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Background Despite robust evidence supporting cardiac rehabilitation (CR), uptake, adherence, and completion remain suboptimal, particularly among underserved populations. Understanding the barriers and facilitators to CR engagement in these groups is essential for developing equitable and accessible services.Aim To identify and synthesise barriers and facilitators influencing the uptake, adherence, and completion of CR programmes among underserved populations globally.Methods Five bibliographic databases were searched for qualitative, quantitative, or mixed-methods studies examining barriers and/or facilitators to CR or physical activity participation among adults from underserved backgrounds published between 1 January 2000 and 9 September 2020. Study selection, data extraction, and quality assessment were conducted independently, in duplicate. Thematic synthesis was guided by the Capability, Opportunity, Motivation-Behaviour (COM-B) model and Theoretical Domains Framework (TDF) to categorise behavioural determinants of CR participation. The review protocol was registered with PROSPERO (CRD42024502384).Results Eighty-five studies (54 quantitative, 22 qualitative, 9 mixed methods) involving 228,660 participants were included. Common barriers included comorbidities, fatigue, lack of CR awareness, communication difficulties, logistical constraints (e.g. distance, cost, time). Facilitators included structured referral processes, perceived physical and emotional benefits, health professional encouragement, social support, flexible delivery (telehealth, home-based options), and a clear understanding of CR’s purpose and value.Conclusion Findings highlight a multifaceted set of barriers and facilitators that intersect at individual, social, and systemic levels. Addressing these factors, particularly through personalised, flexible delivery models and enhanced patient education, may improve CR accessibility and adherence among underserved populations.