Sitting at mother's knee: global hypertension lessons learned

Mother‐to‐child transmission may not be limited to HIV. As a concept, mother‐to‐child transmission may have critical importance and broader implications in the cardiovascular/hypertension noncommunicable disease realm. In this month's Journal of Clinical Hypertension (JCH), Takada and colleagues in a report from Shirakawa, Japan, have documented the association between salt intake of mothers and their 3‐year‐old children. It is both simple and profound in its implications.

It is simple in confirming our intuition. It is based on objective data, while recognizing the challenges of the estimation of sodium intake by spot urine sodium analysis including specific challenges in a 3‐year‐old.

This is superimposed on a dietary analysis database of high sodium intake from INTERMAP. Culturally, obvious dietary targets represent almost 60% of total sodium burden. This includes soy sauce (20%), pickled vegetables and fruits, (9.8%), miso soup (9.7%), fish (9.5%), and salt from restaurants, fast food, and home (9.5%).1 There has been a significant drop in population‐based sodium intake from historic highs. In parallel, the World Health Organization reported an 85% drop in Japan's stroke rate. Many credit a vigorous national health system intervention, including community cooking classes. A focused elderly initiative is balanced by mandatory checkups for 3‐year‐old children.

Mothers were primary caregivers and food preparers for their children 90% of the time. Maternal recommended salt intake (7 g) is exceeded 90% of the time at 10.1 g, with 50% of children increased above goal at 4.5 g. There was a demonstrated association between elevation of sodium intake by mothers (especially if hypertensive) and their children, suggesting linkage.

The concluding message was potential empowerment and subsequent leverage by virtue of knowledge of this association. The simple hope is for overt maternal action to avoid adverse consequences by changing family behaviors. This “knowledge is power” paradigm is consistent with the multimedia and fact sheet–based education models of many high‐income and high‐literacy countries, as well as many middle‐income nations represented in the World Hypertension League (WHL). There is a presumption of positive influence, as recent reports have shown successful improvement of awareness, treatment, and control metrics in high‐income countries.

Unfortunately, 75% of the hypertension burden (>1 billion people) is in mid‐ and low‐income countries, losing ground as hypertension prevalence increases with a widening gap. In addition, now only 7.7% of patients with hypertension have their blood pressure adequately controlled, down from 8.4%.2 The gradient of inequality goes beyond income, manifested by lack of infrastructure support and literacy.

The Shirakawa study is therefore profound in its broader implications, as it touches on issues of cultural diversity, sex, income, and literacy. The common thread has been clearly identified: the critical role of mothers and families. This thread has been incorporated into the School‐EduSalt program in China focused on students and families.3 Dr Valentin Fuster and colleagues’ innovative high‐powered FAMILIA program in Harlem and globally has focused on children and families, spreading the cardiovascular risk message using information communication technologies tools such as Sesame Street.4

Japan enjoys a 99+% literacy rate. According to UNESCO data, women in Haiti have a literacy rate of 57% and men 64%, with a national average of 60%. This is similar to the 58% female, 64% male, and 61% average rate in Bangladesh. Of interest, it mirrors the United Nations’ Least Developed Countries data of 53% female, 68% male, and 60% average. Literacy rates in Africa are substantially less, often mired in the 25% to 40% range. Most literacy‐challenged countries do have substantial sex gaps.5

Indeed, sitting and learning at “mother's knee” has a rich tradition of education for women and girls, when avenues of formal education are not open to them. Using Haiti as an example, beyond heavy salt food preservation and preparation issues, the cultural folklore of salt as a source of strength and vitality is counterproductive, contributing to extraordinarily high salt intakes with associated high hypertension and stroke disease burdens.6 The challenge, with potentially illiterate mothers as the teacher linkage, is how to transition towards mother‐to‐child transmission of validated information in the verbal tradition.

The fact is that despite illiteracy and educational deficits, there is intellectual and caring equipoise across the high‐, mid‐, and low‐income spectrum that demands the respect of innovative and flexible approach solutions that reflect cultural and local realities. The question is how do we effectively address the literacy gradient? Perhaps what is required is an amalgam that takes advantage of mutual strengths including the trickle down of written factual information and bubbling up of verbal traditions––in essence, factual folklore.

Perhaps ironically, business consultant literature may have some hints for the destitute bottom billion. Clayton Christensen and colleagues7 describe catalytic innovation as a variation on the disruptive innovation business model to provide “good‐enough” solutions to inadequately address social problems. While this good‐enough approach may be anathema to some in the public health arena, it is a pragmatic best possible practice start for reality‐based medicine.7 System theorists would tell us to avoid symptomatic solutions and focus on the difficult systemic issues. It is not contradictory advice, as Peter Senge8 would also point to the threat of eroding goals that happens when there is a gap between our goals and reality, and dichotomous responses to either improve our situation or lower the goals.

The path is clear. We must keep our aspirational goals bar high, but meet where people are and not where we think they should be. With that situational understanding, we can then build from there, even if it is from near ground zero, starting with good‐enough solutions. Data clearly show us that it is time to consider innovative solutions for hypertension‐laden, low‐income, low‐literacy countries.

From a business marketing perspective, Peter Guber9 discusses the importance of the purposeful story, with exhortation that “it's the story, stupid!” The challenge for hypertension has always been that it is a negative story, where success is defined by nonpalpable avoidance of catastrophic complication. We need to do a better job selling the global hypertension story, with the corollary that we need to identify and speak specifically to our target audience in a language and with a story they understand.

Colleagues In Care (CIC) approached this problem in a novel way to address the parasite challenge in Haiti, in a community where those fortunate enough for higher education went to the fifth grade. With talented and dedicated partners, a culturally appropriate family‐based story line was developed focused on children, but with simple statements of pertinent health information incorporated into the story. Then, with illustrators and graphic artists, a coloring book medium was developed. It was very successful as the children actually precipitated the family discussion, which was no longer folklore but factual. Subsequently, this approach has been used in many countries for things such as burns and fire safety, diabetes mellitus, and mother/child teaching about safe water. As a bookmark to come back to, many of these programs with coloring books were supported by faith‐based groups and small nongovernmental organizations that were already in place in these destitute rural communities.

The World Hypertension Action Group (WHAG) approach is to partner with faith‐based groups doing medical missions and small nongovernmental organizations in underserved low‐resource venues. Building an education foundation, WHAG will use developing building block tools ranging from coloring books, telling a family story linking salt to hypertension and stroke/heart failure, to more sophisticated information communication technologies–based vetted public education resources and gamification. WHAG's framing structure is related to training focused on the ability to take accurate blood pressure measurement for initial screening and eventual management. Build‐out options will include voluntary database participation and even telemedicine. WHAG will also be partnering with the United Nations’ Small Island Developing States, allowing model partnerships on a reasonable‐size scale, eagerly following partners work in small smart city initiatives (whag4all.org).

The Shirakawa project has profoundly shown us the need to pick up the common thread of mothers and families, and challenges us to tell our global hypertension story better. It is up to us to identify our target by virtue of level of resource, literacy, and cultural factors, and to modify our approaches accordingly. The WHAG developing program is but one approach taking standardized vetted information and multiple approaches, reshuffled in heretofore unconventional ways. It will take an innovative matrix, as indeed there is no simple one‐size‐fits‐all global hypertension solution.

What will work for you and your circumstances? The WHL, WHAG, and JCH forums offer a unique opportunity to report on systems that work well, and share successes and lessons learned as we approach this complex global hypertension challenge together. We have made substantial progress at the top, and now we need to work down the gradient of inequality towards serving the bottom billion.

CONFLICT OF INTEREST

None.

Kenerson J. Sitting at mother's knee: global hypertension lessons learned. J Clin Hypertens. 2018;20:736–738. 10.1111/jch.13266