The Evolving Role of Diversity, Equity, and Inclusion Programs in Academic Health Institutions.

This Viewpoint examines the role of diversity, equity, and inclusion programs in academic health institutions and universities and encourages such institutions to reexamine and reengage with the goals of these programs.

Perceived Experiences of racism in Relation to Genome-Wide DNA Methylation and Epigenetic Aging in the Black Women's Health Study.

BACKGROUND: African American women have a disproportionate burden of disease compared to US non-Hispanic white women. Exposure to psychosocial stressors may contribute to these health disparities. Racial discrimination, a major stressor for African American women, could affect health through epigenetic mechanisms. METHODS: We conducted an epigenome-wide association study (EWAS) to examine the association of interpersonal racism (in daily life and in institutional settings) with DNA methylation in blood in 384 participants of the Black Women's Health Study (BWHS). We also evaluated whether a greater number of perceived experiences of racism was associated with epigenetic aging as measured using different methylation clocks. Models were adjusted for chronological age, body mass index, years of education, neighborhood SES, geographic region of residence, alcohol drinking, smoking, and technical covariates. RESULTS: Higher scores of racism in daily life were associated with higher methylation levels at the cg04494873 site in chromosome 5 (ß = 0.64%; 95% CI = 0.41%, 0.87%; P = 6.35E-08). We also replicated one CpG site, cg03317714, which was inversely associated with racial discrimination in a previous EWAS among African American women. In the BWHS, higher scores of racism in daily life were associated with lower methylation levels at that CpG site (ß = -0.94%; 95% CI = -1.37%, -0.51%; P = 2.2E-05). Higher racism scores were associated with accelerated epigenetic aging in more than one methylation clock. CONCLUSIONS: Exposure to discriminatory events may affect the epigenome and accelerate biological aging, which may explain in part the earlier onset of disease in African American women.

Personal Mastery Attenuates the Association between Greater Perceived Discrimination and Lower Amygdala and Anterior Hippocampal Volume in a Diverse Sample of Older Adults.

There is limited research investigating whether perceived discrimination influences brain structures that subserve episodic memory, namely the hippocampus and amygdala. Our rationale for examining these regions build on their known sensitivity to stress and functional differences along the long-axis of the hippocampus, with the anterior hippocampus and amygdala implicated in emotional and stress regulation. We defined perceived discrimination as the unfair treatment of one group by a dominant social group without the agency to respond to the event. A potential moderator of perceived discrimination is personal mastery, which we operationally defined as personal agency. Our primary goals were to determine whether perceived discrimination correlated with amygdala and anterior hippocampal volume, and if personal mastery moderated these relationships. Using FreeSurfer 7.1.0, we processed T1-weighted images to extract bilateral amygdala and hippocampal volumes. Discrimination and personal mastery were assessed via self-report (using the Experiences of Discrimination and Sense of Control questionnaires, respectively). Using multiple regression, greater perceived discrimination correlated with lower bilateral amygdala and anterior hippocampal volume, controlling for current stress, sex, education, age, and intracranial volume. Exploratory subfield analyses showed these associations were localized to the anterior hippocampal CA1 and subiculum. As predicted, using a moderation analysis, personal mastery attenuated the relationship between perceived discrimination and amygdala and anterior hippocampal volume. Here, we extend our knowledge on perceived discrimination as a salient psychosocial stressor with a neurobiological impact on brain systems implicated in stress, memory, and emotional regulation, and provide evidence for personal mastery as a moderating factor of these relationships.

Perceived Interpersonal Racism in Relation to Incident Coronary Heart Disease Among Black Women.

BACKGROUND: Racism is highly prevalent in the United States. Few data exist about whether perceived interpersonal racism is associated with risk of coronary heart disease (CHD). METHODS: We followed 48 305 participants in the Black Women's Health Study through biennial mailed and Internet-based health questionnaires from 1997, when they provided information on perceived interpersonal racism and were free of cardiovascular disease and cancer, until the end of 2019. We averaged participant responses to 5 validated questions about perceived interpersonal racism in everyday activities, such as "people act as if they think you are dishonest." We summed the positive responses to 3 questions about perceived racism in interactions that involved jobs, housing, and police; scores ranged from 0 (no to all) to 3 (yes to all). CHD cases were defined as nonfatal myocardial infarctions confirmed through medical records, fatal cases identified through the National Death Index, and self-reported revascularization events. We used Cox proportional hazard models adjusting for major confounders to estimate hazard ratios (HRs). RESULTS: During 22 years of follow-up, we identified 1947 incident CHD cases. For women who reported experiences of racism in employment, housing, or involving the police relative to women who reported no such experiences, the age-adjusted HR for CHD was 1.35 (95% CI, 1.13-1.61; Ptrend=0.006), and the multivariable HR for CHD was 1.26 (95% CI, 1.05-1.51; Ptrend=0.05). For women in the highest quartile of perceived interpersonal racism in daily life relative to women in the lowest quartile, the age-adjusted HR for CHD was 1.25 (95% CI, 1.07-1.46; Ptrend=0.006). After multivariable adjustment, the HR was attenuated and no longer statistically significant. CONCLUSIONS: Perceived experiences of interpersonal racism in employment, in housing, and with the police were associated with higher incidence of CHD among Black women, whereas perceived racism in everyday life was not associated with higher risk.

Epidemiology of Sarcoidosis.

Sarcoidosis is a systemic, granulomatous disease with variable presentation earning it the term "the great mimicker." The current epidemiology confirms that the disease occurs worldwide, affecting both sexes, and all races, ethnicities, and ages. To date, no causal exposure or agent has been identified. The organ systems most frequently affected by sarcoidosis are also those with greatest exposure to the natural world suggesting environmental and lifestyle contributions to the disease. These include particulate matter, microorganisms, nicotine, and obesity. In this article, we review the epidemiology of sarcoidosis and discuss these non-genetic risk factors in the hope of providing important insight into sarcoidosis and stimulating future research.

Neighborhood Deprivation and Privilege: an Examination of Racialized-Economic Segregation and Preterm Birth, Florida 2019.

The Black-White disparity in preterm birth persists and is not fully explained by individual-level social, behavioral, or clinical risk factors. Consequently, there is increasing emphasis on understanding the role of structural and area-level factors. Racialized-economic segregation measured as the index of concentration at the extremes (ICE) simultaneously captures extremes of deprivation and privilege. Our objective was to examine associations between preterm birth (PTB) and the index of concentration at the extremes (ICE). In this cross-sectional study, we analyzed 193,957 Florida birth records from 2019 linked to 2015-2019 census tract data from the American Community Survey. We assessed PTB (< 37 weeks gestation) by subtypes: (1) early (< 34 weeks) and late (34-36 weeks) and (2) spontaneous and indicated (i.e., provider-initiated) deliveries. We calculated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for three ICE measures: (1) ICE_INC: income, (2) INC_INC + WB: income + race/ethnicity (non-Hispanic White vs. Black), and (3) INC_INC + WH: income + race/ethnicity (non-Hispanic White vs. Hispanic). Results. For ICE_INC and INC_INC + WB, aORs for residing in the worst-off vs. best-off areas were 1.25 (95% CI: 1.12, 1.46) and 1.21 (95% CI: 1.07, 1.37) for early PTB, respectively, and 1.16 (95% CI: 1.05, 1.28) to 1.22 (95% CI: 1.12, 1.34) for indicated PTB. In conclusion, deprivation captured by ICE was associated with increased odds of early or indicated PTB. Eliminating PTB disparities may require a multifaceted approach that includes addressing the interplay between income and race/ethnicity in residential areas.

Perceived Interpersonal Racism and Incident Stroke Among US Black Women.

Importance: Black individuals in the US experience stroke and stroke-related mortality at younger ages and more frequently than other racial groups. Studies examining the prospective association of interpersonal racism with stroke are lacking. Objective: To examine the association of perceived interpersonal racism with incident stroke among US Black women. Design, Setting, and Participants: The Black Women's Health Study, a prospective cohort study of 59 000 Black women from across the US, assessed the longitudinal association between perceived interpersonal racism and stroke incidence. Stroke-free participants were followed up from 1997 until onset of stroke, death, loss to follow-up, or the end of the study period (December 31, 2019). Cox models were used to estimate hazard ratios (HRs) and 95% CIs, adjusting for major confounders, including education, neighborhood socioeconomic environment, and cardiometabolic factors. Data analysis was performed from March 2021 until December 2022. Exposure: On a questionnaire completed in 1997, participants reported experiences of racism in everyday life and when dealing with situations that involved employment, housing, and interactions with police. Main Outcomes and Measures: Strokes were identified through self-report on biennial questionnaires, medical records adjudication, and linkage with the National Death Index. Results: In 1997, 48 375 Black women (mean [SD] age, 41 [10] years) provided information on perceived interpersonal racism and were free of cardiovascular disease and cancer. During the 22 years of follow-up, 1664 incident stroke cases were identified; among them, 550 were definite cases confirmed by neurologist review and/or National Death Index linkage. Multivariable HRs for reported experiences of racism in all 3 domains of employment, housing, and interactions with police vs no such experiences were 1.38 (95% CI, 1.14-1.67), a 38% increase, for all incident cases and 1.37 (95% CI, 1.00-1.88) for definite cases. For comparisons of women in the highest quartile of everyday interpersonal racism score vs women in the lowest quartile, multivariable HRs were 1.14 (95% CI, 0.97-1.35) for analyses that included all incident stroke and 1.09 (95% CI, 0.83-1.45) for analyses that included definite cases only. Conclusions and Relevance: In this study, Black women who reported experiences of interpersonal racism in situations involving employment, housing, and interactions with police appeared to have an increased risk of stroke, even after accounting for demographic and vascular risk factors, suggesting that the high burden of racism experienced by Black US women may contribute to racial disparities in stroke incidence.

"Does Religious Service Attendance Modify the Relationship between Everyday Discrimination and Risk of Obesity? Results from the Study on Stress, Spirituality and Health".

This study examined the association of everyday discrimination with risk of obesity and the potential modifying effect of religious service attendance. Participants included Black, South Asian, and white women in three cohort studies that belong to the Study on Stress, Spirituality and Health. Logistic regression models estimated odds of obesity classification (BMI ≥ 30) relative to experiences of everyday discrimination. In initial pooled analyses, high levels of discrimination were related to increased odds of obesity. Race-specific analyses revealed marginal associations for white and South Asian women. Among Black women, high levels of discrimination and religious service attendance were both associated with higher odds of obesity. However, among women who attended religious services frequently, higher levels of everyday discrimination were associated with slightly lower odds of obesity. These findings underline the complex association between obesity and religion/spirituality, suggesting that higher levels of discrimination may uniquely activate religious resources or coping strategies. Findings highlight the need for additional studies to examine the impact of everyday discrimination on risk of obesity across racial/ethnic communities and how religious practices or coping strategies might affect these dynamics.

Sarcoidosis and its relation to other immune-mediated diseases: Epidemiological insights.

Several epidemiological studies show a co-occurrence of sarcoidosis with other immune-mediated diseases (IMD). There are many similarities between sarcoidosis and IMDs in their geographical distribution and risk factors. Understanding these similarities and identifying the differences can help us to better understand sarcoidosis and put it into context with other IMDs. In this review, we present the current knowledge about the overlap between sarcoidosis and other IMDs derived from epidemiological studies. Epidemiologic methods utilize study design and statistical analysis to describe the patterns in data and, ideally, identify causal relationships between an exposure and a health outcome. We discuss how study design and analysis may affect the interpretation of epidemiological studies on this topic and highlight some theories that attempt to explain the relation between sarcoidosis and other IMDs.

Hair relaxer use and risk of uterine cancer in the Black Women's Health Study.

BACKGROUND: Chemical hair relaxers, use of which is highly prevalent among Black women in the US, have been inconsistently linked to risk of estrogen-dependent cancers, such as breast cancer, and other reproductive health conditions. Whether hair relaxer use increases risk of uterine cancer is unknown. METHODS: In the Black Women's Health Study, 44,798 women with an intact uterus who self-identified as Black were followed from 1997, when chemical hair relaxer use was queried, until 2019. Over follow-up, 347 incident uterine cancers were diagnosed. We used multivariable Cox proportional hazards regression models, adjusted for age and other potential confounders, to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations of hair relaxer use with risk of uterine cancer. RESULTS: Compared to women who never used hair relaxers or used them infrequently (<4 years and ≤1-2 times/year), the HR for uterine cancer associated with heavy use (≥15 years and at least 5 times/year) was 1.18 (95% CI: 0.81, 1.71). However, among postmenopausal women, compared to never/light use, the HR for moderate use was 1.60 (95% CI: 1.01, 2.53), the HR for heavy use was 1.64 (1.01, 2.64), and the HR for ≥20 years of use regardless of frequency was 1.71 (1.08, 2.72). Results among premenopausal women were null. CONCLUSIONS: In this large cohort of Black women, long-term use of chemical hair relaxers was associated with increased risk of uterine cancer among postmenopausal women, but not among premenopausal women. These findings suggest that hair relaxer use may be a potentially modifiable risk factor for uterine cancer.

COVID-19-Related Racial Discrimination during Lockdown and Its Impact on Asian American Women.

During the lockdown period of the COVID-19 pandemic, Asian American (AA) women have experienced a surge in anti-Asian hate crimes and racial discrimination, and a majority of studies have quantitatively shown the negative impact of these incidents on Asian Americans' well-being. Our research expands on the existing literature by qualitatively investigating types of COVID-19-related racial discrimination during lockdown and its impacts on changes in emotions, behaviors, well-being, and racial identity development among AA women. This study covered two timepoints (December 2019 to May 2020) and the data were collected using an open-ended survey with 40 AA women. Thematic analysis identified core themes related to types of racial discrimination, emotional and behavioral changes, and racial identity status that emerged due to COVID-19-related racial discrimination experiences. The findings shed light on the long-lasting impacts of racial discrimination on AA women's overall well-being and dynamic development of racial identity. Altogether, our findings underscore the need for systematic forms of advocacy to combat anti-Asian racism and call for solidarity for AA women's well-being.

Religion/Spirituality and Prevalent Hypertension among Ethnic Cohorts in the Study on Stress, Spirituality, and Health.

BACKGROUND: Hypertension is a significant public health issue, particularly for Blacks, Hispanics/Latinos, and South Asians who are at greater risk than whites. Religion and spirituality (R/S) have been shown to be protective, but this has been identified primarily in whites with limited R/S measures examined (i.e., religious service attendance). PURPOSE: To assess hypertension prevalence (HP) in four racial/ethnic groups while incorporating an array of R/S variables, including individual prayer, group prayer, nontheistic daily spiritual experiences, yoga, gratitude, positive religious coping, and negative religious coping. METHODS: Data were drawn from the Study on Stress, Spirituality, and Health, a consortium of ethnically diverse U.S. cohorts. The sample included 994 Black women, 838 Hispanic/Latino men and women, 879 South Asian men and women, and 3681 white women. Using a cross-sectional design, prevalence ratios for R/S and hypertension were reported for each cohort, in addition to pooled analyses. Given differences in R/S among men and women, all models were stratified by gender. RESULTS: Different patterns of associations were found between women and men. Among women: 1) religious attendance was associated with lower HP among Black and white women; 2) gratitude was linked to lower HP among Hispanic/Latino, South Asian, and white women; 3) individual prayer was associated with higher HP among Hispanic/Latino and white women; 4) yoga was associated with higher HP among South Asian women, and 5) negative religious coping was linked to higher HP among Black women. Among men: significant results were only found among Hispanic/Latino men. Religious attendance and individual prayer were associated with higher HP, while group prayer and negative religious coping were associated with lower HP. CONCLUSION: Religion/spirituality is a multifaceted construct that manifests differently by race/ethnicity and gender. Medical practitioners should avoid a one-size-fits-all approach to this topic when evaluating prevalent hypertension in diverse communities.

Hypertension is a serious public health issue that affects many Americans, though non-whites are at greater risk than whites. In this study, we examine Black, Hispanic/Latino, and South Asian samples, comparing their hypertension rates to whites. We ask whether one or more aspects of religion and spirituality (R/S) might be associated with prevalent hypertension (i.e., prevalence of hypertension at a single point in time). Religious service attendance is the primary R/S variable examined in relation to hypertension, but we expand this to include individual prayer, prayer in groups, daily spiritual experiences, yoga practice, feelings of gratitude, using God to help cope with problems (positive religious coping), and experiencing doubt or fear about God in the face of challenges (negative religious coping). The results were mixed across racial/ethnic group and gender. Among women, higher religious attendance and gratitude were associated with lower hypertension prevalence, but individual prayer was associated with higher prevalence. Few associations were noted between R/S and hypertension among men. Given these findings, along with extant research, it is important for medical practitioners serving diverse communities to recognize R/S may operate differently for men and women in varied religious and ethnic groups, with differing implications for prevalent hypertension.

Perceived racism associated with declines in self-rated oral health among U.S. Black women.

PURPOSE: Racial disparities in oral health are well-documented. Stress has been associated with both perceived racism and oral health, yet little research has directly investigated the association between perceived racism and oral health. METHODS: We used data from the Black Women's Health Study, a longitudinal cohort study that includes a geographically diverse sample of Black women across the United States. Perceived exposure to racism was assessed via two scales, one assessing lifetime exposure and one everyday exposure. Self-rated oral health was subsequently assessed over multiple time points. We used Cox proportional hazard models to calculate adjusted incidence rate ratios estimating the association between higher levels of perceived racism and incident "fair" or "poor" oral health, and explored potential effect measure modification using stratified models. RESULTS: The adjusted incidence rate ratios (n = 27,008) relating perceived racism to incident fair or poor oral health were 1.50 (95% confidence interval 1.35, 1.66) comparing the highest quartile of everyday racism to the lowest and 1.45 (95% confidence interval 1.31, 1.61) for the highest score of lifetime racism compared to the lowest. We did not see evidence of effect modification. CONCLUSIONS: Higher levels of perceived racism documented in 2009 were associated with declines in self-rated oral health from 2011 to 2019.

Epidemiology of Inflammatory Bowel Disease in a Cohort of US Black Women.

BACKGROUND AND AIMS: Inflammatory bowel disease (IBD), including ulcerative colitis and Crohn's disease, are inflammatory diseases of the gastrointestinal tract. The incidence of IBD is increasing in minority populations; however, little is known about the epidemiology and disease characteristics of IBD in Black women. METHODS: Our study population included participants in the Black Women's Health Study. Diagnosis of IBD was self-reported through the biennial questionnaires starting at baseline in 1995. We estimated the incidence of IBD according to age and geographic region. A follow-up supplementary questionnaire was also sent to a subset of participants who reported diagnosis of IBD to evaluate the accuracy of self-reported diagnosis and to assess disease characteristics. RESULTS: Through December 31, 2021, a total of 609 cases of IBD were reported, of which 142 were prevalent at baseline (prevalence, 0.24%), and 467 were incident (crude incidence rate, 33.2/100 000 person-years). The incidence of IBD was highest in the younger than 30 years age group and similar across geographic region. Among the participants who responded to the supplementary questionnaire, 57.1% had confirmed diagnosis of IBD. CONCLUSIONS: In a large prospective cohort of US Black women, we found that the incidence of IBD was similar to previously published estimates in US White women. Future studies should focus on identifying risk factors for IBD in Black individuals in the United States.

Vitamin D and risk of hypertension among Black women.

Evidence of an association between plasma 25-hydroxyvitamin D [25(OH)D] levels and risk of hypertension, predominantly from studies of White individuals, suggests an inverse relationship. Limited data are available on Black individuals, who are more likely to have vitamin D deficiency. In the Black Women's Health Study (BWHS), a prospective study of 59 000 self-identified Black women from across the US, we assessed levels of a validated predicted vitamin D score in relation to incident hypertension. We followed 42 239 participants who were free of cardiovascular disease and cancer from 1995 to 2019, during which time 19 505 incident cases of hypertension were identified. Cox proportional hazards model were used to calculate multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the association of predicted vitamin D with the risk of incident hypertension. In age-adjusted analyses, there was a strong inverse dose-response association between predicted vitamin D score and hypertension risk, with an HR of .66 (95% CI: .63-.68, p trend < .0001) for the highest quartile of predicted vitamin D relative to the lowest. After control for potential confounders including body mass index, physical activity, and cigarette smoking, the HR was attenuated to .91 (95% CI: .87-.95, p trend = .002). In this prospective cohort study of Black women, predicted vitamin D score was weakly inversely associated with the incidence of hypertension. This observed association may reflect an inability to fully control for confounding factors.

Correlates of nephrolithiasis in US black women: data from the black women's health study.

Nephrolithiasis is a common urologic condition and a significant source of patient morbidity and healthcare expenditure. There are few epidemiologic studies of kidney stones focusing exclusively on Black women. We retrospectively assessed the prevalence and correlates of self-reported kidney stones within the Black Women's Health Study (BWHS). Descriptive statistics and multivariable logistic regression models were used to explore factors associated with nephrolithiasis. As of the 2005 follow-up questionnaire, a cumulative total of 1063 women among 43,178 reported ever being diagnosed with kidney stones for a prevalence of 2.64%. Women with a history of nephrolithiasis were older, slightly heavier, and were more likely to have a comorbid condition (e.g., type-2 diabetes, gallstones), drink alcohol, and consume a Western-style diet. A history of gallstone disease was associated with an odds ratio (OR) of 3.59 (95% confidence interval (CI) 3.09-4.17). The OR for consuming ≥ 7 alcoholic beverages/week, compared to none was 0.61 (0.39-0.94), while the OR for high adherence to the Western diet, compared to low adherence was 1.53 (1.23-1.90). Our findings are consistent with previous studies of primarily white populations relating lifestyle-associated risk factors with nephrolithiasis. Despite their lower prevalence of kidney stones, it is important to focus on vulnerable populations such as Black women given their disproportionate burden of metabolic conditions (e.g., obesity, diabetes) related to kidney stone disease.

Research on Health Disparities: Strategies and Findings From the Black Women's Health Study.

The American Journal of Epidemiology has been a platform for findings from the Black Women's Health Study (BWHS) that are relevant to health disparities. Topics addressed have included methods of follow-up of a large cohort of Black women, disparities in health-care delivery, modifiable risk factors for health conditions that disproportionately affect Black women, associations with exposures that are highly prevalent in Black women, and methods for genetic research. BWHS papers have also highlighted the importance of considering social context, including perceived experiences of racism, in understanding health disparities. In the future, BWHS investigators will contribute to documentation of the role that structural racism plays in health disparities.

Racial and Ethnic Disparities in the Incidence of High-Impact Chronic Pain Among Primary Care Patients with Acute Low Back Pain: A Cohort Study.

OBJECTIVE: We assessed whether race or ethnicity was associated with the incidence of high-impact chronic low back pain (cLBP) among adults consulting a primary care provider for acute low back pain (aLBP). METHODS: In this secondary analysis of a prospective cohort study, patients with aLBP were identified through screening at seventy-seven primary care practices from four geographic regions. Incidence of high-impact cLBP was defined as the subset of patients with cLBP and at least moderate disability on Oswestry Disability Index [ODI >30]) at 6 months. General linear mixed models provided adjusted estimates of association between race/ethnicity and high-impact cLBP. RESULTS: We identified 9,088 patients with aLBP (81.3% White; 14.3% Black; 4.4% Hispanic). Black/Hispanic patients compared to White patients, were younger and more likely to be female, obese, have Medicaid insurance, worse disability on ODI, and were at higher risk of persistent disability on STarT Back Tool (all P < .0001). At 6 months, more Black and Hispanic patients reported high-impact cLBP (30% and 25%, respectively) compared to White patients (15%, P < .0001, n = 5,035). After adjusting for measured differences in socioeconomic and back-related risk factors, compared to White patients, the increased odds of high-impact cLBP remained statistically significant for Black but not Hispanic patients (adjusted odds ration [aOR] = 1.40, 95% confidence interval [CI]: 1.05-1.87 and aOR = 1.25, 95%CI: 0.83-1.90, respectively). CONCLUSIONS: We observed an increased incidence of high-impact cLBP among Black and Hispanic patients compared to White patients. This disparity was partly explained by racial/ethnic differences in socioeconomic and back-related risk factors. Interventions that target these factors to reduce pain-related disparities should be evaluated. CLINICALTRIALS.GOV IDENTIFIER: NCT02647658.

Perceived experiences of racism linked to dental fear and anxiety among Black women.

OBJECTIVES: Dental fear and anxiety are known determinants of delaying or avoiding dental care and vary considerably based on factors such as age and gender. However, little is known about dental fear and anxiety in racial/ethnic minority populations, which bear a disproportionate burden of poor oral health outcomes. Structural and social pathways responsible for producing these disparities are also understudied. Experiences of racism over the lifecourse may contribute to poor oral health outcomes through a pathway of dental fear and anxiety. This paper aimed to evaluate perceived experiences with racism, dental fear and anxiety, and the utilization of dental services, in the Black Women's Health Study (BWHS), a United States-based prospective cohort. METHODS: Analysis of prospective data obtained from a geographic subset of participants in the BWHS was conducted. In 2014, BWHS participants residing in Massachusetts responded to a mailed oral health questionnaire that included the Index of Dental Anxiety and Fear (IDAF-4C+) instrument (N = 484; 69% response rate). Previously collected demographic and health information, along with reported experiences of everyday and lifetime racism, obtained from national BWHS questionnaires between 1995 and 2009, were merged with the Massachusetts-based sub-sample. Associations between high dental anxiety (HDA) (mean IDAF-4C+ score ≥2.5 on the dental fear and anxiety module) and oral health outcomes and perceived racism and HDA were explored via prevalence ratios (PR) calculated using log-binomial regression models, including adjustment for potential confounders. RESULTS: Reported exposures to everyday racism occurred weekly on average for the top 25% of the sample, while 13% of participants reported exposure to multiple (n = 3) experiences of unfair treatment due to their race over their lifetime. HDA was prevalent among 17.8% of the sample and was significantly associated with indicators of poor oral health status. High exposures to everyday and lifetime experiences of racism were positively associated with HDA (PR = 1.08; 95% CI: 0.90, 1.58 and PR = 1.72; 95% CI: 1.03, 2.88, respectively). CONCLUSIONS: Significant associations between racism and HDA, and between HDA and poor oral health and reduced utilization of dental care were observed. Dental anxiety may be a pathway through which perceived experiences with racism may impact oral health outcomes.