“You don’t do it for them, you do it with them” Policymaker Perspectives on Implementing Health Equity Frameworks across the European Union and United Kingdom

“You don’t do it for them, you do it with them” Policymaker Perspectives on Implementing Health Equity Frameworks across the European Union and United Kingdom | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “You don’t do it for them, you do it with them” Policymaker Perspectives on Implementing Health Equity Frameworks across the European Union and United Kingdom Marco Barracchia, James Allen, Daniel Jones, Joanna Kate Peden, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7494799/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Despite growing policy commitments to health equity across the European Union (EU) and United Kingdom (UK), the implementation of Health Equity Frameworks (HEFs) remains inconsistent and fragmented. This study investigates how policymakers understand and apply HEFs in practice and identifies the barriers and facilitators shaping their implementation within multi-level health governance systems. Methods Eighteen semi-structured interviews were conducted with high-level stakeholders from EU institutions, national public health agencies, and Non-governmental organizations (NGOs) engaged in health equity work. Using a directed content analysis informed by the Health Equity Implementation Framework, data were coded across seven domains: innovation characteristics, clinical encounters, patient and community factors, inner context, outer context, societal context, and culturally relevant factors of recipients. Results The participants consistently reported gaps between equity goals and reality. HEFs were often perceived as overly theoretical, Western-centric, and disconnected from the lived realities of marginalized communities, including migrants, LGBTQI + populations, and racialized groups. Barriers included institutional inertia, fragmented governance, lack of equity training across all levels, lack of trans-disciplinarity, inadequate data, and minimal community engagement. Facilitators included co-design with communities, plain-language frameworks, mandatory cross-sector training, integration of lived experience, inclusion of administration staff in health equity training, and stronger funding and accountability mechanisms. Participants emphasized the importance of political will, culturally competent care, and intersectionality in addressing intersecting forms of exclusion. Conclusion Findings highlight that for HEFs to be effective, they must be adaptable, inclusive, and operationalized across all system levels. Recommendations include embedding lived experience in framework design, simplifying language, investing in equity-driven data systems, and mandating cross-sectoral collaboration. A shift towards participatory, rights-based implementation, grounded in structural awareness and long-term political commitment, is essential to translate health equity frameworks into impactful outcomes. Health Equity Health Equity Implementation Framework Implementation Science EU UK Coproduction Health Inequality Introduction Health equity refers to the absence of unfair, avoidable, and remediable differences in health status among different population groups and is achieved when everyone can reach their full potential for health and well-being, ensuring that no individual is disadvantaged due to systemic inequities [ 1 ]. These inequities often stem from social, economic, and structural determinants, including geographic disparities, racism, homophobia, transphobia and cultural biases that disproportionately affect marginalized groups, resulting in unequal power and resource distribution in society [ 2 ]. Disparities in the implementation of health interventions contribute to unequal access and benefits among groups with different levels of social advantage, including life expectancy. Health equity frameworks (HEFs) are essential tools designed to identify, understand, and address these disparities systematically [ 3 ]. They provide a structured approach to implementing policies, programmes, and interventions that promote fairness in health outcomes across all segments of society [ 3 ]. HEFs typically feature principles of equity-focused implementation science (IS), which is the process of integrating and incorporating new practices into a specific context [ 4 ]. IS is the systematic study of methods to integrate evidence-based interventions into real-world settings, considering contextual factors such as population needs, structural challenges, and socio-cultural dynamics [ 4 , 5 ]. IS optimizes the adoption, implementation, and sustainability of health interventions within specific systems [ 6 , 7 ]. Placing HEFs within IS enables stakeholders to address the complex interplay of determinants that perpetuate health inequities, using systems thinking and co-design approaches to reduce disparities and improve health outcomes for disadvantaged communities [ 8 ]. In this study, we aim to examine the multi-level factors shaping the implementation of HEFs across the European Union (EU) and United Kingdom (UK) to unpack how different factors influence the implementation of such frameworks, accounting for political will and commitment, collaboration, resources, and governance across the EU and UK. While policy intentions across the EU and UK have acknowledged the importance of reducing health disparities, the operationalisation of health equity has often lacked coherence and contextual sensitivity. This has ignited a growing interest in HEFs as structured tools to bridge the gap between policy commitments and practice. Understanding how these frameworks are implemented and where they need improvement is essential for ensuring equitable outcomes, particularly in regions like the UK and EU that have made significant legislative commitments but continue to face persistent disparities [ 9 , 10 ]. Health Equity: European Union To tackle health inequities at the EU level, international agreements such as Health in All Policies (HiAP), as defined in Art. 168 of the Treaty of the Functioning of the European Union (TFEU) and promoted by the World Health Organization (WHO) since the Ottawa Charta (1986), acknowledges the need for an integrated approach to health involving different policy fields [ 11 ]. HiAP aligns with HEFs by integrating health considerations across multiple sectors to address the social determinants of health. By embedding health equity into decision-making processes at municipal, national, and EU levels, HiAP fosters cross-sectoral collaboration and governance structures that reduce health disparities [ 11 ]. However, health equity implementation gaps continue to persist in the application of HEFs across the EU despite growing awareness and increased action. These gaps include differences in equity concepts between policymakers and executives, access inequalities from EU cross-border healthcare directives, disparities in municipal health promotion, weak intersectoral collaboration, resource limitations, the voluntary nature of health promotion and limited national support to health prevention, the difficulty of securing political support for health equity investments, and the complexities of achieving health gains across various policy domains [ 12 – 15 ]. The Joint Action Health Equity Europe (JAHEE) initiative has advanced cooperation among countries and facilitated concrete measures to reduce health inequalities, yet significant gaps remain in terms of policy responses, governance, tangible outcomes, and community participation [ 16 ]. To bridge these gaps, researchers recommend incorporating health equity domains into existing implementation frameworks, emphasizing culturally relevant factors, the dynamics of patient-provider interactions, and the broader societal context; however, the existing information on health inequities and their determinants is not automatically transformed into concrete policy actions and measures, and the research lacks direct address of implementation gaps within these frameworks [ 16 – 19 ]. Health Equity: United Kingdom Health equity has been a long-standing concern in the UK. Following publication of the Acheson report, there were measurable reductions from 1998–2010 in geographical health inequalities, particularly in infant mortality rates, demonstrating the potential effectiveness of coordinated, multisector policy approaches to equity [ 20 , 21 ]. However, systemic disparities persist despite the presence of a universal healthcare system. The UK has witnessed growing socioeconomic inequalities in health over the past decade, which have been exacerbated by austerity policies and the impacts of the COVID-19 pandemic [ 9 , 10 ]. Although national strategies and frameworks have been introduced to address these issues, including various WHO-aligned policy tools and data-driven equity assessments, the implementation of these frameworks remains inconsistent across the UK. Devolution has enabled the nations within the UK to adapt their policy responses to health inequalities, offering a unique lens to evaluate localized implementation strategies. In this context, Wales stands out for its legislative and strategic commitment to health equity. Wales has incorporated health equity into its policy and public health landscape, such as in the case of the legislation “The Well-being of Future Generations (Wales) Act 2015.” Wales has, in fact, prioritized sustainable and equitable health outcomes by addressing the social, economic, cultural and environmental determinants of health [ 22 ]. The Welsh Health Equity Status Report Initiative (WHESRi) aims to strengthen Wales' role in addressing health inequities by gathering data, developing digital platforms, forthcoming regulations on Health Impact Assessments (HIAs), and facilitating cross-sector dialogue. Yet, challenges remain in the effective implementation of such frameworks [ 22 , 23 ]. This initiative provides a comprehensive framework to address health inequities exacerbated by systemic challenges, such as housing insecurity (nearly 20% of households lack access to private outdoor spaces) and economic vulnerabilities, including a surge in unemployment due to the COVID-19 pandemic [ 23 ]. Despite similar policy approaches to health inequalities across the UK and in the EU, devolution has allowed for some divergence in implementation. During the COVID-19 pandemic, socio-economic inequities increased, impacting health services, housing, health, education, employment and working conditions, amongst others [ 23 ]. People living in the most deprived areas were twice as likely to be hospitalised or die from COVID-19, and 22% of households lost at least 20% of their weekly income early in the pandemic. Elective admissions fell by 55% and emergency admissions by 30%, and school closures deepened the digital divide, further disadvantaging children from deprived backgrounds. Ethnic minority groups accounted for 33% of critical care admissions despite comprising only 14% of the population, while overcrowded housing, homelessness, and unsafe environments increased exposure risks [ 23 ]. Key population groups with intersectional vulnerabilities were further marginalized, including youth, minority ethnic groups (Black and Asian particularly), LGBTQI + individuals, and people experiencing homelessness. In fact, 28% of children and 23% of all people in Wales live in relative income poverty, with these figures disproportionately higher in the most deprived areas [ 22 , 23 ]. Equity-focused Theories, Models and Frameworks: Implementation Science and Research To translate growing policy commitments to health equity into effective action, public health systems increasingly rely on equity-focused theories, models, and frameworks (TFMs). These frameworks are designed to help stakeholders conceptualize, design, implement, and evaluate strategies aimed at reducing health disparities. TFMs are typically categorized into five types: determinant frameworks, implementation theories, process models, evaluation frameworks, and hybrid frameworks—each offering distinct pathways for understanding and supporting equity-oriented action in health systems [ 3 , 4 ]. Determinant frameworks, such as the Health Equity Implementation Framework (HEIF), focus on identifying contextual factors, such as societal influences and clinical interactions, that predict whether equity-based interventions succeed, especially for marginalized groups [ 19 ]. Implementation theories, including the COM-B model (capability, opportunity, and motivation influencing behavior), explore behavior change mechanisms and are often used to tailor interventions to specific populations and cultural settings [ 6 ]. Process models such as the Equity-Based Framework for Implementation Research (EquIR) offer structured steps to engage communities and address equity barriers at the design and delivery stages [ 5 ]. Evaluation frameworks, like RE-AIM and its equity adaptations, assess outcomes at multiple system levels with an explicit focus on reducing disparities [ 24 ]. Finally, hybrid models such as EQ-DI integrate components from determinant, process, and evaluation frameworks to enable multi-level strategies for equitable implementation outcomes [ 25 ]. Collectively, these HEFs provide comprehensive tools to embed equity within the design and delivery of healthcare programs and policies. Despite their growing use, significant gaps remain in understanding how they are implemented in practice — particularly across complex, multi-level governance systems like the EU, the UK, and their member states. Given this study’s focus on identifying the barriers and facilitators to implementing HEFs across the EU and UK, it is essential to situate these frameworks within the broader field of IS. IS studies the methods that promote the integration of evidence-based practices into specific real-world settings [ 4 ]. It accounts for a range of influencing factors, including the characteristics of the setting, the needs of target populations, and structural, socio-cultural, and geographic conditions [ 5 , 8 , 26 , 27 ]. Thus, IS attempts to systematically study how to design and evaluate activities to facilitate a successful uptake of an evidence-based health intervention [ 6 , 7 ]. Closely related, implementation research (IR) systematically applies these methods to identify context-sensitive solutions, optimize the delivery of policies or interventions, and assess implementation processes across outcome levels [ 28 ]. While limited, there are empirical studies and scoping reviews that have explored similar themes, though typically outside the EU/UK. For example, Ravaghi et al. conducted a qualitative study exploring stakeholder perspectives on health equity and its indicators in Iran, using a comparable methodology to understand contextual barriers to equity [ 14 ]. Similarly, Yusuf et al. examined how health equity is integrated into service delivery systems in Nova Scotia through interviews with policymakers and health professionals [ 29 ]. Reviews such as the scoping protocol by Gustafson et al. have mapped the existing frameworks, facilitators, and barriers to implementing interventions aimed at ethnicity-related health inequities [ 3 ], while others have addressed HEF applications in diverse domains, including population screening[ 30 ], medical education [ 31 ], social needs screening in primary care [ 32 ], and chronic disease prevention [ 33 ]. Despite these contributions, the literature does not provide conclusive evidence on how policymakers in the EU and the UK experience and interpret the implementation of HEFs across multi-level governance systems. HEFs are inherently implementation tools: they are designed not only to conceptualize disparities but to guide the delivery of equitable practices within existing systems. HEFs thus draw heavily from IS and IR to ensure that policies are adapted to local contexts and effectively serve populations that have historically experienced structural disadvantage [ 30 ]. However, IS and IR have not yet fully addressed the specific institutional, economic, and political factors that sustain healthcare inequities, such as racism, social exclusion, regulatory fragmentation, and workforce inequities [ 19 ]. These limitations are reflected in several structural gaps in the field, including the underrepresentation of marginalized communities in implementation studies [ 34 , 35 ]; the lack of meaningful engagement with affected populations during the design of interventions; inconsistent incorporation of equity-related data and methods [ 19 ]; and systemic injustices within the IS workforce itself, which limit its capacity to produce inclusive, representative knowledge [ 36 ]. To address these gaps, we applied the HEIF to investigate the multi-level barriers and facilitators shaping the implementation of HEFs across the EU and the UK, focusing on how policymakers’ perspectives can inform the development of more effective and context-sensitive equity frameworks. While previous studies have explored stakeholders’ views on health equity and its indicators outside the EU and UK [ 14 ], no research to date has examined implementation gaps in the application of HEFs through stakeholder interviews at both EU and UK levels. Additionally, previous research used the HEIF to analyse other domains, including Hepatitis C treatment. Building on preliminary insights from related work on health impact assessments and the social determinants of health [ 37 ], this study contributes new qualitative evidence on how HEFs are experienced, interpreted, and acted upon by key policymakers. By analysing interview data through HEIF [ 19 ], we generate actionable insights to strengthen equity implementation and reduce persistent disparities across EU and UK health systems. Methods Study Design and Setting This study employed an interpretative qualitative, exploratory, observational, and cross-sectional design, guided by a social-constructivist paradigm [ 38 ]. This research used directed qualitative content analysis to identify patterns, categories, and insights into the barriers and facilitators of implementing HEFs in the EU and the UK, based on pre-existing categories established by HEIF. The use of a directed approach enabled the research to begin with pre-determined categories derived from HEIF, allowing a structured analysis while leaving space for the emergence of new themes from the data [ 39 ]. Individual semi-structured interviews were conducted virtually, using the Zoom video communications platform, ensuring accessibility and inclusivity with the participant and principal researcher alone (details on researcher’s background and skills can be found below in the section Authors' Information). Participant Recruitment and Sampling This study included eighteen semi-structured interviews with policymakers to assess the usefulness and identify implementation gaps they have experienced while serving as implementation actors of HEFs. Interviews were conducted until saturation was reached, which indicated the optimal sample size [ 40 ]. Saturation was defined in advance as the point at which at least five consecutive interviews contributed only minor elaborations without generating new themes or codes, which occurred at interview number 16. Two more planned interviews were conducted, reaching 18 interviews in total. This was monitored through ongoing, iterative analysis during data collection. Previous literature indicates that 16–24 interviews can be enough to identify common themes from sites with relatively homogeneous groups [ 41 , 42 ]. Initial contacts were made using institutional networks and project-affiliated mailing lists, through various formal and informal networks including Maastricht University, Public Health Wales, the Health Equity Network, the Andalusian School of Public Health, and the Association of Schools of Public Health in the European Region. All participants received a formal invitation via email, which outlined the study’s aims, methodology, inclusion and exclusion criteria, and ethical safeguards. A total of 64 potential participants were contacted via email. Of these, 56 were successfully reached. Initially, n = 13 agreed to participate, while n = 2 declined due to time constraints. A follow-up email sent one week later yielded an additional n = 7 positive responses. However, n = 2 of these did not proceed with scheduling an interview. This resulted in a final sample of n = 18 expert interviews. Prior to the interviews, all participants received a brief survey containing questions on HEIFs, perceived gaps, and a request for contact details. The complete anonymized quote dataset is available in Additional file 1 [see Additional file 1]. However, given the qualitative focus of this study, only the interview data are analyzed in this manuscript. A total of 18 policymakers were interviewed, including representatives from EU health bodies, national public health agencies, and non-governmental organizations, such as the WHO Europe Region, Spanish Ministry of Health, United Nations, EuroHealthNet, Italian Ministry of Health, and Doctors Without Borders. No relationship was established with participants prior to the study, and interviews lasted 60–90 minutes. This research employed a mixed sampling approach, combining convenience sampling by selecting stakeholders who were readily available and easily accessible through Public Health Wales networks, and purposive sampling by targeting high-level policymakers and experts (e.g., representatives from the WHO Europe Region, national ministries of health, and NGOs) with specific experience in health equity frameworks and implementation [ 38 , 43 ]. Data Collection Procedures Data collection was conducted via semi-structured interviews, allowing for flexibility in exploring participant insights while maintaining comparability across responses. Interviews were conducted virtually, using the Zoom video communications platform, in May 2025. All sessions were audio-recorded, transcribed verbatim, and anonymized to protect participant confidentiality. We included policymakers actively involved in designing, implementing, or evaluating HEFs for at least 3–5 years. Participants had experience working with marginalized or vulnerable populations, were at least 18 years old, and were able to provide informed consent. Proficiency in English, Italian, Portuguese, or Spanish was required. Exclusion criteria included stakeholders with minimal involvement in HEFs and individuals unable to participate due to language barriers or scheduling conflicts. Residency or citizenship in Wales or an EU country was not a requirement, but participants had experience within the contexts being studied. Participants provided informed consent and were offered the opportunity to review the transcript of their interview. No one else was present during the interviews besides the participant and the researcher. Analytical memos were produced after each session. The interview guide was informed by HEIF, ensuring a structured and deductive yet adaptable and emerging approach [ 39 ]. A semi-structured interview guide was developed based on the HEIF framework and included open-ended questions exploring perceived barriers and facilitators to the implementation of health equity, focusing on the perceived gaps. All participants took part in a single interview. Repeat interviews were not deemed necessary, as data saturation was achieved within the initial interviews and clarification was obtained during the sessions themselves. Health Equity Implementation Framework The HEIF, developed through the integration of IS and healthcare disparities research, offers a comprehensive structure for identifying and addressing multi-level factors that influence the equitable adoption of health interventions [ 18 , 19 , 22 ]. Initially applied to challenges such as hepatitis C treatment among Black patients, HEIF assumes that embedding health equity domains within implementation frameworks enhances both scientific rigour and practical equity impact by simultaneously addressing implementation and disparity-related barriers [ 19 ]. HEIF assumes that incorporating health equity domains within implementation frameworks can optimize scientific yield and equity by simultaneously addressing implementation and equity barriers. To guide the directed content analysis, we applied the HEIF, a determinant-based implementation framework developed to explore multi-level barriers and facilitators affecting equitable uptake of interventions. HEIF was chosen due to its dual grounding in health disparities research and IS, making it particularly well-suited to explore policy-practice gaps in health equity efforts across the EU and UK. Preliminary codes were drafted from the HEIF but flexible to emerging categories to capture the richness and complexity of participants' experiences. (Table 1 ) [ 44 ]. The framework supports deductive categorisation of qualitative data through seven domains: (1) Characteristics of the Innovation, (2) Clinical Encounter, (3) Patient and Community Factors, (4) Inner Context, (5) Outer Context, (6) Societal Context, and (7) Culturally Relevant Factors of Recipients. These domains align with the core objectives of this study, which focuses on revealing both systemic and service-level implementation gaps [ 18 , 19 , 22 ]. By applying HEIF to stakeholder interviews through a structured and pre-determined coding scheme, this study ensures that health equity considerations are not only recognized but systematically assessed across different implementation levels [ 45 ]. This approach guided both the development of the interview guide and the organization of the results and tables. Operationalised definitions used in the analysis are detailed in Table 1 . Table 1 Operationalised definitions of Health Equity Implementation Framework (HEIF) domains HEIF Domain Exact or Summarized Definition from Source Culturally Relevant Factors of Recipients Defined as characteristics shaped by recipients’ lived and embodied experience (e.g., implicit bias, race/ethnicity, immigration status, language, health literacy) that influence how innovations are accepted or rejected in given context. Clinical Encounter (Patient–Provider Interaction) Defined as the relationships between patients and providers during appointments. It involves decision-making, communication, and provider behaviors (e.g., implicit bias, dismissiveness) that influence whether an innovation is offered or accepted. Clinical encounters affect satisfaction, trust, and outcomes, especially among marginalized individuals. Patient and Community Factors Mostly refers to patient health beliefs, knowledge, literacy, engagement, and community readiness to adopt innovations as well as how innovations are designed, implemented and evaluated through and with communities. Inner Context (Organizational Factors) Includes internal organizational factors like leadership, culture, history of change, communication, and resources. These influence how innovations are implemented and embedded into routine practice. Outer Context (Policy/System-Level Factors) Encompasses the broader healthcare system, including incentives, mandates, regulatory environments, inter-organizational networks, and system-level resources. These shape external drivers for implementation. Societal Context Refers to economic, physical, and sociopolitical structures (e.g., racism, classism, governance) that operate at macro levels and shape the healthcare system, organizational norms, and recipient experiences. These often institutionalize health inequities. Innovation Characteristics Describes the equity framework or intervention itself (e.g., clarity, fit, usability, adaptability, evidence). These characteristics affect whether the innovation can be tailored to the setting and recipients. Data Analysis Qualitative research plays a key role in implementation studies, as it helps explore how a particular innovation is applied in real-world settings. It focuses on examining the various factors that influence and interact with the implementation process [ 46 ]. To explore how contextual factors either support or hinder implementation, this study applied the HEIF. Directed content analysis was used to validate and extend existing theory and to generate predictions regarding the variables of interest or their interrelationships, aiding in the development of an initial coding framework or identifying connections between codes, also known as deductive category application [ 47 ]. The unit of analysis represented words used by policymakers throughout the interview text [ 48 , 49 ]. Questions to policymakers included open-ended questions and specific questions based on pre-determined categories [ 39 ]. Categories were further classified as “barriers” or “facilitators”. Manual coding using Excel and Word began immediately. Predetermined codes and data that could not be coded, were identified, and analysed later to determine if they represented a new category or a subcategory of an existing code. Ethics and Confidentiality Ethical approval was obtained from Maastricht University, Faculty of Health, Medicine, and Life Sciences Research Ethics Committee (FHML-REC 738). All participants provided written or verbal informed consent prior to participation. All ethical aspects involved in the research, including those related to participant recruitment, data collection, confidentiality, and informed consent, were thoroughly described in the research protocol. Precautions included obtaining informed consent, maintaining confidentiality and anonymity, minimizing any potential risks to participants, and ensuring voluntary participation throughout the research process. Participants were provided with detailed information about the study objectives, procedures, and potential risks and benefits. Informed consent was obtained in writing, and confidentiality was maintained through secure data storage and anonymization protocols. Efforts were made to ensure the equitable recruitment and inclusion of participants from diverse backgrounds and key populations, including LGBTQI + individuals, migrants and racialized participants engaged in high-level health equity policymaking. Participants were not compensated due to the purpose of this research and were provided with access to support resources, such as counseling, if needed. Recruitment strategies avoided coercion and respected participants' autonomy, including clear communication about the voluntary nature of participation. Ethical concerns regarding transcription were minimized through confidentiality agreement within the research team/transcribers; assignment of a code to each interview; substitution of the interviewee's name in the transcription with a code, unless explicitly agreed otherwise; substitution of third-party names; storage of the recording and transcription in a secure location; opportunity for interviewees to review the transcription [ 50 ]. All data processing complied with EU GDPR regulations, ensuring that personal data was protected and only used for research purposes. In line with ethical procedures, interview transcripts were made available for review only to those participants who explicitly requested them (n = 2). Ensuring Trustworthiness Inter-rater reliability checks validated the coding process, where co-authors were given the opportunity to re-review and validate key categories derived from the interviews, and discrepancies were resolved through team discussions [ 47 , 51 ]. Emerging categories and subcategories were refined to capture the richness of participants' experiences. The main author coded all 18 transcripts, while one supervisor and another colleague independently coded 4 transcripts (approximately 22% of the sample) to establish consistency and ensure alignment and inter-coder reliability [ 47 ]. Since the code definitions were clear and subcategories did not overlap, two rounds of independence coding produced approximately the same results [ 52 ]. Overall, triangulation of stakeholders, research bias and reflexivity, continuous validation of data, checking of representativeness of data, self-reflection, peer-debriefing, negative case analysis, and expert consultations will all increase the reliability, validity and credibility of the research [ 38 , 53 – 56 ]. This study adheres to the Consolidated Criteria for Reporting Qualitative Studies (COREQ); the completed checklist is provided in Additional file 2 [see Additional file 2]. Peer debriefing was facilitated through engagement with the Maastricht University Governance and Leadership in European Public Health (GLEPH) group. The peer group consisted of two researchers apart from the main researcher (25 years old, Turkish-born, male, master student with Public Health background and a 25-year-old Armenian-born female expert in public health). Their external perspectives provided a critical reflection on the coding process, thematic structure, and interpretation of findings, strengthening the analytical rigor and transparency of the research process. Interview questions were co-developed with Public Health Wales and other stakeholders to make sure that the critical reference groups were asked understandable questions, thus increasing overall trustworthiness [ 50 ]. Member checks were conducted to make sure stakeholders agreed with the results, and suitable meaning units that were neither too broad nor too narrow were selected to maintain the integrity of the text and enhance trustworthiness [ 49 , 53 ]. Reflexivity To ensure a comprehensive analysis of the qualitative data collected, this study adopted a reflexive approach within a constructivist paradigm, acknowledging the potential influence of the researchers' backgrounds, biases, and preconceptions on the interpretation of the data [ 50 , 57 ]. Self-reflexivity took the form of writing and researching while acknowledging our unique situated narrative shaped by the cultural, social, gender, class, and personal perspectives we bring to research [ 38 ]. The interviews were conducted by the primary researcher (MPH), a postgraduate student in Governance and Leadership in European Public Health with formal training in qualitative methods and experience in qualitative research, project management and cross-national stakeholder engagement. The researcher’s background in HIV policy, LGBTQI + migrants’ health, and human rights advocacy informed a reflexive approach throughout the study. No prior relationship existed between the researcher and the participants. To mitigate potential bias, the lead author maintained a reflexive journal to critically examine assumptions and document analytical decisions during the data collection and analysis processes. Results Eighteen semi-structured interviews were conducted with policymakers, practitioners, and civil society actors involved in health equity work across European settings. Participants described intersecting and multi-level barriers to the implementation of HEFs alongside contextually grounded strategies to support more inclusive and effective implementation. An overview of participant roles, sectors, geographic scope, and levels of responsibility is provided in Table 2 . Additional demographic information, such as age or gender, was deliberately excluded to ensure anonymity, as participants could be easily identified due to the specificity of their positions in each country. Table 2 Demographic characteristics of interview participants n. Country Institution type Level of work 1 Wales NGO, but currently seconded to Government National 2 Switzerland NGO (Non-governmental organization) National 3 Belgium Civil Society Organisation International 4 Italy NGO (Non-governmental organization) International 5 Wales Private Health Company Global 6 Spain Government International 7 England Government Local 8 Denmark Academia and Policy National 9 Portugal International Organization International 10 Wales National Health Service National 11 United Kingdom Government National 12 Wales International Organization International 13 Italy Government International 14 France Academia and Policy Local 15 Scotland Academia and Policy International 16 Denmark International Organization International 17 Finland Academia and Policy Global 18 Wales Health Equity Policy International A summary of the main barriers and facilitators reported across each domain is presented in Table 3 , while Table 4 contains selected illustrative quotes that support the analytic themes. The findings below are structured thematically according to the seven domains of the HEIF and supported by illustrative quotations. Table 3 Summary of barriers and facilitators to health equity framework implementation across HEIF domains in EU and UK HEIF Domain Barriers Facilitators Culturally Relevant Factors of Recipients • Existing frameworks are often perceived as Western Europe-centric, lacking cultural relevance and adaptability to national/local contexts, particularly in Southeast Europe. • Frameworks inadequately account for intersectionality; they treat dimensions of inequality (e.g. race, gender, disability) separately rather than as intertwined and intersecting experiences. • Migrants, racialized communities, and key populations (e.g. Roma, LGBTQI + individuals, migrants) face systemic exclusion, distrust in institutions, and limited culturally competent care. • Socioeconomic precarity (e.g. informal employment, displacement) forces individuals to choose between healthcare and basic survival needs. • Preventive services are unaffordable or underprioritized, undermining early engagement and equity goals. • Digital-first innovations risk excluding those with low digital literacy or unstable internet access. • Health equity frameworks often assume universal access without addressing legal, linguistic, or social barriers. • Frameworks can be strengthened by being co-adapted to specific national and community realities, emphasizing flexibility and simplicity. • Front-of-pack labeling, health literacy campaigns, and community kitchens integrate equity goals with social protection and nutrition, acting as empowering and emancipating forces, rather than having people as passive recipients. • Frameworks should frame health access as a universal right tied to structural justice (not just individual behavior), reinforcing equity principles. • Culturally contextualized primary care, person-centered service design, and locally embedded health promotion increase acceptability and relevance. • Equity frameworks should acknowledge and center lived realities, including the trauma and socio-political exclusions that shape health behavior. • Frameworks must include intersectionality analyses and how intersecting identities shape health outcomes in specific contexts. Clinical Encounter (Patient–Provider Interaction) • Patient-provider interactions are undermined by implicit bias, stigma, and assumptions based on identity (e.g. race, gender identity, migration background, sexual orientation). • Lack of provider diversity and inadequate cultural awareness diminish trust, especially in historically excluded communities. Training on equity is often voluntary, reaching the already sensitized, while those most in need remain unexposed. • Non-clinical staff (e.g. administrative personnel) are often excluded from training, despite being the first point of contact, widening the gap between health equity frameworks and implementation at the clinical level. • Inflexible clinical practices and location-based gaps (especially rural areas) hinder equitable access. • Stigmatized conditions (e.g. drug use, sex work, HIV status) trigger blame and self-censorship among patients, reducing service access. • Co-designed services that reflect users’ lived experience improve trust and uptake (e.g. HIV care in trans-inclusive clinics). • Peer-led training and lived-experience dialogues between patients and providers can humanize services and demystify user needs. • Differentiated service delivery (e.g. for men, South Asian communities) supports inclusive implementation of HEFs. • Framing access challenges as service barriers (rather than user deficits) shifts responsibility and supports equity-centered redesign. • Health equity training should be mandatory, practical, and multidisciplinary, building provider capacity to apply data and frameworks in action. Patient and Community Factors • Health equity frameworks often rely on tokenistic or top-down participation, excluding the most marginalized voices from design and governance. • Community participation tends to involve representatives from established groups, excluding unaffiliated individuals most affected by inequity. • Complex language and professional public health jargon in frameworks alienate non-policy actors (or actors from other policy departments) and limit comprehension. Policymaking often overlooks social location and daily barriers, reinforcing a gap between policy design and situated realities. • Frameworks may fail to identify and include “who’s not in the room,” leading to blind spots in implementation. • Health equity frameworks gain legitimacy and effectiveness when co-designed with marginalized communities through meaningful, remunerated participation. • Engagement strategies should recognize communities as experts in their own lives, promoting community-led monitoring and evaluation. • Place-based, participatory initiatives allow HEFs to be contextually grounded and responsive to local needs. • Youth-led, informal leadership structures and multisectoral collaborations enhance equity outcomes and sustainability. Policy engagement must begin early, ensuring frameworks reflect community-defined priorities from inception. Inner Context (Organizational Factors) • Implementation of HEFs is impeded by institutional inertia, lack of leadership buy-in, and competing priorities. • Organizational silos and absence of clear accountability structures limit cross-departmental collaboration. • Equity initiatives often lack designated staff, budgetary mechanisms, or procedural integration, often leaving them under-resourced. • Frameworks are perceived as theoretical, with limited tools to operationalize them within routine practice (action points) at different organizational level points. • Prevention is systematically underfunded, while treatment receives disproportionate investment. • Health equity must be embedded in organizational strategy, budgeting, procurement, and design and not treated as an add-on. • Training should target not only providers but also leadership, planners, and service designers to embed equity culture across levels. • Storytelling and simplification of frameworks enhance cross-sectoral understanding and organizational buy-in. • Integration of previously vertical programs (e.g. STI or HIV care) into routine primary care aligns with HEF goals. • Equity assessments and implementation guidance should be built into institutional policy cycles. Outer Context (Policy/System-Level Factors) • Policy-level support for HEFs is often weak, lacking enforcement mechanisms and cross-sector coordination. • Political cycles constrain equity initiatives, while the voluntary nature of health promotion limits sustainability. • Fragmentation between national and local governance and autonomous regional healthcare (e.g. Spain, Italy) leads to inconsistent adoption of HEFs. • Civil society organizations essential to equity are underfunded and face limited operational space. • Policymakers often struggle to translate equity mandates into practical, multisectoral action. • Legal instruments such as the Well-being of Future Generations Act and Health in All Policies (HiAP) offer a platform to include HEFs. • Local authorities are well-positioned to translate HEFs into context-specific action. • Municipal engagement in health impact assessments supports the mainstreaming of equity. • Public health authorities must coordinate with transport, housing, and education to ensure cross-sector HEF implementation. • Devolved systems (e.g. Wales) offer opportunities for innovative equity-focused governance models. Societal Context • Structural racism, capitalism, and colonial legacies shape access to power and services, embedding inequality into health systems. Exclusion from policymaking processes reinforces the historical marginalization of already disenfranchised communities (e.g. Roma, migrants, LGBTQI + mobile populations, transgender individuals). • Health equity efforts risk becoming superficial unless they address deeper societal power dynamics and governance structures. • HEFs must be grounded in a recognition of historical and systemic injustice. • Advocacy that connects health equity to broader justice movements (e.g. climate justice, anti-racism) increases support. • Participatory policymaking rooted in empathy, trauma-informed care, intersectionality and collective responsibility strengthens inclusive governance. • Trust-building and shared language among stakeholders are essential for HEF legitimacy. Innovation Characteristics (Framework Design) • HEFs often lack clarity, adaptability, and audience-specific communication strategies. • Definitions of equity, equality, and inequality are confused or inconsistent. • Absence of disaggregated data (e.g. ethnicity, rurality) undermines evidence-based implementation. Frameworks overemphasize individual behavior change and overlook system redesign. • Technical complexity and overwhelming monitoring demands diminish local uptake. • HEFs should use accessible, plain language and multiple audience-specific formats. • Real-time, AI-supported data tools can improve feedback and adaptive learning. • Frameworks must include community-led monitoring and allow iteration over time. • Acknowledging failure as learning fosters innovation and equity improvement. • Equity metrics and local relevance must be prioritized over uniformity. Culturally Relevant Factors of Recipients Participants consistently described current equity frameworks as disconnected from the lived realities of marginalized populations. Several noted that existing models were “Western Europe-centric and disconnected from the realities of Southeast Europe,” with recommendations perceived as overly complex and difficult to localize (participant 5). A lack of intersectional thinking was widely critiqued; frameworks were seen to address vulnerabilities “separately,” failing to reflect multiple disadvantages (participant 15). Respondents noted that existing frameworks frequently treat race, gender, legal status, and disability as separate, siloed variables rather than interconnected systems of exclusion. They emphasized that the lack of culturally contextualized and intersectional HEFs undermines both the legitimacy and effectiveness of implementation efforts, especially for Roma, LGBTQI + migrants, and undocumented populations across the EU and UK. Legal and administrative barriers remained a persistent concern, particularly for undocumented migrants: “not everyone has the right to access health services simply because they are present in the territory” (participant 16). Others highlighted the need to rethink accessibility in more practical terms, such as appointment flexibility to account for gender norms, cultural dynamics and caregiving structures: “if my husband has to bring me and this day works better for him, I will go that day” (participant 14). Community-based initiatives, such as community kitchens and nutrition labelling, were seen as effective entry points for inclusive health promotion. Participants called for frameworks that are “accessible and approachable,” capable of translating equity principles into tangible, culturally contextualized practices (participant 2). Clinical Encounter (Patient–Provider Interaction) Participants described how bias in clinical encounters undermines trust and reinforces inequities. Several noted that racial and gender identities continue to shape patient experiences, with one participant explaining, “if you're a Black person in Europe… and you'd like to ideally find a doctor who is also Black… this is often very difficult… that of course impacts how you’re treated and reduces trust” (participant 1). Training was widely regarded as insufficient and unevenly implemented. “Equity training should be mandatory, not optional,” one participant said, adding that “those holding biases… rarely receive it” (participant 16). Others stressed that current efforts neglect key roles: “it shouldn’t just be for doctors and nurses… front desk staff are often the first point of contact” (participant 7). Participants also highlighted the experience of LGBTQI + individuals, with one stating, “a gay man or a trans woman going to the same service [as a straight man] and not feeling welcome” (participant 3). Structural issues, such as inaccessible locations and poorly calibrated equipment, further marginalized groups: “certain medical equipment is not calibrated to people of a certain skin color” (participant 1). Respondents advocated for differentiated service delivery and inclusive design, suggesting health systems “remove the barriers” by asking not why groups are “hard-to-reach” but “why is my service hard to reach?” (participant 5). Patient and Community Factors Participants emphasized that community engagement must be central, not symbolic. “You don’t do it for them, you do it with them… we need to change this” (participant 1). Several noted that participation often occurs too late in the process—“the population is barely involved at all” (participant 7)—or is based on assumptions rather than lived knowledge: “we often try to understand communities through academic articles, but without speaking directly with people” (participant 16). Majority of participants highlighted the lack of formal mechanisms: “we do not have formal toolkits or checklists for community participation… it often relies on intuition” (participant 17). There was strong support for co-designing HEFs with communities from the outset, “ensuring they have a paid seat at the table” (participant 1). Participants advocated for place-based, community-led initiatives that reflect local context: “they often have the local knowledge” (participant 5). Lived experience was positioned as critical expertise: “now we call them experts by lived experience” (participant 13). Overall, a shift toward relational, context-sensitive, place-based, intersectional and participatory approaches was seen as essential for equitable health system transformation. Innovation Characteristics Participants highlighted that inconsistent terminology and inaccessible language remain key barriers to implementing HEFs. As one put it, “definitions of equity, equality, and inequality are confused or inconsistent” (participant 2), while another stressed, “public health language is often too complex, limiting public engagement and understanding” (participant 2). Simplifying and adapting terminology was viewed as critical: “we need to change the way we speak… if you say drug user, it is completely different if you say person who uses substances” (participant 13). A call for more inclusive, person-centered language resonated across interviews. Frameworks were also seen as failing to reflect individual needs—“those one in eight are not exactly the same… you’ve got to treat people as individuals” (participant 2). Participants recommended adapting communication strategies to diverse audiences: “health equity frameworks should use different language for different audiences… ensuring the message… resonates at every level” (participant 2). The importance of robust, disaggregated data collection was also raised: “if you don’t have the data, what are you basing your policy on?” (participant 3). Technological solutions like AI were cited as promising tools to improve equity monitoring and reduce delays in data use. Inner Context (Organization Level Factors) Participants described a general lack of internal structures to assess and act on health equity. One noted, “we lack structures specifically designed to carry out health equity assessments internally… these tasks are often left undone” (participant 16). Even when awareness was present, the absence of formal processes and limited staff capacity constrained action, especially in under-resourced countries. Communication between different levels of care was also raised as a persistent gap: “we don't have an integrated IT system… technology could address this” (participant 5). Fragmentation between primary and secondary care was seen to hinder continuity and equity in service delivery. There was a shared concern that frameworks remain too high-level to prompt meaningful change. “If we go too high level… we lose people,” one participant said. “Maybe breaking it down… giving them some key action steps. I think that’s key—moving from theory to action” (participant 5). Examples of participatory approaches, such as mobile units and shared decision-making across departments, were seen as effective ways to operationalize equity when grounded in listening and co-creation (participant 1). Outer Context (Policy/System Level Factors) Participants underscored that health equity cannot be achieved through health systems alone. “Health equity needs to move beyond health-only approaches,” one said, referring to the need for integration with employment, housing, and education policies (participant 1). Despite this recognition, cross-sectoral collaboration remained underdeveloped and poorly coordinated. “There’s not a clear pathway… and I think that's causing a lot of confusion as to who's responsible for what” (participant 5). Fragmentation also extended across borders, with strong regional autonomy limiting knowledge exchange: “what’s often missing is better exchange of good practices between autonomous regions and cross-border learning at the EU level” (participant 4). The role of data was often emphasized—both its potential and its politicization. “Without consistent, rights-based data… policymaking remains blind to structural inequities” (participant 1), while others stated that “data can be manipulated by politicians for their own ends” (participant 18). Political will emerged as a crucial vector: “if there is political will, then all the rest can happen” (participant 3). Participants called for long-term investment strategies and stronger EU funding streams to support implementation at national and local levels, with funding being generally understood as one of the main barriers to the effective implementation of HEFs. Societal Context Structural inequities—including patriarchy, colonialism, and capitalism—were seen as fundamental barriers to health equity. “The core of the thing is… colonialism, patriarchy and capitalism—because everything is like about getting more money or not wasting money” (participant 10). Participants described how hegemonic norms built around the white, male, educated body shape clinical and policy decisions, marginalizing those who do not adhere to the standard: “anyone who deviates—by gender, race, disability, or intersecting identities—faces compounded inequities” (participant 1). Most participants felt that majority of HEFs do not explicitly include intersectionality. There was strong concern over the limited accountability of non-binding EU strategies: “the EU has limited competence in health… while real change depends on national governments’ political will” (participant 1). Funding gaps were also perceived as widening: “resources for underserved populations are shrinking, even as demand increases… this financial gap is growing and threatens equity efforts” (participant 17). Participants stressed that lobbying by powerful industries, especially in areas like food policy, often undermines equity-focused reforms: “the main obstacles are the strong opposition from actors who are maximizing their profits” (participant 6). Calls were made for more consistent EU-level support for capacity building, infrastructure, and knowledge exchange and for a stronger parliamentary push against “lobbyism… undermining all those efforts” (participant 6). Table 4 Selected illustrative quotes by HEIF domain HEIF Domain Barriers Facilitators Culturally Relevant Factors of Recipients “these frameworks often feel western europe-centric and disconnected from the realities of southeast europe. while eu-level principles are important, national teams need support to adapt them to their specific governance and cultural contexts. the distance and complexity of current recommendations make local relevance unclear—simplifying them is crucial.” (participant 5) “so you can think of, for example, white cis women with a lot of resources compared to women from the gypsy traveller community who have disabilities and very high levels of ill health. the main thing i would say is that a lot of the frameworks don't account for intersectionality… they look at things separately.” (participant 15) “not everyone has the right to access health services simply because they are present in the territory. there are still many people—especially migrants—who are excluded.” (participant 16) “I was working for some time with some women...muslims who had to go to gynecological visits… they were actually from bangladesh. so I always asked to visit on a certain day and they would never go. then I changed the day and they went. why? because they said “ my husband has to bring me and this day works better for him” (participant 14) “if you are displaced from another country, you don't have legal work, and you live in the street, you don't have the right. and in terms of public health, this is unsustainable. because, for example, infected disease don't ask for passports. they move from individual to individual.” (participant 13) “it's just making sure that you're accessible and approachable and translating what we mean by health equity into something that's tangible for those other communities to buy into.” (participant 2) “front of the pack labelling is important because everybody with different levels of literacy can understand what is in the product.” (participant 6) “community kitchens can play a key role in improving diet quality for low-income populations… linking food access with education, nutrition awareness, and local food systems.” (participant 6) “actually, the issue isn’t just communication—it's a lack of literacy, especially around one health. this isn’t just a minor gap; it’s a major challenge. improving one health literacy is essential, not only for the general public but especially for policymakers and decision-makers. strong governance and leadership depend on it.” (participant 2) “we need to think about what people really need. and what the communities need and what kind of services they would like to see further, rather than to kind of try to organise the health system in most efficient way.” (participant 12) “we need a health system that truly welcomes everyone and can adapt to different realities and needs. primary care, in line with the alma ata principles, should be accessible, person-centered, culturally aware and adaptable throughout a person's life. it should accommodate people’s individual needs—such as adjusting appointment schedules—and ensure continuity of care. (participant 16) Clinical Encounter (Patient–Provider Interaction) “if you're a black person in europe and you're going to a doctor and you would like to ideally find a doctor who is also black… this is often very difficult. that of course impacts how you’re treated and reduces trust a lot.” (participant 1) “training on equity often ends up reinforcing inequalities. those already aware and sensitized seek out training, while those holding biases… rarely receive it. equity training should be mandatory, not optional.” (participant 16) “one of the barriers is that many key roles aren’t included in training—like administrative staff… it shouldn’t just be for doctors and nurses. it should also include those at the front desk, because they’re often the first point of contact in primary care. many patients have already faced multiple barriers before even reaching a consultation. health care doesn’t start with the doctor—it starts much earlier.” (participant 7) “you could go to the doctors as a straight man, go there and feel perfectly safe and welcome, and then a gay man or a trans woman going to the same service and not feeling welcome.” (participant 3) “certain medical equipment not being calibrated to people of a certain skin color” (participant 1) “the is, from my point of view, very far away. if you don't encourage health professionals to in areas of difficult coverage, in rural areas, in marginal neighbourhoods, it makes people in those neighbourhoods have more difficulty accessing the health (participant 11) “people are not sclerotized into one situation, they move. so the services need to move with them.” (participant 13) “not talking about hard-to-reach groups, but thinking my service is hard to reach. so why is my service hard to reach and how do I remove the barriers? I think that's important when we're thinking about service design and marginalised groups and going to those groups in most cases instead of expecting them to come to you” (participant 5) “so if you're implementing something, what kind of skill building and support are you providing to those people who should be implementing your framework?” (participant 5) beyond training, we supported the implementation of differentiated service delivery, helping community organizations co-design hiv prevention services tailored to people’s needs and aligned with national guidelines—expanding access and choice.. and including medical doctors to improve patient-doctor relationships” (participant 2) Patient and Community Factors “you don’t do it for them, you do it with them.. we need to change this” (participant 1)” “participation shouldn’t just be about validating decisions already made; it must start from the beginning… the population is barely involved at all.” (participant 7) “we often try to understand communities through academic articles, but without speaking directly with people… we miss key insights.” (participant 16) "the fact that there is sort of belief that we know everything about the communities we are working on or with, and we don't necessarily need their view. we need just to discuss here and there with some people and that's it." (participant 10) “it's very easy for these implementation frameworks to slip into just solving immediate problems and just having individual level behavioral interventions… and not constantly thinking about how do we redesign the system.”(participant 15) “we do not have formal toolkits or checklists for community participation. engagement often relies on intuition. there is a need for more structured and embedded community participation mechanisms in health equity frameworks and organizations.” (participant 17) “there has been a sort of tendency, let's say, I don't know what to call it, but to include communities only in the evaluation but they should be included since the beginning, like in the design of public health policy in general." (participant 10) “health equity frameworks must be co-designed with marginalized communities, ensuring they have a paid seat at the table to shape solutions that reflect their lived realities.” (participant 1) “in prep policy, for instance, it's just having that understanding of what the community is and what the community looks like that we're trying to work towards and what we're trying to achieve with that community, not on that community, you know, it's working with that community, not on them. you've got to think about your engagement approaches.” (participant 2) “let the community tell them, tell us who they are and what's important to them and what they're here for. don’t assume just because you have a gay migrant in front of you the sexual behavior this person is having. let them tell you.” (participant 1) “we often expect people to come to us within healthcare when actually we probably need to get better at going to them.” (participant 9) “now we call them expert by live experience. so it's not just patient, but are people that know, are experts by lived experience.” (participant 13) “we should be moving towards place-based community-led initiatives and place-based governance simply because from where I sit in the rural kind of health space, context is key. they often have the local knowledge” (participant 5) Inner Context (Organizational Factors) “statutory bodies… need clear guidance on what it means in practice… what’s feasible, and what to prioritize.” (participant 5) “in spain, many specialized STIs clinics were closed, but instead of eliminating them, it would have been better to fully integrate those services into primary care. services like prep, pep, or mpox vaccination should be easily accessible and routinely offered by primary healthcare providers—making them part of everyday care rather than separate, vertical programs” (participant 4) “we lack structures specifically designed to carry out health equity assessments internally. these tasks are often left undone—not because people don’t care, but because there’s no formal system in place, and existing staff are already overburdened with other responsibilities.” (participant 16) “when we think about healthcare, primary and secondary care, communications between primary and secondary care are challenging. we don't have an integrated it system. like these are things, for example, that technology could address”. (participant 5) “if we go too high level with these frameworks, we lose people. so maybe breaking it down. what are like some key first steps that each person could do at a certain level? like giving them some key action steps basically. and I think that's key moving from theory to action.” (participant 5) “from mobile units to culturally sensitive care, effective outreach starts with listening to those most affected and addressing their barriers through shared decision-making, across departments and organizations, with a participatory approach” (participant 1) Outer Context (Policy/System-Level Factors) “without consistent, rights-based data from national systems, segregated by gender, race and ethnicity, policymaking remains blind to structural inequities—cross-border, high-quality data is essential but still largely missing” (participant 1) “you need to know what inequities look like in the employment sector or in housing or in education. because those are things that directly impact your ability to be healthy. health equity needs to move beyond health-only approaches” (participant 1) “one health is implying a sort of collaboration among different ministries for instance. so the ministry of health has to work with the ministry of environment, the ministry of agriculture, of veterinary or whatever you want to call it. and when there is no kind of commitment when there is no sort of conditions that now we are living in a world where everything is interconnected” (participant 8) “a lot of the health equity work really requires cross sectoral collaboration. but that kind of work hasn't really been developed yet. there's not a clear pathway to follow at the moment and I think that's causing a lot of confusion as to who's responsible for what, what should they be trying to do” (participant 5) “a major challenge remains the lack of trust in science among some policymakers, who may prioritize political appeal over evidence-based action." (participant 3) “there are always calls for things like charges? means testing, restricting eligibility, fragmentation, political will, all the things that we know are really unhelpful… but these zombies keep arriving. privatisation, private sector money, always they're in the background.” (participant 15) “data can be manipulated by politicians for their own ends” (participant 18) “political will is really important… if there is political will, then all the rest can happen.” (participant 3) “It’s about having EU funding streams to address health equity frameworks, engaging organizations, the voluntary sector, the third-sector… both internationally and locally... they are struggling a lot” (participant 18) “Health equity is about prevention… if we can ensure to increase the prevention rather than just talking about it... we need to have a long-term view to reach health equity... 10–15 years view” (participant 18) “health equity can’t be achieved through eu health policy or national health policy alone—it's too limited. real progress requires cross-sectoral action, engaging employment, housing, education, and more, because health is shaped by far more than healthcare systems. it’s about breaking the silos. everything impacts your health, not only the health system” (participant 1) “spain has a highly decentralized system with strong regional autonomy. what’s often missing is better exchange of good practices between autonomous regions and cross-border learning at the eu level.” (participant 4) “if we make good policies for entire population, improves what you do with specific populations… doing things for only, say migrants, sometimes are not transversal or longitudinal” (participant 7) “without consistent, rights-based data from national systems… policymaking remains blind to structural inequities.” (participant 1) Societal Context “the core of the thing is… colonialism, patriarchy and... and capitalism because everything is like about getting more money or not wasting money.” (participant 10) “when health systems and policies are built around the standard of an older white male, anyone who deviates—by gender, race, disability, or intersecting identities—faces compounded inequities” (participant 1) “structural obstacles to effective health equity implementation persist due to non-binding strategies, lack of accountability, and absent monitoring frameworks. the eu has limited competence in health—mostly reduced to funding support, best practice exchange, and soft nudging—while real change depends on national governments’ political will” (participant 1) “the main obstacles to food environment policies in europe are the strong opposition from actors who are maximizing their profits, particularly the food industry! (participant 6) “sustainable funding is a major issue. at both eu and member state levels, resources for underserved populations are shrinking, even as demand increases. this financial gap is growing and threatens equity efforts.” (participant 17) “the number of people displaced is exponentially increasing because of the climate change and the ecological catastrophes, because of the wars, because of the diverse economical situation, level of unemployment. health equity frameworks should account for these” (participant 13) “health equity frameworks must address directly and in detail racism, xenophobia, and other structural inequities as fundamental determinants of health.” (participant 1) “through networks like disqo and the roma health network, we tackle discrimination as a fundamental health determinant by connecting grassroots voices to eu policymaking.” (participant 1) “if you stop funding in Africa, it will create further problems…because we are all interconnected” (participant 18) “improving broad policies—urban planning, public spaces, transport, housing, employment—can reduce inequalities for everyone. (participant 7) “the EU can support health equity by funding knowledge exchange, capacity building, and infrastructure development. it can help national, regional, and local authorities design and monitor effective, multisectoral interventions.” (participant 17) “so, unfortunately, not always in europe we have active parliamentarian groups who, for example, work across different parties and across different countries to promote that agenda. I definitely, think that a European Parliament really work should happen at that level. that's where the lobbyism is actually undermining all those efforts.” (participant 6) Innovation Characteristics “definitions of equity, equality, and inequality are confused or inconsistent.” (participant 2) “if you don’t have the data, what are you basing your policy on?” (participant 3) “public health language is often too complex, limiting public engagement and understanding.” (participant 2) “there is definitely a need for some form of joint language, allowing you to speak the same language when you're talking about racism, discrimination and health and how it should be addressed. so we should definitely also spend some time on trying to find a common language” (participant 1) “what do you mean by health equity frameworks? we policymakers should address this question first” (participant 5) “health equity frameworks saying “one in eight people are gay in wales, for instance, that's no good because... those one in eight are not exactly the same. if it is one in eight, you've got to treat people as individuals. and that's the beginning of all equity and we should include this into the policies we make” (participant 2) “health equity frameworks should use different language for different audiences… ensuring the message on health equity resonates at every level.” (participant 2) “AI can help analyze data more efficiently and significantly shorten the time between data collection and publication.” (participant 3) “if you tried something and didn't work in the first year or two, that's not failure. that's great. that's a learning opportunity.” (participant 5) “language changes and evolves, and we can't keep using the same language and assuming that the communities are accepting of that language…there was terminology on STIs I was using 10 years ago that has now completely changed and evolved” (participant 2) “we need to change the way we speak…. “if you say drug user, it is completely different if you say person who uses substances.” (participant 13) Discussion This study explored the complex, multi-level barriers and facilitators influencing the implementation of HEFs across the EU and UK, with a focus on policymaker perspectives. Guided by HEIF, our findings reveal that despite increasing recognition of health equity as a priority, HEFs remain constrained by structural barriers, limited community participation, and fragmented policy environments. Consistent with previous studies using HEIF in primary care and policy contexts, participants highlighted the persistent misalignment between equity goals and implementation practices—particularly among populations facing multi-level structural disadvantage [ 30 ]. Among the most critical influences are social determinants of health, including income, education, employment, housing, transportation, and geography, which are known to significantly shape disparities in health outcomes [ 58 ]. These factors are often intertwined and intergenerational, compounding disadvantages over time and presenting persistent challenges to the effective implementation of equity frameworks, as a person’s immediate surroundings also shape critical lifestyle determinants, such as access to nutritious food, opportunities for physical activity, safe transportation, and environmental conditions like clean water and air [ 59 ]. Participants widely perceived existing HEFs as misaligned with local realities and overly dependent on Western European policy models, reinforcing calls from previous research to center intersectionality and cultural relevance as foundational, not optional, components. Intersectionality theory, grounded in feminist and antiracist traditions, emphasizes that race, gender, class, and migration status must be considered in tandem rather than in isolation, as their intersections produce unique, context-specific experiences of marginalization and privilege [ 60 – 63 ]. While intersectionality is increasingly recognized as a powerful framework in health equity research, its practical integration into methods and policy analysis remains underdeveloped [ 64 , 65 ]. Intersectional analyses reveal that variables like gender, migration status, and class interact in complex ways to shape health outcomes, and failing to account for these intersections leads to inaccurate or incomplete health equity policy and framework responses [ 66 ]. In alignment with the EU SOPHIE project’s approach, participants in this study emphasized that intersectionality must inform not only service delivery but also the design, governance, and monitoring of HEFs to ensure they effectively respond to structurally embedded inequalities across EU and UK contexts [ 67 ]. At the clinical level, this disconnect manifested in patient-provider interactions, where implicit bias, provider homogeneity, and siloed training diminished trust and uptake. Clinical design choices that fail to acknowledge these dynamics risk reinforcing access barriers, what one participant reframed as “why is my service hard to reach?” rather than “why are patients hard to reach.” Internally, organizations were described as lacking the structural mechanisms to translate HEFs into operational routines. Staff shortages, outdated leadership styles, and limited integration between primary and secondary care created fragmented delivery environments. Equity was often viewed as a “soft add-on” rather than a foundational institutional norm, echoing other research identifying this as a failure of system design rather than will. Participants called for stepwise action points tailored to specific institutional roles and identified internal health equity assessments as necessary tools to track progress and distribute accountability. Integrated technology systems were also seen as vital for improving continuity of care and equity responsiveness, especially in rural or high-need settings. In line with previous research, which emphasizes the centrality of trust, shared decision-making, and system-wide organizational change, our findings suggest that differentiated service delivery must be prioritized to reflect user realities, especially for communities historically excluded from health systems [ 68 , 69 ]. Participants widely described community engagement in HEF implementation as symbolic and retrospective — often occurring too late to shape design or governance. This reflects broader findings that community input is frequently treated as a checkbox exercise, lacking mechanisms for accountability [ 70 , 71 ]. Several participants stressed that lived experience should be positioned as a core source of expertise, not an add-on. Without formal structures, such as those outlined in the Nobody Left Outside (NLO) Service Design Checklist, engagement remains siloed and exclusionary [ 72 ]. This disconnect risks undermining both legitimacy and uptake, particularly in marginalized communities. Despite strong policy rhetoric around co-design, practical guidance remains limited across EU and UK health systems, highlighting the need for operational tools that embed participation from the outset. A key area of reflection emerging from this study concerns the characteristics of HEFs themselves. Rather than viewing the design of frameworks as neutral or static, participants engaged critically with how language and terminology can enhance, and sometimes limit, equity implementation. In line with previous critiques of public health discourse, many expressed that the technical vocabulary commonly used in HEFs creates barriers to understanding and uptake, particularly when terms such as “equity” and “vulnerability” are inconsistently applied or poorly defined [ 73 , 74 ]. Our findings indicate that language must evolve with communities and reflect person-first values, e.g., “people who use substances” rather than “drug users,” in line with current recommendations from international organizations, including UNAIDS Terminology Guidelines [ 75 ]. Discussions also underscored the need for frameworks to evolve in tandem with communities, adopting terminology that reflects person-first values, such as “person living with HIV.” Such shifts were seen as essential to dismantling stigma and affirming the dignity of those most affected by inequities. In parallel, data was not merely discussed as a technical input but as a political and ethical component of implementation. The absence of disaggregated, rights-based data by race, migration status, disability, and rurality was viewed as a core obstacle to evidence-based planning and political accountability. These findings reflect broader critiques of health systems that fail to adequately track the populations they serve. At the systems level, our findings reaffirm the need for strong political will and coordinated cross-sectoral action. Participants noted that HEFs cannot succeed in a vacuum, and their implementation is often obstructed by siloed policymaking, short-termism, and policy fragmentation across EU member states and the UK. Consistent with other HEIF-based evaluations, cross-border learning and multi-sector collaboration were seen as necessary conditions for impact but are currently under-resourced and poorly structured [ 76 , 77 ]. The analysis also highlights a growing gap between EU equity discourse and national-level action. There was a clear call for binding obligations and secure, long-term funding streams that include civil society and third-sector organizations in both planning, delivery and evaluation. Many of the challenges identified were linked to deeper societal structures, patriarchy, colonialism, and capitalism, which shape who holds power and whose needs are prioritized. Without addressing these systems, HEFs risk becoming superficial or technocratic. Lobbying by corporate actors, especially in the food and pharmaceutical sectors, was raised as a direct barrier to reform, echoing long-standing critiques of policy capture and the political economy of health. These reflections point to the need for equity frameworks to connect not only with service-level reforms but also with broader justice-based movements that address structural violence and promote systemic change [ 78 , 79 ]. These findings point to concrete actions with direct implications for both policymaking and the development of more effective health equity frameworks across the EU and the UK. A key priority is the local adaptation of HEFs: technical and rigid formats often limit their practical implementation, while simplified, co-created tools that reflect national and community realities are more likely to be implemented effectively. Similarly, comprehensive and mandatory training on equity, extending beyond clinicians to include administrative and frontline staff, is essential to embed equity across all levels of the health system. Embedding lived experience throughout the design, implementation, and evaluation of frameworks, supported by formal tools such as the NLO Checklist, can enhance legitimacy and responsiveness. Communication practices also have clear policy implications: person-first, accessible language that evolves with community input is necessary to reduce stigma and ensure clarity, with terms such as “vulnerability” requiring critical re-examination. At the organizational level, policy reforms should support the structural integration of equity into budgeting processes, leadership responsibilities, and routine operations rather than treating it as a parallel agenda. Investments in disaggregated, rights-based data systems and digital tools are equally important to enable monitoring, transparency, and adaptation. Crucially, these recommendations highlight the need for stronger EU leadership, legal mandates, and sustained funding to overcome fragmented national approaches and support coordinated, cross-sectoral governance for stronger leadership in EU and UK public health systems. Without addressing the structural systems—colonialism, capitalism, patriarchy—that continue to shape inequities in health, HEFs risk underestimating the need for an intersectional and structural approach. Future frameworks in the EU and UK must be aligned with broader justice-based movements if they are to fulfill their transformative potential. Limitations This study acknowledges several methodological limitations. First, the use of pre-existing theory, particularly the HEIF while valuable for structured analysis, may introduce confirmation bias by favouring data that aligns with the framework rather than challenging it [ 39 , 53 ]. Additionally, having pre-existing categories might have biased the way respondents felt about a certain topic (tendency to please the researcher) and the overuse of theory could lead to “blindness” of contextual, nuanced factors. These limitations are “related to neutrality or confirmability of trustworthiness as the parallel concept to objectivity” [ 53 ]. Second, while semi-structured interviews facilitated depth and flexibility, the use of predefined categories may have inadvertently shaped participant responses, introducing social desirability bias—where respondents may align their answers to perceived researcher expectations. This dynamic can restrict authenticity, especially in politically or ethically sensitive discussions on health equity. Third, the mixed convenience and purposive sampling approach, while pragmatic and targeted, may have excluded voices from stakeholders less embedded in formal networks, such as grassroots organizers or individuals from non-English-speaking communities, despite multilingual eligibility criteria. This could limit the inclusiveness of perspectives and risk overrepresenting institutional or technocratic viewpoints. Fourth, while this research leveraged diverse recruitment strategies and triangulated stakeholder groups, interviews were limited to a relatively small sample (n = 18), and data collection was restricted to a specific time frame. These constraints affect the generalizability and temporal relevance of findings. However, saturation was reached, and participants represented a broad cross-section of EU and UK policymakers, thus supporting thematic robustness [ 38 , 80 ]. The inclusion of stakeholder perspectives from multiple EU and UK member states strengthens the relevance and applicability of the findings across diverse settings, supporting their potential transferability beyond the immediate cases examined [ 49 ]. Qualitative research is inherently interpretative, and while steps were taken to mitigate bias, including inter-rater reliability checks, reflexive journaling, and member validation, researcher positionality may still have influenced data interpretation and thematic emphasis [ 49 ]. Yet, a limitation of this study is that full consensus coding with a co-researcher was not employed. Although inter-rater reliability checks were performed on a subset of transcripts to enhance coding consistency, the absence of full co-coding and consensus discussions may have introduced researcher bias in data interpretation. Future studies could strengthen rigour by employing a team-based coding approach with consensus meetings throughout the analytic process. Conclusion This study highlights the persistent gaps between health equity commitments and their implementation across the EU and UK. HEFs often lack cultural relevance, operational clarity, and meaningful community engagement. To address these gaps, HEFs must be co-designed with affected communities, adapted to local contexts, and embedded into routine practice through mandatory, cross-sector training and simplified tools. Stronger political will, rights-based data systems, and long-term EU investment are essential to support sustained, inclusive action. Prioritizing equity as a structural mandate, not an optional add-on, can help translate HEFs into tangible outcomes that reduce disparities and promote justice. Abbreviations EU European Union FHML Faculty of Health, Medicine and Life Sciences GLEPH Governance and Leadership in European Public Health HEF Health Equity Framework HEIF Health Equity Implementation Framework HiAP Health in All Policies IS Implementation Science IR Implementation Research JAHEE Joint Action Health Equity Europe LGBTQI+ Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex, and others NLO Nobody Left Outside SES Socioeconomic Status WHO World Health Organization Declarations Ethics Approval and Consent to Participate Ethical approval for this study was obtained from the Maastricht University, Faculty of Health, Medicine and Life Sciences Research Ethics Committee (FHML-REC 738). All participants provided informed consent before participating in the interviews, signing the Ethics form. Ethical procedures followed the EU General Data Protection Regulation (GDPR) and included secure data handling, anonymization, voluntary participation, and offering participants the option to review their interview transcripts. Consent for Publication Participants were informed that the anonymized findings would be published in a peer-reviewed journal. Explicit consent for the publication of anonymized quotes and insights was obtained from each participant during the informed consent process. Competing Interests The authors declare that they have no competing interests. Funding This research was conducted as part of a master’s thesis in the Governance and Leadership in European Public Health (GLEPH) programme at Maastricht University. No external funding was received for the conduct, analysis, or publication of this research. Funding fees for publication were covered by Public Health Wales, supporting Mr. Marco Barracchia, during his internship at the Policy & International Health Directorate. Author Contribution Marco Barracchia conceptualized and designed the study, developed the interview guide, conducted all interviews, led data coding and thematic analysis, and drafted the manuscript. Dr. Katarzyna Czabanowska provided strategic input on study design and methodology, contributed to the development of the methodological framework, and critically revised the manuscript. Omer Faruk, Jo Peden, and Daniel Jones contributed substantially to study conception, contextual framing of health equity frameworks, and refinement of the interview guide, and provided iterative feedback throughout the analytic process. James Allen contributed to participant recruitment, refinement of the policy analysis, interpretation of findings, and revision of the manuscript. Dr. Milena Pavlova contributed to validation of results, methodological rigour, and critical review of the manuscript. All authors read and approved the final version of the manuscript. Acknowledgement The author extends sincere thanks to the study participants for sharing their valuable insights and lived experiences. Appreciation is also extended to Public Health Wales colleagues’ for their support in participant recruitment and co-development of the interview tools. The author thanks the academic and administrative staff at Maastricht University, particularly within the GLEPH program, for their guidance and encouragement throughout the research process. Data Availability The datasets generated and analyzed during the current study are not publicly available due to confidentiality agreements with the participants but are available from the corresponding author on reasonable request and subject to ethical approval. 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These inequities often stem from social, economic, and structural determinants, including geographic disparities, racism, homophobia, transphobia and cultural biases that disproportionately affect marginalized groups, resulting in unequal power and resource distribution in society [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Disparities in the implementation of health interventions contribute to unequal access and benefits among groups with different levels of social advantage, including life expectancy. Health equity frameworks (HEFs) are essential tools designed to identify, understand, and address these disparities systematically [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. They provide a structured approach to implementing policies, programmes, and interventions that promote fairness in health outcomes across all segments of society [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. HEFs typically feature principles of equity-focused implementation science (IS), which is the process of integrating and incorporating new practices into a specific context [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. IS is the systematic study of methods to integrate evidence-based interventions into real-world settings, considering contextual factors such as population needs, structural challenges, and socio-cultural dynamics [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. IS optimizes the adoption, implementation, and sustainability of health interventions within specific systems [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Placing HEFs within IS enables stakeholders to address the complex interplay of determinants that perpetuate health inequities, using systems thinking and co-design approaches to reduce disparities and improve health outcomes for disadvantaged communities [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this study, we aim to examine the multi-level factors shaping the implementation of HEFs across the European Union (EU) and United Kingdom (UK) to unpack how different factors influence the implementation of such frameworks, accounting for political will and commitment, collaboration, resources, and governance across the EU and UK. While policy intentions across the EU and UK have acknowledged the importance of reducing health disparities, the operationalisation of health equity has often lacked coherence and contextual sensitivity. This has ignited a growing interest in HEFs as structured tools to bridge the gap between policy commitments and practice. Understanding how these frameworks are implemented and where they need improvement is essential for ensuring equitable outcomes, particularly in regions like the UK and EU that have made significant legislative commitments but continue to face persistent disparities [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eHealth Equity: European Union\u003c/h3\u003e\n\u003cp\u003eTo tackle health inequities at the EU level, international agreements such as Health in All Policies (HiAP), as defined in Art. 168 of the Treaty of the Functioning of the European Union (TFEU) and promoted by the World Health Organization (WHO) since the Ottawa Charta (1986), acknowledges the need for an integrated approach to health involving different policy fields [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. HiAP aligns with HEFs by integrating health considerations across multiple sectors to address the social determinants of health. By embedding health equity into decision-making processes at municipal, national, and EU levels, HiAP fosters cross-sectoral collaboration and governance structures that reduce health disparities [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, health equity implementation gaps continue to persist in the application of HEFs across the EU despite growing awareness and increased action. These gaps include differences in equity concepts between policymakers and executives, access inequalities from EU cross-border healthcare directives, disparities in municipal health promotion, weak intersectoral collaboration, resource limitations, the voluntary nature of health promotion and limited national support to health prevention, the difficulty of securing political support for health equity investments, and the complexities of achieving health gains across various policy domains [\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The Joint Action Health Equity Europe (JAHEE) initiative has advanced cooperation among countries and facilitated concrete measures to reduce health inequalities, yet significant gaps remain in terms of policy responses, governance, tangible outcomes, and community participation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. To bridge these gaps, researchers recommend incorporating health equity domains into existing implementation frameworks, emphasizing culturally relevant factors, the dynamics of patient-provider interactions, and the broader societal context; however, the existing information on health inequities and their determinants is not automatically transformed into concrete policy actions and measures, and the research lacks direct address of implementation gaps within these frameworks [\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eHealth Equity: United Kingdom\u003c/h2\u003e\u003cp\u003eHealth equity has been a long-standing concern in the UK. Following publication of the Acheson report, there were measurable reductions from 1998\u0026ndash;2010 in geographical health inequalities, particularly in infant mortality rates, demonstrating the potential effectiveness of coordinated, multisector policy approaches to equity [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, systemic disparities persist despite the presence of a universal healthcare system. The UK has witnessed growing socioeconomic inequalities in health over the past decade, which have been exacerbated by austerity policies and the impacts of the COVID-19 pandemic [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Although national strategies and frameworks have been introduced to address these issues, including various WHO-aligned policy tools and data-driven equity assessments, the implementation of these frameworks remains inconsistent across the UK. Devolution has enabled the nations within the UK to adapt their policy responses to health inequalities, offering a unique lens to evaluate localized implementation strategies. In this context, Wales stands out for its legislative and strategic commitment to health equity. Wales has incorporated health equity into its policy and public health landscape, such as in the case of the legislation \u0026ldquo;The Well-being of Future Generations (Wales) Act 2015.\u0026rdquo; Wales has, in fact, prioritized sustainable and equitable health outcomes by addressing the social, economic, cultural and environmental determinants of health [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The Welsh Health Equity Status Report Initiative (WHESRi) aims to strengthen Wales' role in addressing health inequities by gathering data, developing digital platforms, forthcoming regulations on Health Impact Assessments (HIAs), and facilitating cross-sector dialogue. Yet, challenges remain in the effective implementation of such frameworks [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This initiative provides a comprehensive framework to address health inequities exacerbated by systemic challenges, such as housing insecurity (nearly 20% of households lack access to private outdoor spaces) and economic vulnerabilities, including a surge in unemployment due to the COVID-19 pandemic [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Despite similar policy approaches to health inequalities across the UK and in the EU, devolution has allowed for some divergence in implementation.\u003c/p\u003e\u003cp\u003eDuring the COVID-19 pandemic, socio-economic inequities increased, impacting health services, housing, health, education, employment and working conditions, amongst others [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. People living in the most deprived areas were twice as likely to be hospitalised or die from COVID-19, and 22% of households lost at least 20% of their weekly income early in the pandemic. Elective admissions fell by 55% and emergency admissions by 30%, and school closures deepened the digital divide, further disadvantaging children from deprived backgrounds. Ethnic minority groups accounted for 33% of critical care admissions despite comprising only 14% of the population, while overcrowded housing, homelessness, and unsafe environments increased exposure risks [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Key population groups with intersectional vulnerabilities were further marginalized, including youth, minority ethnic groups (Black and Asian particularly), LGBTQI\u0026thinsp;+\u0026thinsp;individuals, and people experiencing homelessness. In fact, 28% of children and 23% of all people in Wales live in relative income poverty, with these figures disproportionately higher in the most deprived areas [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEquity-focused Theories, Models and Frameworks: Implementation Science and Research\u003c/h3\u003e\n\u003cp\u003eTo translate growing policy commitments to health equity into effective action, public health systems increasingly rely on equity-focused theories, models, and frameworks (TFMs). These frameworks are designed to help stakeholders conceptualize, design, implement, and evaluate strategies aimed at reducing health disparities. TFMs are typically categorized into five types: determinant frameworks, implementation theories, process models, evaluation frameworks, and hybrid frameworks\u0026mdash;each offering distinct pathways for understanding and supporting equity-oriented action in health systems [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Determinant frameworks, such as the Health Equity Implementation Framework (HEIF), focus on identifying contextual factors, such as societal influences and clinical interactions, that predict whether equity-based interventions succeed, especially for marginalized groups [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Implementation theories, including the COM-B model (capability, opportunity, and motivation influencing behavior), explore behavior change mechanisms and are often used to tailor interventions to specific populations and cultural settings [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Process models such as the Equity-Based Framework for Implementation Research (EquIR) offer structured steps to engage communities and address equity barriers at the design and delivery stages [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Evaluation frameworks, like RE-AIM and its equity adaptations, assess outcomes at multiple system levels with an explicit focus on reducing disparities [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Finally, hybrid models such as EQ-DI integrate components from determinant, process, and evaluation frameworks to enable multi-level strategies for equitable implementation outcomes [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Collectively, these HEFs provide comprehensive tools to embed equity within the design and delivery of healthcare programs and policies. Despite their growing use, significant gaps remain in understanding how they are implemented in practice \u0026mdash; particularly across complex, multi-level governance systems like the EU, the UK, and their member states.\u003c/p\u003e\u003cp\u003eGiven this study\u0026rsquo;s focus on identifying the barriers and facilitators to implementing HEFs across the EU and UK, it is essential to situate these frameworks within the broader field of IS. IS studies the methods that promote the integration of evidence-based practices into specific real-world settings [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It accounts for a range of influencing factors, including the characteristics of the setting, the needs of target populations, and structural, socio-cultural, and geographic conditions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Thus, IS attempts to systematically study how to design and evaluate activities to facilitate a successful uptake of an evidence-based health intervention [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Closely related, implementation research (IR) systematically applies these methods to identify context-sensitive solutions, optimize the delivery of policies or interventions, and assess implementation processes across outcome levels [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile limited, there are empirical studies and scoping reviews that have explored similar themes, though typically outside the EU/UK. For example, Ravaghi et al. conducted a qualitative study exploring stakeholder perspectives on health equity and its indicators in Iran, using a comparable methodology to understand contextual barriers to equity [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Similarly, Yusuf et al. examined how health equity is integrated into service delivery systems in Nova Scotia through interviews with policymakers and health professionals [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Reviews such as the scoping protocol by Gustafson et al. have mapped the existing frameworks, facilitators, and barriers to implementing interventions aimed at ethnicity-related health inequities [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], while others have addressed HEF applications in diverse domains, including population screening[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], medical education [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], social needs screening in primary care [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], and chronic disease prevention [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Despite these contributions, the literature does not provide conclusive evidence on how policymakers in the EU and the UK experience and interpret the implementation of HEFs across multi-level governance systems.\u003c/p\u003e\u003cp\u003eHEFs are inherently implementation tools: they are designed not only to conceptualize disparities but to guide the delivery of equitable practices within existing systems. HEFs thus draw heavily from IS and IR to ensure that policies are adapted to local contexts and effectively serve populations that have historically experienced structural disadvantage [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, IS and IR have not yet fully addressed the specific institutional, economic, and political factors that sustain healthcare inequities, such as racism, social exclusion, regulatory fragmentation, and workforce inequities [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These limitations are reflected in several structural gaps in the field, including the underrepresentation of marginalized communities in implementation studies [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]; the lack of meaningful engagement with affected populations during the design of interventions; inconsistent incorporation of equity-related data and methods [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]; and systemic injustices within the IS workforce itself, which limit its capacity to produce inclusive, representative knowledge [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo address these gaps, we applied the HEIF to investigate the multi-level barriers and facilitators shaping the implementation of HEFs across the EU and the UK, focusing on how policymakers\u0026rsquo; perspectives can inform the development of more effective and context-sensitive equity frameworks. While previous studies have explored stakeholders\u0026rsquo; views on health equity and its indicators outside the EU and UK [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], no research to date has examined implementation gaps in the application of HEFs through stakeholder interviews at both EU and UK levels. Additionally, previous research used the HEIF to analyse other domains, including Hepatitis C treatment. Building on preliminary insights from related work on health impact assessments and the social determinants of health [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], this study contributes new qualitative evidence on how HEFs are experienced, interpreted, and acted upon by key policymakers. By analysing interview data through HEIF [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], we generate actionable insights to strengthen equity implementation and reduce persistent disparities across EU and UK health systems.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Setting\u003c/h2\u003e\u003cp\u003eThis study employed an interpretative qualitative, exploratory, observational, and cross-sectional design, guided by a social-constructivist paradigm [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This research used directed qualitative content analysis to identify patterns, categories, and insights into the barriers and facilitators of implementing HEFs in the EU and the UK, based on pre-existing categories established by HEIF. The use of a directed approach enabled the research to begin with pre-determined categories derived from HEIF, allowing a structured analysis while leaving space for the emergence of new themes from the data [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Individual semi-structured interviews were conducted virtually, using the Zoom video communications platform, ensuring accessibility and inclusivity with the participant and principal researcher alone (details on researcher\u0026rsquo;s background and skills can be found below in the section Authors' Information).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipant Recruitment and Sampling\u003c/h3\u003e\n\u003cp\u003eThis study included eighteen semi-structured interviews with policymakers to assess the usefulness and identify implementation gaps they have experienced while serving as implementation actors of HEFs. Interviews were conducted until saturation was reached, which indicated the optimal sample size [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Saturation was defined in advance as the point at which at least five consecutive interviews contributed only minor elaborations without generating new themes or codes, which occurred at interview number 16. Two more planned interviews were conducted, reaching 18 interviews in total. This was monitored through ongoing, iterative analysis during data collection. Previous literature indicates that 16\u0026ndash;24 interviews can be enough to identify common themes from sites with relatively homogeneous groups [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Initial contacts were made using institutional networks and project-affiliated mailing lists, through various formal and informal networks including Maastricht University, Public Health Wales, the Health Equity Network, the Andalusian School of Public Health, and the Association of Schools of Public Health in the European Region. All participants received a formal invitation via email, which outlined the study\u0026rsquo;s aims, methodology, inclusion and exclusion criteria, and ethical safeguards. A total of 64 potential participants were contacted via email. Of these, 56 were successfully reached. Initially, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13 agreed to participate, while \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2 declined due to time constraints. A follow-up email sent one week later yielded an additional \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7 positive responses. However, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2 of these did not proceed with scheduling an interview. This resulted in a final sample of \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18 expert interviews. Prior to the interviews, all participants received a brief survey containing questions on HEIFs, perceived gaps, and a request for contact details. The complete anonymized quote dataset is available in Additional file 1 [see Additional file 1]. However, given the qualitative focus of this study, only the interview data are analyzed in this manuscript. A total of 18 policymakers were interviewed, including representatives from EU health bodies, national public health agencies, and non-governmental organizations, such as the WHO Europe Region, Spanish Ministry of Health, United Nations, EuroHealthNet, Italian Ministry of Health, and Doctors Without Borders. No relationship was established with participants prior to the study, and interviews lasted 60\u0026ndash;90 minutes. This research employed a mixed sampling approach, combining convenience sampling by selecting stakeholders who were readily available and easily accessible through Public Health Wales networks, and purposive sampling by targeting high-level policymakers and experts (e.g., representatives from the WHO Europe Region, national ministries of health, and NGOs) with specific experience in health equity frameworks and implementation [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData Collection Procedures\u003c/h2\u003e\u003cp\u003eData collection was conducted via semi-structured interviews, allowing for flexibility in exploring participant insights while maintaining comparability across responses. Interviews were conducted virtually, using the Zoom video communications platform, in May 2025. All sessions were audio-recorded, transcribed verbatim, and anonymized to protect participant confidentiality. We included policymakers actively involved in designing, implementing, or evaluating HEFs for at least 3\u0026ndash;5 years. Participants had experience working with marginalized or vulnerable populations, were at least 18 years old, and were able to provide informed consent. Proficiency in English, Italian, Portuguese, or Spanish was required. Exclusion criteria included stakeholders with minimal involvement in HEFs and individuals unable to participate due to language barriers or scheduling conflicts. Residency or citizenship in Wales or an EU country was not a requirement, but participants had experience within the contexts being studied. Participants provided informed consent and were offered the opportunity to review the transcript of their interview. No one else was present during the interviews besides the participant and the researcher. Analytical memos were produced after each session. The interview guide was informed by HEIF, ensuring a structured and deductive yet adaptable and emerging approach [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. A semi-structured interview guide was developed based on the HEIF framework and included open-ended questions exploring perceived barriers and facilitators to the implementation of health equity, focusing on the perceived gaps. All participants took part in a single interview. Repeat interviews were not deemed necessary, as data saturation was achieved within the initial interviews and clarification was obtained during the sessions themselves.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eHealth Equity Implementation Framework\u003c/h3\u003e\n\u003cp\u003eThe HEIF, developed through the integration of IS and healthcare disparities research, offers a comprehensive structure for identifying and addressing multi-level factors that influence the equitable adoption of health interventions [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Initially applied to challenges such as hepatitis C treatment among Black patients, HEIF assumes that embedding health equity domains within implementation frameworks enhances both scientific rigour and practical equity impact by simultaneously addressing implementation and disparity-related barriers [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. HEIF assumes that incorporating health equity domains within implementation frameworks can optimize scientific yield and equity by simultaneously addressing implementation and equity barriers. To guide the directed content analysis, we applied the HEIF, a determinant-based implementation framework developed to explore multi-level barriers and facilitators affecting equitable uptake of interventions. HEIF was chosen due to its dual grounding in health disparities research and IS, making it particularly well-suited to explore policy-practice gaps in health equity efforts across the EU and UK. Preliminary codes were drafted from the HEIF but flexible to emerging categories to capture the richness and complexity of participants' experiences. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. The framework supports deductive categorisation of qualitative data through seven domains: (1) Characteristics of the Innovation, (2) Clinical Encounter, (3) Patient and Community Factors, (4) Inner Context, (5) Outer Context, (6) Societal Context, and (7) Culturally Relevant Factors of Recipients. These domains align with the core objectives of this study, which focuses on revealing both systemic and service-level implementation gaps [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. By applying HEIF to stakeholder interviews through a structured and pre-determined coding scheme, this study ensures that health equity considerations are not only recognized but systematically assessed across different implementation levels [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. This approach guided both the development of the interview guide and the organization of the results and tables. Operationalised definitions used in the analysis are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOperationalised definitions of Health Equity Implementation Framework (HEIF) domains\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHEIF Domain\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExact or Summarized Definition from Source\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCulturally Relevant Factors of Recipients\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDefined as characteristics shaped by recipients\u0026rsquo; lived and embodied experience (e.g., implicit bias, race/ethnicity, immigration status, language, health literacy) that influence how innovations are accepted or rejected in given context.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eClinical Encounter (Patient\u0026ndash;Provider Interaction)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDefined as the relationships between patients and providers during appointments. It involves decision-making, communication, and provider behaviors (e.g., implicit bias, dismissiveness) that influence whether an innovation is offered or accepted. Clinical encounters affect satisfaction, trust, and outcomes, especially among marginalized individuals.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePatient and Community Factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMostly refers to patient health beliefs, knowledge, literacy, engagement, and community readiness to adopt innovations as well as how innovations are designed, implemented and evaluated through and with communities.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInner Context (Organizational Factors)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIncludes internal organizational factors like leadership, culture, history of change, communication, and resources. These influence how innovations are implemented and embedded into routine practice.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOuter Context (Policy/System-Level Factors)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEncompasses the broader healthcare system, including incentives, mandates, regulatory environments, inter-organizational networks, and system-level resources. These shape external drivers for implementation.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSocietal Context\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRefers to economic, physical, and sociopolitical structures (e.g., racism, classism, governance) that operate at macro levels and shape the healthcare system, organizational norms, and recipient experiences. These often institutionalize health inequities.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInnovation Characteristics\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDescribes the equity framework or intervention itself (e.g., clarity, fit, usability, adaptability, evidence). These characteristics affect whether the innovation can be tailored to the setting and recipients.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eQualitative research plays a key role in implementation studies, as it helps explore how a particular innovation is applied in real-world settings. It focuses on examining the various factors that influence and interact with the implementation process [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. To explore how contextual factors either support or hinder implementation, this study applied the HEIF. Directed content analysis was used to validate and extend existing theory and to generate predictions regarding the variables of interest or their interrelationships, aiding in the development of an initial coding framework or identifying connections between codes, also known as deductive category application [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The unit of analysis represented words used by policymakers throughout the interview text [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Questions to policymakers included open-ended questions and specific questions based on pre-determined categories [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Categories were further classified as \u0026ldquo;barriers\u0026rdquo; or \u0026ldquo;facilitators\u0026rdquo;. Manual coding using Excel and Word began immediately. Predetermined codes and data that could not be coded, were identified, and analysed later to determine if they represented a new category or a subcategory of an existing code.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eEthics and Confidentiality\u003c/h2\u003e\u003cp\u003eEthical approval was obtained from Maastricht University, Faculty of Health, Medicine, and Life Sciences Research Ethics Committee (FHML-REC 738). All participants provided written or verbal informed consent prior to participation. All ethical aspects involved in the research, including those related to participant recruitment, data collection, confidentiality, and informed consent, were thoroughly described in the research protocol. Precautions included obtaining informed consent, maintaining confidentiality and anonymity, minimizing any potential risks to participants, and ensuring voluntary participation throughout the research process. Participants were provided with detailed information about the study objectives, procedures, and potential risks and benefits. Informed consent was obtained in writing, and confidentiality was maintained through secure data storage and anonymization protocols. Efforts were made to ensure the equitable recruitment and inclusion of participants from diverse backgrounds and key populations, including LGBTQI\u0026thinsp;+\u0026thinsp;individuals, migrants and racialized participants engaged in high-level health equity policymaking. Participants were not compensated due to the purpose of this research and were provided with access to support resources, such as counseling, if needed. Recruitment strategies avoided coercion and respected participants' autonomy, including clear communication about the voluntary nature of participation. Ethical concerns regarding transcription were minimized through confidentiality agreement within the research team/transcribers; assignment of a code to each interview; substitution of the interviewee's name in the transcription with a code, unless explicitly agreed otherwise; substitution of third-party names; storage of the recording and transcription in a secure location; opportunity for interviewees to review the transcription [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. All data processing complied with EU GDPR regulations, ensuring that personal data was protected and only used for research purposes. In line with ethical procedures, interview transcripts were made available for review only to those participants who explicitly requested them (n\u0026thinsp;=\u0026thinsp;2).\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eEnsuring Trustworthiness\u003c/h2\u003e\u003cp\u003eInter-rater reliability checks validated the coding process, where co-authors were given the opportunity to re-review and validate key categories derived from the interviews, and discrepancies were resolved through team discussions [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Emerging categories and subcategories were refined to capture the richness of participants' experiences. The main author coded all 18 transcripts, while one supervisor and another colleague independently coded 4 transcripts (approximately 22% of the sample) to establish consistency and ensure alignment and inter-coder reliability [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Since the code definitions were clear and subcategories did not overlap, two rounds of independence coding produced approximately the same results [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Overall, triangulation of stakeholders, research bias and reflexivity, continuous validation of data, checking of representativeness of data, self-reflection, peer-debriefing, negative case analysis, and expert consultations will all increase the reliability, validity and credibility of the research [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan additionalcitationids=\"CR54 CR55\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. This study adheres to the Consolidated Criteria for Reporting Qualitative Studies (COREQ); the completed checklist is provided in Additional file 2 [see Additional file 2]. Peer debriefing was facilitated through engagement with the Maastricht University Governance and Leadership in European Public Health (GLEPH) group. The peer group consisted of two researchers apart from the main researcher (25 years old, Turkish-born, male, master student with Public Health background and a 25-year-old Armenian-born female expert in public health). Their external perspectives provided a critical reflection on the coding process, thematic structure, and interpretation of findings, strengthening the analytical rigor and transparency of the research process. Interview questions were co-developed with Public Health Wales and other stakeholders to make sure that the critical reference groups were asked understandable questions, thus increasing overall trustworthiness [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Member checks were conducted to make sure stakeholders agreed with the results, and suitable meaning units that were neither too broad nor too narrow were selected to maintain the integrity of the text and enhance trustworthiness [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eReflexivity\u003c/h2\u003e\u003cp\u003eTo ensure a comprehensive analysis of the qualitative data collected, this study adopted a reflexive approach within a constructivist paradigm, acknowledging the potential influence of the researchers' backgrounds, biases, and preconceptions on the interpretation of the data [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Self-reflexivity took the form of writing and researching while acknowledging our unique situated narrative shaped by the cultural, social, gender, class, and personal perspectives we bring to research [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The interviews were conducted by the primary researcher (MPH), a postgraduate student in Governance and Leadership in European Public Health with formal training in qualitative methods and experience in qualitative research, project management and cross-national stakeholder engagement. The researcher\u0026rsquo;s background in HIV policy, LGBTQI\u0026thinsp;+\u0026thinsp;migrants\u0026rsquo; health, and human rights advocacy informed a reflexive approach throughout the study. No prior relationship existed between the researcher and the participants. To mitigate potential bias, the lead author maintained a reflexive journal to critically examine assumptions and document analytical decisions during the data collection and analysis processes.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eEighteen semi-structured interviews were conducted with policymakers, practitioners, and civil society actors involved in health equity work across European settings. Participants described intersecting and multi-level barriers to the implementation of HEFs alongside contextually grounded strategies to support more inclusive and effective implementation. An overview of participant roles, sectors, geographic scope, and levels of responsibility is provided in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Additional demographic information, such as age or gender, was deliberately excluded to ensure anonymity, as participants could be easily identified due to the specificity of their positions in each country.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic characteristics of interview participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003en.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCountry\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInstitution type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLevel of work\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWales\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNGO, but currently seconded to Government\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSwitzerland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNGO (Non-governmental organization)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBelgium\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCivil Society Organisation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInternational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eItaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNGO (Non-governmental organization)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInternational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWales\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrivate Health Company\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGlobal\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSpain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGovernment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInternational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEngland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGovernment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLocal\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDenmark\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAcademia and Policy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePortugal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInternational Organization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInternational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWales\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNational Health Service\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnited Kingdom\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGovernment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWales\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInternational Organization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInternational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eItaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGovernment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInternational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAcademia and Policy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLocal\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eScotland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAcademia and Policy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInternational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDenmark\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInternational Organization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInternational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFinland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAcademia and Policy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGlobal\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWales\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHealth Equity Policy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInternational\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA summary of the main barriers and facilitators reported across each domain is presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, while Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e contains selected illustrative quotes that support the analytic themes. The findings below are structured thematically according to the seven domains of the HEIF and supported by illustrative quotations.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of barriers and facilitators to health equity framework implementation across HEIF domains in EU and UK\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHEIF Domain\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBarriers\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFacilitators\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCulturally Relevant Factors of Recipients\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Existing frameworks are often perceived as Western Europe-centric, lacking cultural relevance and adaptability to national/local contexts, particularly in Southeast Europe.\u003c/p\u003e\u003cp\u003e\u0026bull; Frameworks inadequately account for intersectionality; they treat dimensions of inequality (e.g. race, gender, disability) separately rather than as intertwined and intersecting experiences.\u003c/p\u003e\u003cp\u003e\u0026bull; Migrants, racialized communities, and key populations (e.g. Roma, LGBTQI\u0026thinsp;+\u0026thinsp;individuals, migrants) face systemic exclusion, distrust in institutions, and limited culturally competent care.\u003c/p\u003e\u003cp\u003e\u0026bull; Socioeconomic precarity (e.g. informal employment, displacement) forces individuals to choose between healthcare and basic survival needs.\u003c/p\u003e\u003cp\u003e\u0026bull; Preventive services are unaffordable or underprioritized, undermining early engagement and equity goals.\u003c/p\u003e\u003cp\u003e\u0026bull; Digital-first innovations risk excluding those with low digital literacy or unstable internet access.\u003c/p\u003e\u003cp\u003e\u0026bull; Health equity frameworks often assume universal access without addressing legal, linguistic, or social barriers.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; Frameworks can be strengthened by being co-adapted to specific national and community realities, emphasizing flexibility and simplicity.\u003c/p\u003e\u003cp\u003e\u0026bull; Front-of-pack labeling, health literacy campaigns, and community kitchens integrate equity goals with social protection and nutrition, acting as empowering and emancipating forces, rather than having people as passive recipients.\u003c/p\u003e\u003cp\u003e\u0026bull; Frameworks should frame health access as a universal right tied to structural justice (not just individual behavior), reinforcing equity principles.\u003c/p\u003e\u003cp\u003e\u0026bull; Culturally contextualized primary care, person-centered service design, and locally embedded health promotion increase acceptability and relevance.\u003c/p\u003e\u003cp\u003e\u0026bull; Equity frameworks should acknowledge and center lived realities, including the trauma and socio-political exclusions that shape health behavior.\u003c/p\u003e\u003cp\u003e\u0026bull; Frameworks must include intersectionality analyses and how intersecting identities shape health outcomes in specific contexts.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eClinical Encounter (Patient\u0026ndash;Provider Interaction)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Patient-provider interactions are undermined by implicit bias, stigma, and assumptions based on identity (e.g. race, gender identity, migration background, sexual orientation).\u003c/p\u003e\u003cp\u003e\u0026bull; Lack of provider diversity and inadequate cultural awareness diminish trust, especially in historically excluded communities. Training on equity is often voluntary, reaching the already sensitized, while those most in need remain unexposed.\u003c/p\u003e\u003cp\u003e\u0026bull; Non-clinical staff (e.g. administrative personnel) are often excluded from training, despite being the first point of contact, widening the gap between health equity frameworks and implementation at the clinical level.\u003c/p\u003e\u003cp\u003e\u0026bull; Inflexible clinical practices and location-based gaps (especially rural areas) hinder equitable access.\u003c/p\u003e\u003cp\u003e\u0026bull; Stigmatized conditions (e.g. drug use, sex work, HIV status) trigger blame and self-censorship among patients, reducing service access.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; Co-designed services that reflect users\u0026rsquo; lived experience improve trust and uptake (e.g. HIV care in trans-inclusive clinics).\u003c/p\u003e\u003cp\u003e\u0026bull; Peer-led training and lived-experience dialogues between patients and providers can humanize services and demystify user needs.\u003c/p\u003e\u003cp\u003e\u0026bull; Differentiated service delivery (e.g. for men, South Asian communities) supports inclusive implementation of HEFs.\u003c/p\u003e\u003cp\u003e\u0026bull; Framing access challenges as service barriers (rather than user deficits) shifts responsibility and supports equity-centered redesign.\u003c/p\u003e\u003cp\u003e\u0026bull; Health equity training should be mandatory, practical, and multidisciplinary, building provider capacity to apply data and frameworks in action.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePatient and Community Factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Health equity frameworks often rely on tokenistic or top-down participation, excluding the most marginalized voices from design and governance.\u003c/p\u003e\u003cp\u003e\u0026bull; Community participation tends to involve representatives from established groups, excluding unaffiliated individuals most affected by inequity.\u003c/p\u003e\u003cp\u003e\u0026bull; Complex language and professional public health jargon in frameworks alienate non-policy actors (or actors from other policy departments) and limit comprehension. Policymaking often overlooks social location and daily barriers, reinforcing a gap between policy design and situated realities.\u003c/p\u003e\u003cp\u003e\u0026bull; Frameworks may fail to identify and include \u0026ldquo;who\u0026rsquo;s not in the room,\u0026rdquo; leading to blind spots in implementation.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; Health equity frameworks gain legitimacy and effectiveness when co-designed with marginalized communities through meaningful, remunerated participation.\u003c/p\u003e\u003cp\u003e\u0026bull; Engagement strategies should recognize communities as experts in their own lives, promoting community-led monitoring and evaluation.\u003c/p\u003e\u003cp\u003e\u0026bull; Place-based, participatory initiatives allow HEFs to be contextually grounded and responsive to local needs.\u003c/p\u003e\u003cp\u003e\u0026bull; Youth-led, informal leadership structures and multisectoral collaborations enhance equity outcomes and sustainability. Policy engagement must begin early, ensuring frameworks reflect community-defined priorities from inception.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInner Context (Organizational Factors)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Implementation of HEFs is impeded by institutional inertia, lack of leadership buy-in, and competing priorities.\u003c/p\u003e\u003cp\u003e\u0026bull; Organizational silos and absence of clear accountability structures limit cross-departmental collaboration.\u003c/p\u003e\u003cp\u003e\u0026bull; Equity initiatives often lack designated staff, budgetary mechanisms, or procedural integration, often leaving them under-resourced.\u003c/p\u003e\u003cp\u003e\u0026bull; Frameworks are perceived as theoretical, with limited tools to operationalize them within routine practice (action points) at different organizational level points.\u003c/p\u003e\u003cp\u003e\u0026bull; Prevention is systematically underfunded, while treatment receives disproportionate investment.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; Health equity must be embedded in organizational strategy, budgeting, procurement, and design and not treated as an add-on.\u003c/p\u003e\u003cp\u003e\u0026bull; Training should target not only providers but also leadership, planners, and service designers to embed equity culture across levels.\u003c/p\u003e\u003cp\u003e\u0026bull; Storytelling and simplification of frameworks enhance cross-sectoral understanding and organizational buy-in.\u003c/p\u003e\u003cp\u003e\u0026bull; Integration of previously vertical programs (e.g. STI or HIV care) into routine primary care aligns with HEF goals.\u003c/p\u003e\u003cp\u003e\u0026bull; Equity assessments and implementation guidance should be built into institutional policy cycles.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOuter Context (Policy/System-Level Factors)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Policy-level support for HEFs is often weak, lacking enforcement mechanisms and cross-sector coordination.\u003c/p\u003e\u003cp\u003e\u0026bull; Political cycles constrain equity initiatives, while the voluntary nature of health promotion limits sustainability.\u003c/p\u003e\u003cp\u003e\u0026bull; Fragmentation between national and local governance and autonomous regional healthcare (e.g. Spain, Italy) leads to inconsistent adoption of HEFs.\u003c/p\u003e\u003cp\u003e\u0026bull; Civil society organizations essential to equity are underfunded and face limited operational space.\u003c/p\u003e\u003cp\u003e\u0026bull; Policymakers often struggle to translate equity mandates into practical, multisectoral action.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; Legal instruments such as the Well-being of Future Generations Act and Health in All Policies (HiAP) offer a platform to include HEFs.\u003c/p\u003e\u003cp\u003e\u0026bull; Local authorities are well-positioned to translate HEFs into context-specific action.\u003c/p\u003e\u003cp\u003e\u0026bull; Municipal engagement in health impact assessments supports the mainstreaming of equity.\u003c/p\u003e\u003cp\u003e\u0026bull; Public health authorities must coordinate with transport, housing, and education to ensure cross-sector HEF implementation.\u003c/p\u003e\u003cp\u003e\u0026bull; Devolved systems (e.g. Wales) offer opportunities for innovative equity-focused governance models.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSocietal Context\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Structural racism, capitalism, and colonial legacies shape access to power and services, embedding inequality into health systems. Exclusion from policymaking processes reinforces the historical marginalization of already disenfranchised communities (e.g. Roma, migrants, LGBTQI\u0026thinsp;+\u0026thinsp;mobile populations, transgender individuals).\u003c/p\u003e\u003cp\u003e\u0026bull; Health equity efforts risk becoming superficial unless they address deeper societal power dynamics and governance structures.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; HEFs must be grounded in a recognition of historical and systemic injustice.\u003c/p\u003e\u003cp\u003e\u0026bull; Advocacy that connects health equity to broader justice movements (e.g. climate justice, anti-racism) increases support.\u003c/p\u003e\u003cp\u003e\u0026bull; Participatory policymaking rooted in empathy, trauma-informed care, intersectionality and collective responsibility strengthens inclusive governance.\u003c/p\u003e\u003cp\u003e\u0026bull; Trust-building and shared language among stakeholders are essential for HEF legitimacy.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInnovation Characteristics (Framework Design)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; HEFs often lack clarity, adaptability, and audience-specific communication strategies.\u003c/p\u003e\u003cp\u003e\u0026bull; Definitions of equity, equality, and inequality are confused or inconsistent.\u003c/p\u003e\u003cp\u003e\u0026bull; Absence of disaggregated data (e.g. ethnicity, rurality) undermines evidence-based implementation. Frameworks overemphasize individual behavior change and overlook system redesign.\u003c/p\u003e\u003cp\u003e\u0026bull; Technical complexity and overwhelming monitoring demands diminish local uptake.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; HEFs should use accessible, plain language and multiple audience-specific formats.\u003c/p\u003e\u003cp\u003e\u0026bull; Real-time, AI-supported data tools can improve feedback and adaptive learning.\u003c/p\u003e\u003cp\u003e\u0026bull; Frameworks must include community-led monitoring and allow iteration over time.\u003c/p\u003e\u003cp\u003e\u0026bull; Acknowledging failure as learning fosters innovation and equity improvement.\u003c/p\u003e\u003cp\u003e\u0026bull; Equity metrics and local relevance must be prioritized over uniformity.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eCulturally Relevant Factors of Recipients\u003c/h2\u003e\u003cp\u003eParticipants consistently described current equity frameworks as disconnected from the lived realities of marginalized populations. Several noted that existing models were \u0026ldquo;Western Europe-centric and disconnected from the realities of Southeast Europe,\u0026rdquo; with recommendations perceived as overly complex and difficult to localize (participant 5). A lack of intersectional thinking was widely critiqued; frameworks were seen to address vulnerabilities \u0026ldquo;separately,\u0026rdquo; failing to reflect multiple disadvantages (participant 15). Respondents noted that existing frameworks frequently treat race, gender, legal status, and disability as separate, siloed variables rather than interconnected systems of exclusion. They emphasized that the lack of culturally contextualized and intersectional HEFs undermines both the legitimacy and effectiveness of implementation efforts, especially for Roma, LGBTQI\u0026thinsp;+\u0026thinsp;migrants, and undocumented populations across the EU and UK. Legal and administrative barriers remained a persistent concern, particularly for undocumented migrants: \u0026ldquo;not everyone has the right to access health services simply because they are present in the territory\u0026rdquo; (participant 16). Others highlighted the need to rethink accessibility in more practical terms, such as appointment flexibility to account for gender norms, cultural dynamics and caregiving structures: \u0026ldquo;if my husband has to bring me and this day works better for him, I will go that day\u0026rdquo; (participant 14). Community-based initiatives, such as community kitchens and nutrition labelling, were seen as effective entry points for inclusive health promotion. Participants called for frameworks that are \u0026ldquo;accessible and approachable,\u0026rdquo; capable of translating equity principles into tangible, culturally contextualized practices (participant 2).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eClinical Encounter (Patient\u0026ndash;Provider Interaction)\u003c/h2\u003e\u003cp\u003eParticipants described how bias in clinical encounters undermines trust and reinforces inequities. Several noted that racial and gender identities continue to shape patient experiences, with one participant explaining, \u0026ldquo;if you're a Black person in Europe\u0026hellip; and you'd like to ideally find a doctor who is also Black\u0026hellip; this is often very difficult\u0026hellip; that of course impacts how you\u0026rsquo;re treated and reduces trust\u0026rdquo; (participant 1). Training was widely regarded as insufficient and unevenly implemented. \u0026ldquo;Equity training should be mandatory, not optional,\u0026rdquo; one participant said, adding that \u0026ldquo;those holding biases\u0026hellip; rarely receive it\u0026rdquo; (participant 16). Others stressed that current efforts neglect key roles: \u0026ldquo;it shouldn\u0026rsquo;t just be for doctors and nurses\u0026hellip; front desk staff are often the first point of contact\u0026rdquo; (participant 7). Participants also highlighted the experience of LGBTQI\u0026thinsp;+\u0026thinsp;individuals, with one stating, \u0026ldquo;a gay man or a trans woman going to the same service [as a straight man] and not feeling welcome\u0026rdquo; (participant 3). Structural issues, such as inaccessible locations and poorly calibrated equipment, further marginalized groups: \u0026ldquo;certain medical equipment is not calibrated to people of a certain skin color\u0026rdquo; (participant 1). Respondents advocated for differentiated service delivery and inclusive design, suggesting health systems \u0026ldquo;remove the barriers\u0026rdquo; by asking not why groups are \u0026ldquo;hard-to-reach\u0026rdquo; but \u0026ldquo;why is my service hard to reach?\u0026rdquo; (participant 5).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003ePatient and Community Factors\u003c/h2\u003e\u003cp\u003eParticipants emphasized that community engagement must be central, not symbolic. \u0026ldquo;You don\u0026rsquo;t do it for them, you do it with them\u0026hellip; we need to change this\u0026rdquo; (participant 1). Several noted that participation often occurs too late in the process\u0026mdash;\u0026ldquo;the population is barely involved at all\u0026rdquo; (participant 7)\u0026mdash;or is based on assumptions rather than lived knowledge: \u0026ldquo;we often try to understand communities through academic articles, but without speaking directly with people\u0026rdquo; (participant 16). Majority of participants highlighted the lack of formal mechanisms: \u0026ldquo;we do not have formal toolkits or checklists for community participation\u0026hellip; it often relies on intuition\u0026rdquo; (participant 17). There was strong support for co-designing HEFs with communities from the outset, \u0026ldquo;ensuring they have a paid seat at the table\u0026rdquo; (participant 1). Participants advocated for place-based, community-led initiatives that reflect local context: \u0026ldquo;they often have the local knowledge\u0026rdquo; (participant 5). Lived experience was positioned as critical expertise: \u0026ldquo;now we call them experts by lived experience\u0026rdquo; (participant 13). Overall, a shift toward relational, context-sensitive, place-based, intersectional and participatory approaches was seen as essential for equitable health system transformation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eInnovation Characteristics\u003c/h2\u003e\u003cp\u003eParticipants highlighted that inconsistent terminology and inaccessible language remain key barriers to implementing HEFs. As one put it, \u0026ldquo;definitions of equity, equality, and inequality are confused or inconsistent\u0026rdquo; (participant 2), while another stressed, \u0026ldquo;public health language is often too complex, limiting public engagement and understanding\u0026rdquo; (participant 2). Simplifying and adapting terminology was viewed as critical: \u0026ldquo;we need to change the way we speak\u0026hellip; if you say drug user, it is completely different if you say person who uses substances\u0026rdquo; (participant 13). A call for more inclusive, person-centered language resonated across interviews. Frameworks were also seen as failing to reflect individual needs\u0026mdash;\u0026ldquo;those one in eight are not exactly the same\u0026hellip; you\u0026rsquo;ve got to treat people as individuals\u0026rdquo; (participant 2). Participants recommended adapting communication strategies to diverse audiences: \u0026ldquo;health equity frameworks should use different language for different audiences\u0026hellip; ensuring the message\u0026hellip; resonates at every level\u0026rdquo; (participant 2). The importance of robust, disaggregated data collection was also raised: \u0026ldquo;if you don\u0026rsquo;t have the data, what are you basing your policy on?\u0026rdquo; (participant 3). Technological solutions like AI were cited as promising tools to improve equity monitoring and reduce delays in data use.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eInner Context (Organization Level Factors)\u003c/h2\u003e\u003cp\u003eParticipants described a general lack of internal structures to assess and act on health equity. One noted, \u0026ldquo;we lack structures specifically designed to carry out health equity assessments internally\u0026hellip; these tasks are often left undone\u0026rdquo; (participant 16). Even when awareness was present, the absence of formal processes and limited staff capacity constrained action, especially in under-resourced countries. Communication between different levels of care was also raised as a persistent gap: \u0026ldquo;we don't have an integrated IT system\u0026hellip; technology could address this\u0026rdquo; (participant 5). Fragmentation between primary and secondary care was seen to hinder continuity and equity in service delivery. There was a shared concern that frameworks remain too high-level to prompt meaningful change. \u0026ldquo;If we go too high level\u0026hellip; we lose people,\u0026rdquo; one participant said. \u0026ldquo;Maybe breaking it down\u0026hellip; giving them some key action steps. I think that\u0026rsquo;s key\u0026mdash;moving from theory to action\u0026rdquo; (participant 5). Examples of participatory approaches, such as mobile units and shared decision-making across departments, were seen as effective ways to operationalize equity when grounded in listening and co-creation (participant 1).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eOuter Context (Policy/System Level Factors)\u003c/h2\u003e\u003cp\u003eParticipants underscored that health equity cannot be achieved through health systems alone. \u0026ldquo;Health equity needs to move beyond health-only approaches,\u0026rdquo; one said, referring to the need for integration with employment, housing, and education policies (participant 1). Despite this recognition, cross-sectoral collaboration remained underdeveloped and poorly coordinated. \u0026ldquo;There\u0026rsquo;s not a clear pathway\u0026hellip; and I think that's causing a lot of confusion as to who's responsible for what\u0026rdquo; (participant 5). Fragmentation also extended across borders, with strong regional autonomy limiting knowledge exchange: \u0026ldquo;what\u0026rsquo;s often missing is better exchange of good practices between autonomous regions and cross-border learning at the EU level\u0026rdquo; (participant 4). The role of data was often emphasized\u0026mdash;both its potential and its politicization. \u0026ldquo;Without consistent, rights-based data\u0026hellip; policymaking remains blind to structural inequities\u0026rdquo; (participant 1), while others stated that \u0026ldquo;data can be manipulated by politicians for their own ends\u0026rdquo; (participant 18). Political will emerged as a crucial vector: \u0026ldquo;if there is political will, then all the rest can happen\u0026rdquo; (participant 3). Participants called for long-term investment strategies and stronger EU funding streams to support implementation at national and local levels, with funding being generally understood as one of the main barriers to the effective implementation of HEFs.\u003c/p\u003e\u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\u003ch2\u003eSocietal Context\u003c/h2\u003e\u003cp\u003eStructural inequities\u0026mdash;including patriarchy, colonialism, and capitalism\u0026mdash;were seen as fundamental barriers to health equity. \u0026ldquo;The core of the thing is\u0026hellip; colonialism, patriarchy and capitalism\u0026mdash;because everything is like about getting more money or not wasting money\u0026rdquo; (participant 10). Participants described how hegemonic norms built around the white, male, educated body shape clinical and policy decisions, marginalizing those who do not adhere to the standard: \u0026ldquo;anyone who deviates\u0026mdash;by gender, race, disability, or intersecting identities\u0026mdash;faces compounded inequities\u0026rdquo; (participant 1). Most participants felt that majority of HEFs do not explicitly include intersectionality. There was strong concern over the limited accountability of non-binding EU strategies: \u0026ldquo;the EU has limited competence in health\u0026hellip; while real change depends on national governments\u0026rsquo; political will\u0026rdquo; (participant 1). Funding gaps were also perceived as widening: \u0026ldquo;resources for underserved populations are shrinking, even as demand increases\u0026hellip; this financial gap is growing and threatens equity efforts\u0026rdquo; (participant 17). Participants stressed that lobbying by powerful industries, especially in areas like food policy, often undermines equity-focused reforms: \u0026ldquo;the main obstacles are the strong opposition from actors who are maximizing their profits\u0026rdquo; (participant 6). Calls were made for more consistent EU-level support for capacity building, infrastructure, and knowledge exchange and for a stronger parliamentary push against \u0026ldquo;lobbyism\u0026hellip; undermining all those efforts\u0026rdquo; (participant 6).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSelected illustrative quotes by HEIF domain\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHEIF Domain\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBarriers\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFacilitators\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCulturally Relevant Factors of Recipients\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;these frameworks often feel western europe-centric and disconnected from the realities of southeast europe. while eu-level principles are important, national teams need support to adapt them to their specific governance and cultural contexts. the distance and complexity of current recommendations make local relevance unclear\u0026mdash;simplifying them is crucial.\u0026rdquo; (participant 5)\u003c/p\u003e\u003cp\u003e\u0026ldquo;so you can think of, for example, white cis women with a lot of resources compared to women from the gypsy traveller community who have disabilities and very high levels of ill health. the main thing i would say is that a lot of the frameworks don't account for intersectionality\u0026hellip; they look at things separately.\u0026rdquo; (participant 15)\u003c/p\u003e\u003cp\u003e\u0026ldquo;not everyone has the right to access health services simply because they are present in the territory. there are still many people\u0026mdash;especially migrants\u0026mdash;who are excluded.\u0026rdquo; (participant 16)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I was working for some time with some women...muslims who had to go to gynecological visits\u0026hellip; they were actually from bangladesh. so I always asked to visit on a certain day and they would never go. then I changed the day and they went. why? because they said \u0026ldquo; my husband has to bring me and this day works better for him\u0026rdquo; (participant 14)\u003c/p\u003e\u003cp\u003e\u0026ldquo;if you are displaced from another country, you don't have legal work, and you live in the street, you don't have the right. and in terms of public health, this is unsustainable. because, for example, infected disease don't ask for passports. they move from individual to individual.\u0026rdquo; (participant 13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;it's just making sure that you're accessible and approachable and translating what we mean by health equity into something that's tangible for those other communities to buy into.\u0026rdquo; (participant 2)\u003c/p\u003e\u003cp\u003e\u0026ldquo;front of the pack labelling is important because everybody with different levels of literacy can understand what is in the product.\u0026rdquo; (participant 6)\u003c/p\u003e\u003cp\u003e\u0026ldquo;community kitchens can play a key role in improving diet quality for low-income populations\u0026hellip; linking food access with education, nutrition awareness, and local food systems.\u0026rdquo; (participant 6)\u003c/p\u003e\u003cp\u003e\u0026ldquo;actually, the issue isn\u0026rsquo;t just communication\u0026mdash;it's a lack of literacy, especially around one health. this isn\u0026rsquo;t just a minor gap; it\u0026rsquo;s a major challenge. improving one health literacy is essential, not only for the general public but especially for policymakers and decision-makers. strong governance and leadership depend on it.\u0026rdquo; (participant 2)\u003c/p\u003e\u003cp\u003e\u0026ldquo;we need to think about what people really need. and what the communities need and what kind of services they would like to see further, rather than to kind of try to organise the health system in most efficient way.\u0026rdquo; (participant 12)\u003c/p\u003e\u003cp\u003e\u0026ldquo;we need a health system that truly welcomes everyone and can adapt to different realities and needs. primary care, in line with the alma ata principles, should be accessible, person-centered, culturally aware and adaptable throughout a person's life. it should accommodate people\u0026rsquo;s individual needs\u0026mdash;such as adjusting appointment schedules\u0026mdash;and ensure continuity of care. (participant 16)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eClinical Encounter (Patient\u0026ndash;Provider Interaction)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;if you're a black person in europe and you're going to a doctor and you would like to ideally find a doctor who is also black\u0026hellip; this is often very difficult. that of course impacts how you\u0026rsquo;re treated and reduces trust a lot.\u0026rdquo; (participant 1)\u003c/p\u003e\u003cp\u003e\u0026ldquo;training on equity often ends up reinforcing inequalities. those already aware and sensitized seek out training, while those holding biases\u0026hellip; rarely receive it. equity training should be mandatory, not optional.\u0026rdquo; (participant 16)\u003c/p\u003e\u003cp\u003e\u0026ldquo;one of the barriers is that many key roles aren\u0026rsquo;t included in training\u0026mdash;like administrative staff\u0026hellip; it shouldn\u0026rsquo;t just be for doctors and nurses. it should also include those at the front desk, because they\u0026rsquo;re often the first point of contact in primary care. many patients have already faced multiple barriers before even reaching a consultation. health care doesn\u0026rsquo;t start with the doctor\u0026mdash;it starts much earlier.\u0026rdquo; (participant 7)\u003c/p\u003e\u003cp\u003e\u0026ldquo;you could go to the doctors as a straight man, go there and feel perfectly safe and welcome, and then a gay man or a trans woman going to the same service and not feeling welcome.\u0026rdquo; (participant 3)\u003c/p\u003e\u003cp\u003e\u0026ldquo;certain medical equipment not being calibrated to people of a certain skin color\u0026rdquo; (participant 1)\u003c/p\u003e\u003cp\u003e\u0026ldquo;the is, from my point of view, very far away. if you don't encourage health professionals to in areas of difficult coverage, in rural areas, in marginal neighbourhoods, it makes people in those neighbourhoods have more difficulty accessing the health (participant 11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;people are not sclerotized into one situation, they move. so the services need to move with them.\u0026rdquo; (participant 13)\u003c/p\u003e\u003cp\u003e\u0026ldquo;not talking about hard-to-reach groups, but thinking my service is hard to reach. so why is my service hard to reach and how do I remove the barriers? I think that's important when we're thinking about service design and marginalised groups and going to those groups in most cases instead of expecting them to come to you\u0026rdquo; (participant 5)\u003c/p\u003e\u003cp\u003e\u0026ldquo;so if you're implementing something, what kind of skill building and support are you providing to those people who should be implementing your framework?\u0026rdquo; (participant 5)\u003c/p\u003e\u003cp\u003ebeyond training, we supported the implementation of differentiated service delivery, helping community organizations co-design hiv prevention services tailored to people\u0026rsquo;s needs and aligned with national guidelines\u0026mdash;expanding access and choice.. and including medical doctors to improve patient-doctor relationships\u0026rdquo; (participant 2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePatient and Community Factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;you don\u0026rsquo;t do it for them, you do it with them.. we need to change this\u0026rdquo; (participant 1)\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;participation shouldn\u0026rsquo;t just be about validating decisions already made; it must start from the beginning\u0026hellip; the population is barely involved at all.\u0026rdquo; (participant 7)\u003c/p\u003e\u003cp\u003e\u0026ldquo;we often try to understand communities through academic articles, but without speaking directly with people\u0026hellip; we miss key insights.\u0026rdquo; (participant 16)\u003c/p\u003e\u003cp\u003e\"the fact that there is sort of belief that we know everything about the communities we are working on or with, and we don't necessarily need their view. we need just to discuss here and there with some people and that's it.\" (participant 10)\u003c/p\u003e\u003cp\u003e\u0026ldquo;it's very easy for these implementation frameworks to slip into just solving immediate problems and just having individual level behavioral interventions\u0026hellip; and not constantly thinking about how do we redesign the system.\u0026rdquo;(participant 15)\u003c/p\u003e\u003cp\u003e\u0026ldquo;we do not have formal toolkits or checklists for community participation. engagement often relies on intuition. there is a need for more structured and embedded community participation mechanisms in health equity frameworks and organizations.\u0026rdquo; (participant 17)\u003c/p\u003e\u003cp\u003e\u0026ldquo;there has been a sort of tendency, let's say, I don't know what to call it, but to include communities only in the evaluation but they should be included since the beginning, like in the design of public health policy in general.\" (participant 10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;health equity frameworks must be co-designed with marginalized communities, ensuring they have a paid seat at the table to shape solutions that reflect their lived realities.\u0026rdquo; (participant 1)\u003c/p\u003e\u003cp\u003e\u0026ldquo;in prep policy, for instance, it's just having that understanding of what the community is and what the community looks like that we're trying to work towards and what we're trying to achieve with that community, not on that community, you know, it's working with that community, not on them. you've got to think about your engagement approaches.\u0026rdquo; (participant 2)\u003c/p\u003e\u003cp\u003e\u0026ldquo;let the community tell them, tell us who they are and what's important to them and what they're here for. don\u0026rsquo;t assume just because you have a gay migrant in front of you the sexual behavior this person is having. let them tell you.\u0026rdquo; (participant 1)\u003c/p\u003e\u003cp\u003e\u0026ldquo;we often expect people to come to us within healthcare when actually we probably need to get better at going to them.\u0026rdquo; (participant 9)\u003c/p\u003e\u003cp\u003e\u0026ldquo;now we call them expert by live experience. so it's not just patient, but are people that know, are experts by lived experience.\u0026rdquo; (participant 13)\u003c/p\u003e\u003cp\u003e\u0026ldquo;we should be moving towards place-based community-led initiatives and place-based governance simply because from where I sit in the rural kind of health space, context is key. they often have the local knowledge\u0026rdquo; (participant 5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInner Context (Organizational Factors)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;statutory bodies\u0026hellip; need clear guidance on what it means in practice\u0026hellip; what\u0026rsquo;s feasible, and what to prioritize.\u0026rdquo; (participant 5)\u003c/p\u003e\u003cp\u003e\u0026ldquo;in spain, many specialized STIs clinics were closed, but instead of eliminating them, it would have been better to fully integrate those services into primary care. services like prep, pep, or mpox vaccination should be easily accessible and routinely offered by primary healthcare providers\u0026mdash;making them part of everyday care rather than separate, vertical programs\u0026rdquo; (participant 4)\u003c/p\u003e\u003cp\u003e\u0026ldquo;we lack structures specifically designed to carry out health equity assessments internally. these tasks are often left undone\u0026mdash;not because people don\u0026rsquo;t care, but because there\u0026rsquo;s no formal system in place, and existing staff are already overburdened with other responsibilities.\u0026rdquo; (participant 16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;when we think about healthcare, primary and secondary care, communications between primary and secondary care are challenging. we don't have an integrated it system. like these are things, for example, that technology could address\u0026rdquo;. (participant 5)\u003c/p\u003e\u003cp\u003e\u0026ldquo;if we go too high level with these frameworks, we lose people. so maybe breaking it down. what are like some key first steps that each person could do at a certain level? like giving them some key action steps basically. and I think that's key moving from theory to action.\u0026rdquo; (participant 5)\u003c/p\u003e\u003cp\u003e\u0026ldquo;from mobile units to culturally sensitive care, effective outreach starts with listening to those most affected and addressing their barriers through shared decision-making, across departments and organizations, with a participatory approach\u0026rdquo; (participant 1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOuter Context (Policy/System-Level Factors)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;without consistent, rights-based data from national systems, segregated by gender, race and ethnicity, policymaking remains blind to structural inequities\u0026mdash;cross-border, high-quality data is essential but still largely missing\u0026rdquo; (participant 1)\u003c/p\u003e\u003cp\u003e\u0026ldquo;you need to know what inequities look like in the employment sector or in housing or in education. because those are things that directly impact your ability to be healthy. health equity needs to move beyond health-only approaches\u0026rdquo; (participant 1)\u003c/p\u003e\u003cp\u003e\u0026ldquo;one health is implying a sort of collaboration among different ministries for instance. so the ministry of health has to work with the ministry of environment, the ministry of agriculture, of veterinary or whatever you want to call it. and when there is no kind of commitment when there is no sort of conditions that now we are living in a world where everything is interconnected\u0026rdquo; (participant 8)\u003c/p\u003e\u003cp\u003e\u0026ldquo;a lot of the health equity work really requires cross sectoral collaboration. but that kind of work hasn't really been developed yet. there's not a clear pathway to follow at the moment and I think that's causing a lot of confusion as to who's responsible for what, what should they be trying to do\u0026rdquo; (participant 5)\u003c/p\u003e\u003cp\u003e\u0026ldquo;a major challenge remains the lack of trust in science among some policymakers, who may prioritize political appeal over evidence-based action.\" (participant 3)\u003c/p\u003e\u003cp\u003e\u0026ldquo;there are always calls for things like charges? means testing, restricting eligibility, fragmentation, political will, all the things that we know are really unhelpful\u0026hellip; but these zombies keep arriving. privatisation, private sector money, always they're in the background.\u0026rdquo; (participant 15)\u003c/p\u003e\u003cp\u003e\u0026ldquo;data can be manipulated by politicians for their own ends\u0026rdquo; (participant 18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;political will is really important\u0026hellip; if there is political will, then all the rest can happen.\u0026rdquo; (participant 3)\u003c/p\u003e\u003cp\u003e\u0026ldquo;It\u0026rsquo;s about having EU funding streams to address health equity frameworks, engaging organizations, the voluntary sector, the third-sector\u0026hellip; both internationally and locally... they are struggling a lot\u0026rdquo; (participant 18)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Health equity is about prevention\u0026hellip; if we can ensure to increase the prevention rather than just talking about it... we need to have a long-term view to reach health equity... 10\u0026ndash;15 years view\u0026rdquo; (participant 18)\u003c/p\u003e\u003cp\u003e\u0026ldquo;health equity can\u0026rsquo;t be achieved through eu health policy or national health policy alone\u0026mdash;it's too limited. real progress requires cross-sectoral action, engaging employment, housing, education, and more, because health is shaped by far more than healthcare systems. it\u0026rsquo;s about breaking the silos. everything impacts your health, not only the health system\u0026rdquo; (participant 1)\u003c/p\u003e\u003cp\u003e\u0026ldquo;spain has a highly decentralized system with strong regional autonomy. what\u0026rsquo;s often missing is better exchange of good practices between autonomous regions and cross-border learning at the eu level.\u0026rdquo; (participant 4)\u003c/p\u003e\u003cp\u003e\u0026ldquo;if we make good policies for entire population, improves what you do with specific populations\u0026hellip; doing things for only, say migrants, sometimes are not transversal or longitudinal\u0026rdquo; (participant 7)\u003c/p\u003e\u003cp\u003e\u0026ldquo;without consistent, rights-based data from national systems\u0026hellip; policymaking remains blind to structural inequities.\u0026rdquo; (participant 1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSocietal Context\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;the core of the thing is\u0026hellip; colonialism, patriarchy and... and capitalism because everything is like about getting more money or not wasting money.\u0026rdquo; (participant 10)\u003c/p\u003e\u003cp\u003e\u0026ldquo;when health systems and policies are built around the standard of an older white male, anyone who deviates\u0026mdash;by gender, race, disability, or intersecting identities\u0026mdash;faces compounded inequities\u0026rdquo; (participant 1)\u003c/p\u003e\u003cp\u003e\u0026ldquo;structural obstacles to effective health equity implementation persist due to non-binding strategies, lack of accountability, and absent monitoring frameworks. the eu has limited competence in health\u0026mdash;mostly reduced to funding support, best practice exchange, and soft nudging\u0026mdash;while real change depends on national governments\u0026rsquo; political will\u0026rdquo; (participant 1)\u003c/p\u003e\u003cp\u003e\u0026ldquo;the main obstacles to food environment policies in europe are the strong opposition from actors who are maximizing their profits, particularly the food industry! (participant 6)\u003c/p\u003e\u003cp\u003e\u0026ldquo;sustainable funding is a major issue. at both eu and member state levels, resources for underserved populations are shrinking, even as demand increases. this financial gap is growing and threatens equity efforts.\u0026rdquo; (participant 17)\u003c/p\u003e\u003cp\u003e\u0026ldquo;the number of people displaced is exponentially increasing because of the climate change and the ecological catastrophes, because of the wars, because of the diverse economical situation, level of unemployment. health equity frameworks should account for these\u0026rdquo; (participant 13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;health equity frameworks must address directly and in detail racism, xenophobia, and other structural inequities as fundamental determinants of health.\u0026rdquo; (participant 1)\u003c/p\u003e\u003cp\u003e\u0026ldquo;through networks like disqo and the roma health network, we tackle discrimination as a fundamental health determinant by connecting grassroots voices to eu policymaking.\u0026rdquo; (participant 1)\u003c/p\u003e\u003cp\u003e\u0026ldquo;if you stop funding in Africa, it will create further problems\u0026hellip;because we are all interconnected\u0026rdquo; (participant 18)\u003c/p\u003e\u003cp\u003e\u0026ldquo;improving broad policies\u0026mdash;urban planning, public spaces, transport, housing, employment\u0026mdash;can reduce inequalities for everyone. (participant 7)\u003c/p\u003e\u003cp\u003e\u0026ldquo;the EU can support health equity by funding knowledge exchange, capacity building, and infrastructure development. it can help national, regional, and local authorities design and monitor effective, multisectoral interventions.\u0026rdquo; (participant 17) \u0026nbsp;\u0026ldquo;so, unfortunately, not always in europe we have active parliamentarian groups who, for example, work across different parties and across different countries to promote that agenda. I definitely, think that a European Parliament really work should happen at that level. that's where the lobbyism is actually undermining all those efforts.\u0026rdquo; (participant 6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInnovation Characteristics\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;definitions of equity, equality, and inequality are confused or inconsistent.\u0026rdquo; (participant 2)\u003c/p\u003e\u003cp\u003e\u0026ldquo;if you don\u0026rsquo;t have the data, what are you basing your policy on?\u0026rdquo; (participant 3)\u003c/p\u003e\u003cp\u003e\u0026ldquo;public health language is often too complex, limiting public engagement and understanding.\u0026rdquo; (participant 2)\u003c/p\u003e\u003cp\u003e\u0026ldquo;there is definitely a need for some form of joint language, allowing you to speak the same language when you're talking about racism, discrimination and health and how it should be addressed. so we should definitely also spend some time on trying to find a common language\u0026rdquo; (participant 1)\u003c/p\u003e\u003cp\u003e\u0026ldquo;what do you mean by health equity frameworks? we policymakers should address this question first\u0026rdquo; (participant 5)\u003c/p\u003e\u003cp\u003e\u0026ldquo;health equity frameworks saying \u0026ldquo;one in eight people are gay in wales, for instance, that's no good because... those one in eight are not exactly the same. if it is one in eight, you've got to treat people as individuals. and that's the beginning of all equity and we should include this into the policies we make\u0026rdquo; (participant 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;health equity frameworks should use different language for different audiences\u0026hellip; ensuring the message on health equity resonates at every level.\u0026rdquo; (participant 2)\u003c/p\u003e\u003cp\u003e\u0026ldquo;AI can help analyze data more efficiently and significantly shorten the time between data collection and publication.\u0026rdquo; (participant 3)\u003c/p\u003e\u003cp\u003e\u0026ldquo;if you tried something and didn't work in the first year or two, that's not failure. that's great. that's a learning opportunity.\u0026rdquo; (participant 5)\u003c/p\u003e\u003cp\u003e\u0026ldquo;language changes and evolves, and we can't keep using the same language and assuming that the communities are accepting of that language\u0026hellip;there was terminology on STIs I was using 10 years ago that has now completely changed and evolved\u0026rdquo; (participant 2)\u003c/p\u003e\u003cp\u003e\u0026ldquo;we need to change the way we speak\u0026hellip;. \u0026ldquo;if you say drug user, it is completely different if you say person who uses substances.\u0026rdquo; (participant 13)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the complex, multi-level barriers and facilitators influencing the implementation of HEFs across the EU and UK, with a focus on policymaker perspectives. Guided by HEIF, our findings reveal that despite increasing recognition of health equity as a priority, HEFs remain constrained by structural barriers, limited community participation, and fragmented policy environments. Consistent with previous studies using HEIF in primary care and policy contexts, participants highlighted the persistent misalignment between equity goals and implementation practices\u0026mdash;particularly among populations facing multi-level structural disadvantage [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Among the most critical influences are social determinants of health, including income, education, employment, housing, transportation, and geography, which are known to significantly shape disparities in health outcomes [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. These factors are often intertwined and intergenerational, compounding disadvantages over time and presenting persistent challenges to the effective implementation of equity frameworks, as a person\u0026rsquo;s immediate surroundings also shape critical lifestyle determinants, such as access to nutritious food, opportunities for physical activity, safe transportation, and environmental conditions like clean water and air [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eParticipants widely perceived existing HEFs as misaligned with local realities and overly dependent on Western European policy models, reinforcing calls from previous research to center intersectionality and cultural relevance as foundational, not optional, components. Intersectionality theory, grounded in feminist and antiracist traditions, emphasizes that race, gender, class, and migration status must be considered in tandem rather than in isolation, as their intersections produce unique, context-specific experiences of marginalization and privilege [\u003cspan additionalcitationids=\"CR61 CR62\" citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. While intersectionality is increasingly recognized as a powerful framework in health equity research, its practical integration into methods and policy analysis remains underdeveloped [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Intersectional analyses reveal that variables like gender, migration status, and class interact in complex ways to shape health outcomes, and failing to account for these intersections leads to inaccurate or incomplete health equity policy and framework responses [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. In alignment with the EU SOPHIE project\u0026rsquo;s approach, participants in this study emphasized that intersectionality must inform not only service delivery but also the design, governance, and monitoring of HEFs to ensure they effectively respond to structurally embedded inequalities across EU and UK contexts [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAt the clinical level, this disconnect manifested in patient-provider interactions, where implicit bias, provider homogeneity, and siloed training diminished trust and uptake. Clinical design choices that fail to acknowledge these dynamics risk reinforcing access barriers, what one participant reframed as \u0026ldquo;why is my service hard to reach?\u0026rdquo; rather than \u0026ldquo;why are patients hard to reach.\u0026rdquo; Internally, organizations were described as lacking the structural mechanisms to translate HEFs into operational routines. Staff shortages, outdated leadership styles, and limited integration between primary and secondary care created fragmented delivery environments. Equity was often viewed as a \u0026ldquo;soft add-on\u0026rdquo; rather than a foundational institutional norm, echoing other research identifying this as a failure of system design rather than will. Participants called for stepwise action points tailored to specific institutional roles and identified internal health equity assessments as necessary tools to track progress and distribute accountability. Integrated technology systems were also seen as vital for improving continuity of care and equity responsiveness, especially in rural or high-need settings. In line with previous research, which emphasizes the centrality of trust, shared decision-making, and system-wide organizational change, our findings suggest that differentiated service delivery must be prioritized to reflect user realities, especially for communities historically excluded from health systems [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. Participants widely described community engagement in HEF implementation as symbolic and retrospective \u0026mdash; often occurring too late to shape design or governance. This reflects broader findings that community input is frequently treated as a checkbox exercise, lacking mechanisms for accountability [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. Several participants stressed that lived experience should be positioned as a core source of expertise, not an add-on. Without formal structures, such as those outlined in the Nobody Left Outside (NLO) Service Design Checklist, engagement remains siloed and exclusionary [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. This disconnect risks undermining both legitimacy and uptake, particularly in marginalized communities. Despite strong policy rhetoric around co-design, practical guidance remains limited across EU and UK health systems, highlighting the need for operational tools that embed participation from the outset.\u003c/p\u003e\u003cp\u003eA key area of reflection emerging from this study concerns the characteristics of HEFs themselves. Rather than viewing the design of frameworks as neutral or static, participants engaged critically with how language and terminology can enhance, and sometimes limit, equity implementation. In line with previous critiques of public health discourse, many expressed that the technical vocabulary commonly used in HEFs creates barriers to understanding and uptake, particularly when terms such as \u0026ldquo;equity\u0026rdquo; and \u0026ldquo;vulnerability\u0026rdquo; are inconsistently applied or poorly defined [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Our findings indicate that language must evolve with communities and reflect person-first values, e.g., \u0026ldquo;people who use substances\u0026rdquo; rather than \u0026ldquo;drug users,\u0026rdquo; in line with current recommendations from international organizations, including UNAIDS Terminology Guidelines [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. Discussions also underscored the need for frameworks to evolve in tandem with communities, adopting terminology that reflects person-first values, such as \u0026ldquo;person living with HIV.\u0026rdquo; Such shifts were seen as essential to dismantling stigma and affirming the dignity of those most affected by inequities. In parallel, data was not merely discussed as a technical input but as a political and ethical component of implementation. The absence of disaggregated, rights-based data by race, migration status, disability, and rurality was viewed as a core obstacle to evidence-based planning and political accountability. These findings reflect broader critiques of health systems that fail to adequately track the populations they serve.\u003c/p\u003e\u003cp\u003eAt the systems level, our findings reaffirm the need for strong political will and coordinated cross-sectoral action. Participants noted that HEFs cannot succeed in a vacuum, and their implementation is often obstructed by siloed policymaking, short-termism, and policy fragmentation across EU member states and the UK. Consistent with other HEIF-based evaluations, cross-border learning and multi-sector collaboration were seen as necessary conditions for impact but are currently under-resourced and poorly structured [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. The analysis also highlights a growing gap between EU equity discourse and national-level action. There was a clear call for binding obligations and secure, long-term funding streams that include civil society and third-sector organizations in both planning, delivery and evaluation. Many of the challenges identified were linked to deeper societal structures, patriarchy, colonialism, and capitalism, which shape who holds power and whose needs are prioritized. Without addressing these systems, HEFs risk becoming superficial or technocratic. Lobbying by corporate actors, especially in the food and pharmaceutical sectors, was raised as a direct barrier to reform, echoing long-standing critiques of policy capture and the political economy of health. These reflections point to the need for equity frameworks to connect not only with service-level reforms but also with broader justice-based movements that address structural violence and promote systemic change [\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese findings point to concrete actions with direct implications for both policymaking and the development of more effective health equity frameworks across the EU and the UK. A key priority is the local adaptation of HEFs: technical and rigid formats often limit their practical implementation, while simplified, co-created tools that reflect national and community realities are more likely to be implemented effectively. Similarly, comprehensive and mandatory training on equity, extending beyond clinicians to include administrative and frontline staff, is essential to embed equity across all levels of the health system. Embedding lived experience throughout the design, implementation, and evaluation of frameworks, supported by formal tools such as the NLO Checklist, can enhance legitimacy and responsiveness. Communication practices also have clear policy implications: person-first, accessible language that evolves with community input is necessary to reduce stigma and ensure clarity, with terms such as \u0026ldquo;vulnerability\u0026rdquo; requiring critical re-examination. At the organizational level, policy reforms should support the structural integration of equity into budgeting processes, leadership responsibilities, and routine operations rather than treating it as a parallel agenda. Investments in disaggregated, rights-based data systems and digital tools are equally important to enable monitoring, transparency, and adaptation. Crucially, these recommendations highlight the need for stronger EU leadership, legal mandates, and sustained funding to overcome fragmented national approaches and support coordinated, cross-sectoral governance for stronger leadership in EU and UK public health systems. Without addressing the structural systems\u0026mdash;colonialism, capitalism, patriarchy\u0026mdash;that continue to shape inequities in health, HEFs risk underestimating the need for an intersectional and structural approach. Future frameworks in the EU and UK must be aligned with broader justice-based movements if they are to fulfill their transformative potential.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study acknowledges several methodological limitations. First, the use of pre-existing theory, particularly the HEIF while valuable for structured analysis, may introduce confirmation bias by favouring data that aligns with the framework rather than challenging it [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Additionally, having pre-existing categories might have biased the way respondents felt about a certain topic (tendency to please the researcher) and the overuse of theory could lead to \u0026ldquo;blindness\u0026rdquo; of contextual, nuanced factors. These limitations are \u0026ldquo;related to neutrality or confirmability of trustworthiness as the parallel concept to objectivity\u0026rdquo; [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Second, while semi-structured interviews facilitated depth and flexibility, the use of predefined categories may have inadvertently shaped participant responses, introducing social desirability bias\u0026mdash;where respondents may align their answers to perceived researcher expectations. This dynamic can restrict authenticity, especially in politically or ethically sensitive discussions on health equity. Third, the mixed convenience and purposive sampling approach, while pragmatic and targeted, may have excluded voices from stakeholders less embedded in formal networks, such as grassroots organizers or individuals from non-English-speaking communities, despite multilingual eligibility criteria. This could limit the inclusiveness of perspectives and risk overrepresenting institutional or technocratic viewpoints.\u003c/p\u003e\u003cp\u003eFourth, while this research leveraged diverse recruitment strategies and triangulated stakeholder groups, interviews were limited to a relatively small sample (n\u0026thinsp;=\u0026thinsp;18), and data collection was restricted to a specific time frame. These constraints affect the generalizability and temporal relevance of findings. However, saturation was reached, and participants represented a broad cross-section of EU and UK policymakers, thus supporting thematic robustness [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]. The inclusion of stakeholder perspectives from multiple EU and UK member states strengthens the relevance and applicability of the findings across diverse settings, supporting their potential transferability beyond the immediate cases examined [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Qualitative research is inherently interpretative, and while steps were taken to mitigate bias, including inter-rater reliability checks, reflexive journaling, and member validation, researcher positionality may still have influenced data interpretation and thematic emphasis [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Yet, a limitation of this study is that full consensus coding with a co-researcher was not employed. Although inter-rater reliability checks were performed on a subset of transcripts to enhance coding consistency, the absence of full co-coding and consensus discussions may have introduced researcher bias in data interpretation. Future studies could strengthen rigour by employing a team-based coding approach with consensus meetings throughout the analytic process.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the persistent gaps between health equity commitments and their implementation across the EU and UK. HEFs often lack cultural relevance, operational clarity, and meaningful community engagement. To address these gaps, HEFs must be co-designed with affected communities, adapted to local contexts, and embedded into routine practice through mandatory, cross-sector training and simplified tools. Stronger political will, rights-based data systems, and long-term EU investment are essential to support sustained, inclusive action. Prioritizing equity as a structural mandate, not an optional add-on, can help translate HEFs into tangible outcomes that reduce disparities and promote justice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEuropean Union\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFHML\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFaculty of Health, Medicine and Life Sciences\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGLEPH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGovernance and Leadership in European Public Health\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHEF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth Equity Framework\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHEIF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth Equity Implementation Framework\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHiAP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth in All Policies\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eImplementation Science\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eImplementation Research\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eJAHEE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eJoint Action Health Equity Europe\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLGBTQI+\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex, and others\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNLO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNobody Left Outside\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSES\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSocioeconomic Status\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003cp\u003eEthical approval for this study was obtained from the Maastricht University, Faculty of Health, Medicine and Life Sciences Research Ethics Committee (FHML-REC 738). All participants provided informed consent before participating in the interviews, signing the Ethics form. Ethical procedures followed the EU General Data Protection Regulation (GDPR) and included secure data handling, anonymization, voluntary participation, and offering participants the option to review their interview transcripts.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003cp\u003eParticipants were informed that the anonymized findings would be published in a peer-reviewed journal. Explicit consent for the publication of anonymized quotes and insights was obtained from each participant during the informed consent process.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis research was conducted as part of a master\u0026rsquo;s thesis in the Governance and Leadership in European Public Health (GLEPH) programme at Maastricht University. No external funding was received for the conduct, analysis, or publication of this research. Funding fees for publication were covered by Public Health Wales, supporting Mr. Marco Barracchia, during his internship at the Policy \u0026amp; International Health Directorate.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMarco Barracchia conceptualized and designed the study, developed the interview guide, conducted all interviews, led data coding and thematic analysis, and drafted the manuscript. Dr. Katarzyna Czabanowska provided strategic input on study design and methodology, contributed to the development of the methodological framework, and critically revised the manuscript. Omer Faruk, Jo Peden, and Daniel Jones contributed substantially to study conception, contextual framing of health equity frameworks, and refinement of the interview guide, and provided iterative feedback throughout the analytic process. James Allen contributed to participant recruitment, refinement of the policy analysis, interpretation of findings, and revision of the manuscript. Dr. Milena Pavlova contributed to validation of results, methodological rigour, and critical review of the manuscript. All authors read and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe author extends sincere thanks to the study participants for sharing their valuable insights and lived experiences. Appreciation is also extended to Public Health Wales colleagues\u0026rsquo; for their support in participant recruitment and co-development of the interview tools. The author thanks the academic and administrative staff at Maastricht University, particularly within the GLEPH program, for their guidance and encouragement throughout the research process.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to confidentiality agreements with the participants but are available from the corresponding author on reasonable request and subject to ethical approval. Experts interviewed in this study are easily identifiable, which is the reason for excluding some demographic information in the Results section. However, the dataset supporting the conclusions of this article is included within the article and its additional files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Health equity and its determinants. 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Qual Health Res. 2001;11:522\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Health Equity, Health Equity Implementation Framework, Implementation Science, EU, UK, Coproduction, Health Inequality","lastPublishedDoi":"10.21203/rs.3.rs-7494799/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7494799/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eDespite growing policy commitments to health equity across the European Union (EU) and United Kingdom (UK), the implementation of Health Equity Frameworks (HEFs) remains inconsistent and fragmented. This study investigates how policymakers understand and apply HEFs in practice and identifies the barriers and facilitators shaping their implementation within multi-level health governance systems.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eEighteen semi-structured interviews were conducted with high-level stakeholders from EU institutions, national public health agencies, and Non-governmental organizations (NGOs) engaged in health equity work. Using a directed content analysis informed by the Health Equity Implementation Framework, data were coded across seven domains: innovation characteristics, clinical encounters, patient and community factors, inner context, outer context, societal context, and culturally relevant factors of recipients.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe participants consistently reported gaps between equity goals and reality. HEFs were often perceived as overly theoretical, Western-centric, and disconnected from the lived realities of marginalized communities, including migrants, LGBTQI\u0026thinsp;+\u0026thinsp;populations, and racialized groups. Barriers included institutional inertia, fragmented governance, lack of equity training across all levels, lack of trans-disciplinarity, inadequate data, and minimal community engagement. Facilitators included co-design with communities, plain-language frameworks, mandatory cross-sector training, integration of lived experience, inclusion of administration staff in health equity training, and stronger funding and accountability mechanisms. Participants emphasized the importance of political will, culturally competent care, and intersectionality in addressing intersecting forms of exclusion.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eFindings highlight that for HEFs to be effective, they must be adaptable, inclusive, and operationalized across all system levels. Recommendations include embedding lived experience in framework design, simplifying language, investing in equity-driven data systems, and mandating cross-sectoral collaboration. A shift towards participatory, rights-based implementation, grounded in structural awareness and long-term political commitment, is essential to translate health equity frameworks into impactful outcomes.\u003c/p\u003e","manuscriptTitle":"“You don’t do it for them, you do it with them” Policymaker Perspectives on Implementing Health Equity Frameworks across the European Union and United Kingdom","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-11 11:59:32","doi":"10.21203/rs.3.rs-7494799/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aef4f0cd-6ec0-4697-b86a-9956c2ce9681","owner":[],"postedDate":"September 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-18T06:39:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-11 11:59:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7494799","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7494799","identity":"rs-7494799","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}