objectif de développer une prescription d’activité physique (PAP) qui aiderait à promouvoir efficacement l’AP par les médecins au Luxembourg.

Méthodes: Dans une 1ère phase, un modèle de PAP et son guide d’utilisation ont été créés par 15 experts (médecins, scientifiques du sport et de l’exercice, kinésithérapeutes). Dans une 2ème phase, cette PAP et son guide d’utilisation ont été évalués par un panel de médecins (différents des 15 experts) qui ont été invités à répondre à un questionnaire en 2 tours comprenant respectivement 41 questions et 2 questions.

Résultats: Le panel était composé de 66 médecins. Sur les 41 items de la PAP, six n’ont pas fait l’objet d’un consensus et ont dû être réévalués lors d’un 2ème tour auquel ont participé 50 médecins. Après ce 2ème tour, quatre items n’ont pas fait l’objet d’un consensus et ont ensuite été présentés comme facultatifs. Un consensus a été trouvé concernant le guide d’utilisation de la PAP dès le 1er tour.

Conclusion: Notre étude a permis le développement d’un outil consensuel de prescription d’AP par des médecins pour des médecins. La PAP et son guide peuvent aider les praticiens à promouvoir l’AP bénéfique pour la santé, en conjonction avec une promotion systématique de l’AP au niveau politique pour résoudre le problème de santé publique de l’inactivité physique.

Mots clés: activité physique, prescription d’exercices, maladies chroniques, soins de santé, recommandations.

1. Introduction

The benefits of physical activity (PA) in terms of prevention and treatment of numerous non-communicable diseases such as cardiovascular disease, diabetes, breast and colon cancer, and many others have long been established [1]. Despite the accumulation of evidence to support these findings, the proportion of physically active individuals has continuously decreased over the last decades, and this tendency increases with the level of income of the countries [2,3]. Worldwide, approximately three adults in four and one adolescent in five meet the World Health Organization’s (WHO) minimal recommendations for PA [4]. Despite efforts by the WHO in promoting the reduction of physical inactivity by 15% from 2013 to 2025, this target will not be met if the current trends remain unchanged [3]. In its Global Action Plan on PA, the WHO has recommended the routine assessment of patients’ PA levels in primary and secondary health care services and has insisted on the importance of systems that strengthen PA assessment and counselling [4–6]. Moreover, it recommends a patient-centred and tailored approach to advising PA to increase the efficacy of PA counselling [7].
PA counselling strategies vary widely among countries and can range from brief advice to PA prescription (PAP) with or without PA referral (PAR) [8,9]. PAP can be a standard medical prescription, simply listing exercise recommendations, or it can also be a more specific prescription, specifically designed for exercise prescription. Ideally, a PAP includes one or more of the following elements [10]: the reason for prescription; an assessment of the patient’s current PA level; one or more recommendations for the type of PA recommended; a recommendation on the intensity, frequency, and duration of PA; a potential contraindication to PA; a follow-up appointment. According to Thornton et al. in 2016 [11], the following items were associated with an increased effectiveness of PAP: the presence or risk of a chronic pathology; the individualized evaluation of the patient; the consideration of his/her abilities, needs and interests; the obstacles encountered. In addition, the message and goals conveyed to the patient are brief, clear, and achievable. A follow-up exists and the patient benefits from a favourable environment and encouragement from loved ones, as well as a method of self-monitoring of its PA. In contrast, PAR, which is more complex in its implementation, makes it possible to address a patient to a PA facility, where the patient will be guided and supervised [12]. It is frequently used for patients who have little or no experience in PA practice [10]. PAR is often integrated into a national or regional program, with partial or total reimbursement of associated costs [13]. PAP and PAR have been shown to increase PA levels [8,10,14–16] and are accepted as being safe and efficacious [10,17,18]. Not only is this true for the general population, but evidence shows that the presence of chronic disease increases adherence to PAP/PAR, and the less a person is active, the bigger the benefit of a relative increase in PA [8,18].
In Luxembourg (which is characterised by an important lack of PA and consequently a high mortality rate attributable to physical inactivity, associated with a high proportion of non-communicable disease [19–22]), there is no systemic PA promotion in healthcare settings. Only an estimated 400 to 800 people living with a chronic disease (Luxembourg had 625,000 inhabitants in 2020) regularly participate in therapeutic PA offered as part of the national initiative, most of them being referred by a few medical doctors and physiotherapists [23–25]. In addition, we conducted a survey among the general practitioners in 2018 and found that they were counselling PA to only 27% of their patients [26]. We also showed that almost half of the surveyed general practitioners (47%) did not feel confident enough to advise their patients engaging in PA. Our aim was to fill the gap and provide an adapted tool to promote PA in healthcare settings in Luxembourg.
Therefore, we aimed to develop an exercise prescription model that would allow practitioners to efficiently prescribe PA, considering current evidence on PA prescription and available PAP models while including practitioners in the development of the tool.

2. Methods

We aimed to develop the PAP in a collaborative way with the medical doctors who subsequently might use the PAP daily. Our methods were freely inspired by the Delphi method which is an iterative method of inquiry to obtain experts’ opinions with the aim of establishing a consensus [27]. First, a PAP (and its user guide) was created by a group of experts who also developed a questionnaire to evaluate the PAP (and its user guide) [28]. Second, the developed questionnaire was sent to a panel of medical doctors to sequentially evaluate the PAP (and its user guide). The timeline of the development of the PAP and its user guide is presented in Figure 1.

2.1 Creation of the PAP and its user guide

A first draft of the PAP model was created by AL and a medical doctor (who later withdrew from the study) using their own knowledge from August 2021 to October 2021. This PAP model contained the following sections: patient identification (i.e. name, forename, age, and national registration number), the anthropometrics of the patients (i.e. height, weight, body mass index, PA level, and cardiovascular risk), reasons for prescription (i.e. condition(s)), recommended PA (i.e. type, frequency, duration, intensity), signature and date. It was independently and anonymously evaluated (anonymously to avoid the dominance of one opinion or expert over others [29]) from October 31 to November 15, 2021 by a group of experts via an online questionnaire (Google Forms). This group was composed of 15 experts (excluding MJW and AL who conducted the study): nine medical doctors (cardiologist: n = 1, general practitioners: n = 4, neurologist: n = 1, orthopaedist: n = 1, physical medicine and rehabilitation specialists: n = 2), four physiotherapists, two sport and exercise scientists. The members of this group were selected based on their expertise in medicine, rehabilitation, and sport sciences. Some experts had previous experience in referring their patients for PA. In addition, they were representatives from all hospitals and national rehabilitation centres, from the national medical doctor and physiotherapist associations and from the national health directorate.
In parallel to the evaluation of the first draft of the PAP, MJW conducted a brief literature review to identify the items that should be included in the PAP.
Based on the first evaluation of the PAP by the group of experts and the brief literature review, MJW and AL drafted a second, two-sided version of the PAP. The front page of the PAP contained the following sections: patient identification (i.e. name, forename, sex, age, and national registration number), evaluation of the PA level (i.e. aerobic PA level, strength training level, balance training level), reasons for prescription (i.e. condition(s)), patient’s goals (e.g. improvement of the aerobic capacity, etc.), recommended PA (i.e. type, frequency, duration, intensity), PAR (i.e. to a program which is currently under development), stamp and medical doctor code (including date and signature), and follow-up appointment. The back page of the PAP contained information to remind the patients (along with the medical doctors) of the health benefits of PA, the WHO recommendations, a list of PA contraindications, as well as a brief description of the probable future PAR scheme in Luxembourg. In addition, the brief literature review identified the need to increase the prescribers’ knowledge to promote and prescribe PA. We therefore decided to draft a user guide which we estimated should be added to the PAP to facilitate its use by the medical doctors, as it is already done in several countries [30,31]. It was designed to improve the understanding of the different elements contained in the PAP and to support the medical doctors in their first PAPs. It contained the following sections: introduction, scope, how to use the PAP, WHO recommendations, PA contraindications, probable future PAR scheme, and a presentation of the national health sport federation and its association-members which are already providing PA for people with specific chronic diseases. On March 25, 2022, the second draft of the PAP and the user guide were presented to the 15 experts who provided comments and proposed modifications.
Following adaptations, the PAP and its user guide were again evaluated by the group of experts between May 13 and May 31, 2022 (with a reminder sent on May 24). Seven of the 15 experts provided further comments, leading to a fourth version of the PAP and a third version of the user guide both drafted in June 2022. Beside the modifications of the layout, these new versions underwent only minor changes.

2.2 Evaluation of the PAP model and its user guide

One additional mission of the group of experts was to draft an online questionnaire (Google Forms) which would then be used by a panel of medical doctors (who were not members of the group of experts) to evaluate the PAP and its user guide. The questionnaire focused more precisely on the evaluation of the front page of the PAP, and more broadly on its back page and its user guide. The final questionnaire was designed in such a way that the order of the documents to evaluate was presented in a logical sequence with regards to the information provided. Consequently, the evaluation of the guide preceded the evaluation of the back page of the PAP, which in turn preceded the evaluation of the front page of the PAP. The questionnaire contained a total of 59 questions. Among these questions, two closed questions and one open question evaluated the user guide, two closed questions and one open question evaluated the back page of the PAP, and 39 closed questions and 8 open questions evaluated the different items of the front page of the PAP. The closed questions used a 5-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neither disagree nor agree, 4 = agree, 5 = strongly agree). The remaining 6 questions related to the demographics and characteristics of the panellists: sex, age, years of experience, medical specialties, number of week days on which they performed at least one moderate-to-vigorous PA training session, number of minutes for an average moderate-to-vigorous PA training session, percentage of ­patients advised to engage in PA, confidence in prescribing PA with the present PAP, knowledge of the national sport health federation and its related PA promotion Sport-Santé program, and consent to participate in the survey. Finally, two control closed questions were included in the questionnaire to test participants’ attention. If either of these questions were answered incorrectly, that participant’s responses were excluded from the analysis.
The consensus threshold for closed-ended questions (Likert scale questions) was set at 75%, corresponding to the ­proportion of “agree” and “strongly agree” responses [32]. Conversely, items were excluded if more than 75% of the participants responded with “strongly disagree” and “disagree”. Questions that fell between these two categories were given a second round. In addition, the panellists were able to make comments for each item and submit suggestions for modifications. If an item generated more than 25% of comments among the participants (the threshold was adapted from the study of Slade et al. 2016 [32]), these comments were categorized and analysed. Depending on the convergence of the comments, the PAP or its user guide were then adapted. Exceptionally, an item was changed in regard of an obviously pertinent comment (even if the number of comments did not reach the 25% threshold). A limit of two survey rounds was chosen to reduce the panel members’ burden and ensure a high response rate [27]. Only the panellists who participated in the first round were invited to re-rate items where consensus agreement was not reached. Thus, the ­answers of the previous round were transmitted to the ­panellists, allowing them to reconsider their opinion and reformulate their judgement [29]. To this end, individualised feedback, which compared the panellist’s responses to each non-consensual item with the group average, was prepared. Non-consensual items were re-rated using a new Google Forms questionnaire. Panellists were invited to send a comment justifying their evaluation if it had not changed from the previous round. Lack of consensus for an item in the second round (less than 75% of agreement) led to these items being made optional to make them available for medical doctors who wished to use them.

The PAP and its user guide (which were created by the group of experts) were evaluated from June to September 2022 by a panel of medical doctors recruited by email. The panellists, who were not part of the group of experts, were medical doctors practicing in Luxembourg. We aimed to obtain the participation of a minimum of 20 medical doctors. Given the possible high dropout rate of participants [27], we required the initial participation of 60 medical doctors. An email containing a Google Forms questionnaire (created previously by the 15 experts) and an explanation of the project was emailed by the secretariat of the Association des Médecins et Médecins-Dentistes (national medical doctors’ ­association) to its 1017 members (dentists not included) on June 20, 2022. In addition, a snowball technique in which an email was sent on June 29, 2022 to six direct contacts, 59 medical offices and 12 other medical doctors associations to disseminate the study information, was used to recruit more participants.
The timeline of the evaluation of the PAP model and its user guide is presented in Figure 1. The first round of the evaluation took place between June 20 and July 13, 2022. Participants received two reminders. The second round of the evaluation of the non-consensual items took place between August 9 and August 26, 2022. For this round, participants received four reminders.

3. Results

This section will present the results of the evaluation of the PAP and its user guide by the panellists.

3.1 Characteristics of the participants

We obtained the answers of 68 participants. Two participants’ answers were excluded because they had not passed the control questions assessing their attention. The remaining 66 participants’ answers were extracted from Google Forms and analysed in Microsoft Excel. Four participants did not want to be contacted for the second round of the evaluation of the PAP and its user guide.
Their characteristics are summarized in Table 1. Thirty-six (54.5%) were females. The mean age was 42.7 (± 12.1) years with 14.2 (± 11.7) years of experience as medical doctors. Forty-eight (72.7%) participants were general practitioners. Nine participants (13.6%) declared two medical specialties. The moderate-to-vigorous PA level of the participants was 148.5 (± 115.5) minutes/week. Twenty-nine (46%) declared being informed about the Sport-Santé program and the national health sport. In general, the participants counselled PA to 49.4 (± 27.7) % of their patients. In addition,
58 (87.9%) participants felt confident enough to advise their patients to engage in PA with the present PAP.

3.2 Evaluation of the PAP front page

Out of the 39 questions, 33 obtained a consensus with agreement (proportion of participants who answered, “strongly agree” and “agree”) ranging from 77.3 to 97.0%, disagreement (proportion of participants who answered, “strongly disagree” and “disagree”) ranging from 1.5 to 10.6%, and indifference (proportion of participants who answered, “neither disagree nor agree”) ranging from 0 to 13.6% (Table 2). Of the six items that did not reach consensus, the rate of agreement ranged from 37.9 to 74.2%. For these six items, disagreement ranged from 9.1 to 24.2% whereas indifference ranged from 13.6 to 37.9%. As defined in the study protocol, the latter were re-evaluated in a second round. Additionally, certain items of the PAP reached the threshold of 25% with respect to the proportion of comments, leading to their modification. Especially the title and patient characteristics were subject to comments from 28.8% of the respondents. Consequently, the title was simplified, and the patient characteristics adapted accordingly. Of all participants, 31.8% commented on the section for the evaluation of the patient’s PA level, with some of them requesting further details for the evaluation of the PA level whereas others felt it was up to other professionals to determine the patient’s PA level (e.g., PA professionals). Some other items were changed nonetheless, based on the relevance attributed to certain individual obvious comments. Thus, in the “reasons for prescription” section, the term “diagnosis” was replaced by “motive” to include broader justifications for PA prescription and eliminating the need for a precise diagnosis. In the “recommended PA” section, the specification was added that this section only refers to autonomous patients, and its implications were described in the PAP user guide. Finally, in the same section, the layout of the actual PA prescription with its frequency, duration and intensity was adapted to mirror the layout of the PA level evaluation section, for simpler use.
The six questions that had not reached the defined consensus were re-evaluated during a second round of evaluation. We obtained the response of 50 participants among those eligible for the 2nd round (n = 62). During this round, two further items reached the defined consensus as illustrated by Table 2. Four items did not reach consensus and were therefore made optional. This meant that they would not have to be considered during the routine use of the PAP but would remain available for those prescribers who wished to use them. No element met the exclusion criteria.
The final version of the PAP front page is presented in Figure 2 (please see the supplementary material 1 for the original French version and supplementary material 2 for the German version). It will guide the medical doctor through eight sections during his/her PA prescription (Figure 2).

3.3 Evaluation of the PAP back page

The two questions that briefly evaluated the clarity and relevance of the back page of the PAP met the defined consensus with a level of agreement among participants of 95.5% and 93.9% respectively (Table 2). Furthermore, although the back page of the PAP did not generate a significant proportion of comments, certain details were modified based on the relevance attributed to certain individual comments. Thus, the PA levels cited in the first information box were changed from worldwide levels to Luxembourg’s levels, and certain terms under primary and secondary prevention benefits were simplified for better comprehension by patients. Finally, primary and secondary prevention were defined in the footnote.
The final version of the PAP back page is presented in the Figure 3 (please see the supplementary material 1 for the original French version and supplementary material 2 for the German version). It contains information on the benefits of PA, the WHO recommendations on PA, the WHO good practice information as well as information on the concept of “Maisons Sport-Santé”, a probable future facility where patients may be referred to the practice supervised PA (Fig. 3). This page also contains a QR code which redirects the user to a website containing the document’s references and will later also contain a section for either practitioners, with further sources relevant for PA promotion, or patients, with links to videos for guided PA. The webpage contains resources links which are relevant for PA prescription such as Sweden’s Handbook for PA prescription [30].

3.4 Evaluation of the PAP user guide

The two questions that briefly evaluated the clarity and relevance of the user guide equally reached the defined consensus with an agreement level of 93.9% and 87.9% respectively as shown in Table 2. However, of the 30% of participants that had left a comment, over half felt the guide was too long. The guide was therefore abridged, and key points made to stand in bold writing for quick reading. Other comments requested further details on the referral scheme which remains to be developed.
The final version of the PAP user guide is presented in the Figure 4a and 4b (please see the supplementary material 3 for original French version and supplementary material 4 for the German version). It contains concise supplementary information on every section of the PAP to help practitioners during their first prescriptions.

Figure 4b: User guide of the physical activity prescription.

4. Discussion

Our aim was to collaboratively develop a PAP to hopefully be implemented and used in the healthcare setting in Luxembourg. Experts from diverse backgrounds have interactively participated in the creation and the evaluation of the PAP and its user guide. During the dynamic process that has led to the development of the final PAP model and its user guide, numerous elements have been modified, added, or even suppressed. The items of the PAP which did not reach a consensus may raise some questions. For example, is it necessary to record the patients’ sex or medical conditions to motivate them to be more active? The current PAP, especially the back page, could be sufficient in motivating patients to become more active, without being necessary for them to recall their name, sex, conditions, etc. However, the PAP is also designed to detect the patient’s physical inactivity. In this case, and as with other medical reports, patient identification and reason for prescription are usually recorded. The developed PAP can also act as a PAR form to refer the patient to another provider (which we hope it may also become in the future). In this case, the receiving PA provider requires detailed information on the patients to be able to tailor the supervised PA. The developed PAP is indeed a medicalised form and the involvement of patients in the process would have probably resulted in a different form [33]. However, we think that PA promotion in healthcare settings should be triggered by the healthcare professionals, and it might be suitable to encourage them with peer-developed tools. Nevertheless, the implementation of the PAP by the healthcare providers may remain a challenge [34].
The PAP and its user guide were created by 15 experts (plus AL and MJW) and were evaluated by 66 medical doctors (who were not member of the group of experts). The participation in such studies is often less important and the dropout rate in the sequential evaluation is often high (the dropout rate between the first and second rounds was 19.3% in our study) [27]. Whilst the participation was satisfactory, the recruited sample might not be representative to the medical doctors working in Luxembourg. Indeed, our sample merely represented 3.5% of Luxembourg’s practitioners [35]. Moreover, the panellists of our study were not only younger (42.7 years) than the average age of medical doctors in Luxembourg (mean age of the general practitioners in Luxembourg in 2019: 50.7 years; mean age of the other medical practitioners in 2019: 52.4 years) but they were already more active and reported counselling PA more frequently [21,26,35,36]. In addition, they were more aware of the Sport-Santé program compared to the results of our 2018 survey (46% vs. 21%) [26]. Obviously, caution should be taken because different samples of practitioners participated in the present study and in our 2018 survey. Nevertheless, we may speculate that the present sample of practitioners tends to be more in favour of promoting PA to their patients. Consequently, this may be a bias and practitioners who are more reluctant to PA and its promotion may have different opinions on the PAP and its user guide.
The PAP was developed to be filled in by the practitioners rather than by the patients themselves which is known to be problematic and less accurate [37]. Moreover, 88% of our panellists indicated that the created tools made them feel confident in prescribing PA. This contrasts with our 2018 survey where we observed that only 53% of the general practitioners felt confident enough to advise their patients to engage in PA [26]. Again, caution should be taken because different samples of practitioners participated in the present study and in our 2018 survey. However, we remain confident that the developed PAP may empower the practitioners to address the problem of physical inactivity, especially among those populations who are most concerned by its consequences, such as patients with non-communicable diseases.
The benefits section at the PAP back page is very medicalised. It however has two targets: the practitioners and the patients. Indeed, a non-negligible proportion of practitioners are not familiar with the PA benefits/recommendations [36,38], and it would be timely to reiterate them. We acknowledge that this section (and the rest of the PAP) does not contain messages framed in a patient-centred manner that may better encourage them to be active [39].
Our methods were freely inspired by the Delphi method. Typically, a Delphi study employs an initial stage to generate ideas, in which panellists, who are considered experts in the field, are asked to identify a range of salient issues, which then inform subsequent rounds. Instead, the evaluated resource was initially developed by MJW and AL with the help of a group of experts to review evidence and create an evidence-based prescription tool. Thereafter, the panellists (not including the group of experts nor MJW and AL) who represented the “end user” were later engaged in the two rounds to provide feedback on the developed resource whose initial development they were not involved in. The latter were doctors practicing in Luxembourg who voluntarily participated in the study. Beside the limitations presented previously, the developed PAP and its user guide may serve as another model, among existing PAP models in the world, to be re-evaluated and adapted to the needs of practitioners in accordance with emerging evidence. Whilst PAPs help promote PA by practitioners, they do not replace the urgent need for PA promotion on a policy level to diminish the growing burden of disease caused by increasing inactivity levels across the world [4]. Addressing other barriers to PA promotion by practitioners, such as a lack of knowledge about PA promotion and its benefits, is a key factor [36,38]. To this end, numerous publications underline the need to share knowledge on PA promotion and to create a community of practice for the promotion of PA and its benefits [40,41].
In conclusion, this study has enabled the development of a consensual tool for the promotion of PA by practitioners for practitioners. At present, this tool has yet to be implemented, preferably within the framework of a national PA promotion program addressing the public health challenges associated with physical inactivity.

Acknowledgments

The authors would like to thank Dr Nadine Weiler for her contribution in the early phase of the study. They also would like to thank the 15 experts as well as the 66 panellists.

Funding

No funding.

Conflict of interest

None declared.

Practical implications

– This physical activity prescription is based on evidence and allows for a tailored prescription of physical activity.
– Practitioners feel confident in prescribing physical activity using the developed physical activity prescription.
– Physical activity prescriptions are a means of increasing physical activity and potentially decreasing the burden of disease associated with non-communicable diseases.

Corresponding author

Alexis Lion, PhD
Fédération Luxembourgeoise
des Associations de Sport de Santé
1B rue Thomas Edison,
L-1445 Strassen (Luxembourg)
Tel: +352 27 720 123
Email: contact@flass.lu 

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