. 2025 May 6:5:41.

doi: 10.3310/nihropenres.13957.1. eCollection 2025.

Affordable Cardiac Rehabilitation An Outreach Inter-Disciplinary Strategic Study (ACROSS) - Research Programme Protocol

Rod S Taylor¹, Imran Bashir Chaudhry^{2

3

4}, Mithila Faraque⁵, Panniyammakal Jeemon⁶, Amy Blakemore³, Karina Lovell³, Nusrat Husain³, Tahir Saghir⁷, Saidur Rahman Mashreky⁸, Sivadasanpillai Harikrishnan⁶, Chaudhury Meshkat Ahmed⁹, Abraham Samuel Babu¹⁰, Alex McConnachie¹, Emma McIntosh¹, Rakhshi Memon¹¹, Sally Singh^{12

13}, Alastair Leyland¹, Bhautesh Jani¹, Walter Flores¹⁴; ACROSS Collaborative Group

Collaborators, Affiliations

Collaborators

ACROSS Collaborative Group:
Rezaul Karim, Zia Ul Haq, Nabila Soomro, Zainab B Zadeh, Ameer Khoso, Sehrish Tofique, Farhat Jafri, Riffat Sultana, Huma Naeem, Palash Chandra Banik, Sohel Choudhury, Louise Taylor, Jamal Uddin, Claire Copping, David Innes, Sunil Roy Tn, Stigi Joseph, Vijayan Ganesan, Mukund A Prabhu, Jyothi Vijay Ms, Ramya Das Nk

Affiliations

¹ School of Health and Wellbeing, University of Glasgow College of Medical Veterinary and Life Sciences, Glasgow, Scotland, G12 8TA, UK.
² Pakistan Institute of Living and Learning, Karachi, Sindh, Pakistan.
³ The University of Manchester, Division of Psychology and Mental Health, Manchester, England, UK.
⁴ University of Karachi, Karachi, Sindh, Pakistan.
⁵ Bangladesh University of Health Sciences, Dhaka, Dhaka Division, Bangladesh.
⁶ Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
⁷ National Institute of Cardiovascular Diseases, National Institute of Cardiovascular Diseases, Karachi, Sindh, Pakistan.
⁸ Department of Public Health, North South University, Dhaka, Dhaka Division, Bangladesh.
⁹ Bangabandhu Sheikh Mujib Medical University, Dhaka, Dhaka Division, Bangladesh.
¹⁰ Department of Physiotherapy, Manipal College of Health Professions, Manipal, Karnataka, India.
¹¹ University College London, Faculty of Population Health Sciences, London, England, UK.
¹² Respiratory Sciences, University of Leicester, Leicester, England, UK.
¹³ University Hospitals of Leicester NHS Trust, Leicester, England, UK.
¹⁴ Accountability Research Center, American University Washington College of Law, Washington, District of Columbia, USA.

PMID: 40529206
PMCID: PMC12171719
DOI: 10.3310/nihropenres.13957.1

Affordable Cardiac Rehabilitation An Outreach Inter-Disciplinary Strategic Study (ACROSS) - Research Programme Protocol

Rod S Taylor et al. NIHR Open Res. 2025.

. 2025 May 6:5:41.

doi: 10.3310/nihropenres.13957.1. eCollection 2025.

Authors

Collaborators

ACROSS Collaborative Group:
Rezaul Karim, Zia Ul Haq, Nabila Soomro, Zainab B Zadeh, Ameer Khoso, Sehrish Tofique, Farhat Jafri, Riffat Sultana, Huma Naeem, Palash Chandra Banik, Sohel Choudhury, Louise Taylor, Jamal Uddin, Claire Copping, David Innes, Sunil Roy Tn, Stigi Joseph, Vijayan Ganesan, Mukund A Prabhu, Jyothi Vijay Ms, Ramya Das Nk

Affiliations

¹ School of Health and Wellbeing, University of Glasgow College of Medical Veterinary and Life Sciences, Glasgow, Scotland, G12 8TA, UK.
² Pakistan Institute of Living and Learning, Karachi, Sindh, Pakistan.
³ The University of Manchester, Division of Psychology and Mental Health, Manchester, England, UK.
⁴ University of Karachi, Karachi, Sindh, Pakistan.
⁵ Bangladesh University of Health Sciences, Dhaka, Dhaka Division, Bangladesh.
⁶ Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
⁷ National Institute of Cardiovascular Diseases, National Institute of Cardiovascular Diseases, Karachi, Sindh, Pakistan.
⁸ Department of Public Health, North South University, Dhaka, Dhaka Division, Bangladesh.
⁹ Bangabandhu Sheikh Mujib Medical University, Dhaka, Dhaka Division, Bangladesh.
¹⁰ Department of Physiotherapy, Manipal College of Health Professions, Manipal, Karnataka, India.
¹¹ University College London, Faculty of Population Health Sciences, London, England, UK.
¹² Respiratory Sciences, University of Leicester, Leicester, England, UK.
¹³ University Hospitals of Leicester NHS Trust, Leicester, England, UK.
¹⁴ Accountability Research Center, American University Washington College of Law, Washington, District of Columbia, USA.

PMID: 40529206
PMCID: PMC12171719
DOI: 10.3310/nihropenres.13957.1

Abstract

Background: The evidence and infrastructure needed to access and deliver cardiac rehabilitation (CR) services are absent or lacking in low and middle-income countries (LMICs), resulting in a substantial loss of potential health and socio-economic benefits. Home-based programmes provide an affordable model of delivery that can leverage a scalable increase in CR access in LMICs. ACROSS (Affordable Cardiac Rehabilitation: An Outreach Inter-disciplinary Strategic Study) seeks to co-develop (with patients, caregivers, clinicians, and service commissioners) a culturally and contextually applicable and affordable home-based programme for people with the multimorbidity of coronary heart disease and/or heart failure with co-existing depression and/or anxiety and evaluate the acceptability, clinical effectiveness, and cost-effectiveness of its implementation in Bangladesh, India, and Pakistan and to determine its scalability and sustainability.

Methods: Four linked work packages (WPs). WP1 (cultural adaptation/refinement of home-based rehabilitation): examine rehabilitation implementation barriers/enablers from multiple stakeholder perspectives and co-develop a feasible and acceptable culturally & contextually adapted home-based programme, extended to take account of co-existing depression and/or anxiety; WP2 (external pilot): assess feasibility/acceptability of the co-developed rehabilitation intervention and study design and processes necessary for a full-scale trial; WP3: (multicentre/multi-country hybrid effectiveness and implementation randomised trial) determine the clinical and cost-effectiveness of a culturally adapted home-based rehabilitation intervention for people with coronary heart disease and/or heart failure and depression and/or anxiety; WP4 (capacity building): build research and rehabilitation delivery capacity.

Conclusions: The ACROSS programme overarching goal is to develop a clinically and cost-effective CR model in low-resource settings for people in Bangladesh, India, and Pakistan with a multimorbidity of heart disease and depression and/or anxiety with the potential for substantial health and socio-economic benefits.

Keywords: cardiac rehabilitation; coronary artery disease; heart failure; low and middle income country.; mental health; randomised controlled trial.

Plain language summary

The combination of heart disease alongside depression and anxiety is a common and profound unmet need for global health systems, especially in low and middle-income country settings. It affects people of working age, causing them ill-health and major financial loss. Cardiac rehabilitation is recommended as a core component of health services and includes exercise, education, and psychological support. It has been shown to reduce death rate and hospital admissions and improve the quality of life. However, cardiac rehabilitation services in low- and middle-income countries are virtually absent. Working with partners in Bangladesh, Pakistan, and India, the ‘Affordable Cardiac Rehabilitation: An Outreach Interdisciplinary Strategic Study’ (ACROSS) programme seeks to develop and evaluate the implementation of a clinically effective, affordable, and culturally and contextually appropriate model of home-based rehabilitation. ACROSS has four work packages: (1) Engagement events with those with lived-disease experience, their families, healthcare staff, and service providers to co-develop a culturally and contextually adapted home-based rehabilitation ('ACROSS') programme and training materials for providers; (2) A pilot study to understand if the ACROSS programme is acceptable and practical for patients and staff and whether a full-scale trial is doable; (3) A trial in 3000 patients with multiple long-term conditions that include heart disease and depression and anxiety across several sites in each country to tell us whether the programme improves health outcomes at 12-months and what its affordability is; and (4) Develop a sustainable model of workforce training and implementation to enable long-term programme delivery as well as build partner research capacity. People with lived-disease experience, clinicians, community leaders, and healthcare policymakers have been extensively involved in the planning of ACROSS. Our stakeholder meetings have consistently emphasised the importance of this research and supported the development of our research plans. Patients and stakeholders in each partner country will provide ongoing advice.

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Conflict of interest statement

Competing interests: RST is currently co-Chair of the NIHR Research on Interventions for Global Health Transformation (RIGHT) Funding Committee. NH has been a past Trustee of the Pakistan Institute of Living and Learning (PILL), Abaseen Foundation UK, Lancashire Mind UK and Manchester Global Foundation (MGF). He is a member of the Academic Faculty at the Royal College of Psychiatrists (RCPsych), London. He is a National Institute for Health and Care Research (NIHR) Senior Investigator. He has attended educational events organised by various pharmaceutical industries. RM is CEO of Manchester Global Foundation (UK Charity Number 116841) and trustee of UK Association for Medical Aid to Pakistan (UK Charity Number 1123929). IBC has given lectures or advice to Eli Lilly, Bristol Myers Squibb, Lundbeck, Astra Zeneca, and Janssen pharmaceuticals for which he or his employing institution have been reimbursed, outside the submitted work. Prof Chaudhry was previously a trustee of the Pakistan Institute of Living and Learning (PILL). Other authors declare no conflicts of interest.

Figures

**Figure 2.. Sample size estimation for WP3.**

**Figure 3.. ACROSS Theory of Change model.**

See this image and copyright information in PMC

References

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Affordable Cardiac Rehabilitation An Outreach Inter-Disciplinary Strategic Study (ACROSS) - Research Programme Protocol

Collaborators

Affiliations

Affordable Cardiac Rehabilitation An Outreach Inter-Disciplinary Strategic Study (ACROSS) - Research Programme Protocol

Authors

Collaborators

Affiliations

Abstract

Plain language summary

Conflict of interest statement

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References

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