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Sewage sludge management is crucial for water utilities to move towards a circular valorisation of resources. The current literature focuses mainly on the technological aspects of sludge management strategies. However, the current discussion of these strategies does not consider possible pressures arising from the utilities' civil society stakeholders and from policymakers. To fill this gap, this paper develops a conceptual framework, based on the current literature, that identifies the utility's key decisions on sludge management strategies (valorisation route, overperformance and vertical integration), and links them to possible pressures arising from civil society and existing regulations. Subsequently, the study validates the framework through a multiple explanatory case study, investigating the empirical relevance of such pressures in six water utilities across Europe. The influence of citizens and municipalities is found to be crucial in the choice of sludge valorisation routes. Economic instruments, command and control instruments and, new to the literature, regulatory uncertainty are found to be key policy features influencing utilities' decisions on sludge management. The paper provides a first-of-its-kind investigation that highlights the mechanisms through which policymakers and civil society stakeholders shape utilities' sewage sludge management strategies. The results complement and extend existing theoretical knowledge on the role of institutional pressures in the implementation of sustainable environmental systems. • Stakeholders' influences on utilities' sludge management choices are conceptualised. • Policymakers and civil society influence utilities' sludge management choices. • Incentives, obligations, regulatory uncertainty shape sludge management choices. • Citizens and municipalities drive utilities' sludge management choices. • Utilities' characteristics moderate the impact of institutional influences on their choices. [ABSTRACT FROM AUTHOR]