Abstract A chronic disease management model of care (Empower Health) was launched in rural and urban areas of Ghana and Kenya in 2018. The goal was to improve disease awareness, reduce the burden of disease, and improve the clinical effectiveness and efficiency of managing hypertension. Leveraging the model, clinicians provide patients with tailored management plans. Patients accessed regular blood pressure checks at home, at the clinic, or at community‐partner locations where they received real‐time feedback. On the mobile application, clinicians viewed patient data, provided direct patient feedback, and wrote electronic prescriptions accessible through participating pharmacies. To date, 1266 patients had been enrolled in the “real‐world” implementation cohort and followed for an average of 351 ± 133 days across 5 facilities. Average baseline systolic blood pressure (SBP) was 145 ± 21 mmHg in the overall cohort and 159 ± 16 mmHg in the subgroup with uncontrolled hypertension (n = 743) as defined by baseline SBP ≥ 140 mmHg. SBP decreased significantly through 12 months in both the overall cohort (−9.4 mmHg, p < .001) and in the uncontrolled subgroup (−17.6 mmHg, p < .001). The proportion patients with controlled pressure increased from 46% at baseline to 77% at 12 months (p < .001). In summary, a new chronic disease management model of care improved and sustained blood pressure control to 12 months, especially in those with elevated blood pressure at enrollment.

The Journal of Clinical HypertensionVolume 23, Issue 6 p. 1269-1270 LETTER TO THE EDITOROpen Access The importance of considering cultural and environmental elements in an interventional model of care to fight hypertension in Africa Pauline Cavagna PharmD, Corresponding Author pauline.cavagna@aphp.fr orcid.org/0000-0002-2749-8836 Department of Pharmacy, St Antoine Hospital, AP-HP Sorbonne Université, Paris, France INSERM U970, Paris Cardiovascular Research Center, Université de Paris, Paris, France Correspondence Pauline Cavagna, Pharmacy Department, St Antoine Hospital, AP-HP Sorbonne Université, 184 rue du Fbg ST Antoine, 75012 Paris, France. Email: pauline.cavagna@aphp.frSearch for more papers by this authorKouadio Eulodge Kramoh MD, Institute of Cardiology of Abidjan, Abidjan, Côte d'IvoireSearch for more papers by this authorAbdallahi Sidy Ali MD, Centre National de Cardiologie, Cabinet de Cardiologie, Nouakchott, MauritaniaSearch for more papers by this authorDahdi M. Balde MD, Cardiology Department, University Hospital of Conakry, Conakry, GuineaSearch for more papers by this authorAbdoulaye K. Traore MD, Cardiology Department, Hospital of Sikasso, Sikasso, MaliSearch for more papers by this authorStephanie Khoury MSc, INSERM U970, Paris Cardiovascular Research Center, Université de Paris, Paris, FranceSearch for more papers by this authorXavier Jouven MD, PhD, INSERM U970, Paris Cardiovascular Research Center, Université de Paris, Paris, France Cardiovascular Epidemiology Department, Université de Paris, Paris, France Cardiology Department, AP-HP Centre, European Georges Pompidou Hospital, Paris, FranceSearch for more papers by this authorMarie Antignac PharmD, PhD, Department of Pharmacy, St Antoine Hospital, AP-HP Sorbonne Université, Paris, France INSERM U970, Paris Cardiovascular Research Center, Université de Paris, Paris, FranceSearch for more papers by this author Pauline Cavagna PharmD, Corresponding Author pauline.cavagna@aphp.fr orcid.org/0000-0002-2749-8836 Department of Pharmacy, St Antoine Hospital, AP-HP Sorbonne Université, Paris, France INSERM U970, Paris Cardiovascular Research Center, Université de Paris, Paris, France Correspondence Pauline Cavagna, Pharmacy Department, St Antoine Hospital, AP-HP Sorbonne Université, 184 rue du Fbg ST Antoine, 75012 Paris, France. Email: pauline.cavagna@aphp.frSearch for more papers by this authorKouadio Eulodge Kramoh MD, Institute of Cardiology of Abidjan, Abidjan, Côte d'IvoireSearch for more papers by this authorAbdallahi Sidy Ali MD, Centre National de Cardiologie, Cabinet de Cardiologie, Nouakchott, MauritaniaSearch for more papers by this authorDahdi M. Balde MD, Cardiology Department, University Hospital of Conakry, Conakry, GuineaSearch for more papers by this authorAbdoulaye K. Traore MD, Cardiology Department, Hospital of Sikasso, Sikasso, MaliSearch for more papers by this authorStephanie Khoury MSc, INSERM U970, Paris Cardiovascular Research Center, Université de Paris, Paris, FranceSearch for more papers by this authorXavier Jouven MD, PhD, INSERM U970, Paris Cardiovascular Research Center, Université de Paris, Paris, France Cardiovascular Epidemiology Department, Université de Paris, Paris, France Cardiology Department, AP-HP Centre, European Georges Pompidou Hospital, Paris, FranceSearch for more papers by this authorMarie Antignac PharmD, PhD, Department of Pharmacy, St Antoine Hospital, AP-HP Sorbonne Université, Paris, France INSERM U970, Paris Cardiovascular Research Center, Université de Paris, Paris, FranceSearch for more papers by this author First published: 08 April 2021 https://doi.org/10.1111/jch.14252AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat To the Editor, We read with great interest the article by Otieno et al,1 titled "Improved blood pressure control via a novel chronic disease management model of care in Sub-Saharan Africa: Real-world program implementation results" which presents a novel hypertension management model of care to improve blood pressure (BP) control in sub-Saharan Africa. This model of care is a real innovation that uses smartphones and regular check-ins to ensure optimal patient follow-up. This study, implemented in two middle-income countries, successfully improved and sustained BP control over 12 months of follow-up. Firstly, this model of care, by standardizing the management of hypertension, placed patients at the heart of their care. This model of care developed a direct link between the patient, the physician, and the pharmacy. However, it did not include a traditional health practitioner and it did not seem to take into account the use of traditional medicine. The World Health Organization defines the use of traditional medicine as the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement, or treatment of physical and mental illness.2 The use of traditional medicine is documented in both African countries and worldwide with a prevalence varying between 20% and 80%.3-7 Among African hypertensive patients, the use of traditional medicine is common without an association with age or educational levels.5 In a recent multinational study on sub-Saharan Africa hypertensive patients, the use of traditional medicine was shown to be strongly associated with poor adherence to conventional treatments.8 It would be an interesting and useful addition to include traditional medicine and traditional health practitioners in the model of care presented by Otieno and colleagues. Although this model of care has greatly improved hypertension management in sub-Saharan Africa, it can be improved further by considering other cultural and environmental aspects of Africa, particularly the use of traditional medicine and health practitioners.9 Secondly, in low- and middle-income countries, access to medication is defined by five dimensions (availability, affordability, accessibility, acceptability, and quality of drugs10). In this setting, a large proportion of communities do not have access to more than one antihypertensive drug and, when they are available, they are often not affordable.11 In sub-Saharan Africa, access to medicine is an especially crucial element in a model of care performed to improve BP control, and in this intervention, access to medication is absolutely deleted. Finally, this model of care was implemented across rural and urban facilities in two middle-income countries, whereas African countries are largely classified as low income. It is worth considering whether this model could be generalized to low-income countries as the wealth index of patients has been associated with different levels of hypertension control.12 CONFLICTS OF INTEREST No author has any competing interests. AUTHOR CONTRIBUTIONS All authors have substantial contributions. P. Cavagna, M. Antignac, S. Khoury, and X. Jouven drafted the manuscript. All authors critically revised the manuscript for important intellectual content and approved the final version to be published. REFERENCES 1Otieno HA, Miezah C, Yonga G, et al. Improved blood pressure control via a novel chronic disease management model of care in sub-Saharan Africa: Real-world program implementation results. J Clin Hypertens. 2021: 1- 8. Web of Science®Google Scholar 2 World Health Organization, ed. WHO Traditional Medicine Strategy. 2014-2023. World Health Organization; 2013. Google Scholar 3Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA. 1998; 280(18): 1569- 1575. CrossrefCASPubMedWeb of Science®Google Scholar 4Eddouks M, Maghrani M, Lemhadri A, Ouahidi M-L, Jouad H. Ethnopharmacological survey of medicinal plants used for the treatment of diabetes mellitus, hypertension and cardiac diseases in the south-east region of Morocco (Tafilalet). J Ethnopharmacol. 2002; 82(2–3): 97- 103. CrossrefCASPubMedWeb of Science®Google Scholar 5Osamor PE, Owumi BE. Complementary and alternative medicine in the management of hypertension in an urban Nigerian community. BMC Complement Altern Med. 2010; 10: 36. CrossrefPubMedWeb of Science®Google Scholar 6Nuwaha F, Musinguzi G. Use of alternative medicine for hypertension in Buikwe and Mukono districts of Uganda: a cross sectional study. BMC Complement Altern Med. 2013; 13: 301. CrossrefPubMedWeb of Science®Google Scholar 7James PB, Wardle J, Steel A, Adams J. Traditional, complementary and alternative medicine use in Sub-Saharan Africa: a systematic review. BMJ Glob Health. 2018; 3(5):e000895. CrossrefPubMedWeb of Science®Google Scholar 8Macquart de Terline D, Kane A, Kramoh KE, et al. Factors associated with poor adherence to medication among hypertensive patients in twelve low and middle income Sub-Saharan countries. PLoS One. 2019; 14(7):e0219266. CrossrefCASPubMedWeb of Science®Google Scholar 9Krah E, de Kruijf J, Ragno L. Integrating traditional healers into the health care system: challenges and opportunities in rural Northern Ghana. J Community Health. 2018; 43(1): 157- 163. CrossrefPubMedWeb of Science®Google Scholar 10Wirtz VJ, Kaplan WA, Kwan GF, Laing RO. Access to medications for cardiovascular diseases in low- and middle-income countries. Circulation. 2016; 133(21): 2076- 2085. CrossrefPubMedWeb of Science®Google Scholar 11Rockers PC, Laing RO, Ashigbie PG, Onyango MA, Mukiira CK, Wirtz VJ. Effect of Novartis Access on availability and price of non-communicable disease medicines in Kenya: a cluster-randomised controlled trial. Lancet Glob Health. 2019; 7(4): e492- e502. CrossrefPubMedWeb of Science®Google Scholar 12Antignac M, Diop IB, Macquart de Terline D, et al. Socioeconomic status and hypertension control in Sub-Saharan Africa: the multination EIGHT Study (Evaluation of Hypertension in Sub-Saharan Africa). Hypertension. 2018; 71(4): 577- 584. CrossrefCASPubMedWeb of Science®Google Scholar Volume23, Issue6June 2021Pages 1269-1270 ReferencesRelatedInformation

Isaac Kofi Owusu1, Fred Adomako-Boateng2, Fred Kueffer3, Molly Guy3, Chemuttaai Lang’at3, Daniel B Grossman4, Teri Whitman3, Keith Holloman3, Douglas A Hettrick3* and Opare-Sem O1 1Department of Medicine, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana 2Regional Health Directorate, Ghana Health Service, Kumasi, Ghana 3Medtronic, Inc, Minneapolis, MN, USA 4Mayo Clinic, Rochester, MN, USA

Objective: A novel locally appropriate hypertension management model of care was developed and tested in the Republic of Ghana to address specific socioeconomic and community-related barriers to blood pressure (BP) control. Design and Methods: Patients with a history of hypertension were enrolled and each agreed to visit a participating nearby community pharmacy at least once per week for 6 months for a BP check, symptom review, and medication monitoring. Weekly pharmacy visit data were manually logged into a mobile application by the pharmacy staff. Guideline based logic in the application provided immediate feedback to the patient and transmitted data to the primary physician. Electronic prescriptions, from the primary physician, were accessible to participating pharmacies. Clinic blood pressure from the prior 6 months was also retrieved from patient records. Results: Compliance with weekly BP assessments in the 150 enrolled patients (57± 8 years; 73% Female) was 61% and 2705 total pharmacy BP assessments were conducted. Improvement in overall health awareness was reported in 82% of the patients and 95% indicated a desire to continue using the model of care in the future. During the 6-month voluntary program period, the number of scheduled office visits decreased by 60% compared to standard monthly visits. Despite fewer in clinic visits, average systolic BP decreased significantly from the 6-month pre-trial period baseline (137.4±14.0 to 129.8± 16.3 mmHg, p<0.01). The proportion of patients with blood pressure below target (140 mmHg) for least 75% of all readings increased from 41% in the 6 months prior to enrollment to 62% during the study follow up period (p<0.01). This improvement was associated with potential cardiovascular risk reduction of 5-21% based on previous randomized trials. The proportion of patients with > 75% controlled BP also improved in the subset of patients with BP below target at enrollment from 52% to 76% (p<0.01), implying potential risk benefits even in “well controlled” patients. Conclusions: The care model applied in this hypertensive West African resulted in fewer clinic visits and high patient and clinician satisfaction as well decreased systolic blood pressure and increased proportion of time with controlled blood pressure.

Background: Logistic and socioeconomic barriers limit effective blood pressure (BP) control in many parts of Sub-Saharan Africa, including the Republic of Ghana. We tested a novel hypertension management model of care designed for resource-limited settings. Methods and Results: The “Akoma Pa” model was developed using human-centered design methodology involving patients, physicians, and nurses. The model consisted of a mobile tablet, BP machine and a novel software application in a unique platform to allow for longitudinal patient management. Patients were provided with a tailored hypertension management plan based on their enrollment comorbidities and risk factors. A cohort of 150 hypertensive patients (57±8 years; 73% female) accessed regular blood pressure assessments at a local pharmacy and received real-time automated feedback based on their individualized plan. On the mobile application, clinicians were able to view patient data, provide patients with feedback via SMS on their condition, and write electronic prescriptions which could be accessed by participating pharmacies. Average baseline BP was 135±18/84±10 mmHg in the overall cohort and 153±13/90±11 mmHg in the subgroup with uncontrolled hypertension (n=58). After 6 months of voluntary weekly monitoring, systolic blood pressure decreased significantly (p<0.01) in the overall cohort (-4.7±18.7 mmHg) and in the uncontrolled subgroup (-15.2±17.6mmHg). Systolic blood pressure remained constant in the sub group with controlled pressure at baseline. The proportion of the population with uncontrolled hypertension decreased from 39% to 27% (p=0.01). Patient compliance with weekly BP assessments was 61% and 2,855 BP assessments were conducted. During 33 of the 2,855 BP assessments (1% of pharmacy visits), the software application directly referred patients to a health facility (33 visits in 25 patients). Improvement in overall health awareness was reported in 82% of the participants and 95% of participants indicated a desire to continue using this model in the future. Conclusions: Compliance and satisfaction with this multifaceted hypertension care model were high and led to significant and sustained decreases in blood pressure in this West African hypertensive population.