Overall statement or summary of the article and its findings in your own words:

The article "Vicarious Racism Stress and Disease Activity: The Black Women’s Experiences Living with Lupus (BeWELL) Study" examines the effect of vicarious racism-related stress (or second-hand racism) on a sample of African-American women with Lupus. The objective was to examined associations between vicarious racism stress, direct experiences of racial discrimination, and disease activity.

Building on current research in this area, the study provides relevant findings regarding the role of discrimination (direct and indirect experiences) concerning Lupus disease activity within the American context, which will provide an important contribution to the literature in better understanding the impact of racisms related stress on the disease.

Overall strengths of the article and what impact it might have in your field:

Some of the strengths of the manuscript relate to the originality of the topic, focus on Afro-American women, and large-scale sample size. The study provides evidence of the deleterious health effects of an understudied dimension of racism, the vicarious racism stress, which has critical public health and policy implications considering heightened racial tensions and visibility of racism.

Specific comments on the weaknesses of the article and what could be done to improve it:

Major points in the article which need clarification, refinement, reanalysis, rewrites and/or additional information and suggestions for what could be done to improve the article.

1. It is important to clarify some points of the methodology. The main problem with this section is related to sample selection and the use of insufficiently validated measures. Participants in this study are 438 African American women recruited from the Georgians Organized Against Lupus (GOAL) cohort during 2015 and 2017. But the sample selection process is not clear. The authors do not explain which was the universe from which the 438 women were recruited. Were all of them included in the study? What was the response rate? If any women did not respond, who were they? Were they different concerning the state of the disease?

2. The authors applied a measure of vicarious racism developed for this study. Despite they gave a measure of reliability (Cronbach alpha) they did not offer any other measure of validity, such face, content or construct validity. They should offer details on how this measure was developed if there were any previous instances of conceptual validation with a sub-sample of women to guarantee its validity.

3. I think the study would benefit if the authors put the problem of discrimination and vicarious racism in context. That is: How prevalent is racism for Afro-American women? How often they perceive it?

4. They should also mention that racial discrimination is one of the forms of discrimination to which African American women are exposed, but not the only one. Discrimination based on gender or class may be also present. These multiple forms of discrimination interact and produce negative impacts on health. Although these aspects are not addressed in the methodology, they should be mentioned in the introduction section -and revisited in the discussion-, especially because the study population is women. Furthermore, although the authors point out that stress worsens Lupus disease, they could provide more information about what “active disease” means.

Minor points like figures/tables not being mentioned in the text, a missing reference, typos, and other inconsistencies.

1. In table 1 and the text, the authors describe that the mean SLE activity score was 15.11 (SD=7.97). What does it mean? What is the maximum expected value? The minimum? The same explanation applies to the measure of vicarious exposure to racism, What does it mean the Median 2.75? Is it high?
2. I think that the authors give more importance to statistical significance than to the measure of association. For example, in bivariate correlation, they emphasize the significant associations between vicarious racism stress and SLE activity, but the correlation value (the r) is very weak. The same applies to other measures.

3. Concerning variables, the authors do not explain why some reference categories were selected. The variable education for example, or work status. The order of the variable education is not clear. These ordinal variables were used as dummy variables? The interpretation of the results would benefit if the authors clarified what the measures of association (values of B), mean. As I suggested above, this is just as important as the measure of statistical significance.

4. In the discussion section, the authors introduce some studies in this section that were not used in the literature review. These references are important because they are related to equity in health. Especially such reference related to the differences between interpersonal (or direct) and group discrimination (or indirect, or vicarious), the latter being the focus of this study should be included in the literature review. There is a deep discussion in the literature regarding the discrepancies between these types of discrimination, which should be reflected in this article.

The authors discuss the results with other studies that point in the same direction, it would be interesting if they can give alternative explanations to their results.