Review Reports - Measurement of the Prescription of Physical Exercise in Chronic Diseases: A Proposal of a Scale for Physicians of Second-Level Hospital Practitioners

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript addresses an important topic in contemporary public health and clinical care: the role of exercise prescription in the treatment of non-communicable chronic diseases (NCDs) in medical hospital contexts. The central argument — that physical exercise should be more systematically integrated into clinical protocols — is well-aligned with current global recommendations by WHO and other health authorities.

However, the manuscript suffers from several structural, logical, and scholarly limitations, which significantly impact its current publish ability. The authors must clarify their theoretical framework, support claims with appropriate literature, and refine the argument's coherence and organization.

Title

The title is grammatically awkward and does not clearly reflect the article's structure or main thesis. Revise the title to something more precise and academically structured, such as:

“Hospital-Based Considerations for Prescribing Physical Exercise in the Treatment of Non-Communicable Chronic Diseases”

Abstract

 The abstract lacks structure, and the key components (background, objective, method, results, conclusion) are unclear.

 There is no description of the research method, making it difficult to determine whether this is a theoretical, empirical, or policy commentary paper.

So… First, clearly state the research aim. Second, specify if this is a literature review or conceptual paper. Third, provide at least one key conclusion based on analysis.

And,,, in introduction…. First, state a focused research question or hypothesis. Second, include more recent references (post-2018) from PubMed/Scopus. Thrid, clarify the novelty or contribution of this paper.

Methods

The Materials and Methods section, as currently presented, falls significantly short of academic standards and requires a complete and thorough revision. It lacks a clearly defined study design, fails to specify whether the work is empirical, conceptual, or review-based, and omits essential methodological details such as data sources, selection criteria, analytical procedures, and ethical considerations. Without this foundation, the work cannot be evaluated for rigor, transparency, or reproducibility. Even for a conceptual or theoretical paper, a well-structured methodological rationale—clarifying how information was selected, synthesized, and interpreted—is indispensable. I strongly encourage the authors to restructure this section using appropriate subheadings (e.g., Study Design, Data Source, Analytical Approach, Ethical Statement), articulate the methodology in a transparent and academically sound manner, and include a formal ethical declaration in line with MDPI’s guidelines. Addressing these revisions will substantially improve the manuscript’s clarity, credibility, and suitability for publication.

Most importantly, the manuscript must explicitly address ethical considerations through the inclusion of IRB approval information. If this study involved human participants, their data, or clinical procedures, the authors are ethically obligated to state that the research protocol was reviewed and approved by an Institutional Review Board (IRB) or equivalent ethics committee. The absence of this statement not only limits the paper’s credibility but may prevent publication altogether. If no human participants were involved, the authors must clearly declare that ethical review was not required. Additionally, the section must clearly define the study design—whether conceptual, empirical, or a narrative review—and provide transparent information regarding literature sources, inclusion criteria, analytical procedures, and justification of methodological decisions. These revisions are essential for ensuring the reproducibility, transparency, and scholarly integrity of the manuscript.

Discussion

- Summarize key insights systematically.

- Contrast hospital-based exercise models across countries (e.g., Italy, Korea, UK).

- Offer a structured framework or proposal if claiming policy advancement.

Conclusion

- Restate the central thesis and offer 2–3 clear, evidence-backed suggestions for hospital systems.

References

-Some references are outdated or not peer-reviewed.

-There is inconsistency in formatting (e.g., use of journal names and volume numbers).

Finally, the manuscript suffers from grammatical errors, sentence fragmentation, and ambiguous phrasing throughout. So, Professional English language editing is essential and Avoid passive and vague constructions.

Minor…Use consistent terminology (e.g., “non-communicable diseases” vs. “chronic pathologies”).

Comments on the Quality of English Language

Title

The title is grammatically awkward and does not clearly reflect the article's structure or main thesis. Revise the title to something more precise and academically structured, such as:

“Hospital-Based Considerations for Prescribing Physical Exercise in the Treatment of Non-Communicable Chronic Diseases”

Abstract

 The abstract lacks structure, and the key components (background, objective, method, results, conclusion) are unclear.

 There is no description of the research method, making it difficult to determine whether this is a theoretical, empirical, or policy commentary paper.

So… First, clearly state the research aim. Second, specify if this is a literature review or conceptual paper. Third, provide at least one key conclusion based on analysis.

Methods

Discussion

- Summarize key insights systematically.

- Contrast hospital-based exercise models across countries (e.g., Italy, Korea, UK).

- Offer a structured framework or proposal if claiming policy advancement.

Conclusion

- Restate the central thesis and offer 2–3 clear, evidence-backed suggestions for hospital systems.

References

-Some references are outdated or not peer-reviewed.

-There is inconsistency in formatting (e.g., use of journal names and volume numbers).

Minor…Use consistent terminology (e.g., “non-communicable diseases” vs. “chronic pathologies”).

Author Response

Response to reviewer 1

We would like to express our gratitude to all of you for your in-depth analysis of our work. the thrilled to know that you find the central idea interesting and worthy of publication in a high-impact journal such as HEALTHCARE.

We would like to inform you that we have incorporated the adjustments you kindly recommended so that our article may meet the standards for publication.

Firstly, we have restructured the title to make it more reader-friendly and to better reflect the main thesis of the paper. We appreciate your suggestions for the title.

Secondly, we have revised the abstract according to your recommendations, including key components such as background, objectives, methodology, results, and conclusions. I believe this restructuring makes the work clearer and more accessible to readers.

Thirdly, we have incorporated the research questions to the introduction. We also ensured that most of the references cited are from 2018 to the present year, to consolidate the timeliness and relevance of this study.

Fourthly, we did a complete and thorough review. With the study design as the main objective, we added the selection criteria, analytical procedures, and ethical considerations including the protocol registration approved by the Ethics Committee and the Research Committee of the hospital where the study was conducted. In this way, we aimed to articulate the methodology in a clearer and more methodologically valid manner.

To the methodology section, we attend this, The Journal Article Reporting Standards (JARS) from the American Psychological Association (2011) were followed. Specifically, each subsection included information on research design, participants characteristics, sampling procedures, measures, ethical considerations, and statistical data analysis. The presentation of each subsection was carefully restructured to maintain transparency. Ethical considerations were addressed in Section 2.5, “Ethical Statement”, which reports the approval and revision number obtained by the Hospital’s Ethical Committee, as well as details on participant anonymity and voluntary nature of the participation.

Fifthly, we sought to summarize the key ideas and systematically structure the discussion, highlighting contrasts between models that are applied in other hospital institutions.

The authors, including the lead author, opted not to provide a structured framework or proposal for advancing public health policies, as we believe that the findings of this study can have a direct impact on the local authorities responsible for the institution where the research was conducted.

Sixthly, we updated and ensured the correct structure for all references used in the study. Some documents, such as the WHO guidelines on Physical Activity and Sedentary Behavior 2020, provide evidence-based recommendations on physical activity and sedentary behavior. Although, these are not scientific articles, they are official documents aimed at promoting health awareness. However, if you believe that these references should be removed, we are willing to make the necessary adjustments.

Seventhly, we have corrected the grammatical errors and improved the wording throughout the article.

We sincerely hope that the adjustments we have made meet your expectations regarding this scientific work. We remain at your disposal and look forward to your feedback to proceed with the next steps.

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript, which explores physicians’ practices regarding the prescription of physical exercise for the management of non-communicable chronic diseases in a secondary-level hospital in Mexico.

The study addresses a relevant public health issue and presents a well-structured methodology supported by a validated instrument. However, several aspects require clarification or improvement to enhance the rigor and interpretability of the results:

The authors state that 127 responses were “sufficient for statistical analysis” but do not justify this claim (no sample size calculation or psychometric justification is provided).
Table 1 presents results and should be included in the Results section, not in Materials and Methods.
Did the authors request permission from the original author of the questionnaire for its modification, adaptation, and validation in the Mexican context?
Given that this is an exploratory study, the use of exploratory factor analysis is appropriate. However, future studies aiming to confirm the factor structure and enhance construct validity should consider conducting a confirmatory factor analysis. The absence of a confirmatory factor analysis (CFA) could be acknowledged as a limitation, particularly if the instrument is intended for broader or repeated use. Including this would strengthen the transparency of the validation process.
The sociodemographic characteristics of the 127 participants are missing from the Results section.
The Limitations section should mention the use of a non-probabilistic sample.
Tables 2-7 are not referenced in the text.
The reference to Coletta & Phillips (line 331) is not properly cited in the text.
Please revise the word "ques-tionnaire" (line 164) and the terms “ítem” in Table 7.
The paragraph “Comparative Analysis between Factors” is duplicated (lines 288–301).
Tables 6 and 7 should be presented in English.

I hope these comments are helpful as you revise your manuscript.

Yours sincerely,

Author Response

We would like to express our sincere gratitude to all of you for your in-depth analysis of our work. We are delighted to know that you find the central idea of our scientific paper interesting and worthy of publication in a high-impact journal such as HEALTHCARE.

We would also like to inform you that we have incorporated the adjustments you kindly recommended to ensure that our article meets the standards for publication.

The table has been moved to the Results section (Table 2)
To address your concern, a Confirmatory Factor Analysis (CFA) was conducted. The results are presented in Section 3.3, “Confirmatory Analysis,” and the criteria followed are detailed in Section 2.6.2, “EFA, CFA and Reliability,” of the “2.6 Analytical Approach” section.

After consulting the author of the original article from which we extracted the instrument, we concluded that it was not necessary to request permission for the following reasons:

the original article only publishes the objectives of each item at the time of application but does not share the questions themselves.
As the article is open access, it is considered a free document, although we sought to respect the principle of giving credit to the author of the idea by citing them in our research work (article).

We sincerely hope that the adjustments we have made meet your expectations regarding this first scientific work. We remain at your disposal and look forward to your feedback to proceed with the next steps.

Reviewer 3 Report

Comments and Suggestions for Authors

To enhance its degree of scientific rigor, clarity, as well contribution to the field, the paper will require major revisions. The theme is very timely and addresses a pertinent gap in the practice of exercise prescription for non-communicable diseases in a hospital setting. However, several aspects require improvement in methodology, reporting, and interpretation. Psychometric validation and clinical evidence are interesting ideas, but they are supported by insufficient arguments about whether the selected sampling is valid. There may be biases during the adaptation of the instrument, and there is no general evaluation. Until such a time that these can be handled appropriately through an expansion of analyses, more specific operational definition, etc. and synchronized with norms of curtailment in reporting, e.g., STROBE in the case of observational studies, then they should not be reconsidered.

Title

The title, which reads "Medical hospital consideration on prescription of physical exercise to treat non-communicable-chronic diseases," lacks precision and closure to the study, given its exploratory nature of cross-sectional design and focus on perception and practice of physicians. In the case of scientific research, it is intended that, when referring to the titles, they use succinct yet descriptive language that will enable it to be indexed and the database search (i.e., PubMed) to include the key variables, i.e., the population (physicians in a secondary-level hospital) and methodology (questionnaire-based assessment). The form that is currently used introduces confusion about whether the research is studying institutional policy or individual behavior, which can be confusing to the reader.

Abstract

The abstract itself contains a brief description and has specific structural weaknesses and does not entail a decent separation of the methods, results, and implications in accord with the IMRAD (Introduction, Methods, Results, and Discussion) guidelines of abstracts. Significant psychometrics outcomes, such as Cronbach's alpha (0.857) and McDonald's omega results, are not put into the context of analyzing their influence on the construct validity. In contrast, barriers, such as resource limitations, are explained but not measured and used in determining the effect size. The research hypothesis/hypothetical framework (e.g., Exercise is Medicine initiative) is not stated in the background/objectives, which might hinder its utilization as an independent point in the abstract. A significant redesign would be required to add the measurable findings (e.g., percentages of factor analyses), and these would need to be presented in the form of the PRISMA abstracts or equivalent form of the CONSORT, both of which would be reproducible and significant to global health policy.

Introduction

These constraints to the introduction involve providing the physical inactivity case as a modifiable risk factor that is sometimes causing non communicable disorders according to the World Health Organization (WHO) recommendations and the exercise is medicine (EIM) undertaking yet failing to present a complete picture of the literature analyze, or discuss the mixed evidence on the physician barriers (e.g., time constraint vs. knowledge gap) or the inequalities possessed by the Mexican area. It lacks clarity in operationalizing key research concepts, such as exercise prescription, since the hypotheses cannot be explicitly stated using such tools as PICO. The ka-chinking nature of the story that alternates international data to local application does not have the funneling effect that can undermine the rationality of the cross-sectional approach of the study. Also, systematic gap analysis should be investigated to identify potential explanations for why the focus of the study has been placed on secondary-level hospitals and whether it is possible to hypothesize on the relationship between, e.g., training and referral rates.

Methodology

This methodology section explains how a questionnaire was adapted, and how the validity of the questionnaire was proven using the Delphi technique of asking the experts, and the statistic analysis (e.g., with an exploratory factor analysis through maximum likelihood), though, the work has severe deficiency in detailing how the power estimation of the sample size (n=127) was calculated, and that the methodology is subject to Type II errors, namely when determining moderate effect sizes in that circumstance. The non-probabilistic sample gives rise to a non-probabilistic selection bias. The sensitivity analysis does not cover this bias, and the back-translation validation requirements are not followed in the translation process. This may lead to a greater lack of cross-cultural equivalence, as per ISPOR guidelines. Ethical considerations are presented, yet they do not refer to the procedures that are set out concerning the informed consent or the GDPR equivalent tiers of data protection. Much improvement is required, including, but not limited to, the justification of KMO (0.844), the Bartlett test, and the confirmation analysis to enhance its robustness. Adopting standards can achieve this by selecting instruments to improve methodological replicability concerning instrument reporting.

Results

The last is the results, which can give the reliability (e.g., 0.852 Factor 1), and can logically present the Factor loading in the form of table but will lack the interpretive potential since there would be no inferential statistics output, say chi-square statistics of association between demographics and practices, or the confidence interval of the percentage scores (e.g., 63.8 inquiring about activity levels ). The format of the tables (e.g., the tabular spacing structure of Table 1 has at least a few alignment errors) and the exploratory factor analysis lack communalities and a scree plot, which would allow for verification of the proportion of variance explained. The description notes that one item is truncated due to low loading (0.460) and was not examined using sensitivity analyses as a probable model specification. These ought to comprise wholesale corrections to include graphical distributions (e.g., biplots), within-subgroup analyses (e.g, by specialty) and be STROBE-adherent in supporting the empirical footing.

Discussion

The interpretations of the findings are associated with constraints, such as a lack of available resources when screening the findings and comparing them with each other, and extend to stipulate the global contexts rather than look at a single-site study as a shortcoming that breaches the dimensions of the external validity. The primary source citations are given (e.g., WHO 2020). Still, EBR does not present any evidence quality assessment (e.g., using RADE), nor does it establish any relationships between complications and how they relate to cost-effective or potential measures regarding feasibility. The comparative analysis of variables is functional, but factors such as the physician's experience receive little consideration. The study will have to be significantly modified to allow for the introduction of SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis, other potential explanations (e.g., social desirability bias), and potentially testable hypotheses that future longitudinal studies would be able to address, to generalize the causal inference.

Conclusions

Implications draw conclusions highlighting deficits in both assessment and referrals, as well as urging policy changes in decision making that go beyond the facts, since they imply process changes in institutions that are not supported with empirical evidence of the cross-sectional design, which also carries the danger of an ecological fallacy. It is necessary to come to conclusions that are relatively safely addressed to the context of internal validity of the study, deprived of so-called unjustified appeals to change without measuring the effects of magnitude and mediation. Major revisions should be made to the language to ensure that ambiguities are expressed (e.g., with confidence intervals) and their relationship with goals is established so that congruence with principles of evidence-based practice can be achieved.

References

The reference list is quite comprehensive, though it has been involved with some inconsistency problems regarding the formatting aspect that may not possibly match up to the Vancouver or APA standard requirements. Not all the sources are recent or peer reviewed (e.g., WHO reports), and the sources list can be further extended to include a more Latin American sources to bring it more into perspective. The primary revisions to promote the academic support of the writing include standardization, verification of DOIs, and inclusion of new meta-analyses devoted to the issue of exercise prescription effectiveness.

Author Response

We would also like to inform you that we have incorporated the adjustments you kindly recommended to ensure that our article meets the standards for publication. We have restructured the title to make it more reader-friendly and to reflect the main thesis of the paper. We appreciate your recommendation for the title.
Complete ethical considerations are presented in section “2.5 Ethical Statement” were voluntary and anonymity procedures are presented.
The KMO and Bartlett’s test criteria followed were Williams’ et al. (2010) recommendations for EFA, and are presented in the “2.6.2 EFA, CFA and Reliability Analysis” section: “1. Suitability of data with the Kaiser-Meyer-Olkin and Bartlett's sphericity test for measuring sampling adequacy, with a KMO ≥.5 and significancy (p<.5) as criteria”.
For this instrumental research the estimation of the sample size was made after William’s et al. (2010) authors’ recommendations of suitability of the sample size according to the KMO test. These specifications are presented in the subsection “2.6.2 EFA, CFA and Reliability Analysis”.
Discussion: The study focuses on developing a tool to assess whether physicians support prescribing exercise for patients in secondary hospitals, but it does not focus on the relationship between this practice and patient health outcomes. However, we recommend that future research consider relating it to clinical variables following the clinical evaluation systems you mention.
We have corrected the conclusion.
References were corrected and verified both in the structure and in the DOIs.

We sincerely hope that the adjustments we have made meet your expectations regarding this scientific work. We remain at your disposal and look forward to your feedback to proceed with the next steps.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for addressing my previous comments and for the revisions made to the manuscript. After reviewing the updated version, I believe that the clarifications and adjustments provided have significantly improved the clarity and rigor of the work. I have no further comments at this stage.

Sincerely,

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for addressing my comments.