The benefits of SB and PA interventions targeting populations at high risk for cardiovascular disease have been demonstrated, but the effectiveness and sustainability of the interventions have been limited. This scoping review aimed to identify and evaluate the behavior change techniques to reduce sedentary behavior and increase physical activity in people at high risk for cardiovascular disease. This result may trigger future research to develop more targeted and effective interventions to reduce sedentary behavior and increase physical activity in people at risk for cardiovascular disease.

The research question that guided this review was: “What are the interventions to reduce SB and promote PA among individuals at risk of cardiovascular disease?”

We searched eleven databases, including BMJ Best Clinical Practice, UpToDate, Cochrane Library, EMBase, PubMed, Web of Science, China National Knowledge Infrastructure, Wanfang Data, Chinese Biomedical Database, VIP, Yimaitong Database, from inception to 20 July, 2025. The key concepts were used: “Cardiovascular Disease”, “High Risk OR Risk Factors”, and “Sedentary Behavior OR Movement OR Physical Exercise OR Physical Activity OR Exercise”.

Literature inclusion criteria for this review were: (1) The study subjects were aged ≥20 years and defined as a high-risk population for cardiovascular disease; (2) studies on SB or PA interventions; (3) the evidence type was clinical decision-making, guidelines, best clinical practice, systematic reviews, evidence summaries, expert consensus, and Randomized Controlled Trials (RCTs); (4) the publication language was Chinese and English. Exclusion criteria were: (1) full text not available; (2) low quality assessment of literature; (3) duplicate publication; (4) interpretation/translation/updated version of guidelines or consensus; (5) incomplete content such as drafts/abstracts/conferences.

For summaries of the included evidence, the original literature of the recommendations was evaluated. Guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II), a 2017 update of the UK's clinical guidelines research and evaluation system. The JBI Center for Evidence-Based Health Care RCT Evaluation Tool (2016), Qualitative Research Evaluation Tool (2016), Cross-sectional Research Evaluation Tool (2016), Experimental-like Research Evaluation Tool (2016), Cohort Study Evaluation Tool (2016) and Systematic Evaluation Tool (2016) were used to evaluate the methodological quality of the RCTs, qualitative studies, cross-sectional studies, experimental-like research, cohort study and systematic evaluation.

The abstracted data included author(s), year of publication, country, type of study, main findings. The first draft of the data charts of five randomly selected studies was completed independently by two reviewers (YTY and CW). The chart form was revised through discussion among the research team to extract information from all the included studies. The data were extracted by two authors and checked by another author (QZ). Any disagreements were resolved by discussion among the whole team.

For the coding of behavioral intervention content, two reviewers who had completed prior online training independently performed the coding for the included studies. All 93 BCTs outlined in the BCTTv1 were considered for each study, with both reviewers explaining their rationale for assigning the BCT in each instance. If a consensus could not be reached, the proposed BCT was not included.

Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

A total of 13,865 studies were searched through the database, and 4,956 remained after removing duplicate studies. According to the inclusion and exclusion criteria, 142 studies were reminded after screening the titles and abstracts for full-text reading, of which 123 studies were excluded due to the following reasons: full text not available, type of literature does not match, inconsistency of study population, study content does not match, duplicate content. Therefore, 19 studies were finally included and the literature screening process is shown in Figure 1.

The overall quality of the 19 included studies was moderate, which were described as follows.

The average scores of the five guideline quality evaluations in each field were all above 70% (15–19), and thus they were approved for inclusion. A total of 7 RCTs were included in this study (20–26). Two studies (20, 21) evaluated the item 2 “whether the study subjects were blinded or not” as unclear. Four studies (20–22, 26) evaluated the item 3 “whether allocation concealment was used for grouping” as unclear. Five studies evaluated (21, 22, 24–26) the item 5 “whether outcome evaluators were blinded” as unclear. One study (23) was negative for items 2 and 3. The evaluation results of other items were all yes, and were approved for inclusion.

This study included a total of 3 cross-sectional studies (27–29). In one of the studies (27), the evaluation result for item 2 “How was the research population selected?” was unclear. In the other two studies (27, 28), the evaluation results for item 3 “Did the inclusion and exclusion criteria for the sample clearly describe them?” were negative. The evaluation results of other items were all yes, and were approved for inclusion.

A total of 1 systematic review was included in this study (30), and the question of item 8, “Is the method of synthesizing/combining studies appropriate?” The evaluation result was unclear. The evaluation results of other items were all yes, and were approved for inclusion.

A total of 1 cohort study was included in this study (31), and all items were evaluated as yes, which was approved for inclusion.

A total of 1 quasi-experimental study (32) and 1 qualitative study (33) were included in this study. All items were evaluated as yes and were approved for inclusion.

19 studies included in this scoping review were published between 2003 and 2023. The countries in which studies were conducted were USA (n = 7) (17, 19, 24, 26, 28, 29, 32), the UK (n = 5) (21, 22, 31), China (n = 3) (15, 16, 18), Netherlands (n = 1) (27), Australia (n = 1) (20), Iran (n = 1) (23), Korea (n = 1) (25). The types of studies included guidelines (n = 5), RCTs (n = 7), cross-sectional studies (n = 3), quasi-experimental study (n = 1), cohort study (n = 1),（qualitative study (n = 1), systematic review (n = 1).

Across the 19 studies Based on the BCCTv1 (12), a total of 11 distinct BCTs were identified. The most frequently employed BCTs were “Comparison of behaviour”, “ Repetition and substitution”, “ antecedents”, “Five BCT groupings were not found in any study:” “Associations”, “Comparison of outcomes”, “Reward and threat”, “Scheduled consequences”, “Covert learning”.

A comprehensive breakdown of the coded BCTs for each intervention can be found in Table 1.

Seven studies involve goals and planning, this includes an assessment of the health status (15, 17), PA history (18), and possible risk profile of the person at risk for cardiovascular disease (18). It is recommended that physical activity assessment and counseling be implemented in healthcare settings and that physical activity be included as one of the vital signs (28). Detailed assessments can identify discrepancies between current behaviors and the target behaviors set, leading to the development of targeted implementation plans. At the same time, a written code of conduct is developed, witnessed by others, that requires the subject of the intervention to acknowledge and commit to behavioral change.

Two studies involve feedback and monitoring. With the development of technology, sedentary time, frequency and intensity of PA can be recorded with the help of mobile applications for the study subjects (25). The interventionist as a good monitor should give hints or evaluations based on the performance of the study subjects (32). Prompts and feedback were given to the study participants based on their implementation, thus ensuring that the intervention was implemented correctly and effectively.

Seven studies involve social support. Support for the intervener is also important during the intervention process, with the intervener monitoring the implementation of behavioral changes throughout the process and providing support and assistance when anomalies arise (32). Depending on the intervention site, the person supervising may change. The person supporting in the hospital may be a healthcare worker (33), the person supporting in the community may be a community worker (32), the person supporting at home may be a family member (33), and the person supporting in the workplace may be a coworker (20, 25, 30, 32). Of course in addition to behavioral support, emotional encouragement is equally important. Effective support allows individuals to be more confident and motivated in the change process.

Ten studies involve shaping knowledge. Knowledge of the intervention process should be gained through the collection and interpretation of data, so interventions should be carried out based on evidence and theory (32). Of course knowledge can also be derived from relevant guidelines or expert consensus, which recommend types of exercise during PA, such as swing type exercises: badminton, table tennis, etc (15, 29), aerobic exercises: cycling, running, aerobics, etc (15, 29), resistance exercises: dumbbells, push-ups, squats, machine weights and resistance bands, etc (15, 16, 18, 19), and others: bone-enhancing type exercises, balance-type exercises, or flexibility exercises such as tai chi and yoga (32). Of course the whole process of knowledge formation should be integrated with the social and environmental context, emotions, and perceptions of the research subject to jointly reach a scientifically valid consensus.

One study involves natural consequences. If people at risk for cardiovascular disease don't change their bad habits, continued sedentary behavior and lack of PA are likely to lead to cardiovascular disease, such as coronary heart disease, hypertension, heart failure, arrhythmia, stroke, peripheral artery disease (15). which may eventually lead to death (16). So if the intervention is followed up, we can paste pictures of cerebral infarction into public places or make advertisements to warn the public. We can inspire feelings of regret in people at high risk for cardiovascular disease who subsequently experience adverse outcomes if no change occurs.

Fourteen studies involve comparison of behaviour. Current guidelines in various countries recommend the frequency and intensity of weekly exercise. 30 min of PA 3 times a week, with a heart rate of 70%–80% of maximum heart rate (25). At least 30 min of moderate-intensity PA every day, 5 days a week (at least 150 min/week) (15–18). 15 min of high-intensity PA every day, 5 days a week (at least 75 min/week). For healthy adults, choose 8–10 different resistance exercises, perform each exercise with 1–3 sets of moderate intensity loads, allow 8–12 repetitions per set to achieve voluntary fatigue, and do it ≥2 times per week. Exercises for the same muscle group should be separated by at least 1 day (16, 19). A study has shown that, when repeated regularly, short bursts of vigorous intensity PA can result in substantial improvements in cardiorespiratory fitness and other cardiovascular outcomes (31).

Fourteen studies involve repetition and substitution. To address sedentary behaviors in people at high risk for cardiovascular disease, we can urge the use of beneficial or neutral behaviors to replace undesirable behaviors, such as advocating activity and standing behaviors for a long period of time (18, 20), changing sedentary behaviors to light physical activity or moderate to high physical activity (15, 16, 26), and promoting practice and repetition of alternative behaviors to replace unhealthy behavioral habits. If prolonged healthy behaviors are difficult to adhere to, target behaviors can also be set as small tasks that are simple to difficult and achievable, such as interrupting sedentary activity for 1 h for 8 min of moderate-intensity PA (21), interrupting sedentary activity for 30 min for 2 min of exercise (22), interrupting sedentary activity for 30 min of PA for 1 min of high-intensity PA (26), exercising with a heart rate of 90% of maximum heart rate, and exercising for 45 min after a meal for 20 min of high-intensity PA after a long sedentary period (21). The ultimate goal of the intervention is that health behaviors will eventually become habitual behaviors.

Four studies involve regulation. In order to minimize the development of negative emotions, PA can be integrated into daily life (15). Choosing a single workout may make the whole change boring and make it difficult to stick to. However, the guidelines have given advice on different workouts and there are studies that show that PA is synergistic with each other. For example, running and cycling, running and aerobics, running and racquetball (29).

Eight studies involve antecedents. Creating and altering the physical environment around a research subject can create barriers to unhealthy behaviors, such as changing the workplace environment (20, 25, 30, 32). Avoiding exposure or contact with social environments that can cause specific unhealthy behaviors and advocating for changes in the environment of the communities in which we live (32).

Two studies involve identity. Proposing to the research subjects to be proactive in accepting new perspectives for understanding the target behavior and changing their perceptions about implementing health behaviors makes the research subjects notice the differences between current and past behaviors and perceptions (24, 25), which in turn better facilitates behavioral change.

One study involves self-belief. The intervention process should build the confidence of the subject, encouraging him to be sure that he can do it and will succeed, thus reinforcing the whole training process (32). Self-confidence is an internal thing, have the intervention subject imagine successful behavior change in the scenario in question, encouraging positive self-talk throughout.

Some limitations emerge from this review. First, this review protocol was not registered previously. Second, studies published in English and Chinese were only included in specific databases, thus some relevant studies published in other languages might have been omitted. Lastly, the suboptimal quality of some RCTs highlighted a need for better design and/or reporting of RCTs for interventions aimed at improving adherence. This highlights the necessity for better design and/or reporting of intervention measures aimed at improving compliance. It is essential to provide a transparent and comprehensive description of BCTs and its intervention characteristics to offer clarity for future research. It is recommended that interventionists explicitly indicate BCTs when formulating intervention measures to enhance the accuracy of reporting, understanding, evaluation, and the transmission of effective components. We hope that this review on specific BCTs and the characteristics of successful static behavior and physical activity interventions will be helpful for the development of future intervention measures.