Discussion
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We report findings from 87 post-implementation interviews of patients, CHWs, and physicians assessing COBRA-BPS multicomponent intervention strategies’ acceptability in rural Bangladesh, Pakistan, and Sri Lanka at the health systems level using the theoretical framework of acceptability [Previous evaluations of CHW-led NCD interventions’ acceptability and their barriers and facilitators were mainly limited to pre-implementation studies [Consistent with the feasibility study report, the CHWs in all three countries felt more respected and empowered in the communities and felt motivated to deliver high-quality care [However, we also found some persistent health systems challenges, which, if addressed, could further enhance the acceptability of our COBRA-BPS multicomponent intervention. Of note, the lack of provision of antihypertensive medications free of cost in the primary care clinics was a frequent complaint expressed by the patients [Our study has some limitations. First, the timing of the interviews was after the completion of the trial in Bangladesh and Sri Lanka (2019), and during the course of the trial in Pakistan (2016–2017), albeit after the intervention was implemented in all three countries in 2016. Second, more participants were recruited from Sri Lanka, compared to the Bangladesh or Pakistan, each. However, the country and patient demographics, and health systems of Pakistan and Bangladesh are quite similar and cumulatively they contributed the same number of participants as Sri Lanka, albeit not stratified in the subgroups as originally intended in the protocol. Community engagement efforts prior to scale-up must ensure seeking feedback from all representative subgroups especially in the more populous countries of Bangladesh and Pakistan. Moreover, the acceptability of district and national health managers and policymakers will need to be assessed.In conclusion, our post-intervention assessment on 87 physicians, community health workers, and patients strongly suggest that the multicomponent COBRA-BPS multicomponent intervention is acceptable with a good fit and highly valued by the rural stakeholders Bangladesh, Pakistan, and Sri Lanka. Physicians and community health workers reportedly felt more rewarded despite an increase in workload, which they managed well. Patients’ improved adherence to physicians’ and CHWs’ advice and adopted healthy behaviour. Our findings of excellent acceptability coupled with effectiveness, co-effectiveness, and affordability, make a compelling case for further community engagement for scaling-up COBRA-BPS in the rural communities in Bangladesh, Pakistan and Sri Lanka and other LIMCs with similar healthcare infrastructure.