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Advancing Health Equity through Inclusive and Equitable Publication Practices at Women's Health Issues

      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 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.
      ). 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.

      A Context of Injustice

      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 P.H.
      Black feminist thought: knowledge, consciousness, and the politics of empowerment.
      ;
      Combahee River Collective
      A Black feminist statement.
      ;
      • Crenshaw K.
      Mapping the margins: Intersectionality, identity politics, and violence against women of color.
      ;
      ;
      • Roberts D.
      Killing the Black body: Race, reproduction, and the meaning of liberty.
      ;
      • Ross L.
      • Solinger R.
      Reproductive justice: An introduction.
      ). 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 E.
      • Adekunle D.
      • McMurray P.
      • Asabor E.N.
      • Irie W.
      • Simon M.A.
      • McLemore M.R.
      Health equity tourism: Ravaging the justice landscape.
      ).
      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 L.
      • Solinger R.
      Reproductive justice: An introduction.
      ). 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 D.C.
      Medical bondage: Race, gender, and the origins of American gynecology.
      ;
      • Roberts D.
      Killing the Black body: Race, reproduction, and the meaning of liberty.
      ;
      • Ross L.
      • Solinger R.
      Reproductive justice: An introduction.
      ;
      • Washington H.A.
      Medical Apartheid: The dark history of medical experimentation on Black Americans from Colonial Times to the present.
      )—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 D.
      • Holcomb K.
      • Connors N.K.
      • Bradley L.
      A perspective on J. Marion Sims, MD, and antiblack racism in obstetrics and gynecology.
      ;
      • Shamoo A.E.
      Unethical medical treatment and research in US territories.
      ). 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 N.
      • Stern A.M.
      Mexican Americans and eugenic sterilization: Resisting reproductive injustice in California, 1920–1950.
      ;
      • Roberts D.
      Killing the Black body: Race, reproduction, and the meaning of liberty.
      ;
      • Theobald B.
      Reproduction on the Reservation: Pregnancy, childbirth, and colonialism in the long twentieth century.
      ). 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 P.H.
      Black feminist thought: knowledge, consciousness, and the politics of empowerment.
      ;
      Combahee River Collective
      A Black feminist statement.
      ;
      • Crenshaw K.
      Mapping the margins: Intersectionality, identity politics, and violence against women of color.
      ). 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 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.
      ), 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.

      Our Journal's Actions

      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.
      Figure thumbnail gr1
      Figure 1Women's Health Issues's CARE Framework.
      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 Equity
      Focus AreaGoalsGroups InvolvedActionsSteps and Timeline
      Increasing diversity in who is producing and accessing WHI content
       Author diversityEnsure a welcoming environment for a diverse group of potential authorsAuthors
      • Provide more specifics in author instructions for the benefit of first-time academic authors
      • Monitor WHI author diversity to guide strategies to increase representation
      • Conduct outreach to attract a diverse pool of authors producing high-quality work on a range of topic areas
      • Post new instructions to authors by September 2022
      • Work 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 Board
      • Review current processes and identify areas for improvement
      • Develop 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 nominee
      • By 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, Community
      • Update acceptance email with recommendations for how to disseminate key findings
      • Explore 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 template
      • Board subcommittee develops proposal(s) for broader dissemination and translation and presents at May 2023 editorial board meeting
      Building 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/genderAuthors
      • Conduct outreach and foster relationships with trans and nonbinary scholars
      • Update journal website and author instructions to require reporting how sex/gender information was collected and analyzed
      • Engage WHI editorial board members to conduct outreach to trans and nonbinary scholars
      • Update website and author instructions by late 2022
      • Revisit 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 sectionsAuthors
      • Update 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 sections
      • Update author instructions by late 2022
      • Revisit 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 Staff
      • Develop guidance for editorial staff and reviewers
      • Discuss at board meeting the possibility of a special call for manuscripts on women's health and racism and/or trans and gender diverse health
      • Immediately adopt practice of identifying “nontraditional but rigorous” manuscripts in editorial office discussions about new submissions
      • By early 2023, board members send staff examples of clear, rigorous manuscripts that use nontraditional data sources and/or methodologies
      • Based 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 2024
      • In 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 differencesAuthors
      • Update 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 inequities
      • Update author instructions by late 2022
      • Revisit 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 Board
      • Update author instructions regarding language
      • Update author instructions by late 2022
      • Revisit author instructions annually and identify places where best practices have shifted or additional guidance would be helpful
      Encouraging 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.

      Acknowledgments

      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.

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      Biography

      Authors are members of the Editorial Board and staff of Women's Health Issues.