Contextual Barriers and Facilitators to Exercise-Based Cardiac Rehabilitation in China: A CFIR 2.0-Guided Systematic Review of Policy, Cultural, and Organizational Determinants

Purpose: Exercise-based cardiac rehabilitation (CR) is internationally recognized as an essential component of secondary prevention for coronary heart disease (CHD). However, participation in China remains low. Although barriers to CR have been extensively reported worldwide, China's regional disparities and distinct exercise traditions create context-specific constraints and opportunities. This study conducted a systematic review using the updated Consolidated Framework for Implementation Research (CFIR) 2.0 to identify multi-level factors that facilitate or impede CR implementation within Chinese healthcare systems. Methods: Seven major databases were searched through October 2024 for studies examining determinants of participation in, or delivery of, exercise-based CR among CHD patients or clinical staff. Study quality was evaluated using the Mixed Methods Appraisal Tool, and extracted findings were organized according to the five CFIR 2.0 domains. Results: Twenty studies met the inclusion criteria, and several influences distinctive to the Chinese context were identified. For example, hospitals in better-resourced provinces provided more complete and structured CR services, whereas those in less developed regions faced fragmented referral pathways and severely limited rehabilitation infrastructure. Cultural expectations further shaped engagement, with many patients favoring medication-based management over exercise, despite traditional practices such as Tai Chi and Baduanjin being viewed positively and offering a culturally acceptable entry point for rehabilitation. Digital tools, including mobile-health platforms and wearable devices, increasingly supported participation, particularly where in-person services were difficult to access. At the institutional level, CR implementation was more successful in centers with established multidisciplinary teams and stable funding, while hospitals lacking such support struggled to maintain consistent programs. Conclusion: By clarifying how structural, institutional, and patient-level barriers interact to restrict cardiac rehabilitation in China, the review emphasizes that nationwide advancement will require policy reinforcement, better-trained rehabilitation teams, and implementation approaches tailored to patient needs.