A Qualitative Exploration of Barriers and Enablers to Health Equity Competencies in Clinical Practice: Application of the Health Equity Implementation Framework

Abstract

Introduction:

Health equity is essential to high-quality care, yet implementation in clinical settings remains challenging. The New York State AIDS Institute developed Health Equity Competencies to guide equity-focused care.

Objective:

This study examined barriers and enablers to implement these competencies using the Health Equity Implementation Framework (HEIF).

Methods:

We conducted semi-structured interviews and focus groups with 33 participants, including physicians (39%), residents (24%), administrators (24%), medical students (18%), social workers (6%), and patients (12%). Thematic analysis, guided by the HEIF, organized findings across 5 domains: innovation, clinical encounters, patient/provider factors, inner and outer context, and societal influence.

Results:

Enablers included provider commitment, culturally responsive care, and community outreach. Barriers included limited institutional policies, insufficient bias training, inadequate resources for addressing social needs, and fragmented engagement. The most critical challenges emerged in the outer context (eg, structural barriers to care) and inner context (eg, organizational gaps).

Conclusions:

Aligning provider efforts with institutional support is essential. Structured training, equity-oriented policies, and sustained community partnerships are key to operationalizing equity in clinical practice.

Keywords

health equity clinical practice implementation science health equity implementation framework qualitative research health equity competencies healthcare delivery organizational change equity-focused care

Introduction

The seminal report by the Institute of Medicine (IOM), “Crossing the Quality Chasm,” was a clarion call to healthcare systems to take strategic steps toward improving healthcare quality. The IOM report describes quality care as healthcare that is safe, effective, patient-centered, timely, efficient, and equitable. In this context, equitable care is defined as care that adheres to high-quality standards, regardless of patients’ gender, ethnicity, geography, or socioeconomic status.¹ Equitable care also demands attention to the social and structural context in which patients live. In the absence of this factor, efforts to promote equitable care may not yield optimal health outcomes, thereby limiting health equity. Central to health equity is the notion that every individual can achieve their highest level of health, irrespective of social identity, economic circumstances, or demographic factors.² Efforts to promote health equity are paramount to improving the quality of care. As stated by the Institute for Healthcare Improvement, “there is no quality without equity.”³

Despite increasing awareness, health systems may still encounter challenges in translating health equity principles into clinical practice.^4,5 Barriers to achieving health equity operate at individual, organizational, and systemic levels.^6,7 At the individual level, providers may lack training in culturally responsive care, which can lead to implicit biases and poor patient-provider interactions.⁸ At the organizational level, competing priorities and resource constraints may hamper equity-focused initiatives.⁹ Systemic barriers, such as policy limitations and inequitable allocation of social resources, are additional barriers to advancing equitable care practices and health equity. While national frameworks such as the Institute of Medicine’s Health in All Policies and the Institute for Healthcare Improvement’s (IHI) equity initiatives have advanced institutional commitments to health equity, they often lack operational guidance on how clinicians can integrate equity into day-to-day practice.¹⁰ New frameworks and targeted competencies are needed to guide healthcare institutions in prioritizing, adapting, and implementing health equity constructs into clinical practice.

The Health Equity Implementation Framework (HEIF) offers a valuable multilevel model for understanding and addressing barriers to equitable care by incorporating inner and outer contextual factors, patient and provider influences, and broader societal determinants.¹¹ However, while HEIF powerfully guides implementation processes, it does not delineate specific, observable competencies required of healthcare professionals to translate equity principles into clinical behavior. For example, many institutions have adopted social risk screening tools, but often lack workflows or resource pathways to act on identified needs, highlighting a gap between structural awareness and clinical application.

To complement HEIF’s structural approach, the New York State AIDS Institute developed the Health Equity Competencies for Health Care Providers in 2021. Initially designed for HIV services, these competencies have since been expanded to general healthcare settings. Developed through a collaborative process involving clinicians, educators, public health professionals, and community representatives, the competencies articulate 4 core behavioral domains: (1) Address Social Determinants of Health (SDOH), (2) Engage Actively with Communities and Institutions, (3) Employ Person-Centered Models of Care, and (4) Avoid Bias and Provide Affirming Services.¹²

Together, HEIF and the Health Equity Competencies offer a comprehensive framework: HEIF provides a conceptual foundation for analyzing equity implementation, while the competencies offer concrete actions and expectations for healthcare institutions. This study uses both frameworks to explore how equity competencies are understood and enacted in real-world practice, particularly within institutions serving historically marginalized populations. While the development of the Health Equity Competencies (HEC) informed the conceptual framework and guided data collection, this paper focuses on analyzing the barriers and enablers to implementing equity in healthcare practice. The aim of this study was threefold: (1) to assess clinician-level competencies in addressing health equity challenges; (2) to examine organizational factors influencing readiness for equity-focused care, including resource availability and leadership support; and (3) to identify barriers and enablers to implementing health equity practices in clinical settings.

Methods

Study Design and Health Equity Competencies

This qualitative study employed a thematic analysis approach, guided by the Health Equity Implementation Framework (HEIF), to explore barriers and enablers to implementing health equity in clinical settings. The study focused on how healthcare professionals interpret and apply the New York State AIDS Institute Health Equity Competencies, which remained constant throughout the study and served as a guiding framework for data collection, coding, and analysis.^13,14 While these competencies served as deductive anchors, our analytic approach allowed for the emergence of inductively generated themes that contextualized these competencies in clinical and institutional practice.

Participants and Recruitment

Participants were recruited through hospital clinics, staff meetings, and targeted email outreach at a large academic medical center and affiliated sites. Purposeful sampling was used to ensure diverse representation across clinical roles, levels of seniority, and involvement in health equity initiatives. Eligible participants included hospital faculty, residents, medical students, social workers, patients, and institutional leaders who had direct experience with patient care, policy implementation, or community engagement.

All participants provided informed consent. A total of 33 participants were included: 39% were physicians or administrators, 24% were residents, 18% were medical students, 12% were patients, and 18% were clinical social workers. See Table 1 for the demographics of the participants.

Table 1.

Participant Characteristics by Interview Format.

Interview format	Participant characteristic	Overall, N = 33 (%)
Focus group	Medical student	6 (18)
	Patient	4 (12)
	Resident	8 (24)
	Social worker	2 (6)
Individual	Key informants (eg, department leaders, hospital administrators)	13 (39)

Data Collection

Data was collected through semi-structured interviews and focus groups, each approximately 75 min in length. Sessions were conducted in-person or via secure video conferencing, based on participant preference.

To promote peer-based dialogue, separate focus groups were conducted with medical students, residents, and social workers. Individual interviews were conducted with physicians and institutional leaders due to scheduling considerations and to ensure confidentiality in discussing organizational practices.

Interview Guide Development

A semi-structured moderator guide was developed to align with 4 core Health Equity Competencies: (1) Address Social Determinants of Health (SDOH), (2) Engage Actively with Communities and Institutions, (3) Employ Person-Centered Models of Care, and (4) Avoid Bias and Provide Affirming Services. Each competency was mapped to the corresponding interview questions to ensure alignment with the study framework.¹⁵ For example, questions on patient referrals and access to services were tied to SDOH; inquiries about collaboration with community organizations were linked to community engagement; individualized care practices reflected person-centered care; and questions on discrimination or cultural sensitivity aligned with bias and affirming services. Sample questions included:

Understanding of Health Equity: “How would you define health equity? Are there any existing policies and procedures that promote health equity at [institution]? What would you like to see improved?”

SDOH: “How do you define social determinants of health? Which factors affect your patients or community the most, and why?”

Community Engagement: “How have you sought to engage with the community in your clinical practice? What does community engagement mean to you?”

Tailored probes were included to elicit richer responses and explore emergent themes. All sessions were audio-recorded and transcribed verbatim.

Data Analysis and Trustworthiness

Thematic analysis was conducted using Dedoose,¹⁶ a mixed-methods software platform. A hybrid coding approach—both deductive (based on the 4 competencies) and inductive (emergent themes)—guided the development of a comprehensive codebook. Intercoder agreement was established through consensus discussion and iterative refinement. Two trained members of the research team independently coded a subset of transcripts and met regularly to reconcile discrepancies, refine the codebook, and align interpretations. This consensus-based approach ensured consistency in coding and supported the trustworthiness of the findings. The Health Equity Implementation Framework (HEIF) was used to organize themes across 5 contextual domains: Innovation, Clinical Encounter, Patient and Provider Factors, Inner and Outer Context, and Societal Influence.

Although statistical measures such as Cohen’s kappa were not calculated, consistent with qualitative research traditions that emphasize depth over qualification, analytic rigor was maintained through double coding with consensus reconciliation, regular analytic team meetings, peer debriefings with a senior qualitative researcher, triangulation across participant roles, and an audit trail maintained in Dedoose. This strategy consists of best practices in qualitative research where nuanced interpretation and contextual depth are prioritized over quantification of agreement.¹⁷ Although member checking was not feasible, triangulation of participant roles and iterative team discussions supported thematic saturation and reflexivity.

Ethical Considerations

This study was approved by the Institutional Review Board to ensure ethical conduct.

Participants were informed that participation was voluntary and confidential. No participants disclosed any financial or professional conflicts of interest, and none were required to do so as part of the study protocol.

Results

A thematic analysis guided by the Health Equity Implementation Framework (HEIF) was conducted to explore multilevel factors influencing health equity, from individual knowledge to institutional policy.¹¹ This analysis yielded 5 key themes that shape how health equity is understood and enacted in clinical and organizational contexts. These themes include: (1) providers’ understanding of health equity, health equity competencies; and awareness and implementation of institutional health policies; (2) the role of social determinants of health (SDOH); (3) community engagement; (4) person-centered care; and (5) implicit bias. Together, these themes reflect both the strengths and challenges in advancing equitable care, illustrating how health equity is understood, implemented, and challenged within clinical settings.

Theme 1: Providers’ Understanding of Health Equity

The interviews began by asking participants to share their understanding of the term “health equity.” In general, health equity was described as a need to ensure fair access to care, recognizing that individuals require different levels of support to achieve the same health outcomes. They expressed a strong personal investment in health equity, with motivations ranging from a desire to expand their knowledge to an active commitment to improving equity within the healthcare institution. Participants often made the distinction between equality and equity. Examples of responses included:

My understanding is that equity is a little different than equality, because with equality, then everyone, let’s say, would get the same resources. With equity, you may have someone that may need a little more resource in order to be at the same level as everyone else. (Medical student)

All things can be equal, but it’s not necessarily like equity, if that makes sense. So, for example, you have access to healthcare. But then you might need a language interpreter. (Patient Representative Officer)

I am interested in health equity as a general value of mine. I am concerned about individuals who face challenges in their living environment and in their general life, whether it be their lifestyle, their socioeconomic status, their general behaviors/habits, disposition, and past life as a child growing up in certain cultures or environments. (Physician)

Patients approached health equity from a more personal and experiential perspective, often linking it to their lived experiences with the healthcare system and broader social conditions. While providers focused on systemic interventions, patients framed health equity in terms of how social and environmental factors directly impacted their health.

One patient shared how their poor housing conditions exacerbated existing health issues, leading to an emergency room visit:

There was mold in my apartment, and it made my breathing problems worse. I ended up in the emergency room. But this isn’t just about my apartment—it’s about housing insecurity and the environment we live in.

This response highlights that patient perceive health equity as extending beyond clinical care, encompassing housing, environmental safety, and socioeconomic stability. Patients viewed health equity as addressing the root causes of poor health, rather than merely improving access to medical services.

The discussion then focused specifically on the Health Equity Competencies, with consensus emerging that these competencies were relevant to addressing health equity.

One provider expressed a strong desire to engage more deeply with these competencies, stating:

I would like to know more about the Health Equity Competencies. As a matter of fact, I would like to become a part of an equity committee.

A nursing clinician and professor further emphasized the moral imperative of equitable care, highlighting a deep professional commitment to underserved populations:

I am concerned about those individuals who are at risk, and I want to make sure that I do everything possible to see that they receive good healthcare, quality healthcare is when someone does not face any of those same risks.

Together, these perspectives reflect not only the perceived value of the competencies but also a readiness among some healthcare professionals to lead efforts that advance equity within their institutions.

Leaders who were interviewed expressed a strong commitment to supporting health equity initiatives and recognized the need for policies and better centralization. The following response from a department head demonstrated the need to engage the institution in health equity practices through institutional policies.

I think the general policy is that once you are here, you will be treated with the highest respect, and with the proper treatment, and give you all the resources and support that you need while you are in house with us. I don’t know by heart what by word or what the policy is.

Overall, the voices of institutional leaders reflected both a strong commitment to advancing health equity and a recognition of the structural limitations that constrain consistent implementation. While their intent to foster respectful, inclusive care environments was evident, there was also a noted lack of clarity and specificity regarding existing institutional policies. Aligned with the HEIF domain of Innovation and Inner Setting, this theme explores how providers and patients define health equity and understand institutional policies designed to support it. While providers often articulated health equity as ensuring tailored resources for equal health outcomes, patients emphasized personal lived experiences and systemic barriers, such as housing and environmental conditions. Notably, leadership demonstrated commitment to health equity, yet revealed limited awareness of concrete institutional policies, suggesting a disconnect between intent and policy implementation. This gap reveals barriers in the organizational context and highlights the need for policy clarity and communication.

Participants were then asked to reflect on each of the Health Equity Competencies and identify perceived barriers and enablers to implementing them in clinical practice. These responses laid the groundwork for the subsequent themes, beginning with structural-level influences such as Social Determinants of Health (SDOH), which many participants cited as central to understanding and advancing equity in care delivery.

Theme 2: Addressing Social Determinants of Health (SDOH)

Social determinants of health (SDOH) refer to the environmental, economic, and social conditions in which individuals are born, grow, work, live, and age. These determinants play a critical role in shaping health outcomes and healthcare access, particularly for marginalized communities. Many healthcare providers exhibited a strong awareness of the role SDOH play in shaping patient health outcomes.

As demonstrated below, respondents identified SDOH such as insurance status, language barriers, educational attainment, and systemic discrimination as key drivers of patients’ well-being. A resident reflected on how housing insecurity emerges in patient interactions, highlighting an understanding that such concerns are integral to health.

We have homeless people or they’re about to be kicked out of their apartment. I’ve had calls about that, and I would tell the patients. Alright, I’ll give you the phone number for human resources. Let’s see what they can do to help them.

Similarly, a social worker recognized the prevalence of food insecurity and family strain among the patient population, pointing to broader social pressures affecting their well-being:

Food insecurity, I find that I would have to look online, see where the pantries are to help them get free food. Family issues. You know, we have patients—they have children. They’re struggling to support, too.

A strength of the organization was the dedication of the staff and providers to care for patients. They described acts of compassion, empathy, and generosity. However, this highlighted the need for external resources. The following are examples of responses, mostly from the participants who identified as social workers:

We spend a lot of our money to make sure our patients get what they need. Transportation. Food. Clothes. Like this is what we pay for out of our own pocket a lot of times.

If the patient needs to go home, they don’t have transportation benefit, car service, Uber. You should see my Uber bill.

Then they need to leave, ‘ So you go out, and you buy. And this is the thing that we do in our department. It comes out of our pocket.

We’ve been doing social determinants of health—that’s why we became social workers. So, we’ve been doing this all along, addressing every need that comes along. Food, housing, transport.

These quotes reflect how, in the absence of formal institutional support, individuals often rely on personal funds to meet patients’ basic needs, highlighting an unsustainable approach to addressing SDOH. This theme intersects with HEIF domains of Outer Context and Societal Influence. Participants identified structural barriers—including food insecurity, housing instability, and inadequate transportation—that disproportionately impact marginalized populations. Social workers in particular voiced frustration at having to finance patient needs personally, reflecting institutional resource gaps. These findings underscore how broader societal inequities cascade into clinical settings, necessitating institutional investment in cross-sector collaborations to address upstream determinants of health.

Theme 3: Engaging With Communities and Institutions

Community engagement is a critical component of health equity, requiring healthcare providers to extend their efforts beyond clinical settings and into the communities they serve. When prompted to discuss community engagement, several participants described their involvement in community events and educational outreach initiatives, often collaborating with faith-based organizations, schools, and local community groups. These efforts were viewed as essential enablers for building trust and increasing health awareness in underserved populations. Providers were engaged in community activities to address patients’ needs.

Participants emphasized that communities not only wanted health information presented in a familiar language but also wanted to focus on issues that directly affected them. As 1 nurse educator shared, “I went to a Haitian Creole-speaking church on a Sunday, and they wanted to talk about hypertension and diabetes.”

This engagement was perceived as particularly impactful because patients were more receptive to health information when delivered by someone from their own cultural background: “When they see someone from their culture, they trust you automatically.”

Despite these positive initiatives, providers identified several barriers to meaningful community engagement, particularly the low participation rates among community members. One participant, a physician, questioned the effectiveness of these outreach efforts, noting “Will people take advantage of this? Not really.”

This observation suggests that even when providers make efforts to engage the community, participation may remain limited, possibly due to mistrust, lack of awareness, logistical barriers, or competing priorities among residents. Another significant challenge identified was the need for wider dissemination of outreach. Many initiatives, such as health fairs and educational workshops, were reported to be driven by individual provider efforts and would benefit from coordinated institutional strategies.

A nursing staff reflected on the ad-hoc nature of these programs, particularly within emergency medicine departments: “Outreach here is limited. . . it sits with individual people.” This statement underscores the fragmented nature of outreach efforts, which are often siloed and unsustainable without institutional investment. Mapped to the HEIF domain of Outer Context and Societal Influence, this theme highlights community engagement as both a facilitator and a challenge to advancing equity. Participants described positive outreach efforts, particularly through cultural and faith-based channels. However, engagement was often fragmented and reliant on individual initiative rather than institutional strategy. Limited participation from community members and a lack of systematic planning emerged as barriers, underscoring the need for sustained institutional support for community collaboration.

Theme 4: Employing a Person-Centered Model of Care

Patient-centered care was viewed as an approach that centers on the patient and their family, ensuring that healthcare is culturally and socially responsive in addition to being clinically effective. One provider highlighted the need to ensure inclusivity and respect for identity, recalling an interaction with a transgender patient who had been misgendered by hospital staff:

It’s important that we treat all patients with dignity and respect, and that means acknowledging their identity in a way that makes them feel safe.

Another provider illustrated the holistic nature of person-centered care by describing their efforts to assist a patient struggling to manage seizures due to insurance issues:

It’s not just about treating the symptoms—it’s about making sure patients have what they need outside the hospital to manage their conditions effectively.

Most agree that person-centered care prioritizes patient needs and avoids making assumptions. Some described integrating shared decision-making and trauma-informed care to ensure that patients feel empowered in their healthcare choices.

One participant, a hospital clinician, expressed this idea succinctly

We’re doing with them, not for them. Our sole purpose is to provide the information and empower them to make a decision.

This theme aligns with the HEIF domains of Clinical Encounter and Innovation. Providers expressed commitment to tailoring care to patients’ unique needs, advocating for shared decision-making and cultural humility. Patient perspectives affirmed this need, particularly among individuals with chronic or stigmatized conditions. The emphasis on dignity, individualized care, and inclusive communication reveals how equity is operationalized at the point of care.

Theme 5: Avoiding Bias and Providing Affirming Services

Building on prior themes related to person-centered care and the influence of social and structural conditions, participants identified implicit bias as a persistent barrier to equitable healthcare delivery. Patients described encounters in which they felt dismissed, disbelieved, or judged based on assumptions about their background or appearance. These experiences underscored the emotional and clinical consequences of bias in patient-provider interactions.

One patient with a documented history of heart disease shared an incident in which she felt her symptoms were not taken seriously by a physician:

I was in real pain, and they didn’t believe me. It was like they thought I was making it up, and it took so long to finally get the care I needed.

This account reflects how implicit bias can lead to delays in care and emotional harm, especially when patients sense that their concerns are being minimized or dismissed. Participants emphasized the need for providers to deliver affirming, respectful care that acknowledges patient identity and validates their health concerns. Several providers also acknowledged challenges in delivering affirming services and expressed a desire for more structured training on recognizing and addressing bias in clinical practice.

Participants acknowledge the need to avoid bias and provide affirming services. In discussing this topic, participants identified the need for training. Many providers reported relying on self-directed learning, such as attending conferences, reading independently, or seeking mentorship, rather than engaging in institutionally driven professional development programs. An administrator underscored the importance of systematic, structured training to enhance providers’ competencies and said:

There is a real opportunity here to develop educational programs that help providers understand social determinants of health, identify at-risk patients, and implement strategies to address barriers to care.

Participants described ongoing efforts to enhance training on inclusive care for all patients, as some may struggle with using appropriate pronouns. Another provider emphasized the need for bias training specifically tailored to vulnerable and stigmatized populations, such as LGBTQ+ individuals. One clinician noted: “Training has to be more than just a checkbox; it has to change how we practice.”

Further, a resident suggested that bias training should include real-life scenarios and visual examples to make it more impactful and practical:

It’s one thing to read about bias, but seeing real-life examples and understanding how it happens in practice would help providers recognize and address their biases better.

Therefore, while some training exists, participants desired more specific and ongoing training. Mapped to the HEIF domain of Patient and Provider Factors, this theme addresses implicit bias as a persistent barrier to equitable care. Participants acknowledged microaggressions, cultural insensitivity, and a lack of structured training as key concerns. While some pursued self-directed learning, most called for institutionalized, scenario-based training on bias and affirming care. This finding reflects a system-level need for professional development that supports reflexivity and improves provider-patient communication.

In summary, across themes, clear patterns emerged: a shared understanding of equity values, inconsistent implementation due to structural limitations, and a need for institutional infrastructure to support equity-driven practices. These multilevel dynamics reinforce the relevance of the HEIF as a lens for identifying and addressing barriers at multiple levels of the healthcare system (see Table 2).

Table 2.

Matrix of Emergent Themes Mapped to Health Equity Implementation Domains

Theme	HEIF domain(s)	Level	Key findings	Illustrative quotes
1. Providers’ Understanding of Health Equity and Competencies	Innovation; Patient and Provider Factors; and Inner Context	Individual and Organizational	Providers demonstrated conceptual clarity on equity, recognized its institutional relevance, and showed motivation to lead equity efforts.	“With equality, everyone gets the same resources. With equity. . . some may need more.” “I want to be on an equity committee.”
2. Social Determinants of Health (SDOH)	Outer Context; Patient and Provider Factors; and Societal Influence	Interpersonal and Societal	Participants highlighted how unmet social needs—housing, food, transportation—shape patient outcomes and require systemic attention.	“We spend a lot of our money to make sure our patients get what they need.” “That’s why we became social workers.”
3. Community Engagement	Outer Context; Societal Influence; and Innovation	Organizational and Community	Providers engaged communities through education and partnerships, yet cited low turnout and institutional disconnection as barriers.	“When they see someone from their culture, they trust you automatically.” “Will people take advantage? Not really.”
4. Person-Centered Care	Clinical Encounters and Patient and Provider Factors	Individual and Interpersonal	Emphasized dignity, identity, shared decision-making, and inclusive care practices that empower patients.	“We’re doing with them, not for them.” “Acknowledge their identity in a way that makes them feel safe.”
5. Implicit Bias and Affirming Services	Inner Context; Patient and Provider Factors; and Innovation	Individual and Organizational	Training on bias was seen as essential yet underdeveloped. Providers called for structured, scenario-based, and culturally relevant education.	“Training has to be more than a checkbox.” “Seeing real-life examples would help.”

Discussion

This study applies to the Health Equity Implementation Framework (HEIF) as a lens for identifying factors that enabled or posed barriers to implementation.¹¹ The HEIF identifies enablers and barriers across 5 domains (innovation, clinical encounters, patient and provider factors, inner context and outer context, and societal influence). In general, participants viewed the Health Equity Competencies as an innovation that was beneficial to advancing health equity (innovation).

Participants identified shared decision-making and inclusive care practices as key facilitators of patient-centered engagement within clinical encounters, highlighting their potential to strengthen provider-patient relationships and promote equity in care delivery.

Ensuring bias and stigma-free patient encounters was an essential factor for providers, and some requested additional training in this area (provider factor). Providers remarked on the cultural and linguistic diversity among their patients, which for some may be a potential barrier to patient engagement (provider factors and patient factors). Among hospital leaders, there was a strong consensus about the institution’s commitment to advancing health equity and the need for more explicit policies that institutionalized equity (inner context and outer context). Participants described the magnitude of social determinants in the patient population and relatively few external resources to respond to patients’ needs (societal influences). While participants frequently referenced the importance of social determinants of health (SDOH) in patient care, their responses largely reflected efforts to address individual social needs or risk factors—such as food insecurity, transportation challenges, or housing instability—rather than broader community-level determinants like neighborhood infrastructure, zoning policies, or income inequality. This distinction is essential in interpreting the scope of equity-oriented interventions described in this study.

As noted by Bravemen et al,¹⁸ addressing individual-level social risks involves tailoring care to meet a patient’s immediate social circumstances. In contrast, efforts to influence community-level SDOH require multi-sector collaboration and policy-level change. The emphasis by providers on patient-level needs in this study may reflect the limited institutional infrastructure and resource constraints that restrict their ability to engage in broader upstream action. Future initiatives should aim to integrate both levels of intervention—responding to individual needs while also contributing to structural changes that promote long-term health equity.

Consistent with prior reports, this study supports the idea that while many institutions value health equity in principle, they often struggle to translate these principles into standardized, sustainable practices.¹⁹ This study aimed to explore healthcare providers’ perspectives on incorporating health equity competencies into their clinical practice. Providers overwhelmingly recognized health equity as a critical component of quality care and emphasized the importance of person-centered approaches that integrate patient autonomy, shared decision-making, and cultural responsiveness. However, systemic barriers, including resource limitations and a lack of standardized implementation, often hinder the full realization of these approaches. At the same time, participants described several enablers, including individual provider commitment, community-based partnerships, and culturally responsive communication practices. Some also noted the potential for interprofessional collaboration and leadership to sustain equity work across clinical and organizational levels.

The distinction between individual and institutional responsibility for health equity implementation could be further expanded by examining comparative models such as interprofessional equity leadership teams, institutional equity champions, and the integration of equity into formal quality improvement structures. These models help ensure that individual provider efforts are supported by systemic investment and oversight.

Our finding on implicit bias underscores a broader call for equity training that impacts real-world behaviors and clinical decision-making, not just compliance. Additionally, recent literature supports this need, suggesting that while implicit bias training can improve awareness, the long-term impact on clinical behavior may depend on sustained, interactive approaches.²⁰

A related enabler identified by participants was interested in structural competency training; however, most such efforts were informal or self-directed. Longitudinal, scenario-based training that incorporates role-play, community voice, and ongoing mentorship may offer a more sustainable path forward.

A key insight from this study is the importance of distinguishing between individual providers’ engagement with health equity competencies and the institutional responsibilities required to support their implementation. While clinicians described the competencies in terms of their personal practice and learning needs, administrators more often discussed the structural requirements, such as policies and resource allocation, needed to facilitate widespread adoption. This distinction reflects the findings of Lie et al,²¹ who emphasize that provider training alone is insufficient without system-level investment and institutional support structures.^1,7 Similarly, Powell et al²² describe how effective implementation requires aligning individual behavior change with tailored organizational strategies.

Applying Powell et al’s²² implementation strategies to our findings offers actionable next steps. For example, audit and feedback mechanisms can be used to track equity-related performance; facilitation and equity champions can promote provider engagement and adaptation; and tailored educational meetings can strengthen knowledge around social determinants. These strategies help link identified barriers with evidence-based solutions.

Healthcare organizations are therefore critical in creating the conditions under which individual competencies can be applied and sustained, including the development of formal training programs, leadership support, and ongoing evaluation.^10,23 Recognizing these differentiated but complementary roles is essential to designing interventions that embed equity competencies into both clinical workflows and organizational infrastructure. Future implementation efforts should explicitly integrate these strategies to ensure both sustainability and advancement of system-wide equity. Concrete policy approaches may include establishing institutional equity dashboards, implementing performance-based incentives tied to health equity goals, and incorporating health equity metrics into accreditation or reimbursement frameworks.

Healthcare providers demonstrated a strong understanding of social determinants of health and their impact on patient outcomes; they often lacked the necessary institutional support to address these challenges systematically. Instead, providers frequently relied on personal initiative to bridge gaps in patient care, particularly for vulnerable populations. For example, providers described using their financial resources to assist patients with transportation, food, and other basic needs, highlighting the absence of a structured safety net within the healthcare system. This is indicative of compassion and empathy; however, it may be unsustainable and necessitate additional resources. These findings align with prior studies, which show that SDOH interventions improve patient outcomes but require institutional investment in social work integration, care coordination, and community partnerships.²⁴

Similarly, community engagement efforts to advance health equity largely depended on provider-driven initiatives rather than institutional commitment. Some participants cited partnerships with faith-based organizations and local health fairs as successful strategies; however, these efforts often lacked continuity, scalability, and sustained institutional support. Institutionalizing such efforts—through formal community liaison roles or standing advisory boards—may enhance sustainability and trust. Our findings align with prior research, demonstrating that institutionalizing community engagement, rather than relying on individual efforts, can lead to more effective and long-term interventions.²⁵ Without dedicated resources and formal structures, community engagement efforts risk being episodic rather than embedded into routine healthcare practices.

We also acknowledge that researcher reflexivity is an essential factor in qualitative research. Given that the research team included individuals with clinical and community engagement experience, positionality may have influenced interview dynamics and data interpretation. To mitigate bias, the team engaged in regular reflexive discussions during analysis and maintained an audit trail of analytic decisions. Nonetheless, social desirability bias is possible, particularly in interviews with administrators who may have emphasized institutional commitment more than actual practice. While participant triangulation helped mitigate this issue, future studies may benefit from using external interviewers or anonymous data collection methods to enhance candor further.

This study has several limitations. As a qualitative study conducted at a single academic institution, findings may not be generalizable to other healthcare settings.

Notably, while the study included healthcare providers, administrators, and staff, it did not include a sizeable or proportionate number of patient participants. As a result, the analysis may underrepresent how equity efforts are experienced from the patient perspective—an essential viewpoint in evaluating implementation at the point of care. Future research should prioritize the inclusion of patient voices alongside multi-stakeholder perspectives to provide a more comprehensive understanding of health equity implementation across clinical environments.

This study employed focus groups for medical students, residents, patients, and social workers, while individual interviews were conducted with hospital leaders and physicians. This methodological distinction was intentional and guided by both practical and conceptual considerations. Focus groups enabled dynamic interaction and collective reflection among healthcare professionals and support staff, which helped surface shared experiences and foster dialogue around sensitive topics, such as health equity and institutional support. In contrast, one-on-one interviews with senior staff and leadership allowed for more candid and individualized reflections on institutional policies and strategic decisions.

However, this variation in data collection methods may have introduced differences in depth, openness, or breadth of responses across participant groups. Focus groups may have encouraged consensus-building or limited disclosure due to group dynamics. At the same time, individual interviews may have offered more personal insights but lacked the interactive element that can prompt deeper exploration in group settings. As such, comparisons across groups should be interpreted with caution. Future research should explore the impact of organizational-level SDOH responses and test implementation interventions—such as integrated referral systems, co-location of services, or reimbursement for equity-promoting activities—to assess their feasibility and effectiveness in real-world clinical environments.

Conclusion

This qualitative study identified multilevel barriers and facilitators to implementing health equity competencies in clinical practice. Participants emphasized the importance of institutional alignment, structured training, clear policy, and meaningful community engagement in advancing equity-focused care. Organizational support emerged as a significant enabler in integrating equity practices into clinical workflows.

In addition to summarizing findings, this study offers actionable recommendations for health systems and policymakers. Institutions should consider implementing equity dashboards to monitor progress, embedding equity metrics into performance reviews, and developing incentives that reward equity-focused care delivery. Policies should promote the establishment of interprofessional leadership teams, formal roles for equity champions, and the maintenance of sustained community partnerships.

For researchers and implementation leaders, future directions should focus on testing structured interventions that address organizational-level responses to social determinants of health. Examples include integrated care coordination platforms, formal resource navigation systems, and the co-location of social services within clinical spaces. Evaluating the effectiveness, scalability, and sustainability of these models will be critical to operationalizing health equity as a standard of care.

This study contributes to the implementation of science literature by offering actionable recommendations for integrating health equity competencies across clinical settings. By aligning individual provider behaviors with institutional structures and investing in durable implementation strategies, health systems can transition from aspiration to action in their pursuit of equitable care.

Footnotes

Acknowledgements

We would like to acknowledge the hospital staff, physicians, residents, and students who participated in the interviews.

ORCID iDs

Margaret Salisu

Crystal Marquez

Aayushi Jha

Louise Square

Richard Cotroneo

Charles Gonzalez

Carla Boutin-Foster

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was made possible through funding from the New York State Department of Health (NYSDOH) AIDS Institute Fellowship in Health Equity Promotion program. Funding for faculty mentors was supported in part by a Health Resources and Service Administration grant(D34HP45719-02) and an National Institute for Minority Health grant(1 R25 MD017950-01). The funding source had no involvement in study design, data collection, analysis, or decision to submit the article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

Institute of Medicine Committee on Quality of Health Care in A. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press (US) Copyright 2001 by the National Academy of Sciences. All rights reserved.; 2001.

Braveman

Defining health equity. J Natl Med Assoc. 2022;114(6):593-600. doi:10.1016/j.jnma.2022.08.004

Feeley

There can be no quality without equity. Aust Health Rev. 2020;44(4):503. doi:10.1071/AHv44n4_ED1

Woolf

SH.

Progress in achieving health equity requires attention to root causes. Health Aff. 2017;36(6):984-991. doi:10.1377/hlthaff.2017.0197

Shelton

Hailemariam

Iwelunmor

Making the connection between health equity and sustainability. Front Public Health. 2023;11:1226175. doi:10.3389/fpubh.2023.1226175

Uehling

Hall-Clifford

Kinnard

Wimberly

Advancing equity in U.S. Hospital systems: employee understandings of health equity and steps for improvement. J Healthc Manag. 2023;68(5):342-355. doi:10.1097/jhm-d-22-00187

Browne

Varcoe

Wong

, et al. Closing the health equity gap: evidence-based strategies for primary health care organizations. Int J Equity Health. 2012;11(1):59. doi:10.1186/1475-9276-11-59

Hoyer

Dee

O’Leary

, et al. How do we define and measure health equity? The state of current practice and tools to advance health equity. J Public Health Manag Pract. 2022;28(5):570-577. doi:10.1097/phh.0000000000001603

Hardeman

Murphy

Karbeah

Kozhimannil

KB.

Naming institutionalized racism in the public health literature: a systematic literature review. Public Health Rep. 2018;133(3):240-249. doi:10.1177/0033354918760574

10.

National Academies of Sciences, Engineering, and Medicine. Integrating the Patient and Caregiver Voice into Serious Illness Care: Proceedings of a Workshop. National Academies Press; 2017. doi:10.17226/24802

11.

Woodward

Matthieu

Uchendu

Rogal

Kirchner

JE.

The health equity implementation framework: proposal and preliminary study of hepatitis C virus treatment. Implement Sci. 2019;14(1):26.

12.

NYSDOH AIDS Institute Health Equity Competencies Clinical Work Group. Health Equity Competencies for Health Care Providers. 2021. Accessed March, 2025. https://www.health.ny.gov/diseases/aids/ending_the_epidemic/docs/health_equity_providers.pdf

13.

Levandowski

Murphy

Silk

, et al. Sharing the details: implementing and evaluating the integration of New York State AIDS Institute Health Equity Competencies for health care providers into clinical training activities. Health Equity. 2023;7(1):555-561.

14.

Hsieh

H-F

Shannon

SE.

Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-1288.

15.

Braun

Clarke

. Using thematic analysis in psychology. Qual Res Psychol. 206;3(2):77-101.

16.

Huynh

Media Review: Qualitative and Mixed Methods Data Analysis Using Dedoose: A Practical Approach for Research Across the Social Sciences. Sage Publications; 2021.

17.

Tong

Sainsbury

Craig

Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-357.

18.

Braveman

Gottlieb

The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014;129(1_suppl2):19-31.

19.

Park

Frank

Likumahuwa-Ackman

, et al. Health equity and the Tripartite Mission: moving from academic health centers to academic–community health systems. Acad Med. 2019;94(9):1276-1282.

20.

Sukhera

Watling

Gonzalez

CM.

Implicit bias in health professions: from recognition to transformation. Acad Med. 2020;95(5):717-723.

21.

Lie

Lee-Rey

Gomez

Bereknyei

Braddock

CH.

Does cultural competency training of health professionals improve patient outcomes? A systematic review and proposed algorithm for future research. J Gen Intern Med. 2011;26(3):317-325. doi:10.1007/s11606-010-1529-0

22.

Powell

Beidas

Lewis

, et al. Methods to improve the selection and tailoring of implementation strategies. Implement Sci. 2017;12(1):145. doi:10.1186/s13012-017-0661-3

23.

Wyatt

Laderman

Botwinick

Mate

Whittington

. Achieving Health Equity: A Guide for Health Care Organizations. Institute for Healthcare Improvement; 2016. Accessed June 13, 2025. http://www.ihi.org/resources/Pages/IHIWhitePapers/Achieving-Health-Equity.aspx

24.

Robertson

Chernof

. Addressing Social Determinants: Scaling up Partnerships With Community-based Organization Networks. Health Affairs Forefront; 2020.

25.

Mujica

Day

Hinchliffe

Stanley

Bridges

AJ.

Protecting Racial Justice Advocates From the Harms of Institutional Betrayal at Predominantly White Institutions. ADVANCE Journal; 2025.