"We don't separate out these things. Everything is related": Partnerships with Indigenous Communities to Design, Implement, and Evaluate Multilevel Interventions to Reduce Health Disparities.

Multilevel interventions (MLIs) are appropriate to reduce health disparities among Indigenous peoples because of their ability to address these communities' diverse histories, dynamics, cultures, politics, and environments. Intervention science has highlighted the importance of context-sensitive MLIs in Indigenous communities that can prioritize Indigenous and local knowledge systems and emphasize the collective versus the individual. This paradigm shift away from individual-level focus interventions to community-level focus interventions underscores the need for community engagement and diverse partnerships in MLI design, implementation, and evaluation. In this paper, we discuss three case studies addressing how Indigenous partners collaborated with researchers in each stage of the design, implementation, and evaluation of MLIs to reduce health disparities impacting their communities. We highlight the following: (1) collaborations with multiple, diverse tribal partners to carry out MLIs which require iterative, consistent conversations over time; (2) inclusion of qualitative and Indigenous research methods in MLIs as a way to honor Indigenous and local knowledge systems as well as a way to understand a health disparity phenomenon in a community; and (3) relationship building, maintenance, and mutual respect among MLI partners to reconcile past research abuses, prevent extractive research practices, decolonize research processes, and generate co-created knowledge between Indigenous and academic communities.

American Indian Alaska Native (AIAN) adolescents and obesity: the influence of social determinants of health, mental health, and substance use.

OBJECTIVE: To explore the prevalence of obesity among American Indian and Alaska Native (AIAN) adolescents aged 12-19 years in association with social determinants of health (SDOH), and mental health and substance use disorders. METHODS: Guided by the World Health Organization's Social Determinants of Health Framework, we examined data from the Indian Health Service (IHS) Improving Health Care Delivery Data Project from Fiscal Year 2013, supplemented by county-level data from the U.S. Census and USDA. Our sample included 26,226 AIAN adolescents ages 12-19 years. We described obesity prevalence in relationship to SDOH and adolescents' mental health and substance use disorder status. We then fit a multivariable logit generalized linear mixed model to estimate the relationships after adjusting for other individual and county level characteristics. RESULTS: We observed a prevalence of 32.5% for obesity, 13.8% for mental health disorders, and 5.5% for substance use disorders. Females had lower odds of obesity than males (OR = 0.76, p < 0.001), which decreased with age. Having Medicaid coverage (OR = 1.09, p < 0.01), residing in a county with lower education attainment (OR = 1.17, p < 0.05), and residing in a county with higher rates of poverty (OR = 1.51, p < 0.001) were each associated with higher odds of obesity. Residing in a county with high access to a grocery store (OR = 0.73, p < 0.001) and residing in a county with a higher proportion of AIANs (OR = 0.83, p < 0.01) were each associated with lower odds of obesity. Those with mental health disorders had higher odds of obesity (OR = 1.26, p < 0.001); substance use disorders were associated with decreased odds of obesity (OR = 0.73, p < 0.001). CONCLUSIONS: Our findings inform future obesity prevention and treatment programs among AIAN youth; in particular, the need to consider mental health, substance use, and SDOH.

Social Determinants of Health and Body Mass Index in American Indian/Alaska Native Children.

Objective: To examine the associations between social determinants of health (SDOH) and prevalent overweight/obesity status and change in adiposity status among American Indian and Alaska Native (AI/AN) children. Methods: The study sample includes 23,950 AI/AN children 2-11 years of age, who used Indian Health Service (IHS) from 2010 to 2014. Multivariate generalized linear mixed models were used to examine the following: (1) cross-sectional associations between SDOH and prevalent overweight/obesity status and (2) longitudinal associations between SDOH and change in adiposity status over time. Results: Approximately 49% of children had prevalent overweight/obesity status; 18% had overweight status and 31% had obesity status. Prevalent severe obesity status was 20% in 6-11-year olds. In adjusted cross-sectional models, children living in counties with higher levels of poverty had 28% higher odds of prevalent overweight/obesity status. In adjusted longitudinal models, children 2-5 years old living in counties with more children eligible for free or reduced-priced lunch had 15% lower odds for transitioning from normal-weight status to overweight/obesity status. Conclusions: This work contributes to accumulating knowledge that economic instability, especially poverty, appears to play a large role in overweight/obesity status in AI/AN children. Research, clinical practice, and policy decisions should aim to address and eliminate economic instability in childhood.

Measuring Latinx/@ immigrant experiences and mental health: Adaptation of discrimination and historical loss scales.

Migration processes encompass uncertainty, discrimination, racism, stigma, social isolation, lack of access to resources, fear of deportation, and family separation, having a critical impact on the health of Latinx/@ immigrants in the United States. It is essential to accurately measure the ways in which social, legal, economic, and political contexts impact mental health. This article discusses adaptation and use of discrimination and historical loss measures in a multilevel community-based advocacy, learning, and social support intervention (Immigrant Well-Being Project) with Latinx/@ immigrants in New Mexico, using participatory research approaches. Participants (n = 52) were recruited through community partner organizations and completed four qualitative and quantitative interviews over a 12-month period. The present analysis draws on the baseline quantitative data. Results show it is possible to adapt standardized measures of discrimination developed to assess the experiences of other racial/ethnic groups; however, the most common responses involved response options added by our research team. For the historical loss instrument, there was a high frequency of "never" answers for many items, suggesting that they were not relevant for participants or did not capture their experiences of loss. As with the discrimination measures, the items we added resonated the most with participants. The contexts of discrimination and loss for Latinx/@ immigrant populations are complex, thus the tools we use to measure these experiences and their impact on health must account for this complexity. This study contributes to these endeavors through involving community members in the conceptualization and measurement of discrimination and historical loss among Latinx/@ immigrants. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Associations Between Rurality, pre-pregnancy Health Status, and Macrosomia in American Indian/Alaska Native Populations.

OBJECTIVES: To examine the relationships between pre-pregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), pre-pregnancy body mass index (BMI) and county-level social determinants of health, with infant macrosomia within a sample of American Indian/Alaska Native (AI/AN) women receiving Indian Health Service (IHS) care. METHODS: The sample included women-infant dyads representing 1,136 singleton births from fiscal year 2011 (10/1/2019-9/30/2011). Data stemmed from the IHS Improving Health Care Delivery Data Project. Multivariate generalized linear mixed models were fitted to assess the association of macrosomia with pre-pregnancy health status and social determinants of health. RESULTS: Nearly half of the women in the sample were under age 25 years (48.6%), and most had Medicaid health insurance coverage (76.7%). Of those with a pre-pregnancy BMI measure, 66.2% were overweight or obese. Although few women had pre-pregnancy DM (4.0%), GDM was present in 12.8% of women. Most women had a normal term delivery (85.4%). Overweight, obesity, pre-pregnancy DM, and county-level rurality were all significantly associated with higher odds of infant macrosomia.

Understanding the Associations among Social Vulnerabilities, Indigenous Peoples, and COVID-19 Cases within Canadian Health Regions.

Indigenous Peoples are at an increased risk for infectious disease, including COVID-19, due to the historically embedded deleterious social determinants of health. Furthermore, structural limitations in Canadian federal government data contribute to the lack of comparative rates of COVID-19 between Indigenous and non-Indigenous people. To make visible Indigenous Peoples' experiences in the public health discourse in the midst of COVID-19, this paper aims to answer the following interrelated research questions: (1) What are the associations of key social determinants of health and COVID-19 cases among Canadian health regions? and (2) How do these relationships relate to Indigenous communities? As both proximal and distal social determinants of health conjointly contribute to COVID-19 impacts on Indigenous health, this study used a unique dataset assembled from multiple sources to examine the associations among key social determinants of health characteristics and health with a focus on Indigenous Peoples. We highlight key social vulnerabilities that stem from systemic racism and that place Indigenous populations at increased risk for COVID-19. Many Indigenous health issues are rooted in the historical impacts of colonization, and partially invisible due to systemic federal underfunding in Indigenous communities. The Canadian government must invest in collecting accurate, reliable, and disaggregated data on COVID-19 case counts for Indigenous Peoples, as well as in improving Indigenous community infrastructure and services.

Cohort Profile: The Assessing Economic Transitions (ASSET) Study-A Community-Based Mixed-Methods Study of Economic Engagement among Inner-City Residents.

The Assessing Economic Transitions (ASSET) study was established to identify relationships between economic engagement, health and well-being in inner-city populations given that research in this area is currently underdeveloped. This paper describes the objectives, design, and characteristics of the ASSET study cohort, an open prospective cohort which aims to provide data on opportunities for addressing economic engagement in an inner-city drug-using population in Vancouver, Canada. Participants complete interviewer-administered surveys quarterly. A subset of participants complete nested semi-structured qualitative interviews semi-annually. Between April 2019 and May 2022, the study enrolled 257 participants ages 19 years or older (median age: 51; 40% Indigenous, 11.6% non-Indigenous people of colour; 39% cis-gender women, 3.9% transgender, genderqueer, or two-spirit) and 41 qualitative participants. At baseline, all participants reported past daily drug use, with 27% currently using opioids daily, and 20% currently using stimulants daily. In the three months prior to baseline, more participants undertook informal income generation (75%) than formal employment (50%). Employed participants largely had casual jobs (42%) or jobs with part-time/varied hours (35%). Nested qualitative studies will focus on how inner-city populations experience economic engagement. The resulting evidence will inform policy and programmatic initiatives to address socioeconomic drivers of health and well-being.

The Missing and Murdered Indigenous Relatives Crisis and the Life Expectancy Gap for Native Americans, 2010-2019.

BACKGROUND: We assessed the role of missing and murdered indigenous relatives (MMIR) relevant causes of death in the life expectancy gap between the American Indian and Alaska Native (AIAN) and non-Hispanic White populations. METHODS: Using 2010-2019 National Center for Health Statistics Detailed Mortality files, we created multidecrement life tables and used the age-incidence decomposition method to identify (1) the causes of death that contribute to the gap in life expectancy between White and AIAN, and (2) the mechanisms through which these causes operate. RESULTS: Causes of death relevant to MMIR constituted 4.0% of all AIAN deaths, but accounted for almost one-tenth (9.6%; 0.74 of 8.21 years) of the overall AIAN-White life expectancy gap. MMIR-relevant causes accounted for 6.6% of the AIAN-White life expectancy gap for women and 11.9% of the for men. CONCLUSIONS: This study suggests a critical agenda for research on racial inequities in mortality, with a focus on MMIR.

Social determinants of obesity in American Indian and Alaska Native peoples aged ≥ 50 years.

OBJECTIVE: American Indian and Alaska Native peoples (AI/ANs) have a disproportionately high rate of obesity, but little is known about the social determinants of obesity among older AI/ANs. Thus, our study assessed social determinants of obesity in AI/ANs aged ≥ 50 years. DESIGN: We conducted a cross-sectional analysis using multivariate generalized linear mixed models to identify social determinants associated with the risk of being classified as obese (BMI ≥ 30.0 kg/m2). Analyses were conducted for the total study population and stratified by median county poverty level. SETTING: Indian Health Service (IHS) data for AI/ANs who used IHS services in FY2013. PARTICIPANTS: 27,696 AI/ANs aged ≥ 50 years without diabetes. RESULTS: Mean BMI was 29.8 ± 6.6 with 43% classified as obese. Women were more likely to be obese than men, and younger ages were associated with higher obesity risk. While having Medicaid coverage was associated with lower odds of obesity, private health insurance was associated with higher odds. Living in areas with lower rates of educational attainment and longer drive times to primary care services were associated with higher odds of obesity. Those who lived in a county where a larger percentage of people had low access to a grocery store were significantly less likely to be obese. CONCLUSIONS: Our findings contribute to the understanding of social determinants of obesity among older AI/ANs and highlight the need to investigate AI/AN obesity, including longitudinal studies with a life course perspective to further examine social determinants of obesity in older AI/ANs.

Indigenous data sovereignty and COVID-19 data issues for American Indian and Alaska Native Tribes and populations.

Indigenous Peoples in the United States have been experiencing disproportionate impacts of COVID-19. American Indian and Alaska Native persons are more likely to be infected, experience complications, and die from coronavirus. Evidence suggests that Indigenous persons have 3.5 times the incidence rate of non-Hispanic/Latinx whites. Unfortunately, this is likely a gross underestimate because of a lack of reliable and accurate COVID-19 data for American Indian and Alaska Native populations. Multiple factors contribute to poor data quality including the lack of Indigenous representation in the data and rampant racial misclassification at both the individual and group levels. The current pandemic has shed light on multiple pre-existing issues related to Indigenous data sovereignty in data collection and management. We discuss the importance of centring Indigenous data sovereignty in the systemic efforts to increase COVID-19 data availability and quality. The federal and state governments must support and promote Tribes' rights to access data. Federal and state governments should also focus on bolstering their data availability and quality for aggregated data on AIAN populations and for providing disaggregated Tribal data to Tribes. Given the pivotal moment in the United States with ongoing and parallel pandemics of coronavirus and racism, we urge demographers and population scientists to reflect on the role of structural racism in data, data collection and analysis.

Innovative participatory bilingual data analysis with Latinx/@ immigrants: Language, power, and transformation.

OBJECTIVE: The insights of Latinx/@ immigrants are essential to developing interventions that better address complex multilevel phenomena impacting mental health. Despite important advances in methods that genuinely embody participatory research practices, attention to collaborative data collection, analysis, and dissemination are limited. Our aim is to describe the development and implementation of research practices to address these gaps through an emphasis on and understanding of the centrality of language in collaborative research processes. METHOD: Guided from the outset by community-based participatory research principles, our community-academic research partnership recognized the importance of developing and intentionally studying our collaborative processes. As part of an ethnographic interview study with 24 Latinx/@ immigrants, a community-university research team developed innovative methods, including practices related to research team meetings, data collection, analysis, and dissemination, which we documented through ongoing discussion and reflection. RESULTS: The resulting participatory research processes were grounded in a theoretical framework of praxis and language and included six innovative and iterative stages: (a) Establishing the research team, (b) planning the interview process/data collection, (c) developing the data analysis methodology, (d) interpreting findings to adapt the intervention, (e) integrating results of the participatory process into the analysis, and (f) data analysis for dissemination. CONCLUSIONS: A focus on praxis and language revealed how the language of research structures' power, meaning, feeling, collaboration, analysis, and transformation. We also found that bilingual participatory analytic processes have important implications with respect to achieving genuine inclusion in rigorous research that moves toward equity for Latinx/@ immigrants and other populations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Structural Inequalities Established the Architecture for COVID-19 Pandemic Among Native Americans in Arizona: a Geographically Weighted Regression Perspective.

Native Americans are disproportionately affected by COVID-19. The present study explores whether areas with high percentages of Native American residents are experiencing the equal risks of contracting COVID-19 by examining how the relationships between structural inequalities and confirmed COVID-19 cases spatially vary across Arizona using a geographically weighted regression (GWR). GWR helps with the identification of areas with high confirmed COVID-19 cases in Arizona and with understanding of which predictors of social inequalities are associated with confirmed COVID-19 cases at specific locations. We find that structural inequality indicators and presence of Native Americans are significantly associated with higher confirmed COVID-19 cases; and the relationships between structural inequalities and confirmed COVID-19 cases are significantly stronger in areas with high concentration of Native Americans, particular on Tribal lands. The findings highlight the negative effects that lack of infrastructure (i.e., housing with plumbing, transportation, and accessible health communication) may have on individual and population health, and, in this case, associated with the increase of confirmed COVID-19 cases.

COVID-19 Pandemic and Indigenous Representation in Public Health Data.

Public Health 3.0 calls for the inclusion of new partners and novel data to bring systemic change to the US public health landscape. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has illuminated significant data gaps influenced by ongoing colonial legacies of racism and erasure. American Indian and Alaska Native (AI/AN) populations and communities have been disproportionately affected by incomplete public health data and by the COVID-19 pandemic itself. Our findings indicate that only 26 US states were able to calculate COVID-19‒related death rates for AI/AN populations. Given that 37 states have Indian Health Service locations, we argue that public health researchers and practitioners should have a far larger data set of aggregated public health information on AI/AN populations. Despite enormous obstacles, local Tribal facilities have created effective community responses to COVID-19 testing, tracking, and vaccine administration. Their knowledge can lead the way to a healthier nation. Federal and state governments and health agencies must learn to responsibly support Tribal efforts, collect data from AI/AN persons in partnership with Indian Health Service and Tribal governments, and communicate effectively with Tribal authorities to ensure Indigenous data sovereignty. (Am J Public Health. 2021;111(S3): S208-S214. https://doi.org/10.2105/AJPH.2021.306415).

Consistent Honor, Persistent Disadvantage: American Indian and Alaska Native Veteran Health in the National Survey of Veterans.

Objective: To examine self-rated health and activities of daily living (ADLs) limitations among American Indian and Alaska Native (AI/AN) veterans relative to white veterans. Methods: We use the 2010 National Survey of Veterans and limit the sample to veterans who identify as AI/AN or non-Hispanic white. We calculated descriptive statistics, confidence intervals, and used logistic regression. Results: AI/AN veterans are younger, have lower levels of income, and have higher levels of exposure to combat and environmental hazards compared to white veterans. We found that AI/AN veterans are significantly more likely to report fair/poor health controlling for socioeconomic status and experience an ADL controlling for age, health behaviors, socioeconomic status, and military factors. Discussion: The results indicate that AI/AN veterans are a disadvantaged population in terms of their health and disability compared to white veterans. AI/AN veterans may require additional support from family members and/or Veteran Affairs to address ADLs.

Indigenous Peoples, concentrated disadvantage, and income inequality in New Mexico: a ZIP code-level investigation of spatially varying associations between socioeconomic disadvantages and confirmed COVID-19 cases.

BACKGROUND: The coronavirus disease pandemic has disproportionately affected poor and racial/ethnic minority individuals and communities, especially Indigenous Peoples. The object of this study is to understand the spatially varying associations between socioeconomic disadvantages and the number of confirmed COVID-19 cases in New Mexico at the ZIP code level. METHODS: We constructed ZIP code-level data (n=372) using the 2014-2018 American Community Survey and COVID-19 data from the New Mexico Department of Health (as of 24 May 2020). The log-linear Poisson and geographically weighted Poisson regression are applied to model the number of confirmed COVID-19 cases (total population as the offset) in a ZIP code. RESULTS: The number of confirmed COVID-19 cases in a ZIP code is positively associated with socioeconomic disadvantages-specifically, the high levels of concentrated disadvantage and income inequality. It is also positively associated with the percentage of American Indian and Alaskan Native populations, net of other potential confounders at the ZIP code level. Importantly, these associations are spatially varying in that some ZIP codes suffer more from concentrated disadvantage than others. CONCLUSIONS: Additional attention for COVID-19 mitigation effort should focus on areas with higher levels of concentrated disadvantage, income inequality, and higher percentage of American Indian and Alaska Native populations as these areas have higher incidence of COVID-19. The findings also highlight the importance of plumbing in all households for access to clean and safe water, and the dissemination of educational materials aimed at COVID-19 prevention in non-English language including Indigenous languages.

Sex Differences in Diabetes Prevalence, Comorbidities, and Health Care Utilization among American Indians Living in the Northern Plains.

BACKGROUND: The American Indian (AI) population experiences significant diet-related health disparities including diabetes and cardiovascular disease (CVD). Owing to the relatively small sample size of AIs, the population is rarely included in large national surveys such as the NHANES. This exclusion hinders efforts to characterize potentially important differences between AI men and women, track the costs of these disparities, and effectively treat and prevent these conditions. OBJECTIVE: We examined the sex differences in diabetes prevalence, comorbidity experience, health care utilization, and treatment costs among AIs within a Northern Plains Indian Health Service (IHS) service unit. METHODS: We assessed data from a sample of 11,144 persons using an IHS service unit in the Northern Plains region of the United States. Detailed analyses were conducted for adults (n = 7299) on prevalence of diabetes by age and sex. We described sex differences in comorbidities, health care utilization, and treatment costs among the adults with diabetes. RESULTS: In our sample, adult men and women had a similar prevalence of diabetes (10.0% and 11.0%, respectively). The prevalence of CVD among men and women with diabetes was 45.7% and 34.0%, respectively. Among adults with diabetes, men had a statistically higher prevalence of hypertension and substance use disorders than women. The men were statistically less likely to have a non-substance use mental health disorder. Although men had higher utilization and costs for hospital inpatient services than women, the differences were not statistically significant. CONCLUSIONS: In this AI population, there were differences in comorbidity profiles between adult men and women with diabetes, which have differential mortality and cost consequences. Appropriate diabetes management addressing gender-specific comorbidities, such as substance use disorders for men and non-substance use mental health disorders for women, may help reduce additional comorbidities or complications to diabetes.

COVID-19 in New Mexico Tribal Lands: Understanding the Role of Social Vulnerabilities and Historical Racisms.

The Coronavirus 2019 (COVID-19) pandemic has disproportionally affected Indigenous Peoples. Unfortunately, there is no accurate understanding of COVID-19's impacts on Indigenous Peoples and communities due to systematic erasure of Indigenous representation in data. Early evidence suggests that COVID-19 has been able to spread through pre-pandemic mechanisms ranging from disproportionate chronic health conditions, inadequate access to healthcare, and poor living conditions stemming from structural inequalities. Using innovative data, we comprehensively investigate the impacts of COVID-19 on Indigenous Peoples in New Mexico at the zip code level. Specifically, we expand the U.S. Centers for Disease Control and Prevention's Social Vulnerability Index (SVI) to include the measures of structural vulnerabilities from historical racisms against Indigenous Peoples. We found that historically-embedded structural vulnerabilities (e.g., Tribal land status and higher percentages of house units without telephone and complete plumbing) are critical in understanding the disproportionate burden of COVID-19 that American Indian and Alaska Native populations are experiencing. We found that historically-embedded vulnerability variables that emerged epistemologically from Indigenous knowledge had the largest explanatory power compared to other social vulnerability factors from SVI and COVID-19, especially Tribal land status. The findings demonstrate the critical need in public health to center Indigenous knowledge and methodologies in mitigating the deleterious impacts of COVID-19 on Indigenous Peoples and communities, specifically designing place-based mitigating strategies.

Reservation Lands as a Protective Social Factor: An Analysis of Psychological Distress among Two American Indian Tribes.

The unique physical, cultural, and ecological location of U.S. American Indian reservations simultaneously presents risks for mental health and offers sources of resilience to Native peoples. Using survey data from two American Indian tribes, we explore whether the length of one's life spent on a reservation is associated with lower odds of psychological distress. In both tribes, we find that individuals who live a vast majority of their lives on the reservation have lower odds of psychological distress than individuals who spent portions of their life off or near the reservation. These findings suggest a need to reframe the perception of life experience on tribal reservations but also call for a more nuanced investigation of the life experience of American Indians. This study illustrates the importance of deeply exploring the relationship that American Indians have with their tribal reservation lands.

Civic engagement and political participation among American Indians and Alaska natives in the US.

Within the growing literature seeking to understand civic and political engagement among racial and ethnic minorities, our understanding of political behavior among American Indian and Alaska Native's (AI/AN) remains limited. We use the Current Population Survey Civic Engagement and Voting and Registration supplements (2006-2012) to compare AI/AN voter registration, voting, and overall civic engagement to other racial and ethnic groups and to assess whether factors that predict higher levels of civic engagement vary across these populations. We find a few key socio-economic status indicators that predict civic and political engagement uniquely for AI/ANs, but they are not consistently significant across all years or all types of political participation. We find marital status, age, household size, education, and veteran status to be important in predicting civic engagement for AI/ANs. However, for voting and registration, we find that family income, age, marital status, household size, and residential stability to be important contributors. Although we find AI/ANs are less likely to register and vote compared to non-Hispanic whites, we find that the difference is not statistically significant in congressional years, which may suggest that AI/ANs are engaged in local politics and vote for representatives that will represent their tribal interests in national politics.

Food Insecurity among American Indians and Alaska Natives: A National Profile using the Current Population Survey-Food Security Supplement.

Food insecurity increases the risk for obesity, diabetes, hypertension, and cancer-conditions highly prevalent among American Indians and Alaska Natives (AI/ANs). Using the Current Population Survey Food Security Supplement, we analyzed the food insecurity trends of AI/ANs compared to other racial and ethnic groups in the United States from 2000 to 2010. From 2000 to 2010, 25% of AI/ANs remained consistently food insecure and AI/ANs were twice as likely to be food insecure compared to whites. Urban AI/ANs were more likely to experience food insecurity than rural AI/ANs. Our findings highlight the need for national and tribal policies that expand food assistance programs; promote and support increased access to healthy foods and community food security, in both rural and urban areas; and reduce the burden of diet-related disparities on low-income and racial/ethnic minority populations.