Development and evaluation of home-based cardiac rehabilitation in a low- and middle-income country setting

Uddin, Md. Jamal (2026) Development and evaluation of home-based cardiac rehabilitation in a low- and middle-income country setting. PhD thesis, University of Glasgow.

Abstract

Background
Cardiovascular disease (CVD) is the leading cause of premature death worldwide, disproportionately affecting low- and middle-income countries (LMICs). Despite this, in many LMIC setting including access to cardiac rehabilitation (CR), is extremely limited due to financial, geographic, and workforce constraints. Conventional centre-based CR models are challenging to scale equitably, leaving significant disease and treatment burden. Evidence from high-income countries shows that home-based CR can achieve similar health outcomes while improving accessibility. However, direct implementation in LMICs risks misalignment with local cultural, linguistic, and structural contexts (chapter 1). This doctoral research aimed to undertake a programme of research leading to the development, culturally adaptation, and evaluation of a culturally adapted home-based CR programme tailored to the Bangladeshi population and to inform implementation and future research.

Methods
Four linked research studies were undertaken. A scoping review to examine global literature on methods for adapting complex health interventions, with specific relevance to LMICs (chapter 2). An adaptation study to culturally and linguistically adapt the UK Heart Manual home-based CR programme for the setting of Bangladesh (chapter 3). A mixed methods study to assess the feasibility and acceptability of the adapted home-based programme and evaluation design (chapter 4). A systematic review and meta-analysis of randomised trials, evaluates the clinical and cost effectiveness, safety, and models of delivery of CR undertaken in LMICs (chapter 5).

Results
The scoping review identified 25 studies with a wide variation in their methodological quality, limited theoretical underpinning, inadequate reporting transparency, and a lack of evidence from LMICs. The review findings emphasise the need for a structured, theory-driven, and stakeholder-engaged process to intervention adaptation. The adaptation study resulted in the development of the ‘Bangla Heart Manual’, a culturally tailored, home-based cardiac rehabilitation (CR) intervention reflecting Bangladeshi health beliefs, language, and health system contexts. Stakeholders rated the manual highly for clarity, feasibility, and relevance to patient needs. The external feasibility study conducted in 33 patients demonstrated good participant recruitment and retention, and that Bangla Heart Manual that was useful, easy to integrate into daily routines, and safe, with no serious adverse events. The study also indicated improvements in patient health outcomes including exercise tolerance, lifestyle behaviours, psychological well-being, and health-related quality of life. The systematic review and meta-analysis identified 29 randomised trials of CR in LMICs in 6,489 people with heart disease. In line with evidence from high income settings, the results confirmed that participation in CR improved functional capacity and patient-reported outcomes compared with usual care alone, and that home-based approaches can offer a scalable, cost-effective model in resource-limited health systems.

Discussion and conclusion
The research studies undertaken in this PhD sought to contribute to the evidence-base to improving access to CR in LMICs, with a particular emphasis on Bangladesh. This thesis discusses the strengths and limitations of this research programme and its implications for policy and practice and future research (chapter 6).

• Item Type: Thesis (PhD)
• Qualification Level: Doctoral
• Subjects: R Medicine > R Medicine (General); R Medicine > RA Public aspects of medicine
• Colleges/Schools: College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > MRC/CSO Unit
• Supervisor's Name: Taylor, Professor Rod
• Date of Award: 2026
• Depositing User: Theses Team
• Unique ID: glathesis:2026-86169
• Copyright: Copyright of this thesis is held by the author.
• Date Deposited: 07 Aug 2026 15:05
• Last Modified: 10 Aug 2026 07:32
• Thesis DOI: 10.5525/gla.thesis.86169
• URI: https://theses.gla.ac.uk/id/eprint/86169

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