ACROSS (Affordable Cardiac Rehabilitation: An Outreach Interdisciplinary Strategic Study) is a global research programme funded by the National Institute for Health and Care Research (NIHR) via their Research on Interventions for Global Health Transformation (RIGHT) programme led by the University of Glasgow, in partnership with various universities and healthcare organisations in the UK, Bangladesh, and Pakistan.

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ACROSS Partners

Why ACROSS?

Cardiovascular disease (CVD) is the most prevalent non-communicable disease, the leading cause of global mortality, and a major contributor to premature disability and ill-health. CVD causes an estimated 17.8 million deaths worldwide, corresponding to 330 million years of life lost and another 35.6 million years lived with disability [1],[2].

By 2030, it is estimated that >80% of CVD-related disability and death will occur in low and middle-income countries (LMICs) due to increasing risk factors (e.g., hypertension, smoking, diabetes, obesity). South Asia, where the ACROSS programme will be delivered, contributes to the highest proportion of CVD burden compared to other regions globally [2],[3].

The combination of heart disease alongside depression and anxiety is a common and profound unmet need for global health systems, especially in LMIC country settings. The addition of a mental health problem is associated with a 40–50% increased risk of mortality and major cardiac events and a 30–50% reduction in health-related quality of life (HRQoL) in people with heart disease [4].

Rehabilitation, ‘the action of restoring someone to health or normal life after illness’, is recommended by the World Health Organisation (WHO) as a core component of health services [5],[6]. Rehabilitation includes exercise, education, and psychological support. It has proved to reduce death rate and hospital admissions and improve quality of life and mental well-being. However, due to financial limitations and lack of appropriately trained health care personnel, the availability of rehabilitation services in low- and middle-income countries are currently very sparse.

The overarching aim of the ACROSS programme is to evaluate and implement a sustainable, scalable, culturally and contextually adapted, and affordable model of home-based rehabilitation for people living with multimorbidity, including heart disease and mental health disorders.

Specific research objectives

  1. To co-design with key stakeholders a culturally and contextually adapted affordable home-based rehabilitation programme with low intensity interventions for depression and anxiety.
  2. To co-design ACROSS delivery training for health professionals including a train-the-trainer programme to enable the cascade of training.
  3. To assess the feasibility and acceptability of implementing the ACROSS programme and trial design and examine the parameters and processes of a full-scale trial, including recruitment, randomisation, and retention.
  4. To determine the clinical effectiveness (hierarchical primary outcome of mortality, hospital admission, and health-related quality of life) of the ACROSS programme.
  5. To determine cost-effectiveness of the ACROSS programme in terms of an incremental cost per quality adjusted life year.
  6. To build research and clinical delivery capacity and capability and support south-south partnership and learning to underpin the scalable and sustainable country-wide provision of rehabilitation service.
  7. To embed community and stakeholder engagement to inform the route to impact of the project outputs and findings.

Global ACROSS Study Protocol

Our Study Protocol is outlined in this NIHR Open article.

Methods - ACROSS Work Packages

References

    1. Vaduganathan M, Mensah GA, Turco JV, et al.: The global burden of cardiovascular diseases and risk: a compass for future health. J Am Coll Cardiol. 2022; 80(25): 2361–2371.
      PubMed Abstract  |  Publisher Full Text

    1. Roth GA, Mensah GA, Johnson CO, et al.: Global burden of cardiovascular diseases writing group. Global burden of cardiovascular diseases and risk factors, 1990–2019: update from the GBD 2019 study. J Am Coll Cardiol. 2020; 76(25): 2982–3021.
      PubMed Abstract  |  Publisher Full Text  |  Free Full Text

    1. World Health Organization global status report on noncommunicable diseases 2010. Geneva, Switzerland, 2011.
      Reference Source

    1. Ramaraj R, Chellappa P: Cardiovascular risk in South Asians. Postgrad Med J. 2008; 84(996): 518–23.
      PubMed Abstract  |  Publisher Full Text

    1. Dragioti E, Radua J, Solmi M, et al.: Impact of mental disorders on clinical outcomes of physical diseases: an umbrella review assessing population attributable fraction and generalized impact fraction. World Psychiatry. 2023;22(1):86–104.
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  1. Mulugeta H, Sinclair PM, Wilson A: Prevalence of depression and its association with health-related Quality of Life in people with heart failure in low- and middle-income countries: a systematic review and meta-analysis. PLoS One. 2023;18(3):e0283146.
    PubMed Abstract  |  Publisher Full Text  |  Free Full Text