Table 1 Common barriers to effective control of hypertension, diabetes and secondary prevention of stroke and interventions to address these barriers

Lack of awareness about diseases and their risk factors

• Mass awareness programme for hypertension, diabetes and stroke

• Individual patient education using culturally appropriate awareness material

• Counselling about risk factors (e.g. tobacco, alcohol and high salt use)

Lack of screening facilities at the village level

• Home-based screening of individuals ≥50 years of age for hypertension, diabetes and stroke

Lack of confirmation of diagnosis

• Referral of screen positive individuals to the village outreach clinic

• Evaluation and confirmation of diagnosis of hypertension, diabetes and stroke by the OP

Difficulty accessing healthcare facilities on regular basis

• Periodic village clinic by the OP

• Monthly home visits by the CHW to reduce need to travel outside the village for seeking care

Lack of treatment adherence

• Monthly follow-up by the CHW by making a home visit

• Follow-up by the OP every 2–3 months

Losing or running out of medications

• Availability of medication stock with the CHW

• After consulting the OP, the CHW will replenish the patient’s medications

Stopping medications due to side effects

• Change in medications by the CHW after consulting the OP when there are side effects due to medications

Affordability of medicines

• Free medications