WHAT IS ALREADY KNOWN ON THIS TOPIC

We were unable to identify any contemporary overviews or appraisals of national and international physical activity guidelines for key vulnerable populations—people living with chronic conditions, disability or advanced age.

Such an overview was needed given the significantly higher levels of physical inactivity and sedentary behaviour among these groups compared with the general population.

WHAT THIS STUDY ADDS

This review comprehensively maps and analyses current national and international physical activity guidelines for populations with chronic conditions, disability and advanced age.

While guidelines for advanced age were often provided, a large proportion of countries/regions (46%) lacked physical activity guidelines specific for people with chronic conditions or disability.

As such, a large proportion of countries/regions failed to meet WHO recommendations and lack customised advice to address global inequities in physical activity, and the unique barriers faced by key vulnerable populations.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

The results of this review, and the paucity of studies, emphasise the urgent call for action for the development of contemporary, independent and context-specific national/international guidelines by governing public health authorities specific to populations with chronic conditions and disability, in order to help achieve 2030 WHO targets for physical activity.

Background

Physical inactivity is well-established as one of the leading risk factors for premature death, accounting for an estimated 6% of global mortality.1 The widespread implications of physical activity for physical and psychosocial health are far-reaching, including benefits for primary, secondary and tertiary prevention of non-communicable disease,2 improving functional status, falls risk, and positive effects on mental health and well-being.3 Despite this, it is estimated that globally four out of five adults currently fail to meet WHO guidelines for physical activity.4

Among the groups with the lowest levels of physical activity participation are those with chronic conditions, people with disabilities and people of advancing age.5–7 This is despite the benefits of physical activity in these groups being even greater than that of the wider population, as while these groups will gain the majority of the health benefits as the healthy, younger population, additional reported benefits can include reduced disease progression, lower treatment side effects, improved physical function, maintained independence and mobility, and improvements in social connectedness.5–7

As countries strive to address the growing burden of non-communicable diseases and promote healthier lifestyles, the development and dissemination of evidence-based physical activity guidelines have become a pivotal component of national health policies. In fact, as part of the 2018–2030 Global Action Plan on Physical Activity (GAPPA), an integral framework for directing regional health policy and governance, the WHO recommends that all countries establish physical activity guidelines and set physical activity targets to help the population achieve and maintain target physical activity participation levels.2 8

Despite the clear indication for country-specific physical activity guidelines, there remains a paucity of contemporary guidelines globally for physical activity for all age groups and levels of function in light of novel evidence, maladaptation to changing lifestyle habits, technological advancements and societal attitudes towards physical activity. These factors likely contribute to the deficiency in global guideline adherence.6 Crucially, there is an alarming absence of evidence-based public health guidelines globally for key vulnerable and understudied populations: individuals living with chronic conditions and disability. These populations not only face higher rates of physical inactivity and unique barriers to movement compared with the general population but are also rising significantly in global prevalence.5 6 Current recommendations for these populations often involve general commentary on information suited to the general adult population, alongside non-specific advice to consult a healthcare professional.9 In light of this, a key call for action by the WHO GAPPA is for specific guideline recommendations for people living with chronic conditions and disability across all age ranges, owing to an urgent need to promote safe, effective physical activity in these increasingly relevant populations that address unique barriers to movement.5 6 10 11

There is also a notable demographic shift globally characterised by an increasingly ageing population and a greater burden of chronic conditions and disability, further highlighting the significance of contemporary physical activity guidelines for these populations.12

These three increasingly prevalent populations experience alarming rates of physical inactivity and encounter unique barriers to movement, yet often lack specific advice to address these deficiencies.5 6 Despite this, we were unable to identify any contemporary overviews or appraisals of national and international physical activity guidelines for three key vulnerable populations—individuals living with chronic conditions, with disability, and with advanced age. A concise overview and appraisal of the current breadth and content of physical activity guidelines for these groups was needed to better inform health policy development and future directions for guideline formulation, as the present level of adherence to the WHO recommendations described remains unclear.

Therefore, we aimed to fill this void by identifying discrepancies between existing guideline recommendations for physical activity at the national/regional level and the call for action of the WHO for regions to provide physical activity guideline recommendations specific to populations living with advanced age, chronic conditions and with disabilities. We additionally aimed to highlight guideline advice that aimed to address unique barriers to movement specific for each of these populations, where available. As such, we conducted a scoping review to record, summarise and analyse national and international physical activity guidelines for these three distinct populations according to country/region. In doing so, our review aims to foster a greater understanding of the physical activity guidelines that are currently presented for these underserved populations, and ultimately seeks to provide novel findings relevant to national and international policy stakeholders towards meeting WHO targets to reduce global levels of physical inactivity by 15% by 2030.8

MethodsStudy design

This scoping review adopted a systematic and comprehensive approach to record, summarise and analyse national and international physical activity guidelines globally for individuals with chronic conditions, disability and advanced age. This was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for scoping reviews and reported following the framework outlined by Arksey and O’Malley and further refined by Levac et al.13–15 A review protocol is not publicly available and has not been registered.

Definition of terms

Guidelines and recommendations were defined in accordance with the WHO.16 As such, a guideline was defined as ‘any information product that contains recommendations for clinical practice or public health policy’, and recommendations are ‘statements designed to help end-users make informed decisions on whether, when and how to undertake specific actions such as clinical interventions, diagnostic tests or public health measures, with the aim of achieving the best possible individual or collective health outcomes’.

We defined ‘physical activity’ according to the WHO as ‘any bodily movement produced by skeletal muscles that requires energy expenditure’.17 We also used the WHO definition of ‘sedentary behaviour’ as ‘any waking behaviour while in a sitting, reclining or lying posture with low energy expenditure’.18

The term ‘chronic condition’ was defined in accordance with the WHO, as conditions that are of long duration and are the result of a combination of genetic, physiological, environmental and behavioural factors.19 ‘Disability’ was defined in accordance with the US Centers for Disease Control and Prevention as ‘any condition of the body or mind (impairment) that makes it more difficult for the person with the condition to do certain activities (activity limitation) and interact with the world around them (participation restrictions)’.20 The WHO regards adults aged 60 years and older as ‘older adults’12, however, the specific age cut-off for physical activity guidelines for adults of advanced age varied between countries/regions.

Search strategy

A systematic search strategy was developed collaboratively between coinvestigators (MPR, PCD and CS) to identify relevant literature, including government and non-government organisational guidelines and reports relating to physical activity recommendations for the specified population groups. Six electronic databases were systematically searched from database inception to September 2023. The search was conducted between 2 September 2023 and 30 October 2023 and included OVID Medline, PubMed, Scopus, Embase, Web of Science and Google Scholar, using a combination of keywords and Medical Subject Headings (MeSH) terms. Search terms were Physical OR activity OR exercise OR “sedentary behaviour” AND guidelines OR recommendations AND *country of interest*. Search terms did not seek to limit inclusion to the subpopulations of interest in order to allow inspection of which national guidelines did and did not include recommendations for the populations of interest during data extraction. Grey literature searches involved three search strategies: (1) grey literature databases, (2) custom Google search engines and (3) targeted websites. The grey literature databases included PubMed, ProQuest and CINAHL databases given their suitability for including grey literature.21 Google searches produced extensive outcomes using Google’s relevance-based ranking, which prioritises the most pertinent sources at the forefront of search results. Following the methodology of previous research,22 we incorporated the initial 15 pages, comprising 150 results, into our review. Furthermore, we manually inspected pages 16 and 17 in the Google search results to validate the appropriateness of this approach. The targeted website search included the following: the WHO website, EuroScan International Information Network, WorldWideScience, OpenGrey and International Network of Agencies for Health Technology Assessment.23 In addition, the Google search engine included limiters: site:org and/or site:gov.

Study selection

Inclusion and exclusion criteria were established a priori. Community-facing guidelines and recommendations published by government or non-government organisations at the national/international level pertaining to physical activity, exercise or sedentary behaviour were included. ‘National/international’ level was defined as being nationally funded and/or endorsed by the national/regional governing health authority as their primary guideline resource. Other minor or supplementary guidelines, including those published by other non-government organisations, were not included when not recognised as the region’s primary community-facing guideline. Drafts, older versions and duplicates were excluded. Articles primarily intended for a professional public health audience (eg, guideline advisory committees) rather than intended to address the general community were also excluded. Newsletters, news releases, memoranda and duplicates were also excluded. The screening process involved title and abstract screening followed by full-text assessment. Documents were screened independently by two reviewers, with conflicts resolved through consensus. Articles in languages other than English were translated using online translation software for readability and no language restrictions were employed. Any document that was included by one reviewer but not the other was retained for further consideration in level 2. Level 2 involved a thorough examination of potentially suitable full-text documents or webpages that had been retrieved. Both members of the review team independently assessed these documents for eligibility. Additionally, we manually inspected the reference lists of relevant review papers to identify any potentially overlooked documents. Any disagreements regarding the eligibility of guideline documents were resolved through discussion with a third reviewer. The included guidelines and literature were subsequently manually entered into EndNote software for collation.

Data extraction

Data of interest included guideline recommendation statements for physical activity and/or sedentary behaviour that were explicitly specified to apply to any of the three populations of interest. These guidelines were required to satisfy our predefined definitions for both what constituted a ‘guideline recommendation’ and our populations of interest (see the ‘Definition of terms’ section). More specifically, data extracted included the issuing authority, publication year, target population characteristics, characteristics of the physical activity recommendation (including type, frequency, duration and intensity) and any specific recommendations for sedentary behaviour for each population group. Any references made to address population-specific barriers to movement were additionally extracted using in-text content analysis. Data extraction was conducted independently by three reviewers (HA, RD and NW) using a standardised collection form and verified by a fourth (MPR), with discrepancies resolved through discussion.

Data synthesis, analysis and reporting

The extracted data were synthesised to identify commonalities, variations and deficiencies for the specified three population groups in meeting the specified WHO recommendations. Content analysis of guidelines was performed to produce a summary of key recommendation statements for each country/region pertaining to our definitions of physical activity and sedentary behaviour. Binary ‘yes/no’ judgements were subsequently performed based on meeting inclusion criteria of whether general population and/or subpopulation-specific recommendations were made. Descriptive statistics of these key recommendations in the form of counts and percentages were then used to present these data in tabulated form organised by country/region. Any references made to address population-specific barriers in a guideline were identified via content analysis, and subsequently summarised and described in the results table where evident, but were not counted. In order to better understand gaps in recommendations, particular attention was paid to reporting common recommendations made between guidelines, the proportion of countries/regions that lacked guideline advice for each population, how individualised guidelines were for populations of interest, whether population-specific barriers to movement were addressed, and the level of detail included in recommendations provided.

Where no advice specific to the target population was available in the public-facing physical activity guideline documents, an entry of N/A was made in data tables. Generalised advice, including to ‘consult a healthcare professional for more specific advice’, was not considered a guideline, and a note was made in the comments section when such a statement was observed. Commentary relating to specific conditions, disabilities or for advanced age, without specific regimens recommended, were also not included. Guidelines specifying that advice for the general population was also applicable to the target population were included and considered as guidelines for the target population, however, note was made of this. Where a particular age group is not listed, a guideline specific to this age within the target population was not identified. The number of guidelines that lacked such advice specific to each target population was reported and presented as a percentage of the total number of guidelines available for each population.

Quality appraisal

Any in-text reference made in each guideline document to a specific quality appraisal process was extracted and analysed in a binary ‘yes/no’ method and tabulated when described as having been performed according to commonly used frameworks to demonstrate the different methods of quality appraisal used by different countries. Any such reference made outside of the guideline documents was unable to be included. Given this scoping review’s exploratory nature, further independent quality assessment or critical appraisal of individual guidelines was not performed. Rather, the focus of this study involved mapping the breadth of available national and international guidelines and overviewing their content. Reference is made to the use of the Grading of Recommendations Assessment, Development and Evaluation framework, a widely adopted tool for grading evidence quality used to support guideline recommendations.24

Equity, diversity and inclusion statement

Central to this study was an aim to highlight vital gaps in health policy among key under-represented populations. As such, the study populations chosen were identified as understudied populations especially vulnerable to the health detriments of physical inactivity, and with increasing global prevalence—people with chronic conditions, with disability and of advanced age. In doing so, this study aimed to create a much-needed paradigm for addressing global health inequity in physical activity, and ultimately provide novel findings relevant to meeting the WHO 2030 Global Targets for Physical Activity. Our research team was also gender-balanced and comprised junior medical students and senior researchers.

Patient involvement

Patients were not involved in this study.

Results

A total of 1855 articles were identified from the initial search, with 1232 remaining after removal of duplicates. 82 articles remained after title/abstract screening, leaving 66 verified national or international guideline documents for final inclusion in our analysis after full-text review (see figure 1). We identified 28 separate regions addressed by these articles between the years 2009 and 2023, including four international guidelines, the WHO, WHO Pacific, Nordic and European Union (EU) guidelines (which adhere to WHO recommendations). The WHO guidelines were also used as the national guideline for 19 independent countries and the EU, with 3 countries using the Nordic guidelines. Physical activity guideline recommendations are summarised distinctly for people living with chronic conditions in table 1, with disability in table 2 and with advanced age in table 3. A summary of the identified guidelines and their primary source is shown in online supplemental appendix 1. F igure 2 shows a map depicting regions represented in the identified guidelines. An overview of quality appraisal processes and major sources of evidence specified to have been used by each country/region to support guideline formulation is provided in table 4.

Figure 1

Flow diagram of text screening.

Table 1

Physical activity and sedentary behaviour guideline recommendations for individuals living with chronic conditions

Table 2

Physical activity and sedentary behaviour guideline recommendations for individuals living with disability

Table 3

Physical activity and sedentary behaviour guideline recommendations for individuals with advanced age

Figure 2

World map displaying regions from which national physical activity guidelines were sourced. Countries adopting the international WHO and Nordic physical activity guidelines are not displayed here.

Table 4

Quality appraisal process and major sources of evidence supporting national and international guidelines by country/region, excluding WHO

National guidelines were unable to be identified for several countries despite identification of customised WHO factsheets (Czech Republic, Cyprus and Croatia).25–27 Guidelines were also unable to be sourced for Venezuela and South Korea despite references being made to them in the literature. A number of countries were cited in a recent systematic review as adhering to either WHO, Canadian or US guidelines, but we were unable to identify documented evidence of this: WHO guidelines (Columbia, Thailand, United Arab Emirates (UAE), Zimbabwe), Canadian guidelines (Mozambique, Nigeria) and US guidelines (UAE).23

Guideline contentChronic conditions

15 of the 28 countries/regions (54%) included specific physical activity advice for individuals living with chronic medical conditions with varying degrees of detail: Austria, Finland, Germany, Kenya, Malaysia, Mexico, Norway, Pacific, Qatar, Singapore, Spain, Switzerland, UK, USA and WHO.

Most of the advice involved physical activity recommendations for adults, with nine identified countries (32%) stipulating that advice for the general population could be applied to people with chronic conditions without further modification. A common finding among physical activity recommendations was advising at least 150–300 min of moderate-intensity aerobic physical activity, or at least 75–150 min of vigorous-intensity aerobic physical activity weekly, consistent with WHO guidelines.2 This was accompanied by muscle-strengthening activity advised at least twice weekly. A good practice statement suggesting individuals unable to meet recommendations to aim to engage in physical activity according to their ability was commonly included and specified in table 1 where present. Specific sedentary behaviour advice was less common and provided only in nine guidelines (32%), commonly involving breaking up periods of extended sitting with activity and often providing specific advice for children.

The Qatar guidelines were noted to provide a comprehensive set of specific guidelines for a number of adult chronic medical conditions: obesity, diabetes, hypertension, asthma, chronic obstructive pulmonary disease, heart diseases, osteoarthritis, osteoporosis and cancer (see online supplemental appendix 2). This was accompanied by guidelines for certain conditions for children and adolescents, which further included respiratory disorders, mental health disorders and Down’s Syndrome (see online supplemental appendix 3). The USA also provided specific advice for individuals with certain chronic conditions (osteoarthritis, type 2 diabetes, hypertension and cancer survivors—see online supplemental appendix 4).

Disability

15 of 28 regions (54%) included physical activity advice for individuals living with disability, however, this tended to involve generalised advice to aim to comply with general adult population guidelines with explicit modifications rarely addressed. Eight guidelines (29%) specified advice for children and/or adolescents. The most common recommended regimen for adults was similar to advice for chronic conditions, involving at least 150 min weekly of physical activity at moderate intensity, 75 min weekly of vigorous-intensity physical activity or an equivalent combination of both, alongside activities promoting bone and muscle strengthening being performed at least twice weekly.

For children, at least 60 min of daily vigorous activity was most commonly recommended. The major caveat with this suggestion was to titrate activity to an individual’s level of function as tolerated. The Canadian guidelines notably included specific advice for adults with multiple sclerosis and separately for spinal cord injury. Sedentary behaviour for people with disability was addressed in 11 guidelines (39%), which commonly included suggestions to break up extended periods of inactivity. Notably, Switzerland was the only region to provide specific sedentary behaviour advice for people with mobility impairment. Similarly to chronic conditions, a good practice statement was commonly included and is specified in table 2 where present.

Advanced age

All but three (89%) national/regional guidelines (Netherlands, New Zealand and South Africa) included specific, separate advice for adults with advanced age, commonly defined as either those above 60 or 65 years. These three national guidelines provided advice for all adults with no separate guidance for older adults. Most guidelines advised at least 150 min of moderate-intensity or 75 min of vigorous-intensity physical activity or an equivalent combination weekly. There was a strong emphasis on muscle strength training of at least 2 major muscle groups, as well as balance exercise at least twice per week. These recommendations were frequently caveated with advice to increment intensity slowly if initially inactive and to perform as much as possible if unable to meet guideline advice.

15 regions (54%) provided specific advice for sedentary behaviour in this population, commonly involving breaking up extended periods of sitting down, with some countries providing more detailed advice.

Discussion

This scoping review maps the current national and international guidelines for people with chronic conditions, disability, and those with advanced age. Our findings show that many countries and regions do not publish physical activity guidelines specific to the needs of people with chronic conditions and disability. The results of this study support the urgent call for action for development of contemporary independent national/international guidelines by governing public health authorities specific to populations with chronic conditions and with disability. This represents a crucial strategy towards achieving WHO GAPPA targets by addressing key populations experiencing a higher incidence of physical inactivity and rising in global prevalence.5 6

National and subnational policies and programmes on physical activity participation are considered to be important in order for recommendations to be country-context specific and tailored to meet the needs of the different subnational jurisdictions and subpopulations.8 The development of nation-specific guidelines serve additional roles pivotal to local health promotion, including several identified by the WHO: (1) providing consensus on scientific evidence, (2) raising awareness and knowledge of physical activity health benefits among different groups, (3) informing national policy to support implementation actions, (4) underpinning regional monitoring and surveillance and (5) guiding future national research directions.28

The recommendations when provided for populations with chronic conditions and disabilities commonly mirrored recommendations sourced from general adult population guidelines, with explicit modifications rarely suggested. People with advanced age were more highly represented, and with more individualised recommendations described that deviated from general adult advice. In determining this, we considered statements that (1) simply generalised advice for a given age group can be applied to these specific populations as tolerated and that (2) these populations should seek further professional advice, did not constitute adequately customised, separate guidelines for these subgroups. This was consistent with the 2020 WHO precedence for people with chronic conditions, disability and advanced age requiring distinct recommendations accounting for unique barriers to movement.2 11 It was also evident that several countries, including Brazil and Saudi Arabia, described in their guidelines this need for more specific advice for chronic conditions and disability in future directions of their research.29 30 There was a clear trend that guideline formulation was organised by age groups, which may contribute to why the age-specific population of those with advanced age was more commonly addressed. We also noted occasional overlap in definition between chronic conditions and disability, particularly when a condition rendered a direct impact on mobility (eg, Down’s syndrome and multiple sclerosis). Canada included specific advice for multiple sclerosis and spinal cord injury, which was classified as disability.

Our study examined community-facing guidelines, given their intended purpose of influencing public behaviour. Academic reports were identified during screening for several countries, such as the USA and Australia, which included extensive recommendations and literature reviews oriented at a professional public health audience, such as guideline advisory committees. While these documents typically included more extensive information for a larger range of chronic conditions and disabilities, given the purpose, information and language used were intended for an academic audience and not for the general public, they were excluded from this study. We also observed frequent practice of combining recommendations for chronic conditions and disability together, particularly when recommendations for the general population were stated as being applicable to any other subgroup. This practice may not reliably factor in the differing barriers of those with chronic conditions and those with disability.5 6 31 Importantly, the relationship between advanced age, chronic conditions and disability is interconnected with significant overlap in populations, particularly in light of the increased likelihood of developing chronic conditions and disability with advanced age.2 32 Accordingly, distinct advice to optimise physical activity in individuals intersecting with multiples of these study populations with ensuing physical limitations represents a key challenge to the future of guideline formulation.

Several commonalities in guideline recommendations were evident across physical activity and sedentary behaviour advice as previously discussed, likely owing to an overlapping underlying evidence base supporting each region’s guideline formulation. Common reference was made to published systematic reviews, meta-analyses, retrospective research and the national guidelines of other countries, with a major contributing source being the WHO guidelines. 56% of regional guidelines were also noted to source at least one other country’s national guideline during development, with several referencing the USA, the UK, Canadian and Australian guidelines. For example, the Filipino guidelines did not extend their evidentiary base beyond the guidelines of other regions, with some modifications made to better suit the needs of their population.33 59% of guidelines supported their recommendations with data and statistical reasoning involving some level of literature review. 215 of guidelines mentioned sourcing a combination of literature review, other national guidelines and guidelines published by the WHO (Australia, Germany, Mexico, Qatar, South Africa and Uruguay). Commensurate with a scoping methodology, the scale of this review did not permit comprehensive quality assessment at the level of individual regions and studies.

The findings of our study demonstrate divergence between WHO recommendations and the current quantity and complexity of physical activity guidelines across the majority of regions for these at-risk populations. The WHO GAPPA is recognised as an integral action plan for global health governance with the aim of informing policy responses and implementation by regional governing authorities to improve global health.8 Several nuances in regional implementation of the GAPPA exist, including the caveat that ‘policy actions should be selected according to country context and tailored to meet the needs of different subnational jurisdictions and populations’.8 Hence, prioritisation and feasibility will vary according to region in addressing policy gaps, particularly considering the significant cost and resources involved in undertaking guideline formulation.34 Accordingly, the WHO recognises that lower-resource countries are less likely to be equipped to engage in complex guideline development, and alternative actions are documented in the GAPPA that are less resource-intensive. Specifically, several other policy actions within the GAPPA exist aiming to increase physical activity, organised under four objectives—to creative active societies, environments, people and systems.8 These policy actions include directives such as implementation strategies, investing in urban and transport planning, and disseminating community education. While the decision to prioritise guideline formulation over other public health strategies is complex and dependent on a region’s resources, infrastructure and relative health deficiencies, the outcome of this review is to highlight widespread disparity in meeting the WHO precedent for national and international individualised physical activity guideline formulation specific to key at-risk populations. As such, if limited resources preclude development of individualised guidelines for a region, investment in other less resource-intensive policy actions of the WHO GAPPA should be considered and balanced across the four strategic objectives as suggested by the WHO, such as strengthening provision of physical education, establishing local community exercise programmes and integrating technology into activity surveillance.8

Nonetheless, given the discussed integral role of guidelines in instigating community behaviour change and achieving WHO 2030 global physical activity targets, especially in at-risk populations who often experience limited situation-specific guidance, there are several alternative approaches regional governing bodies can consider if unable to invest in individualised guideline development. While development of individualised guidelines for populations with chronic conditions, disability and advanced age is ideal, adequate representation of these vulnerable populations in some capacity in the guideline development process is likely to still confer benefit.8 A stepwise approach to guideline development can be considered, scaled in descending order to suit varying levels of resourcing:

Development of separate, individualised physical activity guidelines for populations with chronic conditions, disability and advanced age.

Perform a literature review of existing physical activity guideline documents for these groups, extract appropriate recommendations and modify to suit the regional context, taking into account local language, infrastructure, resource and cultural nuances

Consider adaptation of elements of existing guidelines designed for the general population to suit at-risk populations, taking into consideration physical barriers to movement (eg, amputee status, wheelchair-bound, insulin-dependent diabetes) and differences in activity requirements.

Provide easy-to-follow links to other population-specific resources and/or credible organisation-developed recommendations.

Where applicable, highlight whether recommendations for the general population are appropriate for at-risk populations.

Strengths and limitations

This scoping review aimed to adhere to the PRISMA framework extension for scoping reviews, and the structured framework documented by Arksey and O’Malley and further refined by Levac et al.13 14 Accordingly, a systematic method for guideline screening, including grey literature and several electronic databases, was incorporated and involved multiple independent reviewers for document screening and data verification. This analysis assessed multiple subgroups of interest. Chronic conditions, disability and advanced age constitute three populations with high prevalence in the community, lower rates of adherence to physical activity targets, and were identified by the WHO as key areas potentially requiring specific guidelines distinct from other individuals in the same age groups.11 Our analysis also did not include language restrictions with an aim to increase document and regional breadth, however, it is acknowledged that our search strategy did not include search terms in other languages. This study also did not include age restrictions for individuals with chronic conditions and disability and facilitated examination of subpopulations for whom the standard adult guidelines may be inappropriate.

Although we provided an overview of quality appraisal processes and evidence sourcing used by each region, further critical appraisal was beyond the scope of this study. We commented on sedentary behaviour guidelines where they were present, however, did not explicitly search for them when they were not included in the physical activity guidelines. Thus, a noted deficiency of advice in these areas may not be fully representative of whether certain regions have policy documents outside of the physical activity guidelines. Conversely, some physical activity guidelines were found in documents focusing on nutritional advice which may have influenced the level of detail to which they were presented. Finally, recommendations for groups such as pregnant people were often present in the guidelines but were not included in this study. This study, therefore, offers scope for several future directions, including systematic review and meta-analysis, risk of bias and critical quality appraisal, inclusion of guidelines for pregnancy and comparison analysis to broaden our insights. There is also an increasing interest in the literature on appraising the dose-response of different types and durations of physical activity, sedentary behaviour and sleep, which may aid in more reliably formulating guidelines for people with chronic conditions or impairment.2 11 As discussed earlier, a growing challenge of future research is addressing individuals intersecting with multiple of our study populations and with resultant complex activity-limiting factors.

Conclusion

This scoping review maps and analyses contemporary national and international physical activity and sedentary behaviour guidelines globally for people living with (1) chronic conditions, (2) disability and (3) advanced age. While populations with advanced age were often addressed, a large proportion of countries/regions failed to meet WHO recommendations, highlighting a lack of customised advice for increasingly prevalent populations experiencing alarming rates of physical inactivity and unique barriers to movement. Our findings, and the paucity of previous similar studies, emphasise the call for action for development of targeted, inclusive, independent guidelines by governing public health authorities addressing the needs, challenges and contexts of these populations.

Data availability statement

No data are available. Not applicable.

Ethics statementsPatient consent for publication

Not applicable.