A structured comprehensive search strategy was conducted using PubMed, Google Scholar, Embase, Web of Science, Scopus and ProQuest to identify publications in English using search terms in the titles and abstracts (search strategies were adjusted to fit different databased setting): ‘exercise prescription’, ‘exercise treatment’, ‘health policy’, ‘medical system’, ‘clinical provision’, ‘healthcare’, ‘inpatient’, ‘outpatient’, ‘noncommunicable diseases’, ‘cardiovascular diseases’, ‘cancer’, ‘respiratory diseases’, ‘diabetes’. The search process was focused on original studies and reviews articles (in peer-reviewed journals) over the last 15 years. Further related articles were identified from reference lists of retrieved articles; and authority data (e.g., WHO) that were also considered. A total of 76 articles were finally included and the literature search was completed on November 16, 2022.

Our health policy-making analysis below is based around the Health Triangular Policy Framework (HPF) (36). The HPF was developed in 1994 by Wall and Gilson, and has been used in a retrospective or prospective manner to analyze many health-related policy issues (37). The framework highlights how policy implementation is influenced by the elements of policy Content, Context, and Process, and also emphasizes the influence of Actors on these three elements in the policy-making process (38). In the HPF, Content includes policy objectives, operational policies, legislation, regulations, and guidelines. Context refers to systemic factors: social, economic, political, cultural, and other environmental conditions. Process refers to the way in which policies are initiated, developed or formulated, negotiated, communicated, implemented, and evaluated. Actors refer to influential individuals (such as senior policy- and decision-makers), groups, and organizations (see Figure 1) (36). Studies have used this framework to analyze health policy issues in contexts as diverse as Kenya (39), Cambodia (40), and the Eastern Mediterranean regions (37).

Physical exercise is increasingly recognized as of importance in the primary medical care of at least 35 chronic diseases. Exercise not only reduces the risk of developing new chronic NCDs, but also decreases the progression of many existing chronic noncommunicable conditions while improving quality of life (41, 42). Specifically, the significance of exercise intervention as the first-line treatment for several chronic NCDs has been investigated extensively during the past two decades (26). Exercise may induce modifications in gene expression, and affect cardiovascular risk, musculoskeletal function, pulmonary function, hyperinsulinemia, sensitivity to insulin, oxygen consumption, fasting plasma/blood glucose intolerance, body fats, cholesterol, blood pressure, dosage of antidiabetic medications, immunity, sleep quality, self-satisfaction, and consequently general health and fitness. Furthermore, exercise can also improve aerobic capacity, and the mental health of patients (7, 17, 33, 34, 43).

Not everything is known, of course, and there remains important work to be done to explore the different types and dosage of exercise that are suitable for exercise prescription following specific diagnoses and conditions for NCD patient populations. A 2008 American College of Sports Medicine (ACSM) report noted, for example, that Moderate to Vigorous Physical Activity (MVPA) reduced breast and colon cancer risk. In 2018, the ACSM report was expanded to include more types of cancers whose risk was reduced by MVPA. These included endometrial, esophageal, kidney, lung, stomach, and bladder cancers (7, 41). Engagement in regular exercise activity is not only feasible and safe for cancer patients but also improves the tolerance for treatment, facilitates recovery, reduces the length of hospital stays, slows progression, and reduces risks associated with recurrence, readmission, and mortality (44).

The ‘Health Care Providers Action Guide’ was developed by the ACSM. It outlines six basic steps for working with health care providers and patients to facilitate and manage medical referrals, including assessment of the physical activity levels of patients, determination of patients’ readiness to change, prescription of exercise for patients, provision of patients’ physical activity referrals, and promotion of exercise in clinics (45). Several resources have also been developed, including exercise implementation tools, handouts, and patient reports. Examples such as physical activity algorithms with an initial assessment by a nurse or clinician, link into exercise prescription and patient education, concluding with suggested readings to encourage patients to change behavior from inactive to active (46). Adaptation of the physical activity algorithm into clinical practice allows for an opportunity to increase patients’ participation in their own health outcomes using a prescribed exercise routine. Similar forms of guidance have been developed by ACSM and other organizations: examples include ACSM guidelines on using exercise for cancer survivors (47); the Enhanced Recovery After Surgery (ERAS) programme (48); and the Pulmonary rehabilitation exercise prescription in chronic obstructive pulmonary disease guidelines etc. (49).

Exercise education and consultation are further relevant factors for patients with NCDs. The identification of patient intervention capacity and suitability can be achieved by considering the various contraindications and constraints, preferences, barriers and facilitators for exercise, and the potential benefits relevant to them, whether those be physiological, psychosocial or economic (50). Further steps, aims and objectives of exercise need to be prioritized according to the most valuable outcome for the patients (e.g., symptom management, improving mood, minimizing a decline in cardiorespiratory fitness, reversing loss of muscle mass, survival etc.). Therefore, it is essential to provide the patients with information relating to the exercise components that are necessary for achieving specific goals. It is worth noting here that some may prioritize long-term exercise benefits over short-term goals, physiological over psychosocial or functional benefits, and that the goals and priorities for many will likely change over time (50). The flexibility of exercise education and consultation are particularly important when patient exercise preferences fail to align with achieving their desired goals (50). Physical exercise education and consultation are facilitators for NCDs patients to participate in exercise programmes. The skills and knowledge developed by patient education and exercise guidelines may provide confidence and competence in minimizing adverse reactions to related individual medical situations, such as the fear of hypoglycemia. Additionally, health professional training and improving community engagement is also essential in exercise prescription support following discharge, based on the physician’s guidance (51).

The scope of exercise prescription practice is dynamic and can be responsive to the needs of patients and society. The ideal condition is for health services to provide adequate recognition and support for interdisciplinary intervention through proper legislation and policies (52). Unstructured referral from physicians deprives patients of medical services such as diagnosis, health promotion, and complication prevention (53). The most significant considerations for implying multidisciplinary team care are cost and convenience (54). In primary care, physicians, nurses, physiotherapists, and other health professionals working together in a medical services team is an effective strategy to achieve multidisciplinary health service goals. Furthermore, at the primary health care level, organizing people-centered integrated health services that are safe for patients and of assured quality with effective referral networks between basic health care and hospital care is essential (53, 55, 56). Multidisciplinary practice can be aided by standardized procedures, policies, and regulations. Furthermore, the organizational structure of service delivery and clinical responsibilities suggests that it can be responsive to the needs of patients and communities rather than practitioner-led delivery (53).

Health clubs and personal trainers are traditional outlets for the promotion of physical activity and exercise regimens, and physicians are not depending on these partnerships to promote physical activity to their patients in a sufficient manner (54). Not only is inter-hospital collaboration required, collaboration between physicians and community practitioners is an important link for patients with NCDs after they leave the clinic or are discharged from the hospital (54). Fostering multisectoral public and commercial partnerships that bring together government and society to promote health policies is vital to address concerns such as financing, accessibility, efficiency, and the quality of health care (57).

From a patient perspective, common reasons for non-adherence to exercise prescription include physical and psychosocial factors such as patient missed sessions, dropouts because of wellness problems, hospital readmissions, disease progressions, adverse skeletal events, or a paucity of interest, motivation, knowledge and/or confidence (24, 44, 51, 58). From an institutional and physician perspective, major barriers for service integration are related to limited funding, lack of a detailed implementation plan, limited availability of suitable programmes, and low organizational buy-in (lack of public funding and resources). In addition, the physicians’ characteristics of lacking exercise science educational backgrounds, related knowledge, and specific professional qualifications have also been noted as detrimental (24, 32, 44, 51, 58). Furthermore, in real work situations the lack of time for counselling, workload pressures, and extra work concerns, would all disrupt clinic efficiency and have been identified as related issues contributing to barriers for providing exercise prescription to patients (58). Some accessibility barriers related to location, cost and exercise schedules coinciding with treatment days have also been identified. In addition, political and economic context arrangements, such as minimal structured reimbursement policies; and barriers related to collaboration and leadership with stakeholder and other actor groups in social context are also issues that cannot be ignored (58).

Among the documented international examples of effective uses of exercise in the prevention and treatment of NCDs are the following three initiatives:

Health policy design comprises a set of decisions, plans and actions taken within a society to achieve a specific healthcare goal, or a set of actions taken by an agency or organization at the national, regional or local levels of government to promote public health (36). Based on the evidence discussed above we can reasonably claim that NCDs patients would be greatly advantaged by a healthcare system shift in conceptualization toward an exercise health promotion initiative, including re-orientation of the general practice environment and collaboration with exercise professionals in inpatient and outpatient provision. At a societal level, healthcare support includes developing practical infrastructure, equipment base and peer networks; and improvements in the confidence of patients for exercise interventions, making them more receptive to exercise prescription. The following table outlines the health policy-making analysis for implementation of exercise prescription in regard to NCDs (See Table 1).

There is evidence that providing effective exercise guidance for patients can help increase physical activity levels and decrease disease rates, thereby reducing the financial burden on governments (28). However, exercise prescription or physical activity advice for patients with NCDs are not included in the academic curriculum of most medical professionals (30, 61, 62). A previous survey outlined a lack of formal undergraduate medical education knowledge related to the medical benefits of exercise and physical activity in 1975. Subsequent surveys since 1975 have demonstrated little improvement (30). For example, most US medical students do not have the competence, skills, or confidence to counsel patients on exercise prescription following graduation (30). It is essential that newly qualified physicians are aware of the role that exercise as medicine can play in treating and preventing disease. A more recent study reported that exercise guidelines and exercise prescription education programmes provide the tools and knowledge to assess properly patients’ activity levels and offer individualized recommendations, while also increasing practitioner confidence to engage in exercise prescription (28).

Physicians may lack knowledge and confidence to prescribe exercise as medicine because of the paucity of detailed instruction in medical schools (63). Training and education for physicians on the benefits of different modes of exercise prescription, and how to structure exercise intervention to each patient’s needs, can empower them with confidence and knowledge (28). Conceptualization and implementation of an exercise prescription medical education course is needed to provide health care staff with the ability to assess, counsel, and refer patients for physical activity and exercise. This development is crucial to prevent and treat chronic noncommunicable diseases and is required urgently (22). Exercise prescription training needs to be integrated into most of phases of medical education, and can be facilitated in medical schools, residency programmes, credentialing processes and continuing education requirements (30). The development and implementation of professional standards must include performance and ethics, standards of conduct, and core clinical skills. They need to be established under a standards development framework in which all aspects are evidence-based, benchmarked against international standards such as those of the American College of Sports Medicine, and consistent with the needs of patients and practitioners (61). Assessment of the quality of education and training programmes is also required, to ensure they give clinical exercise physiology graduates the skills and knowledge to practice safely and competently. A university curricula programme accreditation framework should be developed based on current national health service provision models (61). There may also be a need to include specialized mandatory courses and conduct an evaluation of exercise prescription within the physicians’ final examination for the degree.

There is also a requirement to develop physicians’ communication skills to enable them to guide patients in the behavioral change scenarios of exercise adaptation and maintenance in daily life. Furthermore, physicians need to be encouraged to engage with community physical activity/exercise resources, which is consistent with the evolution of patient-centered care (30). When medical students graduate, they should be able to demonstrate proficiency in the prescription of exercise and assessment; and should also be knowledgeable about the principles of exercise counselling and behavioral strategies related to patients’ personal health (30). Additionally, developing collaborations between medical schools/universities and healthcare institutions not only provides more exercise medicine practical information, but also provides internship opportunities.

There is a programme available in the US called Exercise is Medicine Greenville (EIMG). This is the first partnership engaging a medical school, a health care system, and a community organization combining resources collectively to educate physicians on the clinical benefits of exercise (22). Several universities have now successfully incorporated sports and exercise medicine into their medical curriculum in places as diverse as Colombia, South Carolina, the United Kingdom, and Iran. These curricula have included a focus on exercise medicine and how to successfully prescribe exercise for patients (30, 64–67). This extensive system needs further development, consolidation, expansion, and exploration as a model of best practice.

The installation of an exercise prescription facility within existing NCDs medical care provision settings may require slight infrastructural adjustment to ensure the availability of suitable spaces, and any necessary equipment, to provide instruction in different forms of exercise. There will also be a need for the hiring of experienced exercise science specialists, and medical staff who possess exercise prescription skills. A concerted effort is required to identify and develop the correct implementation strategies to stimulate a cultural shift and debate in the host organization (44).

Exercise testing is necessary when health/fitness and clinical exercise professionals are concerned about individuals’ risk, or when they require additional information to design exercise prescription (68). An 18-year cross-sectional study provided data on the safety of clinical Chinese population-based exercise testing, and was expressed as the number of adverse events per 10,000 tests (using 95% confidence intervals). These results suggested that clinical exercise testing was safe and that the low incidence of adverse events recorded might be due to the overall changes in clinical practice over time (69). In real practice, the clinical exercise test would need to meet three important aspects: address patients’ needs, be time efficient, and be cost-effective. NCDs patients should be screened using a health risk appraisal questionnaire or a self-reported medical history (including patients and family health history, comorbidities, additional chronic diseases and related treatments, and physical activity and exercise history). An example would be the modified American Heart Association/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire (41) for the presence of risk factors for various cardiovascular, pulmonary, renal, and metabolic diseases as well as other conditions such as pregnancy and orthopedic injury that require special attention when developing exercise prescription. Further medical evaluation measures, including blood pressure, heart rate and some anthropometric indicators should also be conducted to determine any health issues that contribute to risks of morbidity and/or mortality. Physical activity assessment needs to be incorporated into standard medical examination routines during clinical visiting and as part of the treatment plan (22). This recommendation should be considered not only for patients at high risk of exercise-related complications; regular exercise testing should be recommended for all patients prior to participating in a light- to moderate-intensity exercise programme (68). Evidence-based, specific, and valid measures of physical status would aid physicians in examination and discussion of exercise prescription with patients (70).

Technology-based support, such as mobile-technology, wearable devices, texts, and emails, improves compliance among patients and has been validated previously (31, 71–73). Suggestions to design and develop special software/applications to enhance exercise prescription adherence are gaining momentum. Digital support tools can be used for the purpose of including information such as the patient’s medication history, illness, and physical fitness levels; follow-ups using remote monitoring after outpatient’s service or discharge should be attractive to many healthcare systems and providers. Using these methodologies, patients can live at home and by using multiple intelligent devices communicate with the physician to access supervision and instructions. This communication helps with follow-up over the next weeks or months to monitor compliance with exercise prescription and provide encouragement. This method can also expand the opportunities for increased accuracy and acceptance of exercise intervention. Remote consultation is also featured by consistency and regularity, low cost and acceptability to the patient’s family. In addition to the digital health system mentioned previously, the workflows for exercise prescription will need to be compatible with existing workflows and working procedures to limit burdens and increase efficiency (24).

Community exercise resources are another important component for effective exercise continuation in compliance with physician’s instructions following discharge. Health providers and physicians will often wish to refer patients to community resources to integrate exercise into their daily lives. These include the use of self-directed resources, such as public sports facilities, bike-sharing programmes, and the use of local parks (22). Aligning community and healthcare partners to provide a clinic-to-community model may be beneficial for implementing exercise as a core prevention strategy for assisting patients who are at risk for NCDs, to regress, reverse, and minimise the progression of disease (74).

For general practitioners and fitness related personnel, focusing on the theoretical study and practical operation of exercise interventions for NCDs needs to be re-evaluated. The potential way to ensure the quality of exercise prescription is the development of an exercise prescription credential to recognize qualified and certified fitness professionals who work with patients referred from health care providers (22). This includes medical practice, health care knowledge, NCDs prevention and treatment, exercise rehabilitation, and scientific exercise understanding. Follow-up evaluation after the implementation of the policy should not be ignored, and investigations and surveys should be conducted to further determine the effectiveness of exercise prescription implementation, as well as patients’ confidence levels and intervention effects.

Achieving universal health coverage (UHC) is a sub-target of the Sustainable Development Goals (SDGs) (36). The acceptance and coverage of government universal medical insurance and commercial insurers to include exercise prescription in the claim for reimbursement is the cornerstone of long-term development of exercise prescription. Medical insurance system support is essential for physicians and patients to adhere to exercise prescription. If medical insurance policies generally provide more reimbursement for inpatient care, this incentivizes patients to use hospital resources for even minor health conditions, and therefore inhibits healthcare treatment from primary clinics (75). The government’s healthcare policy could support the treatment of most NCDs in outpatient settings. This would provide savings in medical resources and medical expenses and improve the health level of the entire population in the long term. In addition, this provision would increase the treatment capacities of related hospitals and healthcare establishments. For example, outpatient medical body checks/tests related to patient symptoms and physical exercise ability, should be part of every physician’s exercise prescription, and follow-up exercise medical assistance should be reimbursed as usual. The implementation of exercise prescription in clinical provision would reduce the expenditure of drugs, intravenous infusion therapy and inpatient care. On the other hand, it also indirectly reduces the expenses of inpatient medical reimbursement and provides a virtuous healthy cycle. Nevertheless, medical insurance policies should set a limited coverage for exercise prescription in primary health care/clinic provision, by means of setting a maximum limit for total reimbursement, to avoid over-use of medical services. Figure 2 provides a general outline of the suggestions of implementation of exercise prescription.