Editorial: Racial and ethnic inequalities in multiple long-term conditions: current trends and viable solutions

The presence of two or more long-term health conditions (i.e. multiple long-term conditions (MLTCS)) poses significant challenges for individuals and health systems (1). MLTCs are associated with poor quality of life, increased morbidity, mortality (2), healthcare utilisation, polypharmacy (3) and a greater need for multi-department consultations (4). The overall global prevalence of MLTCs is estimated at 37.2% (5) and is projected to increase in the coming decades (6). Yet, the prevalence of MLTCs and its impact is not felt equally across racial/ethnic groups. A growing body of evidence suggests that racially/ethnic minoritised people prematurely and disproportionately experience the burden MLTCs (7)(8)(9). The Research Topic,Solutions, was conceptualised to showcase the state of the art in racial/ethnic inequalities in MLTCs and illuminate viable solutions to address existing inequalities. In this Editorial, we critically discuss the seven articles contributing to this Research Topic, all of which add to the vast body of literature documenting racial/ethnic inequalities in health(care) outcomes. First, we describe the scope of the studies, and the key themes that cut across the articles. Second, we discuss the ways in which these articles advance our understanding of racial/ethnic inequalities in MLTCs. Lastly, we consider the implications for policy and practice to address existing health inequalities (including MLTCs).Of the seven articles comprising this Research Topic, five articles provide insights into health(care) outcomes and experiences of racially/ethnic minoritised people living in countries such as the UK (n=1) and the US (n=4) which have historically contributed to the established body of literature on racial/ethnic inequalities in health. Two articles provide insights into racial/ethnic inequalities among understudied populations living in China (n=1) (10), and Germany (n=1) (11). Collectively, the articles provide insight into the circumstances and experiences of a range of racial/ethnic minoritised groups including Black, African, Afrodiasporic and/or Muslim healthcare users in Germany (11); Black/African American, Latino, Asian people in the US (12)(13)(14)(15); Black, Asian and Mixed ethnic people in the UK (16); and Zhiguo, Akha, Zhuang, Dai, Yi and Hmong ethnic minority groups in China (10).The contributing articles adopt a range of research designs, thereby, providing a comprehensive understanding of racial/ethnic inequalities in health(care). The quantitative studies (n=4) alert us to the characteristics of long-term conditions, MLTCs and their impact on ethnic minority populations in Yunan province in China (10), racial inequalities in infant mortality (15), racial differences in knowledge, attitudes toward vaccination, and risk practices related to Lyme Disease (LD) (14), the association of socioeconomic deprivation and ethnicity on the risk of diabetes (16), and the disproportionate financial hardship experienced by Black, Latino, and Asian households with children during the COVID-19 pandemic (13). Conversely, the qualitative studies (n=2) provide in-depth insights into health(care) experiences of racially/ethnic minoritised people (11) and health providers perspectives of the influences of Cancer disparities among Latinos in the US (12). These articles span different conditions, stages of the disease process and aspects of the care continuum. Crucially, the articles give insight into the pathways through which single conditions progress to MLTCs. For instance, Ramirez and colleagues suggest that the stress of a Cancer diagnosis can also result in mental health issues, underscoring the link between physical and mental health conditions (12). Similarly, Deng and colleagues posit that delayed or inadequate diagnosis and treatment of chronic diseases further contribute to rapid disease progression and preventable disability, particularly among vulnerable populations (10). In their study examining the association of socioeconomic deprivation and ethnicity on the risk of diabetes, Au-Yeung and colleagues found that socioeconomic deprivation increased the risk of (pre)diabetes (16). They hypothesise that limited income, lower health literacy, housing instability, and reduced food access negatively influence an individual's ability to effectively manage their health and increases the risk of developing complications associated with diabetes (16).Across all articles, a central theme is the interaction between structural and social factors in producing racial and ethnic inequalities in health and healthcare, including the development and management of MLTCs. Ramirez and colleagues identify a combination of environmental and genetic influences, cultural and linguistic barriers, health behaviours, and systemic access issues as key contributors to Cancer disparities among Latino populations in the US (12).Others further demonstrate how racially/ethnic minoritised groups are disproportionately concentrated in occupations and living environments that adversely affect health outcomes (10,12,14). Deng and colleagues, for example, highlight how harsh living conditions and geographical and infrastructural barriers restrict health literacy and self-care capacity, increasing vulnerability to disease (10). Similarly, Au-Yeung and colleagues show how structural constraints such as poverty, limited education, and inadequate housing reduce access to healthy food and opportunities for physical activity, thereby, worsening health outcomes and quality of life (16).Several studies explicitly position structural racism as an upstream driver of health inequalities (11,13,15). Saiyed and colleagues link city-level poverty rates with both overall infant mortality rates and Black infant mortality rates (15). Jimenez and colleagues demonstrate how systemic racism exacerbated pre-existing economic inequality during the COVID-19 pandemic (13). Gangarova and colleagues further reveal the dual mechanism by which structural racism operates. First, healthcare users are discriminated against in healthcare encounters. Second, they avoid healthcare services due to prior experiences of being othered, ignored or unheard (11). These repeated experiences cultivate mistrust in healthcare systems among racially/ethnic minoritised healthcare users constraining their capacity engage with care (11).The articles collectively demonstrate how structural processes, particularly racism and discrimination, interact with social factors to shape the conditions in which racial/ethnic minoritised groups live and work, as well as their access to, and use of healthcare services for managing health conditions. Together, the findings highlight important implications for policymakers and practitioners seeking to reduce racial/ethnic health inequalities, including those related to MLTCs. Several contributions emphasise the need for further research to deepen understanding of these inequalities. For example, Shafquat and colleagues identify racial differences in knowledge, attitudes, and practices related to LD as contributors to inequitable outcomes, calling for further investigation into information sources, trust in those sources, and how these vary by race/ethnicity (14). Similarly, Saiyed and colleagues report the lack of statistically significant associations between some structural racism composite indices and inequity measures, underscoring the need to refine or identify different indicators of structural determinants in urban health research (15).Other studies recommend tailored/targeted interventions to address inequities (10,16), alongside greater attention to inclusion, cultural relevance, and accessibility in both research and care delivery (12). Echoing this, Saiyed and colleagues stress the importance of engaging local communities to understand contextual histories, identify priority issues, and co-develop effective interventions (15). Multiple authors further highlight the need to address upstream structural drivers (e.g. poverty, unemployment, income inequality, and residential segregation) to inform equitable policy responses (13,15,16). Finally, Gangarova and colleagues caution against overlooking racialisation processes, which reveal how subtle, normalised forms of racism are enacted within healthcare systems (11). They argue for anti-racist policies that move beyond cultural competence to address racism at structural, institutional, and interpersonal levels.