Table 1.

Reasons for low attendance following referral and challenges identified in verifying visits at clinics

Theme	Description
Reasons
Risk perception	A common problem across all four sites was the disbelief of the individuals screened that their CVD level of risk was high and that a referral visit with a health professional was necessary. The lack of symptoms made the referral seem unnecessary.
Influence of traditional versus Western medical care	Many individuals deferred to their beliefs in traditional medicine over the screening assessment, which reduced the rate of follow-up at Western medical facilities.
Lack of trust in the role of CHWs in screening for CVD	Individuals were unaccustomed to CHWs performing CVD risk assessment as well as making referrals to health facilities. Their perceptions of the roles of CHWs were limited to dispensing of medication and/or provision of health education.
Acceptance of referrals made by CHWs by health professionals	The authority of the CHW to refer persons at risk to the clinics was disputed at almost all the sites. CHWs were not regarded as qualified to make referrals of the type provided in the study, by both clinical and clerical staff at the clinics. The ability of the CHWs to assess CVD risk was also perceived as a threat by the health professionals.
Fear of reprimand and the lack of support from health facilities.	Individuals did not wish to be ‘scolded’ by health personnel for not seeking help sooner despite not knowing they were at risk of CVD.
Communication barriers	Individuals that spoke different languages to the health professionals at the referring facilities anticipated difficulties in communicating and did not see the value in attending the referral visit.
Opportunity cost of attending health facilities	Individuals that were employed identified the opportunity costs related to attending clinics for the referral visits as being inhibitory.
Cost of medication	Individuals referred for formal diagnosis and treatment were not always guaranteed free access to medication. In Guatemala, for instance, referred participants were discouraged from attending due to the incurred expense of accessing medicine.
Travel cost of attending health facilities	The travel costs associated with attending a referral visit prevented some individuals from attending the referral visit.
Challenges
Access to health facilities and patient medical records	While the individual sites had arranged for referral visits to take place at individual health centres with clinic directors, this permission did not always translate to administrators at various levels at these clinics accommodating the study coordinators’ attempts to verify the visits.
Patient health records could not be found	In two of the countries, patient records could not be found due to a lack of systematic re-filing of folders. Single paper records were often misplaced between different programs of care.