Table 4 Key themes identified and major findings

Perceived usefulness of the risk management program

• High-risk community members were satisfied with the intervention.

• Most villages doctors maintained a positive attitude on the program.

Content of risk management program

• EDSS was a promising tool for CVD management.

• EDSS needed to be designed in local language.

• Mobile or wireless internet signals needed to be improved.

• The use of western medications was a concern among the high-risk community members.

Fidelity to the risk management program

• Lack of knowledge, and traditional cultural belief were the main barriers to medication adherence.

• Village doctors showed a high level of fidelity to the intervention.

Barriers and facilitators to implementation

• Lack of trained personnel, large existing workload, financial incentive, and transportation were identified as major challenges for implementation.