Food resources and kitchen skills plus aerobic training (FoRKS+) for black adults with hypertension: A pilot trial protocol.

BACKGROUND: Midlife hypertension is associated with cognitive decline and Alzheimer's disease and related dementia (ADRD), suggesting that blood pressure control may be a therapeutic target for dementia prevention. Given excess hypertension in non-Hispanic Black (NHB) adults, blood pressure control may also reduce ADRD disparities. We describe a pilot randomized controlled trial (RCT) to evaluate the feasibility and preliminary efficacy of a multicomponent lifestyle-based intervention versus enhanced usual care on cognition among middle-aged NHB adults. METHODS AND STUDY DESIGN: The Food Resources and Kitchen Skills plus Aerobic Training (FoRKS+) study is a 2-arm, single-blinded trial that compares those receiving the FoRKS+ program (target N = 64) versus those receiving enhanced usual care (target N = 64) in local federally-qualified health centers. Key eligibility criteria include self-identified NHB adults between ages 35-75 with a mean systolic blood pressure ≥ 130 mm/Hg obtained from 24-h ambulatory blood pressure monitoring. The FoRKS+ program includes 5 weeks of hypertension self-management courses, 11 weeks of nutrition courses, and 12 weeks of aerobic training in dietitian and health coach-led virtual groups. We will collect data on primary cognitive outcomes, feasibility, hypothesized intervention mediators and moderators, and demographic and health covariates at baseline, near intervention weeks 16-, and 28 (primary outcome assessment), and week 52 follow-up. We will use mixed-effects modeling to examine intervention effects on cognition. DISCUSSION: This pilot RCT will examine the feasibility and preliminary effects of a multicomponent lifestyle intervention on cognitive function in NHB adults, which may have implications for reducing health disparities in ADRD.

A Longitudinal Theory-Based Investigation of how Environmental Aesthetics predicts Home-based Exercise.

INTRODUCTION: Environmental aesthetics is a recognized macro environmental correlate of physical activity participation. Extrapolating this effect, we hypothesize this variable to also function as a determinant of exercise participation in the microenvironment, such as the home. Specifically, we predict that the environmental aesthetics of the location of cardio and resistance training equipment will predict determinants of exercise participation within the Integrated Behavior Change (IBC) model. METHODS: Adult owners of exercise equipment (N = 231) completed measures on the environmental aesthetics of their cardio and resistance training equipment, exercise time, and constructs from the IBC model across three consecutive monthly surveys. Study hypotheses were tested using multilevel structural equation modeling with participants (level 2) nested within time (level 1). RESULTS: The model revealed predictive effects of intention, habit, and planning on exercise participation over time. The findings indicated a total effect of autonomous motivation on intention and habit. In addition, environmental aesthetics of cardio and strength training equipment predicted autonomous motivation, along with habit and intention when accounting for indirect effects. Finally, planning moderated the intention-behavior relationship, indicating that participants who scored higher on planning were more likely to translate their intentions to behavior. CONCLUSIONS: These findings provide informative notes for designing effective home-based exercise programs, which have increased in popularity over the past recent years. Specifically, experimental studies that provide exercise equipment should ensure that the location of the equipment is appealing to the participant to increase the likelihood equipment use and exercise engagement.

Investigating the Relationship Between Physical Activity Disparities and Health-Related Quality of Life Among Black People With Knee Osteoarthritis.

INTRODUCTION: Knee osteoarthritis (OA) is the most common form of arthritis, which is a leading cause of disability. Although no cure exists for knee OA, physical activity has been shown to improve functionality, which can improve an individual's health-related quality of life (HR-QOL). However, racial disparities exist in participating in physical activity, which can result in Black people with knee OA experiencing lower HR-QOL compared with their White counterparts. The purpose of this study was to investigate disparities of physical activity and related determinants, specifically pain and depression, and how these constructs explain why Black people with knee OA experience low HR-QOL. METHODS: Data were from the Osteoarthritis Initiative, a multicenter longitudinal study that collected data from people with knee OA. The study used a serial mediation model to test whether a change in scores for pain, depression, and physical activity over 96 months mediated the effects between race and HR-QOL. RESULTS: Analysis of variance models found Black race to be associated with high pain, depression, and lower physical activity and HR-QOL at baseline and month 96. The findings supported the prospective multi-mediation model, which found pain, depression, and physical activity to mediate between race and HR-QOL (ß = -0.11, SE = 0.047; 95% CI, -0.203 to -0.016). CONCLUSION: Disparities in pain, depression, and physical activity could explain why Black people with knee OA experience lower HR-QOL compared with their White counterparts. Future interventions should address sources of pain and depression disparities by improving health care delivery. Additionally, designing race- and culture-appropriate community physical activity programs would help to achieve physical activity equity.

Immune priming prior to pathogen exposure sheds light on the relationship between host, microbiome and pathogen in disease.

Dynamic interactions between host, pathogen and host-associated microbiome dictate infection outcomes. Pathogens including Batrachochytrium dendrobatidis (Bd) threaten global biodiversity, but conservation efforts are hindered by limited understanding of amphibian host, Bd and microbiome interactions. We conducted a vaccination and infection experiment using Eastern hellbender salamanders (Cryptobranchus alleganiensis alleganiensis) challenged with Bd to observe infection, skin microbial communities and gene expression of host skin, pathogen and microbiome throughout the experiment. Most animals survived high Bd loads regardless of their vaccination status and vaccination did not affect pathogen load, but host gene expression differed based on vaccination. Oral vaccination (exposure to killed Bd) stimulated immune gene upregulation while topically and sham-vaccinated animals did not significantly upregulate immune genes. In early infection, topically vaccinated animals upregulated immune genes but orally and sham-vaccinated animals downregulated immune genes. Bd increased pathogenicity-associated gene expression in late infection when Bd loads were highest. The microbiome was altered by Bd, but there was no correlation between anti-Bd microbe abundance or richness and pathogen burden. Our observations suggest that hellbenders initially generate a vigorous immune response to Bd, which is ineffective at controlling disease and is subsequently modulated. Interactions with antifungal skin microbiota did not influence disease progression.

Continuous Glucose Monitoring and Other Wearable Devices to Assess Hypoglycemia among Older Adult Outpatients with Diabetes Mellitus.

BACKGROUND: Hypoglycemia (HG) causes symptoms that can be fatal, and confers risk of dementia. Wearable devices can improve measurement and feedback to patients and clinicians about HG events and risk. OBJECTIVES: The aim of the study is to determine whether vulnerable older adults could use wearables, and explore HG frequency over 2 weeks. METHODS: First, 10 participants with diabetes mellitus piloted a continuous glucometer, physical activity monitor, electronic medication bottles, and smartphones facilitating prompts about medications, behaviors, and symptoms. They reviewed graphs of glucose values, and were asked about the monitoring experience. Next, a larger sample (N = 70) wore glucometers and activity monitors, and used the smartphone and bottles, for 2 weeks. Participants provided feedback about the devices. Descriptive statistics summarized demographics, baseline experiences, behaviors, and HG. RESULTS: In the initial pilot, 10 patients aged 50 to 85 participated. Problems addressed included failure of the glucometer adhesive. Patients sought understanding of graphs, often requiring some assistance with interpretation. Among 70 patients in subsequent testing, 67% were African-American, 59% were women. Nearly one-fourth (23%) indicated that they never check their blood sugars. Previous HG was reported by 67%. In 2 weeks of monitoring, 73% had HG (glucose ≤70 mg/dL), and 42% had serious, clinically significant HG (glucose under 54 mg/dL). Eight patients with HG also had HG by home-based blood glucometry. Nearly a third of daytime prompts were unanswered. In 24% of participants, continuous glucometers became detached. CONCLUSION: Continuous glucometry occurred for 2 weeks in an older vulnerable population, but devices posed wearability challenges. Most patients experienced HG, often serious in magnitude. This suggests important opportunities to improve wearability and decrease HG frequency among this population.

COVID-19: Implications for Physical Activity, Health Disparities, and Health Equity.

Physical activity is one of the most efficacious pathways to promoting mental and physical health, preventing disease, and, most important during the COVID-19 pandemic, bolstering a stronger immune system. Efforts to "flatten the curve" have resulted in the temporary closure of exercise facilities and gyms, suspension of sport activities, and advisories to avoid public recreational spaces. All of these changes have made traditional opportunities to be physically active difficult to access. These changes have also exacerbated existing disparities in access to social and environmental supports for physical activity, potentially contributing to a widening gap in physical activity participation among those at greatest risk for COVID-19. Physical activity can play a special role in reducing the inequitable consequences of COVID-19; however, expansion and better targeting of evidence-informed interventions are needed that address the unique barriers present in communities that have been economically and socially marginalized to achieve health equity in COVID-19 outcomes. This review highlights effective and feasible strategies that provide more equitable access to physical activity programs and spaces across the United States. With a renewed investment in physical activity, this behavior can play a crucial role in improving population health and reducing disparities during the COVID-19 pandemic and beyond.

Kinesiophobia Predicts Physical Function and Physical Activity Levels in Chronic Pain-Free Older Adults.

Advanced aging is associated with a general decline in physical function and physical activity. The current evidence suggests that pain-related fear of movement (i.e., kinesiophobia) is increased in the general older adult population and impacts physical activity levels in patients with chronic pain. However, whether kinesiophobia could impact physical activity and function in relatively healthy, chronic pain-free older adults remain unclear. Thus, the purpose of this study was to examine whether fear of movement due to pain predicted self-reported and objective levels of physical function and physical activity in healthy older adults without chronic pain. Fifty-two older adults were enrolled in this study. The participants completed the International Physical Activity Questionnaire (IPAQ) and wore an accelerometer on the hip for 7 days to measure physical activity. Measures of sedentary time, light physical activity, and moderate to vigorous physical activity were obtained from the accelerometer. Measures of physical function included the Physical Functioning subscale of the Short Form-36, Short Physical Performance Battery (SPPB), the 30-s Chair Stand test, and a maximal isometric hand-grip. The Tampa Scale of Kinesiophobia (TSK) was used to measure fear of movement or re-injury associated with pain. Potential covariates included self-reported activity-related pain and demographics. Hierarchical linear regressions were conducted to determine the relationship of kinesiophobia with levels of physical activity and physical function while controlling for activity-related pain and demographics. TSK scores did not predict self-reported physical activity on the IPAQ. However, TSK scores predicted self-reported physical function (Beta = -0.291, p = 0.015), 30-s Chair Stand test scores (Beta = -0.447, p = 0.001), measures from the SPPB (Gait speed time: Beta = 0.486, p < 0.001; Chair stand time: Beta = 0.423, p = 0.003), percentage of time spent in sedentary time (Beta = 0.420, p = 0.002) and light physical activity (Beta = -0.350, p = 0.008), and moderate to vigorous physical activity (Beta = -0.271, p = 0.044), even after controlling for significant covariates. These results suggest that greater pain-related fear of movement/re-injury is associated with lower levels of light and moderate to vigorous physical activity, greater sedentary behavior, and worse physical function in healthy, chronic pain-free older adults. These findings elucidate the potential negative impact of kinesiophobia in older adults who don't report chronic pain.

Environments and situations as correlates of eating and drinking among women living with obesity and urban poverty.

Objective: One path to improving weight management may be to lessen the self-control burden of physical activity and healthier food choices. Opportunities to lessen the self-control burden might be uncovered by assessing the spatiotemporal experiences of individuals in daily context. This report aims to describe the time, place, and social context of eating and drinking and 6-month weight change among 209 midlife women (n = 113 African-American) with obesity receiving safety-net primary care. Methods: Participants completed baseline and 6-month weight measures, observations and interviews regarding obesogenic cues in the home environment, and up to 12 ecological momentary assessments (EMA) per day for 30 days inquiring about location, social context, and eating and drinking. Results: Home was the most common location (62%) at times of EMA notifications. Participants reported "yes" to eating or drinking at the time of nearly one in three (31.1% ± 13.2%) EMA notifications. Regarding social situations, being alone was significantly associated with less frequent eating and drinking (OR = 0.75) unless at work in which case being alone was significantly associated with a greater frequency of eating or drinking (OR = 1.43). At work, eating was most common late at night, whereas at home eating was most frequent in the afternoon and evening hours. However, eating and drinking frequency was not associated with 6-month weight change. Conclusions: Home and work locations, time of day, and whether alone may be important dimensions to consider in the pursuit of more effective weight loss interventions. Opportunities to personalize weight management interventions, whether digital or human, and lessen in-the-moment self-control burden might lie in identifying times and locations most associated with caloric consumption.Clinical trial registration: NCT03083964 in clinicaltrials.gov.

Physical activity and sedentary behavior in people with spinal cord injury: Mitigation strategies during COVID-19 on behalf of ACSM-EIM and HL-PIVOT.

People with spinal cord injury (SCI) face unique challenges during the COVID-19 pandemic, including greater risk of poor COVID-19-related outcomes, increased social isolation, and restricted access to important services. Furthermore, COVID-19 related restrictions have decreased already low levels of physical activity (PA) in this population. Therefore, the purpose of this commentary is to: 1) address the impact of COVID-19 on PA and sedentary behavior (SB) in people with SCI; 2) provide potential SB reduction strategies to guide future research; and 3) provide recommendations to increase PA and reduce SB on behalf of the American College of Sports Medicine Exercise is Medicine (ACSM-EIM) and Healthy Living for Pandemic Event Protection (HL-PIVOT) using a social-ecological model targeting the individual-, social environment-, physical environment-, and policy-level determinants of behavior in people with SCI.

Levine Cancer Institute Financial Toxicity Tumor Board: A Potential Solution to an Emerging Problem.

PURPOSE: Fiscal distress or "financial toxicity," in which patients experience challenges in paying for treatment, are becoming dominant problems for patients with cancer because of burgeoning health care costs and strategies implemented by health insurance payers to reduce their level of expenditure. We report the structure and function of the first Financial Toxicity Tumor Board (FTTB). Modeled on the concept of a conventional multidisciplinary tumor board, FTTB functions as a multidisciplinary conference providing broad problem-solving approaches to financial toxicity. METHODS: The FTTB, with participation from physicians, nurses, financial counselors, nurse navigators, social workers, and administrators, meets monthly and is focused on financial toxicity and financial worry experienced by patients with cancer. It is linked to a Patient Assistance Program for oncologic pharmaceutical agents as this domain constitutes a critical area of financial toxicity for many patients. RESULTS: In the first years of function, more than $55-$60 million of personal expenditure has been avoided for 1,749 and 1,819 patients, respectively, as well as more than $1.3 million copay assistance provided for financially challenged patients. Problems addressed have included payer impediments, underinsurance, complexities of certification, coding or billing issues, and inadequate internal standard operating procedures. CONCLUSION: A focus on proactive management of financial toxicity through the function of multidisciplinary FTTBs substantially ameliorates this burgeoning international problem. This concept is presented early as it may be leveraged readily in other centers.

Social Cognition and Socioecological Predictors of Home-Based Physical Activity Intentions, Planning, and Habits during the COVID-19 Pandemic.

'Shelter in place' and 'lockdown' orders implemented to minimize the spread of COVID-19 have reduced opportunities to be physically active. For many, the home environment emerged as the only viable option to participate in physical activity. Previous research suggests that availability of exercise equipment functions as a determinant of home-based physical activity participation among the general adult population. The purpose of this study was to use a socioecological framework to investigate how the availability of exercise equipment at home predicts behavioral decisions, namely, intention, planning, and habits with respect to participation in physical activity. Participants (n = 429) were adults recruited in U.S. states subject to lockdown orders during the pandemic who completed measures online. A structural equation model indicated that availability of cardiovascular and strength training equipment predicted physical activity planning. Social cognition constructs mediated the relationship between each type of exercise equipment and intentions. Autonomous motivation and perceived behavioral control were found to mediate the relationship between each type of exercise equipment and habit. The availability of large cardiovascular and strength training equipment demonstrated significant predictive effects with intention, planning, habit, and autonomous motivation. Facilitating these constructs for home-based physical activity interventions could be efficacious for promoting physical activity.

Depressive symptom severity as a predictor of attendance in the HOME behavioral weight loss trial.

OBJECTIVE: We examined whether total depressive symptoms and symptom clusters predicted behavioral weight loss attendance among economically disadvantaged adults in a randomized controlled trial. METHODS: 150 adults with obesity were randomized to 12 months of in-person, video conference, or enhanced usual care weight loss groups. We categorized percent session attendance in the intervention arms into three levels: no attendance, poorer attendance, and better attendance. RESULTS: Higher baseline Patient Health Questionnaire-8 (PHQ-8) score was associated with a greater odds of being in the poorer versus better attendance group (OR = 1.94, 95% CI: 1.02-3.69, p = .04). A similar relationship between PHQ-8 score and odds of being in the no attendance versus better attendance group was observed but was not statistically significant (OR = 1.63, 95% CI: 0.94-2.81, p = .08). Both cognitive/affective and somatic clusters contributed to the depressive symptoms-attendance relationships. CONCLUSION: Greater depressive symptoms at the start of a behavioral weight loss program may predict poorer subsequent session attendance. Screening for and addressing depression may improve intervention uptake. ClinicalTrials.gov Identifier: NCT02057952.

Context-Sensitive Ecological Momentary Assessment: Application of User-Centered Design for Improving User Satisfaction and Engagement During Self-Report.

BACKGROUND: Ecological momentary assessment (EMA) can be a useful tool for collecting real-time behavioral data in studies of health and health behavior. However, EMA administered through mobile technology can be burdensome, and it tends to suffer from suboptimal user engagement, particularly in low health-literacy populations. OBJECTIVE: This study aimed to report a case study involving the design and evaluation of a mobile EMA tool that supports context-sensitive EMA-reporting of location and social situations accompanying eating and sedentary behavior. METHODS: An iterative, user-centered design process with obese, middle-aged women seeking care in a safety-net health system was used to identify the preferred format of self-report measures and the look, feel, and interaction of the mobile EMA tool. A single-arm feasibility field trial with 21 participants receiving 12 prompts each day for momentary self-reports over a 4-week period (336 total prompts per participant) was used to determine user satisfaction with interface quality and user engagement, operationalized as response rate. A second trial among 38 different participants randomized to receive or not to receive a feature designed to improve engagement was conducted. RESULTS: The feasibility trial results showed high interface satisfaction and engagement, with an average response rate of 50% over 4 weeks. Qualitative feedback pointed to the need for auditory alerts. We settled on 3 alerts at 10-min intervals to accompany each EMA-reporting prompt. The second trial testing this feature showed a statistically significant increase in the response rate between participants randomized to receive repeat auditory alerts versus those who were not (60% vs 40%). CONCLUSIONS: This paper reviews the design research and a set of design constraints that may be considered in the creation of mobile EMA interfaces personalized to users' preferences. Novel aspects of the study include the involvement of low health-literacy adults in design research, the capture of data on time, place, and social context of eating and sedentary behavior, and reporting prompts tailored to an individual's location and schedule. TRIAL REGISTRATION: ClinicalTrials.gov NCT03083964; https://clinicaltrials.gov/ct2/show/NCT03083964.

Addressing people and place microenvironments in weight loss disparities (APP-Me): Design of a randomized controlled trial testing timely messages for weight loss behavior in low income Black and White Women.

BACKGROUND: Behavioral interventions for weight loss have been less effective in lower income and black women. These poorer outcomes may in part be related to these women having more frequent exposures to social and physical situations that are obesogenic, i.e., eating and sedentary cues or situations. OBJECTIVES: Working with obese, lower income Black and White Women, Addressing People and Place Microenvironments (APP-Me) was designed to create awareness of self-behavior at times and places of frequent eating and sedentary behavior. DESIGN: APP-Me is being evaluated in a randomized controlled trial with 240 participants recruited from federally qualified health centers located in a single Midwestern city. All participants complete four weeks of ecological momentary assessments (EMA) of situations and behavior. At the end of the four weeks, participants are randomized to enhanced usual care (UC) or UC plus APP-Me. METHODS: APP-Me is an automated short messaging system (SMS). Messages are text, image, audio, or a combination, and are delivered to participants' mobile devices with the intent of creating awareness at the times and places of frequent eating or sedentary behavior. The EMA data inform the timing of message deliveries. SUMMARY: This project aims to create and test timely awareness messages in a subpopulation that has not responded well to traditional behavioral interventions for weight loss. Novel aspects of the study include the involvement of a low income population, the use of data on time and place of obesogenic behavior, and message delivery time tailored to an individual's behavioral patterns.

Promoting ADL independence in vulnerable, community-dwelling older adults: a pilot RCT comparing 3-Step Workout for Life versus resistance exercise.

BACKGROUND: Resistance exercise is effective to increase muscle strength for older adults; however, its effect on the outcome of activities of daily living is often limited. The purpose of this study was to examine whether 3-Step Workout for Life (which combines resistance exercise, functional exercise, and activities of daily living exercise) would be more beneficial than resistance exercise alone. METHODS: A single-blind randomized controlled trial was conducted. Fifty-two inactive, community-dwelling older adults (mean age =73 years) with muscle weakness and difficulty in activities of daily living were randomized to receive 3-Step Workout for Life or resistance exercise only. Participants in the 3-Step Workout for Life Group performed functional movements and selected activities of daily living at home in addition to resistance exercise. Participants in the Resistance Exercise Only Group performed resistance exercise only. Both groups were comparable in exercise intensity (moderate), duration (50-60 minutes each time for 10 weeks), and frequency (three times a week). Assessment of Motor and Process Skills, a standard performance test on activities of daily living, was administered at baseline, postintervention, and 6 months after intervention completion. RESULTS: At postintervention, the 3-Step Workout for Life Group showed improvement on the outcome measure (mean change from baseline =0.29, P=0.02), but the improvement was not greater than the Resistance Exercise Only Group (group mean difference =0.24, P=0.13). However, the Resistance Exercise Only Group showed a significant decline (mean change from baseline =-0.25, P=0.01) 6 months after the intervention completion. Meanwhile, the superior effect of 3-Step Workout for Life was observed (group mean difference =0.37, P<0.01). CONCLUSION: Compared to resistance exercise alone, 3-Step Workout for Life improves the performance of activities of daily living and attenuates the disablement process in older adults.

Physical activity behavior predicts endogenous pain modulation in older adults.

Older adults compared with younger adults are characterized by greater endogenous pain facilitation and a reduced capacity to endogenously inhibit pain, potentially placing them at a greater risk for chronic pain. Previous research suggests that higher levels of self-reported physical activity are associated with more effective pain inhibition and less pain facilitation on quantitative sensory tests in healthy adults. However, no studies have directly tested the relationship between physical activity behavior and pain modulatory function in older adults. This study examined whether objective measures of physical activity behavior cross-sectionally predicted pain inhibitory function on the conditioned pain modulation (CPM) test and pain facilitation on the temporal summation (TS) test in healthy older adults. Fifty-one older adults wore an accelerometer on the hip for 7 days and completed the CPM and TS tests. Measures of sedentary time, light physical activity (LPA), and moderate to vigorous physical activity (MVPA) were obtained from the accelerometer. Hierarchical linear regressions were conducted to determine the relationship of TS and CPM with levels of physical activity, while controlling for demographic, psychological, and test variables. The results indicated that sedentary time and LPA significantly predicted pain inhibitory function on the CPM test, with less sedentary time and greater LPA per day associated with greater pain inhibitory capacity. Additionally, MVPA predicted pain facilitation on the TS test, with greater MVPA associated with less TS of pain. These results suggest that different types of physical activity behavior may differentially impact pain inhibitory and facilitatory processes in older adults.

Achieving Equity in Physical Activity Participation: ACSM Experience and Next Steps.

There is clear and consistent evidence that regular physical activity is an important component of healthy lifestyles and fundamental to promoting health and preventing disease. Despite the known benefits of physical activity participation, many people in the United States remain inactive. More specifically, physical activity behavior is socially patterned with lower participation rates among women; racial/ethnic minorities; sexual minority youth; individuals with less education; persons with physical, mental, and cognitive disabilities; individuals >65 yr of age; and those living in the southeast region of the United States. Many health-related outcomes follow a pattern that is similar to physical activity participation. In response to the problem of inequities in physical activity and overall health in the United States, the American College of Sports Medicine (ACSM) has developed a national roadmap that supports achieving health equity through a physically active lifestyle. The actionable, integrated pathways that provide the foundation of ACSM's roadmap include the following: 1) communication-raising awareness of the issue and magnitude of health inequities and conveying the power of physical activity in promoting health equity; 2) education-developing educational resources to improve cultural competency for health care providers and fitness professionals as well as developing new community-based programs for lay health workers; 3) collaboration-building partnerships and programs that integrate existing infrastructures and leverage institutional knowledge, reach, and voices of public, private, and community organizations; and 4) evaluation-ensuring that ACSM attains measurable progress in reducing physical activity disparities to promote health equity. This article provides a conceptual overview of these four pathways of ACSM's roadmap, an understanding of the challenges and advantages of implementing these components, and the organizational and economic benefits of achieving health equity.