Barriers and facilitators of cardiac rehabilitation focusing on underserved groups: a mixed-methods systematic review
7 affiliations
- 1Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- 2Cardiac Rehabilitation and Research Centre, Physical Therapy Department, Chest Diseases Hospital, Kuwait Ministry of Health, Kuwait city, Kuwait
- 3Department of Physiotherapy, Faculty of Medical Technology, University of Tripoli, Tripoli, Libya
- 4School of Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- 5Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University, and Liverpool Heart and Chest Hospital, Liverpool, UK
- 6Cardiovascular Health Sciences, Research Institute of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
- 7Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, UK
Abstract
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.
PROSPERO registration number: CRD42024502384
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BibTeX
@article{humoud2026barriers,
title = {{Barriers and facilitators of cardiac rehabilitation focusing on underserved groups: a mixed-methods systematic review}},
author = {Hanan A Humoud and Ahlam A AbuElkhair and Ghislaine D Mbolo and Benjamin J Buckley and Nefyn H Williams and Deirdre A Lane},
journal = {BMJ Open},
year = {2026},
month = oct,
doi = {10.1136/bmjopen-2026-119214},
url = {https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2026-119214},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Barriers and facilitators of cardiac rehabilitation focusing on underserved groups: a mixed-methods systematic review
AU - Hanan A Humoud
AU - Ahlam A AbuElkhair
AU - Ghislaine D Mbolo
AU - Benjamin J Buckley
AU - Nefyn H Williams
AU - Deirdre A Lane
PY - 2026
DA - 2026/10/29
JO - BMJ Open
DO - 10.1136/bmjopen-2026-119214
UR - https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2026-119214
AB - 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. PROSPERO registration number: CRD42024502384
SN - 2044-6055
SN - 2044-6055
ER -