In this entry, we review and discuss gender differences in health and mortality and how they vary over time and cross‐nationally. We then summarize our integrative framework of constrained choice. This framework demonstrates how decisions made and actions taken at the levels of family, work, community, and government shape men's and women's opportunities to pursue health and, in so doing, contribute to observed disparities. Constrained choice provides a holistic, systematic approach to understanding this paradox and demonstrates that a multidisciplinary approach is essential to understanding gendered health inequalities. Constrained choice is intended to inform health‐conscious decision‐making and policy creation at the national, state/province, or local levels of government as well as employment settings, and to help families and individuals develop health consciousness in making everyday life decisions.

Background: Despite numerous calls for standardized collection of sexual orientation and gender identity (SOGI) data in clinical settings, uptake of this practice still lags. Objectives: This study conducted a preimplementation assessment of staff attitudes toward SOGI data collection within an adult primary care practice in an urban academic medical center in the northeastern United States. Research Design: We created a process map of the flow of patient data from the point of registration to the clinical encounter to identify all staff roles associated with registration and patient demographic data collection. We purposively sampled staff members across these roles and conducted semistructured virtual interviews between November 2021 and February 2022. The research team used deductive and inductive coding and conducted a thematic analysis to identify barriers and facilitators to implementation. Subjects: Nine clinical staff and eleven nonclinical staff were interviewed. Measures: Participants were asked about their general experiences with lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients, their perspectives on collecting this data, and potential barriers and facilitators to incorporating this into the workflow. Results: The main themes that emerged were the relevance of SOGI data to the clinical practice; concerns about patient acceptability; the prevalence of cis-gender, heteronormative assumptions; and concerns about linguistic, cultural, and generational differences. Differences were noted between clinical and nonclinical staff. Conclusions: Greater education is needed to help both clinical and nonclinical staff understand how patients’ SOGI demographics can be used to provide affirming, patient-centered care. Implementation strategies can be tailored to address specific barriers at the individual, organizational, and social levels.

Visual scribing is a form of notetaking in which the visual scribe pays attention to live discussions and captures the themes and ideas that emerge through the combined use of pictures, diagrams, doodles, and text. In recent years, visual scribing has become increasingly used; however, as this field has emerged from practice and not academia, related literature and theory remain scarce. The act of visual scribing during research activities can be a practice that facilitates the documentation of a researcher’s individual observations, yet also serves to understand researchers’ own reasoning as observers. Additionally, when scribing products are shared with research participants, this helps increase trust and mutual understanding as knowledge is being co-created in an accessible medium (illustration). In this way, scribing becomes both a practice for, and product of, research. In this article we describe how visual scribing methods were used as a complementary approach for notetaking, data collection, and analysis in a community engagement project focused on birth equity in California. We found three main benefits of using visual scribing as part of a broader set of qualitative approaches: (1) triangulation, (2) expanded insight, and (3) participant engagement. Here we present the literature that informed our approach, lessons learned, and potential areas for future inquiry.

Racial disparities in stillbirth rates are well-documented but the association with structural racism has not been adequately studied. Using the Structural Racism Index, a novel index that assesses Black/White disparities in multiple socioeconomic indicators and quantifies exposure to systemic inequalities, this study investigates the relationship between structural racism and Black/White stillbirth rate disparities across US counties. Using CDC Vital Statistics data from 2016 - 2019, stillbirth rates were calculated for non-Hispanic Black (NHB) compared to non-Hispanic White (NHB) populations at the county level. The Structural Racism Index (SRI) and its relationship to differences in stillbirth rates by race was studied. Analyses were restricted to counties with more than 50,000 Black residents and at least 10 stillbirths to assure model stability. Linear regression of the stillbirth rate were performed and adjusted for county level access to resources using the CDC’s Social Vulnerability Index (SVI) and other county level socioeconomic factors. A total of 149 counties, representing 1.5 million residents and 70% of the US Black population, met inclusion criteria. The average stillbirth rate was 10.4 in the NHB population versus 5.3 per 1000 in the NHW population. After adjusting for SVI, each standard deviation increase in the SRI score still resulted in a 12% increase in the rate of stillbirth disparity (aOR 1.12, 95% CI 1.07-1.17). The disparity in rates was not explained by county level differences in social vulnerability as measured by the SVI or county level factors like education, unemployment, or poverty. There are significant racial disparities in rates of stillbirth between NHB and NHW populations at the US county level and structural racism as measured by the Structural Racism Index is strongly associated with these differences. Measures such as the CDC’s SVI do not adequately account for the differences observed thus other measures such as the SRI should be considered to better understand how exposure to structural racism leads to worse health outcomes.

BACKGROUND:Through applied research and health care quality improvement, California has achieved a maternal mortality (MM) rate significantly lower than that measured nationally. However, Medicaid (Medi-Cal)-insured births in the state continue to experience disproportionate shares of MM and severe maternal morbidity (SMM), which often precedes death. Failure to engage the Medi-Cal community in this work may impede efforts to increase equity. METHODS:This community engagement project used deliberative democracy methods to engage stakeholders with lived experience in California's Medi-Cal perinatal care system to generate an actionable and specific agenda of recommendations to decrease MM and SMM in the Medi-Cal population. FINDINGS:A total of 37 Medi-Cal stakeholders-representing birthing people, providers, health plan administrators, and advocates-participated in longitudinal co-learning sessions on the topics of MM/SMM in Medi-Cal. Most of these stakeholders (75.7%) then participated in deliberation sessions. Deliberation recommendations fell into five distinct categories: Medi-Cal perinatal covered benefits, data collection and dissemination, patient experience and its link to care quality, Medi-Cal reimbursement rates, and accountability with respect to racism in perinatal care. Stakeholders identified the Medi-Cal system actors best positioned to implement specific recommendations to directly impact MM/SMM. CONCLUSIONS:This project demonstrates the feasibility and success of using deliberative democracy methods to generate local and community-generated solutions to critical problems in health equity. Active and engaged stakeholders were keen to identify both immediate actions and long-term research and quality improvement paradigm shifts to support birth equity in Medi-Cal.

Purpose: This study estimated associations between neighborhood socioeconomic status (NSES), walkability, green space, and incident falls among postmenopausal women and evaluated modifiers of these associations, including study arm, race and ethnicity, baseline household income, baseline walking, age at enrollment, baseline low physical func-tioning, baseline fall history, climate region, and urban-rural residence.Methods: The Women's Health Initiative recruited a national sample of postmenopausal women (50-79 years) across 40 U.S. clinical centers and conducted yearly assessments from 1993 to 2005 (n 1/4 161,808). Women reporting a history of hip fracture or walking limitations were excluded, yielding a final sample of 157,583 participants. Falling was reported annually. NSES (income/wealth, education, occupation), walkability (population density, diversity of land cover, nearby high-traffic roadways), and green space (exposure to vegetation) were calculated annually and categorized into tertiles (low, intermediate, high). Generalized estimating equations assessed longitudinal relationships. Results: NSES was associated with falling before adjustment (high vs. low, odds ratio, 1.01; 95% confidence interval, 1.00- 1.01). Walkability was significantly associated with falls after adjustment (high vs. low, odds ratio, 0.99; 95% confidence interval, 0.98-0.99). Green space was not associated with falling before or after adjustment. Study arm, race and ethnicity, household income, age, low physical functioning, fall history, and climate region modified the relationship between NSES and falling. Race and ethnicity, age, fall history, and climate region modified relationships between walkability and green space and falling.Conclusions: Our results did not show strong associations of NSES, walkability, or green space with falling. Future research should incorporate granular environmental measures that may directly relate to physical activity and outdoor engagement.& COPY; 2023 Jacobs Institute of Women's Health, George Washington University. Published by Elsevier Inc. All rights reserved.

The built environment can influence physical activity behavior. Walk Score is a widely used measure of the neighborhood built environment to support walking. However, studies of the association between Walk Score and accelerometer-measured physical activity are equivocal and no studies have examined this relationship among older adults. We analyzed data from a large, diverse sample of women (n = 5650) with a mean age of 79.5 (SD = 6.7) at time of accelerometry wear in the Women's Health Initiative Objective Physical Activity Cardiovascular Health Study in the United States to examine associations between neighborhood Street Smart Walk Score (SSWS) and accelerometer-measured physical activity. Participants wore triaxial accelerometers for seven days and SSWS was determined from home addresses. 67 % of the sample lived in "car-dependent" locations (SSWS 0-49 out of 100); only 3 % lived in "walker's paradise" locations (SSWS 90-100). The multivariable model indicated an association between SSWS and accelerometer-measured physical activity (steps/day) in the total sample. The association varied by neighborhood socioeconomic status; in high socioeconomic status neighborhoods, higher SWSS was associated with greater steps per day, while no significant association between SWSS and physical activity was observed in low socioeconomic neighborhoods. This study should catalyze furtherresearch regarding the utility of SSWS in determining neighborhood walkability for older women across different neighborhood settings and suggests other built environment factors must be considered when determining walkability. Future studies should examine what factors influence walkability and develop age-relevant methods to assess and characterize neighborhood walkability.

Research and data collection related to what is historically known as “women's health” is consistently underfunded and marginalizes the health risks and experiences of women of color and transgender people. In the wake of the pandemic, the United States has an opportunity to redesign and reimagine a modern public health data infrastructure that centers equity and elevates the health and well-being of under-represented communities, including the full spectrum of gender identities. This piece offers a blueprint for transformational change in how the United States collects, interprets, and shares critical data to deliver greater health justice for all.

Background The association of social isolation or lack of social network ties in older adults is unknown. This knowledge gap is important since the risk of heart failure (HF) and social isolation increase with age. The study examines whether social isolation is associated with incident HF in older women, and examines depressive symptoms as a potential mediator and age and race and ethnicity as effect modifiers. Methods and Results This study included 44 174 postmenopausal women of diverse race and ethnicity from the WHI (Women's Health Initiative) study who underwent annual assessment for HF adjudication from baseline enrollment (1993–1998) through 2018. We conducted a mediation analysis to examine depressive symptoms as a potential mediator and further examined effect modification by age and race and ethnicity. Incident HF requiring hospitalization was the main outcome. Social isolation was a composite variable based on marital/partner status, religious ties, and community ties. Depressive symptoms were assessed using CES‐D (Center for Epidemiology Studies‐Depression). Over a median follow‐up of 15.0 years, we analyzed data from 36 457 women, and 2364 (6.5%) incident HF cases occurred; 2510 (6.9%) participants were socially isolated. In multivariable analyses adjusted for sociodemographic, behavioral, clinical, and general health/functioning; socially isolated women had a higher risk of incident HF than nonisolated women (HR, 1.23; 95% CI, 1.08–1.41). Adding depressive symptoms in the model did not change this association (HR, 1.22; 95% CI, 1.07–1.40). Neither race and ethnicity nor age moderated the association between social isolation and incident HF. Conclusions Socially isolated older women are at increased risk for developing HF, independent of traditional HF risk factors. Registration URL: http://www.clinicaltrials.gov; Unique identifier: NCT00000611.

Tremendous advances in women's health have occurred in the 30 years since the launch of Women's Health Issues, yet not all women have benefited equally (Vyas et al., 2021Vyas A.N. Borkowski L. Bird C.E. Frick K.D. Markus A.R. Salganicoff A. Weisman C.S. 30 Years of Women's Health Issues.Women’s Health Issues. 2021; 31: 1-3Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar). Inequities in health outcomes by race, ethnicity, sexual orientation, and gender identity reflect structural racism and other systemic inequities, as well as institutional and interpersonal racism, and other intersecting forms of discrimination that individuals encounter as they seek health care. Today, we are deep in the midst of a national and global reckoning around racism and other forms of inequality and discrimination—including but not limited to sexism, heterosexism, and transphobia, and health inequities—as well as a pandemic that demonstrates the horrific consequences of unjust structures, systems, institutions, and practices. This article describes how the editorial board and staff of Women's Health Issues approach these complex topics and steps we are undertaking to advance equity. In the field of women's health, we acknowledge both the intersecting forms of oppression that shape the experiences of women with multiple marginalized identities and the fact that cisgender women are not the only ones who need “women's” health care and research. Black feminist and other critical scholars have explained how our laws and cultural standards both implicitly and explicitly reinforce white supremacy and other forms of oppression (Collins, 1990Collins P.H. Black feminist thought: knowledge, consciousness, and the politics of empowerment. Routledge, New York1990Google Scholar; Combahee River Collective et al., 1982Combahee River CollectiveA Black feminist statement.in: Hull G.T. Bell-Scott P. Smith B. All the women are white, all the Blacks are men, but some of us are brave. Feminist Press, New York1982: 13-22Google Scholar; Crenshaw, 1991Crenshaw K. Mapping the margins: Intersectionality, identity politics, and violence against women of color.Stanford Law Review. 1991; 43: 1241-1299Crossref Google Scholar; Peller et al., 1995Peller G. Thomas K. Crenshaw K. Gotanda N. Critical race theory: The key writings that formed the movement. New Press, New York1995Google Scholar; Roberts, 1997Roberts D. Killing the Black body: Race, reproduction, and the meaning of liberty. Pantheon Books, New York1997Google Scholar; Ross and Solinger, 2017Ross L. Solinger R. Reproductive justice: An introduction. University of California Press, Berkeley2017Crossref Google Scholar). The fields of academic medicine, public health, and public policy, as well as the broader scientific community, have a moral obligation to stop upholding white supremacy, racism, and gender discrimination, among other forms of oppression, and to replace unjust systems and practices with ones that acknowledge and repair centuries of damage. As a peer-reviewed journal that aims to advance women's health, Women's Health Issues recognizes our position of privilege within academic literature and the women's health movement, and our responsibility to repair damage and to help create and maintain equitable systems and practices within these contexts. Peer-reviewed literature is a privileged mode of knowledge production and dissemination. Access to this mode of knowledge production is shaped by the same systems of oppression that dramatically shape individual health and well-being. These systems directly and indirectly influence what research questions are “important” and “timely”; which methods are deemed “rigorous” or “scholarly”; the language used; and who is acknowledged as an expert and what form that recognition takes. This is evident through continued publication of manuscripts that fail to acknowledge the reality of race as a social construct with real health consequences and studies that incorrectly attribute health disparities to race, rather than the structural racism that exacerbates disparities; the ongoing emphasis in the health behavior literature on individual factors without sufficiently acknowledging the role of social determinants of health shaped by policies and cultural norms; and narratives grounded in deficit models that pathologize women of color and other groups that are economically and socially marginalized. We also see it in the phenomenon of health equity tourism (Lett et al., 2022Lett E. Adekunle D. McMurray P. Asabor E.N. Irie W. Simon M.A. McLemore M.R. Health equity tourism: Ravaging the justice landscape.Journal of Medical Systems. 2022; 46: 17Crossref PubMed Scopus (8) Google Scholar). In the women's rights movement, advocacy and the scholarship supporting it have often centered the needs and voices of White women while ignoring the experiences of women of color and their scholarship (Ross and Solinger, 2017Ross L. Solinger R. Reproductive justice: An introduction. University of California Press, Berkeley2017Crossref Google Scholar). Many of the most impactful advances in women's health were made through the forced or coerced labor of women of color with White women as the primary beneficiaries (Owens, 2017Owens D.C. Medical bondage: Race, gender, and the origins of American gynecology. University of Georgia Press, Athens2017Crossref Google Scholar; Roberts, 1997Roberts D. Killing the Black body: Race, reproduction, and the meaning of liberty. Pantheon Books, New York1997Google Scholar; Ross and Solinger, 2017Ross L. Solinger R. Reproductive justice: An introduction. University of California Press, Berkeley2017Crossref Google Scholar; Washington, 2008Washington H.A. Medical Apartheid: The dark history of medical experimentation on Black Americans from Colonial Times to the present. Knopf Doubleday Publishing Group, New York2008Google Scholar)—a long and shameful list of examples that includes surgeries without anesthesia on enslaved women by J. Marion Sims and testing of oral contraceptives in Puerto Rico and Haiti without the necessary informed consent (Khabele et al., 2020Khabele D. Holcomb K. Connors N.K. Bradley L. A perspective on J. Marion Sims, MD, and antiblack racism in obstetrics and gynecology.Journal of Minimally Invasive Gynecology. 2020; 28: 153-155Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar; Shamoo, 2022Shamoo A.E. Unethical medical treatment and research in US territories.Accountability in Research. 2022; 24: 1-4Crossref Scopus (0) Google Scholar). Similarly, much of the mainstream advocacy for policies to enhance reproductive rights and autonomy has centered the needs of White, cis-gender, heterosexual women, often to the detriment of women of color and people whose sexuality or gender identities are the subject of discrimination and marginilization. Mainstream discussions of reproductive autonomy often focus on the right to prevent pregnancy without fully acknowledging the reproductive injustice of coerced sterilization used against Black, Latina, and Native women (Lira and Stern, 2021Lira N. Stern A.M. Mexican Americans and eugenic sterilization: Resisting reproductive injustice in California, 1920–1950.Aztlan: A Journal of Chicano Studies. 2021; 39: 9-34Google Scholar; Roberts, 1997Roberts D. Killing the Black body: Race, reproduction, and the meaning of liberty. Pantheon Books, New York1997Google Scholar; Theobald, 2019Theobald B. Reproduction on the Reservation: Pregnancy, childbirth, and colonialism in the long twentieth century. University of North Carolina Press, Chapel Hill2019Crossref Google Scholar). Such an approach ignores how overlapping systems of oppression impact individuals' health and well-being and further erases the experiences of those most marginalized (Collins, 1990Collins P.H. Black feminist thought: knowledge, consciousness, and the politics of empowerment. Routledge, New York1990Google Scholar; Combahee River Collective et al., 1982Combahee River CollectiveA Black feminist statement.in: Hull G.T. Bell-Scott P. Smith B. All the women are white, all the Blacks are men, but some of us are brave. Feminist Press, New York1982: 13-22Google Scholar; Crenshaw, 1991Crenshaw K. Mapping the margins: Intersectionality, identity politics, and violence against women of color.Stanford Law Review. 1991; 43: 1241-1299Crossref Google Scholar). This continues to undermine efforts toward health equity and for advancing the fields of academic medicine, health policy, and public health. Women's Health Issues launched in 1990 in response to a research and policy landscape that largely ignored women's health needs. Research studies typically involved only male laboratory animals or enrolled majority-male study populations and failed to analyze results by gender; policymakers assumed findings from solely or majority male populations applied to women. The 1993 National Institutes of Health Revitalization Act's requirement directing the agency to establish guidelines for including women and multiracial populations in research marked an important turning point (and our 30th anniversary editor's note highlights some additional milestones; Vyas et al., 2021Vyas A.N. Borkowski L. Bird C.E. Frick K.D. Markus A.R. Salganicoff A. Weisman C.S. 30 Years of Women's Health Issues.Women’s Health Issues. 2021; 31: 1-3Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar), but we are still far from achieving gender, let alone racial, ethnic, or other diversity, equity in research and policy. Women's Health Issues remains committed to publishing and disseminating research on the effects and opportunities of changes in health care, policies, and social forces, and to prioritizing publications that advance health equity focused on gender. As our journal carries on the tradition of working toward a future free from gender-based inequities in health care and social services, we commit to working specifically to end racism, in all its forms and at all levels, and other intersecting and compounding forms of oppression and discrimination in publication practices. Also, given our journal's longstanding focus on how health outcomes vary by gender, we are very interested in and committed to publishing work that includes and examines experiences of transgender and nonbinary people. As Women's Health Issues considers efforts to encourage appropriate consideration and discussion of issues around inequity and the translation of research to benefit society, including those who are socially and economically marginalized, we honor the input from various groups that are interacting. Figure 1, Women's Health Issues's CARE Framework, depicts four key groups for our journal: the communities that participate in and should benefit from research, which includes but is not limited to our readers; the authors who produce the research; the reviewers of the research, who enhance its quality; and the editorial board. These four groups make up the CARE Framework, as the value of caring is represented in the efforts to adopt practices that recognize the historical context and lived experiences faced by all. To successfully advance health equity, a shared understanding and communication about historical context, lived experience, and the impact of racism must occur between the community involved in research and the authors performing the research. When the authors submit their work and receive and respond to reviewer feedback, a clear shared understanding of the issues of racism and inequity is also important. The editorial board's communication with authors and reviewers requires a similar common understanding of structural inequity; in addition to providing feedback, the editorial board sets expectations and considers methods to report findings in ways that contribute to policy and practice and are responsive to communities' needs and concerns. The last of these forms of communication, which includes hearing from advocates and affected communities, will help Women's Health Issues to learn from communities, as well as sharing the findings we publish. This public commitment to action builds on both formal and informal steps that we have taken in recent years. For instance, we have increased the guidance we give to authors based on the content of their individual manuscripts during the revision process as we have become aware of evolving best practices around language and naming racism as a cause of inequities; now, we are formalizing this guidance in new author instructions. In recent years, we have increased racial and ethnic diversity on our editorial board, added an “associate” category for editorial board members to allow a pathway for early career scholars to learn from more senior board members and advance professionally, and adopted an informal practice of prioritizing review invitations that will increase the diversity of our reviewer pool, knowing that review invitations often lead to new author submissions and that some authors eventually become board members. Now, we will develop a more formal practice for identifying and building relationships with diverse pools of potential reviewers and board members. Table 1 outlines specific actions that we commit to taking, intended as a starting point for our journal's work. We are committed to self-reflection and humility as we examine and continuously re-examine our processes at all levels, with the goals of increasing access to knowledge and knowledge production and adopting more inclusive processes and language. Our staff and board commit to taking the actions listed in Table 1 in the coming months and years. We recognize that these actions are not on their own sufficient, and are constrained by what we consider feasible for our small staff and board. Given that, we also commit to seeking additional sources of funding to allow us to take larger steps.Table 1Actions Women's Health Issues Will Take to Advance EquityFocus AreaGoalsGroups InvolvedActionsSteps and TimelineIncreasing diversity in who is producing and accessing WHI content Author diversityEnsure a welcoming environment for a diverse group of potential authorsAuthorsProvide more specifics in author instructions for the benefit of first-time academic authorsMonitor WHI author diversity to guide strategies to increase representationConduct outreach to attract a diverse pool of authors producing high-quality work on a range of topic areasPost new instructions to authors by September 2022Work with our publisher, Elsevier, on collection of author demographics (separate from consideration of manuscripts) and report breakdown once available (timeline dependent on Elsevier)Engage WHI editorial board members to conduct outreach to a diverse group of authors regarding contributing to the journal; initiate quarterly reporting on outreach efforts Diversity of reviewers and editorial boardReview and revise process for identifying and recruiting reviewers and board membersReviewers, Editorial BoardReview current processes and identify areas for improvementDevelop and implement a process for recruiting a diverse group of reviewers and board members with expertise in emerging fields of inquiry that center community voices (e.g., community-based participatory research, deliberative democracy)For reviewers: Use board member-generated list of people we would like to have as WHI authors as a source of potential reviewers (quarterly updates)For potential board members: On an ongoing basis, identify reviewers and authors who do strong work for WHI and would bring diversity of perspective/expertise to the board. Each time there is an open board seat, conduct outreach to these people with the goal of having at least one person from this list as a nomineeBy early 2023, develop a proposal (e.g., to Elsevier) for obtaining ongoing additional funding to allow for expansion of the board while continuing to pay honoraria to board members Accessibility of findingsEncourage authors to highlight key findings in accessible formats for communities for whom research findings are most relevantAuthors, CommunityUpdate acceptance email with recommendations for how to disseminate key findingsExplore opportunities for broader dissemination and translation (e.g., additional free access to articles, additional publicity/recognition for articles with particular relevance for communities, etc.)By late 2022, develop recommendations for authors to be included in acceptance email, and add information to email templateBoard subcommittee develops proposal(s) for broader dissemination and translation and presents at May 2023 editorial board meetingBuilding a more inclusive scope of research Gender inclusivityExplicitly welcome research involving trans and nonbinary participants, and foster relationships with trans and nonbinary scholars to facilitate submissions; require authors to specify how they collected and analyzed information on sex/genderAuthorsConduct outreach and foster relationships with trans and nonbinary scholarsUpdate journal website and author instructions to require reporting how sex/gender information was collected and analyzedEngage WHI editorial board members to conduct outreach to trans and nonbinary scholarsUpdate website and author instructions by late 2022Revisit author instructions annually and identify places where best practices have shifted or additional guidance would be helpful MethodologyRequire authors to justify selection of demographic characteristics and reference groups and address potential for implicit bias in measurement; encourage authors to include positionality statements in their Methods sectionsAuthorsUpdate author instructions to include justification for selection of demographic characteristics and reference groups and address potential for implicit bias in measurement; explain the value of positionality statements and encourage their inclusion Methods sectionsUpdate author instructions by late 2022Revisit author instructions annually and identify places where best practices have shifted or additional guidance would be helpful Research considered for publicationConsider for publication submissions using nontraditional data sources and/or methodologies, provided the manuscript is clear and the investigation rigorousAuthors, Editorial StaffDevelop guidance for editorial staff and reviewersDiscuss at board meeting the possibility of a special call for manuscripts on women's health and racism and/or trans and gender diverse healthImmediately adopt practice of identifying “nontraditional but rigorous” manuscripts in editorial office discussions about new submissionsBy early 2023, board members send staff examples of clear, rigorous manuscripts that use nontraditional data sources and/or methodologiesBased on those examples, editorial staff draft guidelines for evaluating nontraditional manuscripts and share them with the board by mid-2023; based on feedback, revise and begin using by early 2024In 2023, board members will discuss the possibility of a special call for manuscripts Explicit descriptions of racismAsk authors discussing inequities by race to identify the form(s) of racism likely at work (e.g., interpersonal, institutional, structural)—and ensure they avoid suggesting a biological basis for differencesAuthorsUpdate author instructions to require that authors include a description of the form(s) of racism they explored and avoid suggesting a biological basis for race inequitiesUpdate author instructions by late 2022Revisit author instructions annually and identify places where best practices have shifted or additional guidance would be helpful Specific, inclusive, and respectful languageRequire authors to use inclusive and respectful language and be specific about racial/ethnic groups and gender definitions; language should be person-first (e.g., “people with diabetes” rather than “diabetics”) or reflect the identity of the group in question (e.g., “disabled people”)Authors, Editorial BoardUpdate author instructions regarding languageUpdate author instructions by late 2022Revisit author instructions annually and identify places where best practices have shifted or additional guidance would be helpfulEncouraging inclusive dissemination of findings Dissemination of research findings through nontraditional platformsGrow the promotion/dissemination of WHI findings through nonacademic channels to make relevant research available to the communityEditorial Board, Authors, Community MembersDevelop a toolkit to help authors create information products that are accessible to communities that can use research findings and disseminate their findings to a range of audiences.Create a toolkit by early 2023 and begin distributing it to authors in mid-2023.Abbreviation: WHI, Women's Health Issues. Open table in a new tab Abbreviation: WHI, Women's Health Issues. The authors thank other members of the Women's Health Issues editorial board for participation and support: Lori Bastian, MD, MPH; Arlene S. Bierman, MD, MS; Janine Austin Clayton, MD; Karen M. Freund, MD, MPH; Lisa H. Harris, MD, PhD; Anne Rossier Markus, JD, PhD, MHS; Kristin M. Mattocks, PhD, MPH; Megan M. Landry, DrPH, MPH; Alina Salganicoff, PhD; Mary E. Slaughter, PhD, MS; and Carol S. Weisman, PhD. Authors are members of the Editorial Board and staff of Women's Health Issues.

BACKGROUND:Although adherence to the American Cancer Society (ACS) Guidelines on Nutrition and Physical Activity for Cancer Prevention associates with lower risk of obesity-related cancer (ORC) incidence and mortality, evidence in Black and Latina women is limited. This association was examined in Black and Latina participants in the Women's Health Initiative (WHI). METHODS:Semi-Markov multistate model examined the association between ACS guideline adherence and ORC incidence and mortality in the presence of competing events, combined and separately, for 9301 Black and 4221 Latina postmenopausal women. Additionally, ACS guideline adherence was examined in a subset of less common ORCs and potential effect modification by neighborhood socioeconomic status and smoking. RESULTS:Over a median of 11.1, 12.5, and 3.7 years of follow-up for incidence, nonconditional mortality, and conditional mortality, respectively, 1191 ORCs (Black/Latina women: 841/269), 1970 all-cause deaths (Black/Latina women: 1576/394), and 341 ORC-related deaths (Black/Latina women: 259/82) were observed. Higher ACS guideline adherence was associated with lower ORC incidence for both Black (cause-specific hazard ratio [CSHR]highvs.low : 0.72; 95% CI, 0.55-0.94) and Latina (CSHRhighvs.low : 0.58, 95% CI, 0.36-0.93) women; but not conditional all-cause mortality (Black hazard ratio [HR]highvs.low : 0.86; 95% CI, 0.53-1.39; Latina HRhighvs.low : 0.81; 95% CI, 0.32-2.06). Higher adherence was associated with lower incidence of less common ORC (Ptrend  = .025), but conditional mortality events were limited. Adherence and ORC-specific deaths were not associated and there was no evidence of effect modification. CONCLUSIONS:Adherence to the ACS guidelines was associated with lower risk of ORCs and less common ORCs but was not for conditional ORC-related mortality. LAY SUMMARY:Evidence on the association between the American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention and cancer remains scarce for women of color. Adherence to the guidelines and risk of developing one of 13 obesity-related cancers among Black and Latina women in the Women's Health Initiative was examined. Women who followed the lifestyle guidelines had 28% to 42% lower risk of obesity-related cancer. These findings support public health interventions to reduce growing racial/ethnic disparities in obesity-related cancers.

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ObjectivesTo determine how baseline weight status contributes to differences in postmenopausal weight gain among non-Hispanic Blacks (NHBs) and non-Hispanic Whites (NHWs).MethodsData were included from 70,750 NHW and NHB postmenopausal women from the Women's Health Initiative Observational Study (WHI OS). Body Mass Index (BMI) at baseline was used to classify women as having normal weight, overweight, obese class I, obese class II or obese class III. Cox proportional hazards was used to estimate the hazard of a 10% or more increase in weight from baseline.ResultsIn both crude and adjusted models, NHBs were more likely to experience ≥10% weight gain than NHWs within the same category of baseline weight status. Moreover, NHBs who were normal weight at baseline were most likely to experience ≥10% weight gain in both crude and adjusted models. Age-stratified results were consistent with overall findings. In all age categories, NHBs who were normal weight at baseline were most likely to experience ≥10% weight gain. Based on the results of adjusted models, the joint influence of NHB race/ethnicity and weight status on risk of postmenopausal weight gain was both sub-additive and sub-multiplicative.ConclusionNHBs are more likely to experience postmenopausal weight gain than NHWs, and the disparity in risk is most pronounced among those who are normal weight at baseline. To address the disparity in postmenopausal obesity, future studies should focus on identifying and modifying factors that promote weight gain among normal weight NHBs.

Three overlapping public health crises have profound consequences for the health of women of color in the United States: 1) deeply rooted systemic racism, tragically exposed by police violence (Alang, McAlpine, McCreedy, & Hardeman, 2017); 2) the COVID-19 pandemic, which has much higher death rates for Black, Hispanic, and Native American populations (Artiga & Orgera, 2020; Centers for Disease Control and Prevention, 2020a); and 3) a tripled mortality rate from pregnancy-related conditions for Black and Native women compared with White women (McDormand, DeClercq, Cabral, & Morton, 2016).