Technology‐bAsed cardiac rehabilitation therapy (TaCT) for women: Intervention implementability, usability, engagement and acceptability in a middle‐income setting

Abstract

BACKGROUND:

Despite the benefits of cardiac rehabilitation (CR), women are under-represented, especially in lower-income settings. Technology may be leveraged to tailor CR to better engage women, but this has never been tested in a middle-income country. This study assessed the implementability, usability, engagement, and acceptability of Technology-bAsed Cardiac rehabilitation Therapy (TaCT) in women with cardiovascular disease (CVD) in a middle-income country.

MATERIALS AND METHODS:

Data from intervention arm participants in a randomized trial was analyzed. The trial was undertaken in the outpatient cardiology department of a private tertiary care center in India. The 6-month CR intervention was delivered via an app (individualized secondary prevention recommendations), website (patient education), WhatsApp (standardized behavior change promotion messages, yoga/relaxation video, support chat), and bi-weekly one-on-one phone calls with a nurse trainee (risk factor management). At the end of the intervention, participants’ engagement, usability (System Usability Scale), and, acceptability (/5) of the program were evaluated using descriptive statistics.

RESULTS:

50 women were randomized to intervention; one died and 49 (100%) were retained. Some participants faced challenges such as internet availability issues and technical glitches. There were no adverse events. Engagement was high for calls (mean = 11.6 ± 1.4/12), WhatsApp messages (mean = 34.2 ± 4.6/36 read) the website (74–151 hits/education page), and the mobile app (7.2 ± 4.2 times/patient); there were no group chat messages. Usability was rated as “excellent” (94.7 ± 5.2/100). Acceptability with the overall intervention was high (means ≥4.5/5), but was lower for information understandability, including diet and exercise recommendations.

CONCLUSIONS:

Favorable implementability and acceptability, as well as excellent usability and engagement with TaCT were established. Along with favorable outcome results, this suggests that TaCT may serve as a valuable intervention to improve women’s access and adherence to CR in resource-constrained environments.

Background

Cardiovascular diseases (CVD) are a leading health burden globally, particularly in middle-income countries (MICs) such as India, and among women.[1] For instance, ischemic heart disease accounted for 188.3 million disability-adjusted life-years (DALYs) globally in 2021 and ranks among the top five contributors to DALYs in India.[2] Patients with established CVD are at heightened risk of recurrent events and procedures compared to those without CVD,[3] thus necessitating secondary prevention.[4]

Cardiac rehabilitation (CR) -- a comprehensive, outpatient model[5] of chronic disease management -- has been demonstrated to improve outcomes,[6] including in MICs[7] and in women.[8] Despite this, CR remains under-utilized for manifold reasons at the health system, referring clinician, program, and patient levels,[9,10] but particularly in India this under-utilization is primarily due to capacity constraints[11] and accessibility issues for women.[12,13]

Remote CR models leveraging technology have been developed to address these challenges, showing equivalent short-term benefits to traditional CR.[14,15,16,17] These models are cost-effective and well-accepted by patients in areas with good technology access.[18,19,20] However, there has been limited assessment of such interventions in MICs[21,22,23] and in women.[24]

Recently, women-tailored CR models have been reviewed, with promising effects in high-income countries.[25,26] Electronic CR that addressed the barriers women in MICs face, such as lack of transportation, depression, time conflicts due to multiple roles, and others[9,27,28] was sorely needed; a comprehensive eCR model (Technology-bAsed Comprehensive Cardiac Rehabilitation Therapy; TaCT) tailored for women in India was hence developed.[29] The objectives of this study were to assess intervention implementability/fidelity, engagement, usability, and acceptability.

Materials and Methods

Study design and setting

This was a sub-study of a trial, reporting data from intervention participants only (single group, pre-test/post-test). The trial compared an eCR intervention, known as TaCT, with standard care on the primary outcome of functional capacity; results were supportive of positive effects on primary as well as secondary outcomes such as quality of life, heart-health behaviors, and anxiety symptoms.[29] Primary and secondary outcomes are reported elsewhere[30]; intervention usability, engagement, and acceptability are reported herein, by the trial protocol.[29]

Following a pilot study with ten patients, participants were recruited consecutively from the outpatient Cardiology department at Kasturba Hospital in Manipal, India from January to September 2023. Baseline data was collected from consenting participants. Intervention engagement was tracked throughout the trial. Participants were followed up at six months to complete surveys during their regularly scheduled visits to the outpatient cardiology department (through to March 2024). If any patients missed their in-person follow-up visit, responses for the self-reported measures were obtained over the telephone.

Study participants and sampling

The inclusion criteria were: Women between the age of 40–65 years, who possessed an Android-based smartphone.[29] They had to be able to read and communicate in Kannada and/or in English. With regard to cardiac condition, only stable CVD patients who had been diagnosed for at least one month were eligible. Patients with other cardiac conditions, comorbid peripheral or cerebrovascular diseases, which limited their exercise, or other health conditions which limited their ability to participate in CR were excluded. Based on the sample size calculation for the trial,[29] 50 women were recruited to the intervention arm.

Intervention

TaCT development and final characteristics are described in detail elsewhere.[29] In brief, the 6-month TaCT outpatient, technology-based phase II CR intervention aimed to support female patients in adopting heart-healthy lifestyle changes such as increasing exercise, diet, adhering to medications, managing stress, and quitting tobacco (where applicable), in alignment with secondary prevention recommendations.[31]

Developed within the context of an existing CR program, the comprehensive CR intervention was offered at no cost, and delivered virtually by a female nurse-researcher. It was designed to address common CR barriers for women such as time constraints and travel issues.[9] The intervention included the following components:

1. an android mobile app named “Sukhi Hrudaya” for individualized secondary prevention recommendations (i.e., tailored exercise and dietary plans were provided based on participants’ functional capacity and dietary recall) and reminders (i.e., medical appointments/tests, TaCT calls, cardiac medications),

2. a website (https://www.sukhihrudaya.in/), with four educational pages to support self-management (i.e., exercise, nutrition, adherence to medical treatment, and other lifestyle modifications)

3. WhatsApp messages (https://www.whatsapp.com/download) to prompt heart-health behavior and adherence: These 37 texts were based on the Mobile4-Heart trial,[32] with some slight modifications to ensure local relevance; some texts were also created to address health behaviors other than exercise.

4. WhatsApp for yoga/relaxation (video link provided via message) and peer support via group chat, as well as

5. bi-weekly one-on-one phone calls to discuss risk factor management, self-management progress and address psychosocial concerns. A template was used to support the nurse–researcher-initiated and pre-scheduled calls.

Data collection tool and technique

Participants reported sociodemographic and clinical characteristics; other information including medications was extracted from medical charts. Translation of items to Kannada for patient reports where patients desired is detailed elsewhere.[29]

Any issues regarding intervention implementation were documented by the nurse-researcher in the pilot and the trial, such as the reason for inability to reach a patient for a phone call, or failure to send a WhatsApp or text message. Any implementation issues raised were notated (verbatim as applicable) following all contacts with participants. Any adverse events were recorded.

Engagement with each component of the intervention was assessed throughout the trial. The number of times patients logged in to the Sukhi Hrudaya app, the number of “hits” on each page of the intervention website, the number of read WhatsApp messages, contributions to the WhatsApp group chat, any contacts initiated by patients to the intervention team, and the number of completed biweekly calls, were captured systematically. The specific webpage hits were recorded for sections such as about the project, general dietary guidelines, exercise and physical activity, other lifestyle modifications, treatment adherence, and contact us. This data provided a comprehensive overview of how actively participants engaged with various components of the intervention.

Intervention usability was assessed post-intervention using the System Usability Scale (SUS).[33,34] Participants were asked to respond about all aspects of the TaCT intervention. It is a 10-item questionnaire, with items scored on a 5-point Likert-type scale from 1 (strongly disagree) to 5 (strongly agree). Overall scores range from 0 to 100: A score above 85 is considered ‘excellent’ usability, a score between 68 and 84 is considered ‘good’ usability.

Lastly, acceptability was measured through a 24-item survey based on previous research and adapted for this trial.[35] Items were rated on a scale from 1 “strongly disagree” to 5 “strongly agree”, with some items reverse-scored to minimize acquiescence bias. These were assessed at 6 months by the end of intervention.

Ethical consideration

The trial was approved by the Kasturba Medical College and Kasturba Hospital Institutional Ethics Committee (IEC: 471/2020), Karnataka, India. Note the committee recommended a maximum age of 65 given older participants may have had more comorbidities and less comfort with technology use. Informed written consent was obtained from all participants before their inclusion in the study.

Statistical analysis method

Jamovi version 2.3.28 (https://www.jamovi.org/download.html) was used to analyse the data. Internal reliability of the acceptability items was computed (i.e., Cronbach’s alpha). Identified issues with intervention implementation and fidelity, as well as any observed adverse events or harms, were collated. Issues were categorized or content analyzed as applicable, and enumerated.[36]

Box plots were generated to discern the normality of continuous variables. A descriptive analysis of engagement, usability, and acceptability was performed, using frequencies and percentages or means and standard deviations; median and quartiles were computed where variables were not normally distributed.

Results

Participant characteristics

The consent rate for the trial was above 95%.[30] All but one participant was retained for the follow-up assessments (98%). There were no concerns about contamination, as no participants were referred to our outpatient center-based CR.

Respondent characteristics are shown in Table 1. Most women were in their early 50s, one-third lived in the city, and education attainment was not high. Most were married, with two children on average, and involved in unpaid domestic management, approximately 56 hours per week. Over half shared their smartphone. In addition, over half of the participants had to pay for medications out-of-pocket, yet most patients were on multiple cardiac medications; all were also on at least one non-cardiac medication (data not shown). Data reported elsewhere suggested reasonable function, few tobacco users, moderate adherence to heart-health behaviors, moderate quality of life, and mild anxiety.[30]

Table 1.

Pre-intervention sociodemographic and clinical characteristics of intervention participants, n=50

	n (%)/mean±SD or median (Q1, Q3)c
Sociodemographic
Age (years)	52.3±5.3
Area of residence (n, % urban)	18 (36.0%)
Marital status (n, % married)	41 (82.0%)
Highest education
Intermediate or diploma (14 years of schooling) or more	15 (30.0%)
High school certificate (12 years of schooling)	15 (30.0%)
Middle school certificate (8 years of schooling)	10 (20.0%)
Primary school certificate (5 years of schooling)	10 (20.0%)
Work status
Full or part-time work for pay	13 (26.0%)
Disability or modified duties	1 (25.0%)
Retired	3 (6.0%)
Not employed (e.g., household management)	33 (66.0%)
Worrying about affording basic needs and healthcare
Not at all	18 (36.0%)
Sometimes	31 (62.0%)
Often	1 (2.0%)
Payment for heart medications/no health insurance coverage
Pay out-of-pocket	30 (60.0%)
Have benefits	3 (6.0%)
Other	17 (34.0%)
Someone who supports you emotionally and with health-wise
All the time	11 (22.0%)
Most of the time	39 (78.0%)
Number of children	2 (2, 3)
Primary person responsible for doing housework at home (n, % yes)	12 (24.0%)
Average hours spent per week doing housework	56 (42, 63)
Smartphone access
Have own	24 (48.0%)
Shared	26 (52.0%)
Clinical Characteristics a
Age at first diagnosis of heart disease	49 (46, 53)
Family history of heart disease (n, % yes)	26 (52.0%)
Cardiac risk factors
Hypertension	43 (86.0%)
Dyslipidemia	24 (48.0%)
Diabetes	19 (38.0%)
Obesity	9 (18.0%)
Pre-diabetes	4 (8.0%)
Body mass index	26 (24, 29)
Cardiac history b
Percutaneous coronary intervention	24 (48.0%)
Myocardial infarction	16 (32.0%)
Other CAD/IHD	30 (60.0%)
Coronary artery bypass surgery	0
Menopausal Status
Pre	9 (18.0%)
Peri	7 (14.0%)
Post	27 (54.0%)
Don’t know	7 (14.0%)
Hysterectomy (n, % yes)	7 (14.0%)
History of metabolic disorder of pregnancy (n, % yes)	8 (16.0%)
Sleep (hours/day)	8 (7, 8.5)
Drink alcohol (n, % yes)	26 (52.0%)
Comorbidities
Hypothyroidism	6 (12.0%)
Anemia	4 (8.0%)
Other	3 (6.0%)
None	37 (74.0%)
Cardiac Medicationsb
Statin	43 (86.0%)
Anti-platelet	32 (64.0%)
Beta-blocker	27 (54.0%)
Anti-glycemic	21 (42.0%)
Calcium channel blocker	18 (36.0%)
ACE-inhibitor or ARB	12 (24.0%)
Nitrates	4 (8.0%)
Diuretic	2 (4.0%)
Insulin	3 (6.0%)

CAD=coronary artery disease, IHD=Ischemic heart disease, CR=cardiac rehabilitation, ACE-inhibitor=Angiotensin-converting enzyme inhibitor, ARB=Angiotensin receptor blockers, CR=cardiac rehabilitation, SD=standard deviation. ^aall self-reported except body mass index and medications, but patient interview augmented with patient chart information where applicable. ^ball that apply ^cwhere not normally distributed, median and quartiles 1 and 3 are reported

Intervention implementation/fidelity and harms

During the pilot study, internet availability issues and limitations related to internet usage data created participation disparities, while technical glitches led to frustration and decreased engagement. Participants experienced anxiety related to learning new technology and integrating it into their routines, with time commitment issues further impacting adherence. Additionally, privacy and confidentiality concerns about data security and trust in the technology affected participant engagement. Furthermore, sharing of phones, phone under-use, and restricted usage further affected patient participation. Some participants expressed anxiety related to a three and six-month follow-up assessment, and many participants were not willing to come on-site for the latter assessment. Implementation challenges included insufficient time for the orientation of participants to the intervention, difficulties in integrating TaCT within the existing healthcare system, and the requirement for outcome assessors to have specialized skills in performing the Incremental Shuttle Walk Test. Based on the pilot, more time was allotted for training and orientation of each participant (including information around privacy/confidentiality), the 3-month assessment was dropped (except for diet) such that all assessments were done at six months follow-up, and some additional functional capacity tests were added, which could be completed at home to support follow-up via phone and augment retention.

There were no harms or adverse events reported during the TaCT trial; one participant in the intervention arm died, but this was adjudicated as unrelated to the trial (i.e., inpatient post-surgery). There was no intervention dropout otherwise. Forty-nine (98.0%) patients completed the six-month follow-up assessments on the phone.

Intervention engagement

Intervention engagement is summarized in Table 2; overall, it was moderate to high across all modalities except for the WhatsApp group chat. Across the 6 months, women logged in to the mobile app, Sukhi Hrudaya, a median of 7 times (Q1 = 4, Q3 = 10). On the website, most participants read “about” the eCR initiative, with 74–151 “hits” on the heart-health behavior and treatment education webpages.

Table 2.

Intervention usability, engagement, and acceptability at 6-months end of intervention assessment, n=49

	n (%)/Mean±SD or median (Q1, Q3)d
Usability Scorea (/100)	96 (92.5, 100)
Engagement
Number of times patients accessed the mobile App	7 (4, 10)
Number of completed biweekly calls per patient (/12)	11.6±1.4
WhatsApp
Number of “read” messages per patient (/36)	34.2±4.6
Total number of contributions to group chat	0
Total number of contacts from patients to nurse-researcher	33 (66.0%)
Website –Total Hits (all pages)	1603
About TaCT	1103 (68.8%)
Nutrition	151 (9.4%)
Exercise and physical activity	91 (5.6%)
Other lifestyle modifications (e.g., tobacco cessation, psychosocial management)	81 (5.0%)
Adherence to treatment (e.g., medication, medical appointment/tests)	74 (4.6%)
Contact TaCT	103 (6.4%)
Acceptability b
The CR intervention met my approval	4.5±0.5
The CR intervention was appealing to me	4.6±0.4
I liked this CR intervention	4.6±0.4
I welcomed the CR intervention	4.5±0.5
I will use the information in my daily life	4.6±0.4
I understood all the information	4.6±0.4
The CR intervention content was clear	4.6±0.4
The text messages were relevant to my life	4.7±0.4
I got all the information I needed	4.1±0.3
I will refer to this website again	4.1±0.3
I would recommend this CR intervention to my female friends and family	4.6±0.4
The information was easy to read	4.7±0.4
The CR intervention helped me manage my heart health	4.3±0.4
I liked the support in the WhatsApp chat	3.9±0.2
The phone calls were very helpful	4.1±0.3
I liked the yoga and meditation video	4.8±0.3
This CR intervention met my needs as a woman with heart disease	4.3±0.4
I was not sure how much to exercise or whenc	3.9±0.6
There was too much intervention contentc	1.9±0.1
The information was difficult to understandc	4.7±0.4
I was not sure how to change my diet or follow the diet planc	3.2±1.0
I wish there would have been more in-person visitsc	3.9±0.7
I preferred to look at the materials on my own rather than having a call with the CR nursec	3.7±0.7
It was confusing on the calls when we talked about my blood pressure or cholesterolc	4.2±0.4

SD=standard deviation, CR=cardiac rehabilitation, TaCT=Technology-bAsed Cardiac rehabilitation Therapy. ^amaximum 100. Rating interpreted as “excellent usability”. ^bscored from 1 “strongly disagree” to 5 “strongly agree” ^creverse-scored. ^dwhere not normally distributed, median and quartiles 1 and 3 are reported

A read receipt was received for 95% of the 36 WhatsApp messages sent [Table 2]. No participant used the group chat to contact other female CR participants. The WhatsApp chat was used only to contact the nurse–researcher, most commonly to arrange the subsequent phone call to address their concerns, but this was done by about two-thirds of participants.

Women participated in almost all of the 12 calls [Table 2]. The average length of the calls was 12 minutes. Patients most commonly discussed and raised questions about: Their symptoms, cardiac tests (e.g., bloodwork, diagnostic imaging) and interventions, medications, blood pressure status, dietary recommendations to support weight reduction, exercise, as well as the availability of physician specialists to treat their comorbidities.

Intervention usability and acceptability

Table 2 displays the “excellent” perceived usability of TaCT on the SUS. The Cronbach’s alpha for the acceptability items was 0.85, which is considered more than acceptable.[37] Table 2 also shows the very high acceptability ratings, including regarding the volume, readability and utility of the information, the helpfulness of the bi-weekly calls and yoga video, as well as with the appeal and implementability of the intervention. The participants perceived the intervention met their needs as women.

There are several exceptions, however. The information was rated as very difficult to understand, while at the same time, they reported they understood all the information, suggesting some elements of the intervention were clearer (e.g., app, WhatsApp) than others (website). Moreover, they reported confusion on the calls about how to control their blood pressure and lipids, but these queries were clarified. Participants were somewhat unclear about what diet or exercise plan to follow. Finally, there was some variation amongst participants in terms of individualized preferences for in-person visits, and calls versus engaging with the CR materials asynchronously. Despite these challenges, most participants expressed willingness to recommend the intervention to others and believed it helped manage their heart health.

Discussion

Clinical guidelines recommend women-focused CR,[38] and hence there have been some preliminary efforts to tailor eCR to address their needs and preferences. To our knowledge, this had not yet been undertaken in a low-resource setting, where women are even less likely to access these proven services due to barriers that can be mitigated by technology. Following a pilot study where some implementation challenges were identified and mitigated, this sub-study of the TaCT trial has demonstrated the high engagement, usability, and acceptability of the eCR intervention. Women rated TaCT usability in the “excellent” range. Patients completed over 11 out of 12 biweekly calls on average, logged into the app over 7 times, and “read” 34 out of 36 WhatsApp messages, and the four educational webpages were visited 74–151 times, indicating high engagement. They rated the overall intervention acceptability favorably as well (most scores in the high 4s out of 5), including its applicability to their lives as women and their intention to incorporate the information into their daily lives. However, some participants rated certain risk management aspects as challenging to understand.

To our knowledge there has been one previous eCR model developed for women (HerBeat),[39] undertaken in the high-income country of the United States.[24] The intervention comprised a mobile app (also including videos), web-based dashboard, and smartwatch (leveraging heart rate and step count data), with the latter not being as feasible in a lower-resource setting. Usability was also rated highly by women – but lower than that for TaCT -- at 83.6 on the SUS. A subsequent randomized pilot trial of HerBeat further supported efficacy about functional capacity among other outcomes, implementability, and acceptability.[40] Online women-focused CR education is available open access (Cardiac College for Women),[41,42] however it is designed to supplement supervised CR and was developed in the global North.[41] Data also support its usability and acceptability.[42] Another women-focused web-based CR model is being co-designed for rural and remote women in the high-income country of Australia (CR Especially for Women; CREW).[43]

Implications

The results of this study hold implications for practice, policy, and research. Understanding and meeting women’s specific preferences can support the optimal engagement of women in eCR interventions. Chiefly, it was surprising that there was no use of the group chat feature, given previous research has suggested women desire to engage with peers within CR.[44,45] The lack of engagement with the peer support chat may be explained by the fact that the participants never met synchronously online or in person, negating the development of trust and rapport necessary for active group communication. The preference for one-to-one messaging with the researcher could be attributed to a greater sense of comfort and trust in communicating with someone familiar rather than with unfamiliar peers, the expertise of the nurse–researcher versus peers, and/or preference for more private than group communication. Whether one group in-person synchronous session would be feasible in a low-resource setting warrants investigation, but at the least a videoconferencing session could be offered so that women with transportation, time, and inclination could attend. Overall, given the needs of women with CVD, the social component of the TaCT model should be augmented.

This could involve offering the yoga or relaxation sessions online synchronously for example, Relatedly, it is unknown how often the yoga and relaxation video was viewed and hence whether the psychological component of the intervention was of sufficient intensity, but outcome data do show reductions in anxiety were achieved.[30] Future research on the social component of TaCT is warranted.

Regarding policy and practice implications, results from the study also offer other insights on further refinement and customization of the TaCT intervention that would better meet women’s needs as well as best practices in eCR.[46,47,48,49] It may be prudent to bring some parsimony to the intervention by minimizing the number of technologies used or delivery modalities. To enhance the intervention, providing detailed, user-friendly educational materials through video tutorials could improve understanding of necessary lifestyle changes. A feedback mechanism within the app could help track progress and provide tailored advice. Improving the app’s user interface to include intuitive, accessible information on diet and exercise could further enhance user engagement and comprehension.

Regarding policy implications, unfortunately, TaCT cannot be delivered further without resourcing. To sustain and scale TaCT, the intervention must be fully funded and resourced, integrated into the cardiac continuum of care (including a CR program), and trained healthcare workers must be funded.[50] Indeed, frameworks outline key aspects needed to support the scale-up of CR in low-resource settings,[51] highlighting the importance of intervention integration into health systems and institutions, as well as increasing population coverage.[52] However, this work proffers some facilitators to future implementation, namely demonstration of practice benefit and alignment with local context.[53] A health economic analysis of TaCT and its broad implementation should be pursued.

Limitations and recommendation

Caution is warranted when interpreting the results. The single-center design limits generalizability beyond a tertiary facility in the specific region of the middle-income country of India. Relatedly, the geographic location of participants in the tertiary facility was not considered, and thus the generalizability of the findings to rural/remote versus urban-residing patients cannot be determined without further research.

Website “hits” were not captured per patient, and also as raised above the number of times patients engaged in yoga or meditation is not known. A further limitation pertains to potential social desirability bias given some measures were collected over the phone with the nurse-researcher, as well as acquiescence since there were some conflicting acceptability ratings. Moreover, given all participants were not queried specifically about implementation logistics, quantification was limited. The nature of the design precludes causal conclusions, but this is a sub-study of a randomized trial.

Conclusion

These preliminary results support TaCT, or tailored eCR for women with CVD in middle-income settings, as implementable, engaging, highly usable, and acceptable. This suggests that TaCT has the potential to improve women’s access and adherence to CR in resource-constrained environments. This research aligns with United Nations Sustainable Development Goal 3, ensuring good health and well-being for all. Given also data on its effectiveness in improving functional capacity, quality of life, heart-health behaviors, and anxiety,[30] future research is warranted to explore the long-term impacts and scalability for broader implementation and sustainment.

Data availability

Based on institutional ethical committee requirements, data are only available from the corresponding author upon reasonable request.

Ethical clearance

The study was approved by the Kasturba Medical College and Kasturba Hospital Institutional Ethics Committee (IEC: 471/2020).

CTRI Registration No: CTRI/2021/07/035197

Conflicts of interest

The authors declare that they have no competing interests.

Funding Statement

The mobile app development in this study was supported by the Public Health Research Initiative (PHRI) - Research Grant awarded to Dr. Sonia R.B. D'Souza. by Indian Institute of Public Health Gandhinagar (IIPHG), Public Health Foundation of India (PHFI), in collaboration with Department of Science and Technology (DST) - Grant Account Reference IMPACC (IV)/ dl851303/DELHI/DL-DLH, 2019. Ms. Henita Joshna Menezes, Ms. Akhila Satyamurthy and Mr. Shrikant Sahu are supported through the Dr. TMA Pai PhD Scholarship of Manipal Academy of Higher Education, Manipal. Ms. Akhila Satyamurthy has received funding from Heart Failure Association of India (HFAI/RG/2022/1). Dr. Abraham Samuel Babu has received funding from Indian Council of Medical Research, Govt. of India (5/4/1-9/2019-NCD-II).