Understanding the gap between need and utilization in outpatient care—The effect of supply-side determinants on regional inequities

The present study analyzes the effect of supply-side determinants on regional inequities in outpatient care. Inequities are measured by the degree of disparity between need for and actual utilization of outpatient health services in the 412 German districts. Outpatient care needs of each district are determined by applying the regression model of the German risk structure compensation scheme. We find that supply-side factors account for half of the model's coverage of regional inequities. The remaining regional variance explained by the model may be attributed to socioeconomic and (socio-)geographic determinants as well as price effects. Our findings call for strengthening the role of GPs as coordinators in the health care system, countering the geographic maldistribution of physicians and introducing adequate programs to improve the level of care in socially deprived districts. The study also highlights the importance of differentiating between need, demand and utilization of health services in order to understand the root causes of inequities.     

Inequalities in neighbourhood socioeconomic characteristics: potential evidence-base for neighbourhood health planning

Background  

Population health planning aims to improve the health of the entire population and to reduce health inequities among population groups. Socioeconomic factors are increasingly being recognized as major determinants of many aspects of health and causes of health inequities. Knowledge of socioeconomic characteristics of neighbourhoods is necessary to identify their unique health needs and enhance identification of socioeconomically disadvantaged populations. Careful integration of this knowledge into health planning activities is necessary to ensure that health planning and service provision are tailored to unique neighbourhood population health needs. In this study, we identify unique neighbourhood socioeconomic characteristics and classify the neighbourhoods based on these characteristics. Principal components analysis (PCA) of 18 socioeconomic variables was used to identify the principal components explaining most of the variation in socioeconomic characteristics across the neighbourhoods. Cluster analysis was used to classify neighbourhoods based on their socioeconomic characteristics.     

Editorial – Reducing health inequities requires a new national health research agenda

The Commission on Social Determinants of Health (CSDH) reported in August 2008 and held out the vision of a more equitable world. The Commission understood that this would be achieved by understanding the magnitude of inequities, and through careful inquiry into what works in different contexts around the world to determine how action for equity could be improved. In Australia, while we do describe our health inequities, what we don't do so well is understand the evidence on social determinants and how action on them offers the best hope of promoting population health equitably. Without this understanding, we are unlikely to spawn a generation of research on social determinants that really comes to grips with the complexity of action to improve health and well‐being in an equitable way.     

Poverty,Housing, and the Rural Slum: Policies and the Production of Inequities,Past and Present

We studied historical materials to examine the conditions that gave rise to California''s rural slums, the consequences of their emergence, and how interpretations of housing, health, and welfare policies by government officials, and public health officials in particular, produced health inequities for residents of these communities. For more than a century, successive groups of immigrants and domestic migrant laborers have worked on California''s farms and faced numerous challenges, among them a lack of safe and affordable housing, poor working conditions, and denial of public services. Although these experiences are not new, nor are they unique to agricultural workers, they illustrate a longer history in which inequities and injustices have been rooted in the exploitation and disposability of labor. Ameliorating or even redressing inequities will require understanding the social determinants of health through ecological approaches that can overcome the historical, social, and political causes of inequity.FOR MORE THAN A CENTURY, waves of immigrants, predominantly non-White, have composed the agricultural workforce in California.1 By the early twentieth century, public health played a significant role in reinforcing constructions of race and class, particularly regarding immigrant populations.2 Nativist rhetoric often intertwined diseases with immigrants and reinforced the idea that immigrants threatened the health of the United States. In some cases, immigrants were excluded or were denied access to general assistance and health care services. In other cases, immigrants refused these services for fear of being deemed a public charge and running the risk of deportation.Although the 1937 California Welfare and Institutions Code formalized an obligation for local counties to provide access for general assistance and medical care for the indigent, regardless of an individual''s migration status, use of these services required proof of residency, which was at times an insurmountable burden for immigrants and domestic migrant agricultural workers who followed the crops.3 These requirements affected and depended on the ability to establish formal residency as well as where such residency was established.Rather than focusing on the history of immigration and public health in urban communities, we examined the impact of health and housing policies on populations in rural California.4 By documenting this history, particularly regarding housing and formal residency for agricultural laborers in rural areas in the post–World War II period, we sought to address an important gap at the intersection of labor and public health history and illustrate how the inequities agricultural workers experienced were embedded in differential treatment toward immigrants and the disposability of labor. Government officials and public health officials, in particular, participated in worsening the inequities through their application and interpretation of health and welfare policies.     

Health disparities in Canada today: some evidence and a theoretical framework

This paper documents contemporary evidence on patterns of health disparities in Canada and suggests theoretical mechanisms that give rise to these patterns. The overall health of Canadians, as measured by life expectancy or mortality, has improved dramatically over the past 30 years and some disparities have diminished slightly (e.g., life expectancy by income group for men), while others have increased (e.g., diabetes for Aboriginal peoples). Arguably the most egregious health disparities in Canada are those existing between Aboriginals and the rest of the Canadian population. This paper focuses specifically on three social determinants and their effects on disparities in health; Aboriginal status, income, and place. Overall we take the approach that disparities in health could be alleviated by reducing inequities in the distribution of these determinants. We further argue that these social determinants are proxies for opportunities, resources and constraints; all of which influence health outcomes. We suggest that policies focus on reducing the social inequities that lead to health disparities in Canada, rather than focusing on the disparities in health alone. Since the social determinants described here have been found to influence an array of disease outcomes, tackling them, rather than their outcomes, may have a greater overall influence on the health of the population.     

Health disparities in Canada today: Some evidence and a theoretical framework

This paper documents contemporary evidence on patterns of health disparities in Canada and suggests theoretical mechanisms that give rise to these patterns. The overall health of Canadians, as measured by life expectancy or mortality, has improved dramatically over the past 30 years and some disparities have diminished slightly (e.g., life expectancy by income group for men), while others have increased (e.g., diabetes for Aboriginal peoples). Arguably the most egregious health disparities in Canada are those existing between Aboriginals and the rest of the Canadian population. This paper focuses specifically on three social determinants and their effects on disparities in health; Aboriginal status, income, and place. Overall we take the approach that disparities in health could be alleviated by reducing inequities in the distribution of these determinants. We further argue that these social determinants are proxies for opportunities, resources and constraints; all of which influence health outcomes. We suggest that policies focus on reducing the social inequities that lead to health disparities in Canada, rather than focusing on the disparities in health alone. Since the social determinants described here have been found to influence an array of disease outcomes, tackling them, rather than their outcomes, may have a greater overall influence on the health of the population.     

Health, human development, and governance in Latin America and the Caribbean at the beginning of the 21st century]

The issue of the reciprocal relationship between health and development has recently taken on greater importance in Latin America and the Caribbean (LAC), given the persistence of extreme poverty and the political and social difficulties due to macroeconomic imbalances and crises of governance. This piece reviews concepts of sustainable human development, social determinants of health in general and of health inequities in particular (gender, ethnic group, income level), and the relationship between health and economic growth in the medium term and the long term. An analysis is made of how persistent poverty in countries of LAC relates to disparities in health conditions, access to health services, and health care financing, as well as to such health determinants as nutrition and environmental sanitation. Health inequities most strongly affect the most excluded and vulnerable sectors of the population. In the face of this situation, the author stresses that putting a priority on health inequities is vital to safeguarding the governability and the social and political stability of countries in LAC in the next decade.     

Does public health advocacy seek to redress health inequities? A scoping review

The public health (PH) sector is ideally situated to take a lead advocacy role in catalysing and guiding multi‐sectoral action to address social determinants of health inequities, but evidence suggests that PH's advocacy role has not been fully realised. The purpose of this review was to determine the extent to which the PH advocacy literature addresses the goal of reducing health and social inequities, and to increase understanding of contextual factors shaping the discourse and practice of PH advocacy. We employed scoping review methods to systematically examine and chart peer‐reviewed and grey literature on PH advocacy published from January 1, 2000 to June 30, 2015. Databases and search engines used included: PubMed, CINAHL, PsycINFO, Social Sciences Citation Index, Google Scholar, Google, Google Books, ProQuest Dissertations and Theses, Grey Literature Report. A total of 183 documents were charted, and included in the final analysis. Thematic analysis was both inductive and deductive according to the objectives. Although PH advocacy to address root causes of health inequities is supported theoretically and through professional practice standards, the empirical literature does not reflect that this is occurring widely in PH practice. Tensions within the discourse were noted and multiple barriers to engaging in PH advocacy for health equity were identified, including a preoccupation with individual responsibilities for healthy lifestyles and behaviours, consistent with the emergence of neoliberal governance. If the PH sector is to fulfil its advocacy role in catalysing action to reduce health inequities, it will be necessary to address advocacy barriers at multiple levels, promote multi‐sectoral efforts that implicate the state and corporations in the production of health inequities, and rally state involvement to redress these injustices.     

Multisectoral lessons from healthy communities

The healthy communities movement can provide insight into population health efforts in the United States, particularly in the context of recent health care reform. The movement has evolved from multisector partnerships that focused on improving the health, well-being, and quality of life for people and the social determinants of health to partnerships that focus more on chronic disease prevention, health equity, and environmental change. Evaluating the effects of community programs on population health has been challenging for a number of reasons. More metrics need to be developed for population health that will address inequities and focus policies on long-term health effects.     

Women's health, men's health, and gender and health: implications of intersectionality

Although intersectionality is now recognized in the context of women's health, men's health, and gender and health, its full implications for research, policy, and practice have not yet been interrogated. This paper investigates, from an intersectionality perspective, the common struggles within each field to confront the complex interplay of factors that shape health inequities. Drawing on developments within intersectionality scholarship and various sources of research and policy evidence (including examples from the field of HIV/AIDS), the paper demonstrates the methodological feasibility of intersectionality and in particular, the wide-ranging benefits of de-centering gender through intersectional analyses.     

Twenty years since Ottawa and Epp: researchers' reflections on challenges, gains and future prospects for reducing health inequities in Canada

November 2006 marked the 20-year anniversary of the Ottawa Charterfor Health Promotion and Canada's Epp Report. Encapsulatingthe tenets of health promotion (HP), these publications articulateda vision for reducing health inequities, and described a policyframework for achieving this vision, respectively. These documentsalso triggered the launch of the population health (PH) field,focused on elucidating the empirical relationships between socioeconomicgradients and population health inequities. Over two decades,a rich HP/PH theoretical and evidentiary base on socioeconomicgradients in health has established. Yet, despite valuable contributionsfrom Canadian researchers, insufficient headway has been madein this country to achieve the Charter's vision. There are numerous challenges to reducing population healthinequities in Canada. Informational challenges include complexityof HP/PH evidence, and inadequate knowledge translation beyondtraditional targets. Institutional challenges include the relativeimmunity of the healthcare sector to funding reductions, andthe organization of policy responsibilities into silos. Concernsfrom non-healthcare sectors of ‘health imperialism’,and inter-governmental tensions are interest-related challenges,while ideological challenges include lack of media discourseon health inequities and a strong neo-liberal political climate. Gains have been made in Canada towards reducing health inequities.The HP/PH discourses are firmly entrenched in academic and policyspheres across the country, while several inter-sectoral policyinitiatives are currently underway. HP/PH researchers couldbe more proactive in the knowledge-translation sphere by engagingother researchers outside of medicine and health, non-healthcarepolicy-makers, and the general public, vis-à-vis themedia, on the health inequities knowledge base. Ultimately,significant and sustained progress will only be made if researchersand other champions recognize the inherently political aspectof their work and understand how to overcome ideologically drivenresistance.     

Exploring the promises of intersectionality for advancing women's health research

Women's health research strives to make change. It seeks to produce knowledge that promotes action on the variety of factors that affect women's lives and their health. As part of this general movement, important strides have been made to raise awareness of the health effects of sex and gender. The resultant base of knowledge has been used to inform health research, policy, and practice. Increasingly, however, the need to pay better attention to the inequities among women that are caused by racism, colonialism, ethnocentrism, heterosexism, and able-bodism, is confronting feminist health researchers and activists. Researchers are seeking new conceptual frameworks that can transform the design of research to produce knowledge that captures how systems of discrimination or subordination overlap and "articulate" with one another. An emerging paradigm for women's health research is intersectionality. Intersectionality places an explicit focus on differences among groups and seeks to illuminate various interacting social factors that affect human lives, including social locations, health status, and quality of life. This paper will draw on recently emerging intersectionality research in the Canadian women's health context in order to explore the promises and practical challenges of the processes involved in applying an intersectionality paradigm. We begin with a brief overview of why the need for an intersectionality approach has emerged within the context of women's health research and introduce current thinking about how intersectionality can inform and transform health research more broadly. We then highlight novel Canadian research that is grappling with the challenges in addressing issues of difference and diversity. In the analysis of these examples, we focus on a largely uninvestigated aspect of intersectionality research - the challenges involved in the process of initiating and developing such projects and, in particular, the meaning and significance of social locations for researchers and participants who utilize an intersectionality approach. The examples highlighted in the paper represent important shifts in the health field, demonstrating the potential of intersectionality for examining the social context of women's lives, as well as developing methods which elucidate power, create new knowledge, and have the potential to inform appropriate action to bring about positive social change.     

Review article: freedom to lead a life we have reason to value? A spotlight on health inequity in the Asia Pacific region

The Asia Pacific region is home to more than 60% of the world's population. Life expectancy at birth differs between countries by as much as 27 years. This article suggests that asymmetric economic growth, unplanned urbanization, marked environmental change, unequal improvements in daily living conditions, and the unequal distribution and access to quality health care have contributed to health inequities in the Asia Pacific region. Contextually specific evidence and action are needed. This requires ongoing monitoring of health inequities and systematic evaluation of societal changes and their impact on health inequities. It requires better understanding of how to translate theoretical and empirical demonstrations of the social and environmental impact on health inequities into evidence-informed policies and programs, in diverse geopolitical, socioeconomic, and sociocultural contexts across the Asia Pacific region and the range of associated complex policy processes. A spotlight is needed on health inequities and their causes else the status quo will persist.     

Who and What Is a “Population”? Historical Debates,Current Controversies,and Implications for Understanding “Population Health” and Rectifying Health Inequities

Context: The idea of “population” is core to the population sciences but is rarely defined except in statistical terms. Yet who and what defines and makes a population has everything to do with whether population means are meaningful or meaningless, with profound implications for work on population health and health inequities. Methods: In this article, I review the current conventional definitions of, and historical debates over, the meaning(s) of “population,” trace back the contemporary emphasis on populations as statistical rather than substantive entities to Adolphe Quetelet's powerful astronomical metaphor, conceived in the 1830s, of l’homme moyen (the average man), and argue for an alternative definition of populations as relational beings. As informed by the ecosocial theory of disease distribution, I then analyze several case examples to explore the utility of critical population‐informed thinking for research, knowledge, and policy involving population health and health inequities. Findings: Four propositions emerge: (1) the meaningfulness of means depends on how meaningfully the populations are defined in relation to the inherent intrinsic and extrinsic dynamic generative relationships by which they are constituted; (2) structured chance drives population distributions of health and entails conceptualizing health and disease, including biomarkers, as embodied phenotype and health inequities as historically contingent; (3) persons included in population health research are study participants, and the casual equation of this term with “study population” should be avoided; and (4) the conventional cleavage of “internal validity” and “generalizability” is misleading, since a meaningful choice of study participants must be in relation to the range of exposures experienced (or not) in the real‐world societies, that is, meaningful populations, of which they are a part. Conclusions: To improve conceptual clarity, causal inference, and action to promote health equity, population sciences need to expand and deepen their theorizing about who and what makes populations and their means.     

NAVIGATING the Future Through the Past The Enduring Historical Legacy of Federal Children's Health Programs in the United States

The United States excels at treating the most complex medical conditions, but our low-ranking health statistics (relative to other countries) do not match our high-end health care spending. One way to understand this paradox is to examine the history of federal children''s health programs. In the 1800s, children''s health advocates confronted social determinants of health to reduce infant mortality. Over the past 100 years, however, physicians have increasingly focused on individual doctor–patient encounters; public health professionals, meanwhile, have maintained a population health perspective but struggled with the politics of addressing root causes of disease. Political history and historical demography help explain some salient differences with European nations that date to the founding of federal children''s health programs in the early 20th century. More recently, federal programs for children with intellectual disability illustrate technical advances in medicine, shifting children''s health epidemiology, and the politics of public health policy.HOW DID CHILDREN''S HEALTH in the United States get to where it is today? In some community hospitals in Miami, Florida, my hometown, every birth is attended by a board-certified obstetrician and a board-certified neonatologist. Prenatal care for expectant mothers is widely available, and children are screened and treated for a host of medical conditions from infancy through their school years. If serious illness occurs, vast resources go to medical specialists and hospitals to address the needs of affected children and their mothers. Yet in some neighborhoods, 48% of children aged 3 years are overweight or obese, and asthma rates are double the national average.1 My community is not unique: throughout the United States, we excel at treating the most complex medical conditions, yet we rank poorly relative to other nations on population health measures. In a 2006 international comparison, the United States was first in health care spending and 39th in infant mortality rate (IMR).2 Despite a century of dramatic progress in infant and child mortality, significant disparities that correlate with income, race, and ethnicity persist.3Uneven access to health care is one explanation for our relatively poor health outcomes: millions of US children are uninsured or underinsured, with negative consequences for their health.4 A related factor is that advances in medical care may improve overall health but exacerbate health care disparities, because some populations with better access benefit first from new treatments and health advice.5 A different set of explanations focuses on the social determinants of health.6 Because health is determined by a complex array of genetic, behavioral, social, and environmental factors, access to health care is only one contributing influence on population health. Long-standing differences in housing, nutrition, life experiences, and built environment affect health across the life span and contribute to disparities among populations in the United States.7 The US health care system rarely addresses these underlying causes with the intensity or resources that are devoted to medical care.8 For example, a 2010 study estimated that local, state, and federal investment in public health programs amounts to less than $100 per person in the United States; overall health care spending, by contrast, is more than $6000 per capita.9The neglect of public health in the United States is a vitally important phenomenon that first took shape and then accelerated during the 20th century. In the 19th century, medical practitioners were deeply concerned with each patient''s environment, and they were frequently involved in local public health issues. In larger cities, public health professionals viewed social and political reform as critical to improving population health.10 Over the past century, physicians and public health professionals followed diverging professional trajectories, and tensions arose over the best way to improve the health of US citizens.11 Physicians have increasingly focused on providing technologically sophisticated care to patients in acute care settings; public health professionals, meanwhile, have become responsible for collecting vital statistics, monitoring epidemics, testing for specific diseases, providing health education, addressing maternal and children''s health, and investigating environmental health hazards.12 Both have increasingly relied on the impartial mantle of science while reducing alliances with overtly political groups that address issues such as income, housing, and civil rights.13The 75th anniversary of Title V of the Social Security Act provides an auspicious opportunity to explore how these broader historical trends have affected children''s health. Federal health agencies such as the Maternal and Child Health Bureau (MCHB) have their origins in this landmark legislation,14 and exploring the history of federal programs is one sampling device for understanding the US approach to children''s health. To that end, I reviewed the history of medical care for children in the United States over the past 200 years, explored the origins of federal children''s health programs in the United States in the early 20th century and how those programs differed from those of our European counterparts, and examined how federal intellectual disability programs serve as an example of how Title V leaders (members of the federal government who implemented Title V and distributed funding) crafted strategies to improve children''s health since the 1940s. Decisions made over the past 100 years continue to affect children''s health today.     

Editorial – Towards equity as core business for policy makers and practitioners

To achieve health equity means that we must be concerned with creating equal opportunities for health and with bringing health differentials down to the lowest level possible. Jones points to the need to address the social determinants of health and the social determinants of equity. Each requires different actions on the part of the health sector in particular, and on the part of government, civil society and the private sector in general. There are multiple reasons to be concerned about andcommitted to eliminating inequities in health and in the distribution of its determinants. Ultimately, however, ‘the true measure of a nation's standing is how well it attends to its children – their health and safety, their material security, their education and socialisation, and their sense of being loved, valued, and included in the families and societies in which they are born’. The WHO Commission on the Social Determinants of Health was a compelling reminder of this and of the consequences if we fail.     

Improving Health and Building Human Capital Through an Effective Primary Care System

To improve population health, one must put emphasis on reducing health inequities and enhancing health protection and disease prevention, and early diagnosis and treatment of diseases by tackling the determinants of health at the downstream, midstream, and upstream levels. There is strong theoretical and empirical evidence for the association between strong national primary care systems and improved health indicators. The setting approach to promote health such as healthy schools, healthy cities also aims to address the determinants of health and build the capacity of individuals, families, and communities to create strong human and social capitals. The notion of human and social capitals begins to offer explanations why certain communities are unable to achieve better health than other communities with similar demography. In this paper, a review of studies conducted in different countries illustrate how a well-developed primary health care system would reduce all causes of mortalities, improve health status, reduce hospitalization, and be cost saving despite a disparity in socioeconomic conditions. The intervention strategy recommended in this paper is developing a model of comprehensive primary health care system by joining up different settings integrating the efforts of different parties within and outside the health sector. Different components of primary health care team would then work more closely with individuals and families and different healthy settings. This synergistic effect would help to strengthen human and social capital development. The model can then combine the efforts of upstream, midstream, and downstream approaches to improve population health and reduce health inequity. Otherwise, health would easily be jeopardized as a result of rapid urbanization.     

Action on the social determinants of health: A historical perspective

Abstract

A renewed concern with social factors has emerged in global public health, spearheaded by the World Health Organization's Commission on Social Determinants of Health. The coming decade may see significant health gains for disadvantaged populations if policies tackle the social roots of health inequities. To improve chances of success, global action on social determinants must draw lessons from history. This article reviews milestones in public health action on social determinants over the past 50 years. The goal is to bring into sharper focus the persistent challenges faced by social determinants agendas, along with distinctive opportunities now emerging. The historical record highlights the vulnerability of health policy approaches incorporating social determinants to resistance from entrenched interests. The Commission on Social Determinants of Health can consolidate political support by building collaborative relationships with policymakers in partner countries. However, this strategy must be complemented by engaging civil society constituencies. Historically, successful action on social determinants has been spurred by organized civil society demand.     

Eliminating health care inequities through strengthening access to care

Objective

To provide a research agenda and recommendations to address inequities in access to health care.

Data Sources and Study Setting

The Agency for Healthcare Research and Quality (AHRQ) organized a Health Equity Summit in July 2022 to evaluate what equity in access to health care means in the context of AHRQ's mission and health care delivery implementation portfolio. The findings are a result of this Summit, and subsequent convenings of experts on access and equity from academia, industry, and the government.

Study Design

Multi-stakeholder input from AHRQ's Health Equity Summit, author consensus on a framework and key knowledge gaps, and summary of evidence from the supporting literature in the context of the framework ensure comprehensive recommendations.

Data Collection/Extraction Methods

Through a stakeholder-engaged process, themes were developed to conceptualize access with a lens toward health equity. A working group researched the most appropriate framework for access to care to classify limitations identified during the Summit and develop recommendations supported by research in the context of the framework. This strategy was intentional, as the literature on inequities in access to care may itself be biased.

Principal Findings

The Levesque et al. framework, which incorporates multiple dimensions of access (approachability, acceptability, availability, accommodation, affordability, and appropriateness), is the backdrop for framing research priorities for AHRQ. However, addressing inequities in access cannot be done without considering the roles of racism and intersectionality. Recommendations include funding research that not only measures racism within health care but also tests burgeoning anti-racist practices (e.g., co-production, provider training, holistic review, discrimination reporting, etc.), acting as a convener and thought leader in synthesizing best practices to mitigate racism, and forging the path forward for research on equity and access.

Conclusions

AHRQ is well-positioned to develop an action plan, strategically fund it, and convene stakeholders across the health care spectrum to employ these recommendations.     

Lessons for achieving health equity comparing Aotearoa/New Zealand and the United States

Aotearoa/New Zealand (Aotearoa/NZ) and the United States (U.S.) suffer inequities in health outcomes by race/ethnicity and socioeconomic status. This paper compares both countries’ approaches to health equity to inform policy efforts. We developed a conceptual model that highlights how government and private policies influence health equity by impacting the healthcare system (access to care, structure and quality of care, payment of care), and integration of healthcare system with social services. These policies are shaped by each country’s culture, history, and values. Aotearoa/NZ and U.S. share strong aspirational goals for health equity in their national health strategy documents. Unfortunately, implemented policies are frequently not explicit in how they address health inequities, and often do not align with evidence-based approaches known to improve equity. To authentically commit to achieving health equity, nations should: 1) Explicitly design quality of care and payment policies to achieve equity, holding the healthcare system accountable through public monitoring and evaluation, and supporting with adequate resources; 2) Address all determinants of health for individuals and communities with coordinated approaches, integrated funding streams, and shared accountability metrics across health and social sectors; 3) Share power authentically with racial/ethnic minorities and promote indigenous peoples’ self-determination; 4) Have free, frank, and fearless discussions about impacts of structural racism, colonialism, and white privilege, ensuring that policies and programs explicitly address root causes.