Disparities In Exposure Research Articles

Disparities in Exposure to Pro-Tobacco and anti-Tobacco Advertisements in the United States

Disparities in Exposure to Pro-Tobacco and anti-Tobacco Advertisements in the United States

Increasing disparities in human exposure to perfluorooctanesulfonic acid: findings from per- and polyfluoroalkyl substance concentrations in 1999-2018 NHANES

The disparities in exposure to environmental hazards have fueled the environmental justice movement, which has garnered increasing attention and momentum over the past few decades. However, research addressing exposure disparities pertaining to chemicals remains notably limited. Here, leveraging data from the National Health and Nutrition Examination Survey spanning the period from 1999 to 2018, we unveiled that the perfluorooctanesulfonic acid (PFOS) exhibited the highest concentration in human biomonitoring in general U.S. population, with a mean value of 14.54 ± 19.59ng/ml. Subsequently, the mean concentrations of Perfluorooctanoic acid (PFOA), perfluorohexane sulfonic acid (PFHxS), perfluorononanoic acid (PFNA), and perfluorodecanoic acid (PFDA) were 3.33 ± 3.19, 2.29 ± 3.13, 1.07 ± 1.30, and 0.34 ± 0.71, respectively. Meanwhile, although females or Non-hispanic White exhibited relatively higher levels for most per- and polyfluoroalkyl substances (PFASs) compared to other groups. The individuals with higher household incomes demonstrated elevated exposure to PFASs. Interestingly, despite lower exposure burdens were observed in Non-Hispanic Black individuals, females, and individuals with low family income, we identified relatively higher exposure disparities in these populations. In particular, exposure disparities for general U.S. population exposure to PFOS exhibited an approximate 50% increase from 1999 to 2018, despite a concurrent decline of 84% in biomonitoring levels. Meanwhile, the population aging has led to an exacerbation of human exposure to PFOS by 12.4%. Our findings underscore the necessity of ensuring equitable protection from PFAS exposure for all populations, although further investigation is required to understand the underlying mechanisms driving these disparities.

Trends in socioeconomic disparities in urban heat exposure and adaptation options in mid-size U.S. cities

There is ample evidence that Environmental Justice communities experience high levels of extreme heat. However, it is unknown how disparities in urban heat exposure and adaptation options change over time. This study investigates socioeconomic disparities over time in urban heat exposure and adaptation options in eight mid-sized Northeastern cities. We ask: How were socioeconomic factors associated with heat exposure and adaptation options over time? We analyzed disparities at the census block group level and census block level, respectively. At the census block group level, we ran spatial regression models between socioeconomic variables, including race, income, gender, and age, and heat exposure and adaptation variables, including land surface temperature, normalized different vegetation index (NDVI), tree cover, and air conditioning ownership rate. We found that: Low median household income is always associated with high LST and low NDVI from 1990 to 2020; Low percentage of females is always associated with high LST and low NDVI from 1990 to 2020. High percentage of POC is associated with high LST in 2010 and 2020, but not in 1990 and 2000; Low median household income and low percentage of elderly are associated with lower tree cover; High percentage of POC, low percentage of elderly, and low median household income are associated with lower AC rates. In analysis at the census block level by city, we found that disparities in urban heat exposure between predominantly POC and predominantly white communities increased in most cities during 1990-2020. Predominantly POC communities consistently have lower vegetation cover over time in most cities. Disparities in vegetation cover per unit area increased in most cities, whereas disparities in vegetation cover per capita decreased in most cities. Our findings of the trends in disparities in heat exposure and adaptation are useful for forecasting disparities in the future. These findings also suggest that interventions should prioritize cities with increasing disparities in heat exposure and adaptation.

You make me feel like dancing: the effects of dance exposure on children’s cultural interests and social-emotional development

Stratification by race and socioeconomic status generates disparities in cultural exposure and consumption. Though public education can serve as a mechanism for addressing social inequalities, schools with high concentrations of low-income and minority students often lack the resources to provide enriching cultural experiences. Efforts to make cultural exposure and consumption more equitable remain stymied by school and neighborhood stratification, as well as by lingering questions about the value of cultural consumption for students. Employing a randomized research design, we analyze the effects of elementary students in under-resourced school participating in a collaborative dance program provided by a major ballet company. We find that participation increases students’ enthusiasm for dance and sense of self-efficacy. Students with prior lower levels of arts and culture exposure demonstrate the largest gains in self-efficacy and experience an increase in their sense of school connectedness. Male students, who were less enthusiastic about dance prior to the program, show the largest increase in dance enthusiasm. These findings demonstrate that targeted efforts by schools and arts organizations can play a meaningful role in students’ cultural capital acquisition, which in turn leads to higher student self-efficacy and sense of belonging, particularly for students with lower levels of arts and cultural learning experience.

Asking Why Is Necessary to Address Health Disparities: A Critical Approach for Solution-Oriented Environmental Epidemiological Research.

In environmental epidemiology, we use an array of tools from various, related disciplines to answer key questions about environmental exposures in relation to health outcomes. Typically, we ask questions related to what, who, where, when, and how. We value these questions because they contribute to novel scientific discovery and our understanding of disease etiology linked to environmental exposures. In addition, these questions help us better understand who might be at highest risk of exposure and subsequent risk of disease. Although necessary for the goals of environmental epidemiology, these questions are insufficient for addressing environmental health disparities. Specifically, these questions may be able to help us describe exposure-health outcome associations but are limited in their ability to move beyond identification to intervening on observed disparities to achieve environmental health equity. We sought to emphasize the need to value and routinely add the key question of "Why?" in environmental epidemiological studies. In asking this additional critical question, we can identify and incorporate the structural determinants and drivers of environmental exposure disparities and determine whether these factors are linked to existing and historically recalcitrant health disparities. Further, we can design effective studies that build on existing frameworks to address the fundamental causes of environmental health disparities. This commentary underscores the need to routinely incorporate "why" questions in the practice of environmental epidemiology. By asking and addressing "Why?" we can employ better, more solution-oriented study designs, improve data collection, and enhance our ability to collaborate with diverse study populations through trust-building and community-engaged research. Incorporating these approaches will move environmental epidemiology forward from mostly documenting to actively addressing environmental health disparities. https://doi.org/10.1289/EHP14513.

Persistent Environmental Injustice due to Brake and Tire Wear Emissions and Heavy-Duty Trucks in Future California Zero-Emission Fleets.

The adoption of zero-emission vehicles (ZEVs) offers multiple benefits for the climate, air quality, and public health by reducing tailpipe emissions. However, the environmental justice implications of the nonexhaust emissions from future ZEV fleets for near-roadway communities remain unclear. Here, we model the on-road fine particulate matter (PM2.5) emissions across all California counties and assess the near-roadway exposure disparities at the census block group level in the Los Angeles County in 2050, when almost all passenger vehicles are projected to be ZEVs. We found that promoting zero-emission heavy-duty trucks generates more air quality benefits for disadvantaged communities than light-duty passenger vehicles. Persistent disparities in near-roadway PM2.5 levels, however, exist due to the remaining brake and tire wear emissions and increased truck traffic in disadvantaged communities. We recommend implementing fleet-specific ZEV policies to address brake and tire wear emissions and optimizing freight structures to address these persistent environmental justice issues in California.

Evaluating chronic disease approaches to ameliorate tobacco-related health disparities: Study protocol of a hybrid type 1 implementation-effectiveness trial

BackgroundBlack, Indigenous, and People of Color (BIPOC) communities experience higher prevalence of cardiovascular disease and related chronic conditions compared to White communities due to disparities in tobacco exposure. Smoking can be effectively treated but evidence-based treatments are less likely to be offered to or used by BIPOC patients. We present the study protocol of the Smoking Cessation Outreach for Racial Equity (SCORE) trial that tests the effect of adding longitudinal care coordination to current standard of care for smoking cessation to promote health equity among BIPOC patients. MethodsLongitudinal Proactive Outreach (LPO; 4 culturally tailored outreach call cycles over one year by motivational interviewing trained counselors to connect patients to cessation counseling and medication) will be added to the current standard of care, Ask-Advise-Connect (AAC; primary care providers asking all patients if they smoke, and if smoking, advising to quit and connecting to treatment). We will conduct a hybrid type 1 implementation-effectiveness trial to examine the direct effect of AAC + LPO (a multilevel health system intervention) vs. AAC on population-level combustible tobacco abstinence at 18 months and treatment utilization among 2000 BIPOC adults who smoke across two healthcare systems in Minnesota. Participants will be surveyed at 6, 12, and, 18 months post-enrollment to assess outcomes. The primary outcome is biochemically confirmed combustible cigarette abstinence at 18 months. DiscussionLPO has potential to promote health equity by addressing barriers caused by structural racism, including access to care, care fragmentation, and provider racism, by systematically reaching out to all BIPOC patients who smoke. ClinicaltrialsgovNCT05671380.

Modeling cigarette smoking exposure in subsets of the population

Modeling cigarette smoking exposure in subsets of the population Understanding and acknowledging various factors that impact cigarette smoking and exposure is critical when creating public health interventions to curb tobacco use. Here, Theodore R. Holford from Yale University discusses the impact of different approaches to tobacco control. The harmful effects of cigarette smoking have been widely recognized for more than 50 years (1), and the huge toll that it has taken in shortening lives has led to the recognition of an urgent need to reduce associated exposure. Because cigarette smoking is an addictive behavior, it has been a public health challenge to reduce the level of exposure in the population, even though alternative approaches have been used. These approaches include the introduction of taxes that increase cost to users, changing the legal age at which cigarettes can be purchased, introducing clean air laws that limit locations where individuals are allowed to smoke, and establishing resources that will assist those who wish to quit smoking. These efforts can be undertaken on a national level, but more often, such efforts are implemented at different times and in different ways in different regions. In the US, these laws are more commonly introduced by a state, county, or city. (2) This introduces geographic disparities in cigarette smoking exposure, and it is important to understand these differences when planning approaches to protect public health.

Unpacking “Social Vulnerability” and “Equity”: Critical Insights From Stormwater Climate Adaptation Research in the US Gulf Coast

AbstractThis paper assesses how the concepts of social vulnerability and equity are discursively constructed in co‐production research settings with a co‐created decision support tool. The data was collected during workshops (32 communities represented) and interviews (24 communities represented) with stormwater managers and stakeholders (SMS) working in small cities, counties/parishes, and villages and towns within 100 miles of the US Gulf Coast. Findings from participant observation of workshops show that SMS express similar viewpoints regarding indicators of social vulnerability to climate‐related hazards, often defining vulnerable people as less physically mobile or as having few monetary resources. Individuals articulated “community” through a lens of homeownership and often described their relationship to residents as strained. Findings from interviews reveal divergent viewpoints on the imperative and rationale for integrating social vulnerability data into stormwater assessments and planning. Interviews also generated more critical reflection than was present in workshops regarding racial disparities in flood hazard exposure. A key insight from this article is that tools and team composition matter but there is nuance in the degree to which they matter considering a range of contextual factors. The article argues that co‐production teams must plan for alternatives and different scenarios given the messiness of co‐production in practice and that research is needed to reveal the conditions under which specific tools matter for equity in terms of both process and outcomes.

Sociodemographic and dietary predictors of maternal and placental mycoestrogen concentrations in a US pregnancy cohort.

Zearalenone (ZEN) is a mycotoxin contaminating grains and processed foods. ZEN alters nuclear estrogen receptor α/β signaling earning its designation as a mycoestrogen. Experimental evidence demonstrates that mycoestrogen exposure during pregnancy is associated with altered maternal sex steroid hormones, changes in placental size, and decreases in fetal weight and length. While mycoestrogens have been detected in human biospecimens worldwide, exposure assessment of ZEN in US populations, particularly during pregnancy, is lacking. To characterize urinary and placental concentrations of ZEN and its metabolites in healthy US pregnant people and examine demographic, perinatal, and dietary predictors of exposure. Urine samples were collected in each trimester from pregnant participants in the UPSIDE study and placenta samples were collected at delivery (Rochester, NY, n = 317). We used high performance liquid chromatography and high-resolution tandem mass spectrometry to measure total urinary (ng/ml) and placental mycoestrogens (ng/g). Using linear regression and linear mixed effect models, we examined associations between mycoestrogen concentrations and demographic, perinatal, and dietary factors (Healthy Eating Index [HEI], ultra-processed food [UPF] consumption). Mycoestrogens were detected in 97% of urines (median 0.323 ng/ml) and 84% of placentas (median 0.012 ng/g). Stability of urinary mycoestrogens across pregnancy was low (ICC: 0.16-0.22) and did not correlate with placental levels. In adjusted models, parity (multiparous) and pre-pregnancy BMI (higher) predicted higher urinary concentrations. Birth season (fall) corresponded with higher placental mycoestrogens. Dietary analyses indicated that higher HEI (healthier diets) predicted lower exposure (e.g., Σmycoestrogens %∆ -2.03; 95%CI -3.23, -0.81) and higher percent calories from UPF predicted higher exposure (e.g., Σmycoestrogens %∆ 1.26; 95%CI 0.29, 2.24). The mycotoxin, zearalenone (ZEN), has been linked to adverse health and reproductive impacts in animal models and livestock. Despite evidence of widespread human exposure, relatively little is known about predictors of exposure. In a pregnant population, we observed that maternal ZEN concentrations varied by maternal pre-pregnancy BMI and parity. Consumption of ultra-processed foods, added sugars, and refined grains were linked to higher ZEN concentrations while healthier diets were associated with lower levels. Our research suggests disparities in exposure that are likely due to diet. Further research is needed to understand the impacts of ZEN on maternal and offspring health.

Group-Delivered Trauma-Focused CBT Integrating Racial Socialization: A Multiple Case Study

In addition to disparities in interpersonal trauma exposures, Black youth in the U.S. experience the compounding stress of racial trauma, both of which are associated with a disproportionate mental health burden. Black youth also face barriers to engaging with trauma-specific therapies to address trauma-related mental health problems, with research suggesting that they are less likely to complete trauma-specific treatment. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence-based therapy for trauma-related mental health problems in youth ages 3 to 18. Metzger and colleagues (2021) proposed a set of cultural considerations for Black families to address racial stressors and enhance engagement in TF-CBT. The aim of the current multiple case study was to demonstrate the utility of group-delivered TF-CBT integrating these considerations for a single telehealth group of Black adolescents and their caregivers. We describe the intervention, patient engagement and clinical outcomes, and feedback from families regarding their experience with the group model. We also outline clinical and implementation challenges and highlight directions for future research and clinical practice.

Global and national burden of type 2 diabetes mellitus attributable to PM2.5 air pollution: An analysis of the GBD study from 1990 to 2019.

Epidemiological studies have established a link between air pollution and an elevated risk of type 2 diabetes mellitus (T2DM). This study aims to measure the impact of T2DM related to fine particulate matter (PM2.5) pollution by examining death rates and disability-adjusted life years (DALYs) from 1990 to 2019 in the United States of America. Using data from the Global Burden of Disease (GBD) database, we examined death and DALY rates per 100,000 populations in T2DM patients, specifically focusing on ambient particulate matter pollution (APMP) and household air pollution (HAP). We assessed average annual percentage change (AAPC) across various age and gender groups, states, and socio-demographic index (SDI) categories. Our findings reveal a significant decline in death rates and DALYs in the United States of America over the last 30 years, with more pronounced decreases among females and older adults. Despite national progress, state-level variations indicate complex interactions between environmental regulations, healthcare access, and socio-economic factors. Some states, such as Oregon, Idaho, and Alaska, exhibited increased AAPC. Our study emphasizes the need for targeted policies and interventions to reduce PM2.5 exposure and further address regional disparities, ensuring continued improvement in public health outcomes.

Air pollution inequality and its temporal trends in Nordic countries

ABSTRACT The demand for research on air pollution inequality in Nordic countries is rising with the growing evidence of adverse health effects. We examined socio-economic and ethnic disparities in air pollution exposure from 1990 to 2016. Results revealed that exposure to PM2.5 and NO2 was generally higher in municipalities with higher income, education and immigrant populations. Disparities mostly decreased over time, benefiting almost all groups. But, ozone exposure increased in many regions. The findings highlight the need for attention to rising ozone levels and disproportionate exposure of immigrants.

SchoolHEAT: Racial and Ethnic Inequity in School Temperature.

Exposure to high environmental temperature is detrimental to health through multiple pathways. This paper describes disparities in school-based high-temperature exposure at metropolitan schools in the United States. Using school location and sociodemographic data from the National Center for Education Statistics, neighborhood data from the US Census Bureau, and land surface temperature (LST) data from the Aqua Earth-observing satellite mission, we find that for every 10% more Black or Hispanic residents in the neighborhood, schools have LST 0.25°C and 0.38°C hotter, respectively. When the Black or Hispanic student population is greater than the neighborhood population, LST is an additional 0.20°C and 0.40°C for each 10% increase in students over neighborhood population, respectively. Black and Hispanic students are overrepresented in the hottest schools, making up 58.7% of students in the hottest 20% of schools, compared to only 30.0% of students in the coolest 20% of schools.

Children’s exposure to chemical contaminants: Demographic disparities and associations with the developing basal ganglia

Children are regularly exposed to chemical contaminants that may influence brain development. However, relatively little is known about how these contaminants impact the developing human brain. Here, we combined silicone wristband exposure assessments with neuroimaging for the first time to examine how chemical contaminant mixtures are associated with the developing basal ganglia—a brain region key for the healthy development of emotion, reward, and motor processing, and which may be particularly susceptible to contaminant harm. Further, we examined demographic disparities in exposures to clarify which children were at highest risk for any contaminant-associated neurobiological changes. Participants included 62 community children (average age 7.00 years, 53% female, 66% White) who underwent structural neuroimaging to provide data on their basal ganglia structure and wore a silicone wristband for seven days to track their chemical contaminant exposure. 45 chemical contaminants—including phthalates and their alternatives, brominated flame retardants, organophosphate esters, pesticides, polycyclic aromatic hydrocarbons, and polychlorinated biphenyls—were detected in over 75% of wristbands. Notable demographic disparities in exposure were present, such that Non-White and lower-income children were more exposed to several contaminants. Exposure to chemical contaminant mixtures was not associated with overall basal ganglia volume; however, two organophosphate esters (2IPPDPP and 4IPPDPP) were both associated with a larger globus pallidus, a basal ganglia sub-region. Results highlight demographic disparities in exposure and suggest possible risks to a brain region key for healthy emotional development.

A Comparative Study to Explore the Variability of Heavy Metal Concentration in the Teeth of Residents of Non-gated Versus Gated Societies.

Human populations face increasing exposure to heavy metals, which pose significant health risks. Dental tissues, such as dentin and enamel, provide a reliable biomarker for assessing long-term heavy metal exposure due to their stable nature. This study aims to explore the variability of heavy metal concentrations in the teeth dentine of residents living in gated versus non-gated societies near the Yamuna Riveraround the Jamia Millia Islamia, New Delhi, India. Sixty-nine participants were enrolled, 27 from gated societies and 42 from non-gated societies. Participants underwent elective dental extraction,following whichheavy metal concentrations were measured in extracted tooth dentine using atomic absorption spectrophotometry. Demographic data including age, gender, tooth types, and drinking water sources were recorded. Statistical analysis included Mann-Whitney's test, Spearman correlation heatmap, and principal component analysis (PCA). Residents of non-gated societies exhibited significantly (p< 0.005) higher mean concentrations of heavy metals compared to gated societies except for cadmium (p = 0.495). Subgroup analysis based on drinking water sources revealed significant (p<0.001) variations in heavy metal concentrations, suggesting the influence of water quality on environmental exposure. PCA provided insights into underlying trends and correlations among heavy metal variables. This study provides valuable insights into heavy metal contamination among residents living near the Yamuna River, highlighting disparities in exposure based on residential environment and drinking water sources. Participants from non-gated societies exhibited higher mean concentrations of heavy metals compared to those from gated societies, emphasizing the influence of socio-economic factors, urban infrastructure and environmental management practices on heavy metal accumulation. The study's findings underscore the need for targeted interventions to address heavy metal exposure across diverse population groups, improve water quality standards, and enhance access to safe drinking water.

Comparison of pesticide contamination between captive-reared and wild grey partridges: insights into environmental exposure disparities.

Pesticide contamination is often cited as a key factor in the global decline of farmland birds. However, the majority of studies on pesticide exposure in non-target fauna are not representative of what happens in nature because they are limited to artificial conditions. The aim of this study was to define and compare, for the first time, pesticide contamination in grey partridges (Perdix perdix) from two different contexts, i.e., captivity vs. the wild. Blood samples taken from 35 captive and 54 wild partridges in 2021-2022 were analysed for 94 pesticides most commonly used in French agriculture. Captive partridges had 29 molecules detected in their blood (12 herbicides, 14 fungicides, and three insecticides) compared to wild partridges, which had 50 molecules (13 herbicides, 23 fungicides, and 14 insecticides). Of these pesticide compounds found in individuals, 26 were banned. Captive partridges had significantly fewer pesticide molecules than wild partridges, with one to 14 pesticides per captive individual and 8 to 20 pesticides per wild individual. Nineteen molecules were common to both groups, with concentrations up to three times higher in wild partridges than in captive partridges. Our results thus show multiple exposures for most of our individuals, especially in wild partridges, which can lead to cocktail effects, which are never considered. Furthermore, the difference in contamination between the wild and captive partridges reflects the multiple routes of contamination in nature, in particular, due to the use of a wide range of habitats by wild partridges.

PM2.5 exposure disparities persist despite strict vehicle emissions controls in California.

As policymakers increasingly focus on environmental justice, a key question is whether emissions reductions aimed at addressing air quality or climate change can also ameliorate persistent air pollution exposure disparities. We examine evidence from California's aggressive vehicle emissions control policy from 2000 to 2019. We find a 65% reduction in modeled statewide average exposure to PM2.5 from on-road vehicles, yet for people of color and overburdened community residents, relative exposure disparities increased. Light-duty vehicle emissions are the main driver of the exposure and exposure disparity, although smaller contributions from heavy-duty vehicles especially affect some overburdened groups. Our findings suggest that a continued trend of emissions reductions will likely reduce concentrations and absolute disparity but may not reduce relative disparities without greater attention to the systemic factors leading to this disparity.

Sex differences among patients with intentional poisoning presenting to the emergency Department at a Tertiary Care Centre in Beirut, Lebanon.

Poisoning poses a worldwide public health challenge and recent data from Lebanon in 2020 revealed that over half patients presenting with acute toxicological exposure intentionally poisoned themselves, primarily with suspected suicidal intent. This study aims to assess sex disparities in intentional toxicological exposures among patients presenting to the Emergency Department, at a tertiary care centre in Lebanon. This was a secondary analysis of an existing toxicological database, including patients aged 6 years and older admitted due to acute overdose from March 2015 to August 2022. A total of 444 cases of intentional poisoning were analysed, with 302 (68.0%) women. The primary cause of intentional poisoning was suspected suicide in both sexes, significantly more common in women (85.1% versus 65.5%, P < 0.001). Specific agents exposed to patients varied by sex; sedatives/hypnotics/antipsychotics, antihistamines, and melitracen/flupentixol were significantly more prevalent in women (P < 0.001) while men showed higher prevalence for ethanol (P = 0.02), stimulants, street drugs and opioids (P < 0.001). Our study underscores substantial sex differences in intentional poisoning cases in Lebanon. Women exhibited a higher likelihood of exposures to sedatives/hypnotics/antipsychotics, antihistamines and melitracen/flupentixol, while stimulant drugs, ethanol, and opioids were prevalent in men. Developing proper and effective sex-specific measures may mitigate potential physical and psychological consequences.

Identifying groups at-risk to extreme heat: Intersections of age, race/ethnicity, and socioeconomic status

Anthropogenic climate change has resulted in a significant rise in extreme heat events, exerting considerable but unequal impacts on morbidity and mortality. Numerous studies have identified inequities in heat exposure across different groups, but social identities have often been viewed in isolation from each other. Children (5 and under) and older adults (65 and older) also face elevated risks of heat-related health impacts. We employ an intersectional cross-classificatory approach to analyze the distribution of heat exposure between sociodemographic categories split into age groups in the contiguous US. We utilize high-resolution daily air temperature data to establish three census tract-level heat metrics (i.e., average summer temperature, heat waves, and heat island days). We pair those metrics with American Community Survey estimates on racial/ethnic, socioeconomic, and disability status by age to calculate population weighted mean exposures and absolute disparity metrics. Our findings indicate few substantive differences between age groups overall, but more substantial differences between sociodemographic categories within age groups, with children and older adults from socially marginalized backgrounds facing greater exposure than adults from similar backgrounds. When looking at sociodemographic differences by age, people of color of any age and older adults without health insurance emerge as the most exposed groups. This study identifies groups who are most exposed to extreme heat. Policy and program interventions aimed at reducing the impacts of heat should take these disparities in exposure into account to achieve health equity objectives.