Table 2.

Most salient barriers to cardiovascular disease care in Indian context.

CATEGORY	SPECIFIC BARRIER	ILLUSTRATIVE QUOTES
patient	Low health literacy	‘I don’t know about (CVD) symptoms. Earlier I had an accident (when asked about the cause of CVD).’ (Patient-02)
	Socio-economic status (Poverty)	‘If they don’t have money to eat well the question about avoiding disease, (CVD) you know…so there is where the problem starts…mainly in lower economic status.’ (caregiver-02)
	Cost of care (affordability)	‘There is one medicine Vymada (medicine to treat heart failure), that one strip is around 1075 Rs. He has to take 60 tablets in a month. So, it’s around 4000 Rs for us. We sell milk, we sell crop then only we can get it. We are farmers.’ (Caregiver-04)
	Long queues	‘Here the line (for patient registration) starts midnight 2 am. So, I stand in line. Then they said they will make a card in morning 11 am. Cardiologist doctor comes here at 2pm. So, we got the number and showed to doctor.’ (Patient-04)
	Difficulties in maintaining self-care habits: misconceptions around diet, exercise, tobacco, alcohol use	‘The biggest misconception they have is they need to exercise only in the morning. And no benefit after that.’ (Physician-07)
	Competing obligations and lack of family support	‘With the fragmentation of the family, the family is getting nuclear, there are not many people to take care of elderly.’ (Caregiver 12)
provider	Time constraints and high patient volume	‘Sometimes we feel that one patient needs more time than the other, but we are always in the rush, finishing the rounds, coming here for the OPD, doing some ECHO, then the CATH lab, then again rounds, so I feel it is the shortage of time (Greatest barrier to chronic care of CVD). (Cardiologist-26)
	Mis-information epidemic	‘Many of the highly literate people who are computer savvy, they are (What I call them is misinformed) of this misinformation because of this misinformation going on in various social media so that misinformation epidemic must be controlled so sometimes that takes lots of time.’ (Physician-09)
	Lack of focus on prevention	‘We know what is killing us, we are not prepared to stop it because the smoking industry is more powerful than the few doctors who are concerned about it.’ (Cardiologist-04)
	Polypharmacy and poor adherence to medications	‘When you have 20 drugs, they must make sure that he understands which drugs are essential. So, it is a challenge.’ (Physician-09)
	Mixed recommendations from other health practitioners	“They (patients) have to follow one (doctor) and then follow the other one and sometimes there may be overlap of therapies which may not be properly addressed. (doctor).’ (Physician-12)
	Inadequate uptake of evidence-based guidelines	‘Lack of repeated upgradation of knowledge among the physicians. Many of the physicians are not keeping themselves updated with the knowledge. That is a very big problem.’ (Physician-09)
	Beliefs about traditional medicine practices	‘Some patients are having their own ideas about getting treatment from some alternative sources of medicine, so they don’t listen to us, and they take what they want.’ (Physician-14)
health system	Shortage of trained manpower	‘I think number one challenge is the (limited) availability of the (trained) manpower, so they need to have qualified people available in the hospital around the clock.’ (Health administrator-01) ‘We don’t have a dedicated heart failure staff – heart failure nurse, heart failure dietician.’ (Cardiologist-24)
	Lack of counsellor or patient care coordinator	‘The things which are missing are you know there is a concept something called as a counsellor which is not there too much in Indian health infrastructure.’ (Physician-02)
	Lack of robust communication systems	‘Firstly, I think there is lot of misguidances to the patient, as to how, when and where they should approach which specialty. That is the thing that is not fixed in our country.’ (Physician-09)
	Poor referral linkages	‘Unless the patient is very sick and they (private clinics) want to get rid of the patient or if the patient in due course become sick they refer otherwise they keep the patient and after that once the patient spends 60-70 thousand rupees they send the patient for government scheme, there we are supposed to treat the patient, do angioplasty, everything it is very difficult for us so we can’t tell it openly because if you tell it openly that doctor is not going to refer to you at all.’ (Cardiologist-26)
	Lack of monitoring systems to follow-up patients	‘If there is a lot to follow-up we don’t remember also because nothing is computerized.’ (Cardiologist-02)