Evaluating the role of pharmacists and m-Health strategies in the management of hypertension in General Pueyrredon

Hypertension is one of the main cardiovascular risk factors in Argentina and the cause of a high number of diseases and deaths. Although there is extensive knowledge about effective treatments and preventive strategies, there is a gap that limits the translation of this knowledge on the benefits of the patients, especially of the poorer ones. Almost half of hypertensive patients do not know their condition and most of them are not appropriately controlled. Lack of access to health services due to multiple types of barriers as well
as the lack of patients' adherence to control and treatment are the main problems that explain this gap. The incorporation and integration of the pharmacists to the health system and the use of Information and Communication Technologies (ICTs) have showed highly promising results in the improvement of the management of this condition; however, they are scarcely used in Argentina. In 2018, the Secretariat of Health of the Municipality of General Pueyrredón, Province of Buenos Aires, prompted an innovating
community-program, which incorporates the pharmacists to the municipal health system as well as a virtual platform ("Health MGP", https://saludmgp.rpmplay.com/) and a mobile app targeted to hypertensive patients. Pharmacists' incorporation will improve patients' access to health services, as most people have a pharmacy near their home and they do not need a scheduled turn to assist. Besides, pharmacists will collaborate in patients' follow-up, through blood pressure, counselling and medication use supervision. The
virtual platform will permit hypertensive patients to be part of a virtual community, in which other hypertensive patients and health professionals participate and through which, the patient can interact with others and be actively involved in the management of the disease. The mobile app will send reminders to hypertensive patients to support their involvement in the program and reinforce adherence to recommendations. We propose a mixed-study to assess the access, acceptability, adoption and impact of this program,
and to use this experience as a case study to promote the debate among key stakeholders of the policy and legal fields about the pharmacists' participation in the health system as well as the use of ICTs in the management of NCDs and hypertension. The incorporation of these technologies not only constitutes the future in the management of Chronic Disease but also represents a shift in the paradigm of care. They contribute to the transformation of the health system from one that is essentially reactive to one that is
proactive through the active involvement of the patient in the self-management of their disease.

Hypertension is one of the main cardiovascular risk factors in Argentina, with a high prevalence (36%) and an important social, economic and health impact. Despite the availability of highly effective treatment and preventive strategies, only half of hypertensive patients are aware of their condition and the majority are not appropriately controlled. The incorporation of pharmacists and the use of information & communication technologies (ICTs), are two of the strategies that have shown to be effective in the improvement of
hypertensive patients' management. This proposal is aimed at evaluating the access, acceptability, adoption and impact of an innovating program, which incorporates pharmacists, social marketing and the use of ICTs ("Health MGP" https://saludmgp.rpmplay.com/ and a mobile app) in the diagnosis, treatment, monitoring and control of hypertension in patients with different types of health coverage and from different social strata at the Municipality of General Pueyrredón, Province of Buenos Aires, Argentina. Adult residents of this city (>18 years old), excluding pregnant women, will constitute the eligible population. A mixed method study will be conducted.

This research is aimed at strengthening the diagnosis, treatment, monitoring and control of hypertension in people with hypertension who belong to different social vulnerability strata of the Municipality of General Pueyrredón, Province of Buenos Aires, through the implementation of an innovating program which incorporates pharmacists, ICTs (virtual platform and a mobile app - m-Health-) and social marketing as central axis of the innovation. The research will permit the assessment of the program acceptance
and valuation by users and implementers. Also, it will be used to generate information about its effect on the improvement of patient access to health services and on the modification of behaviours associated with the disease monitoring and control. This information will be critical for the development of the scaling-up strategy beyond patients recruited during the research. There is evidence that shows that the effectiveness of programs that employ ICTs and m-Health varies according to social vulnerability. Thus, the stratified implementation strategy as well as the implementation of marketing social strategies through m-Health according to the prevalent barriers in each stratum will permit the generation of knowledge and learned lessons on the most effective strategies in each population group, particularly in those with the highest vulnerability (social marketing segmentation). Initiatives like the proposed one make it possible to "adapt" the supply to demand characteristics, eventually increasing access to health services as well as its impact on disease management and control. The administration panel of the virtual platform will allow the creation of the first hypertensive patient registry of the city, with real time information of multiple variables of each patient included. This registry will represent a highly relevant contribution from the epidemiological and public health perspective. The research represents an innovating initiative in the country for different reasons. Although there is extensive international evidence about the effectiveness of the programs incorporating pharmacists on hypertension control improvement, there are no similar programs in our country. The program that will be held by the Municipality of General Pueyrredón integrates pharmacists into the municipal health system through the creation of units of care constituted by PHCCs and nearby pharmacies and the use of a virtual platform with a free mobile app for enrolled hypertensive patients as the communicational support of the whole program. Besides, physicians working at the SS-S and PS-S will be invited to participate and be registered on the platform. It is expected that the involvement of these sectors in the municipal program will contribute to the integration of services that currently work in a disjointed way. This experience could be scaled up to the prevention and control of other NCDs, such as diabetes. In effect, different studies have already assessed the incorporation of pharmacists in the management and control of this disease, with promising results.
The role of pharmacists in the prevention and control of NCDs has not been studied in Argentina. Therefore, this experience could be used as a case study to prompt changes to local and national policies specifically related to the participation of pharmacists. The implementation of DDs in the last year of the research is aimed at creating spaces for exchange among key actors of the local and national health system. In these spaces, and through evidence informed deliberation, particularly on the basis
of program results and lessons learned, it would be possible to foster changes in the health system to strengthen its capacities to respond to health care needs of patients with NCDs. The assessment of costs associated to the implementation of the program is another relevant contribution of the research, as it is critical information for the sustainability and scaling-up