Barriers and facilitators of cardiac rehabilitation focusing on underserved groups: a mixed-methods systematic review

Objective To identify and synthesise the barriers and facilitators influencing the uptake, adherence and completion of cardiac rehabilitation (CR) programmes among underserved populations globally. Design Mixed-methods systematic review. Data sources MEDLINE (Ovid), PubMed, CINAHL, PsycINFO and Scopus were searched from 1 January 2000 to 9 September 2025. Reference lists and grey literature were also screened. Eligibility criteria for selecting studies Qualitative, quantitative and mixed-methods studies examining barriers and/or facilitators to CR or physical activity participation among adults with cardiovascular disease from underserved populations (eg, women, ethnic minority groups and individuals with low socioeconomic status). Conference abstracts, editorials and studies without full text were excluded. Data extraction and synthesis Study selection, data extraction and quality appraisal were conducted independently in duplicate. Methodological quality was assessed using the Mixed-Methods Appraisal Tool. Qualitative findings were synthesised thematically and mapped to the Capability, Opportunity, Motivation-Behaviour model and Theoretical Domains Framework. Quantitative findings were summarised using frequency-based vote counting. Results 85 studies (54 quantitative, 22 qualitative and 9 mixed-methods studies) involving 228 660 participants were included. Frequently reported barriers included comorbidities and fatigue, limited awareness of CR, communication difficulties, long travel distance, transportation and cost barriers, time constraints and inconsistent referral practices. Key facilitators included structured or automatic referral, health professional recommendation, family and social support, perceived physical and psychological benefits, improved self-efficacy and flexible delivery models such as home-based, telehealth or hybrid programmes. Conclusions Barriers and facilitators to CR participation among underserved populations operate across individual, social and health system levels. Strategies that incorporate systematic referral, patient education, behavioural support and flexible delivery models may improve equitable access and sustained engagement with CR. CRD42024502384