feminist approach case study

• Open access
• Published: 03 August 2021

Feminism, gender medicine and beyond: a feminist analysis of "gender medicine"

• Ayelet Shai 1 , 2 ,
• Shahar Koffler 3 &
• Yael Hashiloni-Dolev 4  

International Journal for Equity in Health volume  20 , Article number:  177 ( 2021 ) Cite this article

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The feminist women’s health movement empowered women’s knowledge regarding their health and battled against paternalistic and oppressive practices within healthcare systems. Gender Medicine (GM) is a new discipline that studies the effect of sex/gender on general health. The international society for gender medicine (IGM) was embraced by the FDA and granted funds by the European Union to formulate policies for medical practice and research.

We conducted a review of IGM publications and policy statements in scientific journals and popular media. We found that while biological differences between men and women are emphasized, the impact of society on women is under- represented. The effect of gender-related violence, race, ethnic conflicts, poverty, immigration and discrimination on women’s health is seldom recognized. Contrary to feminist practice, GM is practiced by physicians and scientists, neglecting voices of other disciplines and of women themselves.

In this article we show that while GM may promote some aspects of women’s health, at the same time it reaffirms conservative positions on sex and gender that can serve to justify discrimination and disregard the impact of society on women’s lives and health. An alternative approach, that integrates feminist thinking and practices into medical science, practice and policies is likely to result in a deep and beneficiary change in women’s health worldwide.

Introduction

The women’s health movement, which emerged during the 1960s and 1970s along with the second wave of feminism, recognized the female body as the vessel that mediates male dominance. Feminists demanded improved healthcare and the elimination of sexism in healthcare systems. Activists fought to empower women’s knowledge, gain control over reproductive rights, and reclaim power from the paternalistic medical community [ 1 ]. They likewise battled against the oppression of women, manifest in the denial of access to abortions and contraceptives, prostitution, sexual violence, pornography, and beauty industry standards. Later, feminists criticized the medicalization and commercialization of reproduction and labor and the exploitation of underprivileged women in the reproductive industry [ 2 ].

Feminist thinkers coined the term “gender” to differentiate between biological and social aspects of being male or female and to emphasize the role of culture and society in the construction of human sexuality [ 3 ]. Later thought problematized the biological category of sex itself, pointing to it as a social construct no less than gender [ 4 ]. Moreover, recent scientific evidence reveals that it is impossible to separate sex and gender [ 5 , 6 ], and that the dichotomy of two sexes is ignoring a more complex biological and social reality [ 7 ].

The new discipline of gender medicine (GM) aspires to examine the influence of gender on general medical issues. It argues that modern medical knowledge is based on observations and trials conducted mainly on men and that this wrong should be righted to achieve medical knowledge better suited to women [ 8 ]. The International Society for Gender Medicine (IGM) was founded in 2006 and was embraced by the European Union and the FDA [ 9 ]. It is consulted by institutions such as the Israeli parliament [ 10 ] and professional societies, for example the European Federation of Internal Medicine [ 11 ]. The IGM was granted financial resources from the European Union to promote its cause [ 12 ] and holds international conferences. Recently, medical schools introduced GM into their curricula. Since many consider the IGM to be representative of women’s health interests, it is vital to assess its views and actions and their implications for women [ 13 ]. Moreover, the recognition of GM as a discipline and its endorsement by the professional milieu is an opportunity to assess the attitude of the bio-medical world to feminist thinking and criticism. Thus, our goal was to analyze GM from a feminist perspective.

For this purpose, we reviewed scientific publications by past and present officials of IGM and of the Israeli Society for Gender and Sex Conscious Medicine (ISGSCM), listed on their websites, as well as their public appearances and press interviews. The scientific literature review included 27 articles concerning sex/gender-related issues published from 2010 until May 2020 in journals with an impact factor of 4 or more or a rank of 40 or less. In addition, we reviewed the report of the European Gender Medicine Network (EUGENMED) [ 12 ], an extensive project held between 2013 and 2015, that aimed to summarize the scientific data on gender and medicine and formulate recommendation for future policies. The popular media literature review included 24 relevant interviews and articles that were retrieved by searching the internet for entries containing the names of the IGM and the ISGSCM officials and reviewing their content. Interviews and articles in English and Hebrew, containing discussions on sex/gender and medicine, were included. Popular media publications were included in the analysis because GM has an explicit political agenda which it aims to promote also in popular venues.

Our study builds on the Foucauldian analysis of knowledge looking into the relationship between discourse and power, through the lens of the discourse of professional disciplines, in order to study the boundaries of thought used in a given time and discipline [ 14 ]. Thus, we analyzed the studied texts through the lens of power/knowledge relationships, ideology, and inequality. We formed two integrated files, one consisting of medical publications, the second of texts from the media. The texts were analyzed using a qualitative analysis method. Main themes concerning sex/gender and medicine were extracted from the texts inductively [ 15 ]. In addition, in dialog with themes in the feminist literature, we searched for what is missing in the discussion, in a deductive manner. The first two authors of the study who are MD’s read and discussed in several rounds the first medical file, identifying themes, and matching them with the relevant literature. The second file was analyzed by the third author, who is a social scientist. As a second step agreements were reached between all authors to prevent the potential bias of a single researcher and using inter-rater reliability to increase the validity of the results.

We hereby critically assess these publications in the context of current feminist thinking, noting both the topics discussed and those that were overlooked, or only seldom mentioned. After presenting our findings we discuss their implications.

Analysis of GM works

The scientific articles we reviewed focus on several subjects: Seventeen articles focused on the association between sex/gender, risk of disease and response to therapy, mainly in the field of cardiovascular diseases and related disorders [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ]. Two articles studied the influence of sex/gender on treatment decisions and care plans [ 33 , 34 ]; 5 articles focused on associations between sex/gender and the human brain, cognition, and mood [ 25 , 35 , 36 , 37 , 38 ] ; 2 dealt with the effect of sex/gender on working conditions and promotion in healthcare [ 39 , 40 ], 2 focused on sex/gender in medical education [ 41 , 42 ] and 1 focused on sex in preclinical research [ 43 ]. The articles we reviewed are summarized in Table  1 . The EUGENMED project summary reported on 5 working fields: 1. Sex/gender, risk of disease and treatment outcomes in cardiovascular medicine, pulmonary medicine, diabetes mellitus and psychiatry (depression). 2. Sex/gender and public health, focusing on risk factors for non-communicable diseases 3. Sex/gender in basic research. 4. Sex/gender in medical education. 5. Sex/gender and pharmacology, clinical trials and pharmaceutical regulation [ 12 ]. Each summary of a working field contained a detailed review of scientific literature and advocacy for future actions.

In the following paragraphs, we discuss the reviewed medical and popular literature according to topics raised by feminist writings on sex/gender in health/medicine.

Is it possible to separate the effect of sex and gender on health?

Although it uses the word “gender”, GM focuses mostly on biological sex, stressing biological differences between the sexes in physiological and pathological conditions. However, this division ignores human complexity and the criticism of determinist models of sex differences highlighted by feminist thinkers since the 1990s [ 3 ] and subordinates the critical concept of gender to the biological concept of sex.

Many behavioral, psychological, and social variables correlate with sex category (being female or male). It is therefore often impossible to distinguish the contribution of these factors (i.e., gender) from that of biological variables (i.e., sex) to observed health differences between women and men. In addition, gender-related behaviors and experiences were shown to affect biological qualities thought to stem from sex category, such as levels of sex hormones, making the separation between sex effects and gender effects even more difficult [ 5 , 44 , 45 , 46 , 47 ].

Indeed, many unacknowledged factors may mediate ostensibly sex-driven differences. For example, GM publications quote observational studies according to which women suffer from more cardiac sequalae after acute coronary syndrome (ACS) [ 17 , 27 ]. However, a recent study demonstrated that gender roles, such as being the primary provider, employment, and household responsibilities, rather than sex, are those associated with prognosis after ACS [ 48 ]. Gender associated behaviors were shown to influence seemingly sex related differences in osteoporosis [ 49 , 50 ] and melanoma [ 51 , 52 ]. Researchers have shown that sex related differences documented in laboratory animals can stem from behavior and living condition and not from biological differences [ 46 ]. Thus, sex differences are often caused by other variables, that correlate with the sex category. Searching for these variables and their significance to health, instead of using sex as a proxy for their values, would benefit personalized medicine [ 6 ].

Feminist researchers pointed out that research often builds on a pre-assumption that sex differences in the brain exist [ 44 ] and that arguments about alleged sex differences that echo cultural stereotypes receive public attention [ 53 ]. It was shown that sex differences in the brain are often context- related, and change with time and circumstances [ 7 , 47 ]. Of note, mothers were shown to behave differently towards male and female babies [ 54 ], implying that the brains of women and men are exposed to different stimuli from an extremely early stage of development.

While sex and gender are regarded as two separate entities [ 12 ], biological qualities of sex such as sex hormone levels are altered by gender related experiences and behaviors such as nurturing, competition and sexual activity in both men and women [ 55 , 56 , 57 ]. This suggests that social, material, and cultural factors likely contribute to some of the differences between men and women in health outcomes. It also suggests that addressing gender disparities is essential to improve health outcomes for women, and that both epidemiological and basic research should address the numerous social factors which differ between men and women. Gender disparities and their relation to health are addressed in a minority of the GM publication we reviewed [ 22 , 28 ] and are mentioned in working field 2 of the EUGENMED report [ 12 ], but the vast majority of publications do not address gender issues. The EUGENMED workshop dedicated to basic research discusses biological sex alone, and does not acknowledge the data concerning the entanglement of biological sex and gender, nor does it call for research on this subject [ 12 ]. Moreover, some IGM officials explicitly state that “gender medicine is not feminist, it’s about real science” [ 58 ], thus denying the political and scientific origins of the GM project.

Exposure to physical and sexual violence in childhood and adulthood have a profound and prolonged impact on many women’s lives. Although violence is generally under-reported, the United Nations reported in 2012 that between ten and 40% of women worldwide experienced sexual violence during their lifetime and between seven and 68% experienced physical violence [ 59 ]. Studies have repeatedly shown the association of childhood abuse with cardiovascular [ 60 , 61 ], autoimmune, metabolic diseases [ 62 ], chronic pain [ 63 , 64 , 65 ] and with mortality in women [ 66 ]. Studies discern long- lasting biological changes in abuse survivors such as increased pituitary stress response [ 67 ], increased inflammation [ 68 ] and even DNA changes such as decreased telomere length in leukocytes [ 69 ] and epigenetic changes in the brain, which can be transmitted to subsequent generations [ 70 ]. These gender-related life experiences often go unnoticed in the public sphere and in healthcare systems [ 71 ], and may mediate many seemingly sex differences in health.

Depression and anxiety are twice as common in women than in men. Abuse and violence increase the risk of depression, anxiety and post-traumatic stress disorder [ 72 , 73 , 74 ] mediated by chronic biological changes in multiple cellular and molecular components of brain function [ 75 ]. Failing to address the causative role of gender-related violence and discrimination in women’s mood disorders results in women being labeled “emotional” and “unstable”, bolstering discrimination and the silence surrounding gender-related violence. The GM studies and policies we reviewed refer to violence and childhood abuse only marginally, and do not address violence and abuse when discussing mood disorders [ 12 ]. The Israeli GM society, led by the former IGM president, states that trauma is less common in women on its webpage, reflecting a lack of understanding of the prevalence and consequences of childhood abuse and adult-life violence experienced by women [ 76 ]. Only one IGM member, Gillian Einstein, addresses violence in her scientific work [ 77 ] and public appearances.

Unfortunately, we do not fully understand the long-term health consequences of abuse and violence in women. Likewise, specific diagnostic and therapeutic interventions are not being developed. GM does not address these important issues, nor does it mention the urgent need to improve our understanding of the long-term health consequences of gender-related violence.

Some perceived sex differences in health may arise from diagnostic criteria that do not account for gender differences in manifestations of diseases. For example, depression in men may be overlooked when manifested as alcohol and substance abuse [ 78 , 79 ]. Gender appropriate diagnostic criteria of osteoporosis improves its diagnosis and treatment in men [ 80 ]. Autism in women was shown to be underdiagnosed, probably because the tendency to internalize problems and camouflage social difficulties, as well as gender appropriate repetitive interests are common in autistic females [ 81 ]. These examples demonstrate that simply focusing on sex differences in epidemiology, without considering complex interactions with gender, can result in under-diagnosis and inappropriate treatment in both men and women.

Is there a binary division between the physiology of women and men?

Dividing men and women into two biological categories with different features and qualities constituted the basis for women’s oppression throughout history [ 82 , 83 ]. Several GM publications assume the existence of biological differences between male and female brains, cognitive abilities, and emotional expressions, attributing these to biological factors such as sex hormones [ 36 , 37 ]. However, scientific evidence shows that even when a statistically significant difference in found, considerable overlap in the distribution of measurements of single variables (e.g., specific psychological qualities and cognitive abilities) between the sexes exists [ 5 , 6 , 84 ]. For example, an extensive review of 26 meta-analyses looking for sex differences in psychological and cognitive traits found that, for almost all the traits studied, differences were close to zero or small and a considerable overlap existed [ 85 ].

In addition, when multiple variables are tested simultaneously in female and male brains, a mosaic distribution of “feminine” and “masculine” qualities across variables is found [ 7 , 51 , 86 , 87 ]. This means that in an individual brain, each variable tested shows its own degree of similarity to the phenotype more common in females or in males, so that varying degrees of “femininity” and “masculinity” are found across variables in each person. Mosaic patterns were seen in brain structure on functional MRI, when assessing psychological traits by questionnaires [ 86 ], and even when assessing cellular brain structure postmortem [ 88 ]. Mosaic pattern are also seen in the effect of external stimuli, like stress, on brain function [ 89 ]. These important data shed light on the complex interactions between biological sex, the environment, and the brain, and highlight the fact that it is impossible to categorize human brains as ‘male’ or ‘female’. Of note, the groundbreaking study that delineated the brain mosaic theory was firmly rejected by the former IGM president [ 38 ].

Listening and learning from other disciplines and from women themselves

The women’s health movement empowered women to learn and share their health-related knowledge. The revolutionary book ‘Our Bodies Ourselves’, written by women for women, cherished women’s experience and challenged the authoritative position of the healthcare system. This enabled women to expose misconceptions and prejudice in medical practice. GM is practiced and discussed by physicians and scientists. In our review of GM work we did not find studies regarding women’s concerns in health, not a call for such work. While GM focuses mainly on cardiovascular health and diabetes [ 12 , 18 , 22 , 26 , 27 , 28 , 30 ], it is plausible that women from diverse backgrounds have different health concerns and priorities. The EUGENMED project involved patient’s organizations, but not feminist organizations, as stakeholders [ 12 ]. Empowerment of women regarding their health is also absent from GM discussions and recommendations.

Intersections between gender, oppression, and racial discrimination

Poverty, discrimination, economic insecurity and ethnic conflicts profoundly affect the epidemiology of common diseases and treatment outcomes [ 48 ]. These adversities generate chronic stress and affect nutrition, physical activity, exposure to pollution, access to healthcare and more. The capitalistic system generates and broadens economic inequalities between countries worldwide and within states and societies. “Black feminism” and intersectionality theory demonstrate how race, class, ability, and appearance interact with gender to generate privilege and discrimination [ 90 ]. GM publications recognize the effect of poverty and racial discrimination on cardiovascular risk [ 12 , 28 ], however a call to improve and study minority women’s health is lacking. Minority women in the US, Canada, Israel, Europe, and Australia report discrimination within healthcare systems and discriminatory institutional policies and stigmas, with negative effects on their health [ 91 , 92 ]. Gender discrimination in healthcare is suggested by the findings described in several of the studies we reviewed [ 16 , 18 , 19 , 20 , 23 , 27 ]. For example – a study found that women undergoing hemodialysis in Austria were less likely to be treated via a vascular shunt and less likely to be referred to kidney transplantation [ 16 ]. Other studies showed that women with type 1 diabetes [ 20 ] and women hospitalized for heart failure [ 27 ] were less likely to be treated per current guidelines, that women were at higher risk for acute ischemic events in a cohort of patients after cardiac catheterization [ 19 ], and that women with type 1 diabetes were more likely to suffer hypoglycemia and severe hypoglycemia when treated in clinical trials of galgarin insulin [ 18 ]. Discrimination in healthcare practices and access to medical and social services may contribute to these and other [ 23 ] findings, however only 1 article [ 27 ] mentions this possibility. A discussion regarding the need for further studies looking specifically at discriminatory practices is also lacking. Racial discrimination in healthcare is not discussed at all in the publications we reviewed, and even refuted when faced with findings regarding inadequate treatment provided to Arab minority women in Israel [ 24 ].

The “Me-too” protest against sexual violence and the “Black Lives Matter” movement reminded us that gender related violence and racial discrimination are prevalent even among seemingly liberal institutions in western societies. These uprisings share values and practices with the feminist movement, empowering women and minorities and cherishing their voices and perspectives. They teach us that real change is accomplished only by questioning the practices, interests, and power-structures of institutions.

GM has brought the issue of sex/gender and general health to the forefront of popular and professional discourse, appropriating, and mainstreaming the discussion that was initiated by the feminist women’s health movement in the 1960s. This process has obvious advantages and opportunities, such as raising awareness of health professionals, institutions, and regulatory agencies to gender differences in health, allocation of funds to research on gender and health, and better designed pharmaceutical studies. However, this mainstreaming has been accompanied by the return of professional dominance, while the voices of feminist activists go unheard. Moreover, GM ignores important scientific progress, made by feminist scientists, regarding the complex associations between sex, gender, and health. By stressing the biological division between sexes, on the one hand, and under-representing the toll of violence, oppression, ethnic conflicts, and discrimination on the lives and health of women, on the other, GM accepts conservative positions on sex and gender and reaffirms the current practices of healthcare systems worldwide. Generally, it does not posit poignant criticism to mainstream medicine, and the topics studied tend to avoid more contested health issues such as chronic pain syndromes, sexual abuse, ethnic conflict, the health consequences of beauty standards, and others.

A way forward

Feminist scientists have shown that much can be achieved by studying the mechanisms linking biology, gender, and society. A continued effort in this direction is required to improve our understanding of these mechanisms, and to implement this knowledge into clinical practice. An approach that integrates feminist epistemology and methodology into the study and practice of medicine and strives to understand the complexity of gender can improve the health of both women and men [ 79 , 80 ] worldwide. Feminist activists should work together with physicians to re- define “Gender Medicine”, prioritize research and policy topics, and participate in the design of clinical studies. Efforts should be made to listen to diverse women, learn about the health challenges they face and incorporate their priorities into policies and studies. Studies that critically examine healthcare systems and the bio-scientific world for discriminatory practices and blind spots, and studies that examine the health toll of diverse forms of gender related violence and oppression should be encouraged.

Our review of the IGM/ ISGSCM indicate that while their work focuses on sex differences, it neglects the influence of gender, namely the social aspect of being a woman or a man, on biology, physiology, and health. We found that for the most part, their writing ignores the effect of gender norms, gender-related behaviors, and gender-related violence on biology and health. Moreover, it endorses a binary vision of 2 distinct sexes with different biological qualities, while overlooking the evidence that indicate a more complex social and biological reality. Indeed, the IGM/ ISGSCM work may improve some aspects of women’s health, however we should aim to promote a wider approach to gender and medicine – one that studies complex interactions between society and biology and that tackles difficult subjects such as debilitating chronic pain syndromes, violence, and health concerns of racial minorities. We believe that integrating the achievements of the IGM, those of the feminist women’s health movement and of current feminist scientists and activists can bring about a deep and meaningful change in the health of women worldwide.

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Ayelet Shai initiated the work described in this manuscript. Ayelet Shai and Yael Hashiloni-Dolev formulated the article’s concept and defined the work’s specific goals and methodology. All authors contributed to the literature search and analysis. Ayelet Shai and Yael Hashiloni-Dolev wrote the manuscript. The author(s) read and approved the final manuscript.

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Ayelet Shai is the head of Oncology in the Galilee Medical Center. She specializes in breast cancer and gynecological malignancies and conducts bio-medical research on women’s cancers. She also studies the intersections between medicine and society. She served in the leading committee of the “women and reproductive technologies” project in the feminist organization Isha Le’Isha and is currently a fellow in the Center for Health, Law and Ethics of the University of Haifa. She is member of Israel’s National Council for Prevention, Diagnosis and Treatment of Malignant Diseases and serves on the ethics Committee of the Galilee Medical Center. She has published several articles on bio-medical research as well as medical ethics and teaches Oncology and medical ethics.

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What can policymakers learn from feminist strategies to combine contextualised evidence with advocacy?

• Eleanor Malbon   ORCID: orcid.org/0000-0002-6840-498X 1 ,
• Lisa Carson 2 &
• Sophie Yates 1 , 3  

Palgrave Communications volume  4 , Article number:  104 ( 2018 ) Cite this article

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We give a short overview of feminist perspectives on the use of evidence in policy making, covering both empirical and conceptual work. We present the case of the Conflict Tactics Scale, a measure of interpersonal violence that is both widely used and heavily criticised in work on violence between intimate partners. We examine this case to illustrate the way that feminist advocacy and research organisations use gender informed theory to counter positivist narratives about intimate partner violence. In doing so, we show that the evidence-based policy approach, even when considered as principle or ideal, frames the policy-making process as “objective”, and in doing so ignores the gendered contexts in which knowledge is produced, used and translated into policy and implementation. By examining feminist approaches to this case study, we can learn from feminist advocate researchers the importance of context, normative arguments and the politicisation of evidence in policymaking and implementation.

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Introduction

On a recent Sunday morning, one of our co-authors (Sophie Yates) was walking home with her male partner from the local craft market, having purchased a crusty baguette. Seeing how comically sharp the end of this loaf was, she lunged at her partner as if to stab him in the back with a sword. Unfortunately, he moved at the last moment and instead she rasped the rough edge of the baguette against his arm, drawing blood. He yelped in pain, and understandably got a little irritated with our chastened co-author. The resulting scab took over a week to heal. This incident—which devoid of context, appears to comprise a woman attacking and injuring her male partner with a weapon—can be used to help illustrate a problem with the most commonly used measure of intimate partner violence in population samples: the Conflict Tactics Scale (CTS).

The CTS has been in use for nearly 40 years, and results derived from this measure are used to support claims that women and men are equally violent in intimate relationships, that a focus on gender inequality as a driver of this violence is misplaced, and that policy and practice responses should focus on individualised interventions rather than those based on the way that gender and power shape our society. In this article, we show how feminist advocate researchers have strongly criticised the CTS on theoretical grounds (Nixon, 2007 ; Allen, 2011 ; DeKeseredy and Schwartz, 2011 ), and used research methods sensitive to power and context to empirically draw its validity into question (Currie 1998 ; Lehrner and Allen 2014 ; Ackerman 2016 ). To contextualise this we also give an overview of feminist understandings of evidence, validity of evidence, and evidence in policymaking.

In most established democracies, there is a desire to combine policymaking with evidence, earning a notch of legitimacy for policy and research alike. The use of evidence in policymaking is a good idea, but like many good ideas it is more complicated in practice than it is in theory. It is useful to think of evidence based policymaking (EBP) as a principle or ideal rather than an accomplishable outcome, which allows us to make comparisons between different ideals of EBP (Head, 2010 ). We can differentiate at least two sorts of ideals about the use of evidence in policymaking (see Cairney, 2016 ); the first is the ‘evidence hierarchy’ approach which emphasises objectivity in evidence and downplays the way that politics, theory and values intersect in policymaking (see for example the work of economist and influential Australian politician Andrew Leigh ( 2010 ). This approach tends to highlight a ‘hierarchy of evidence’ to be used in policymaking, starting with randomised controlled trials as the ‘gold standard’ (Leigh, 2010 ; Guyatt et al., 1995 ). What is limiting about the ‘evidence hierarchy’ approach to policymaking is the model of policy formation that it espouses, which is linear and denotes a ‘clean’ relationship between evidence and advocacy (Parsons, 2002 ; Young et al., 2002 ; Pawson, 2006 ; Bacchi and Eveline, 2010 ; Head, 2010 ; Crammond and Carey, 2017 ). For example, the ‘evidence hierarchy’ promotes an ideal of researchers who ‘discover’ or confirm particular facts that are then passed to advocates who use the information to lobby receptive policymakers for change. However, in practice the process is rarely so smooth. Depictions of a ‘clean’ or objective relationship between evidence, researchers and policymakers leave little space for the realities of advocacy and normative arguments in politics. This representation of the policy formation process has been critiqued as linear (Young et al., 2002 ), naïve (Cairney, 2016 ) and a parody (Marmot, 2004 ).

We suggest a different approach to evidence and policy, informed by political science and philosophy, which emphasises a theoretically driven approach to evidence production and advocacy (see Wylie, 1987 ; Anderson, 2004 ; Cairney, 2016 ). In this paper, we draw on ideas and theories by feminist philosophers of science, combined with the practices of feminist advocate researchers who critique the use of evidence in domestic and family violence policymaking, to illustrate a politically informed approach to evidence in policymaking. We do not present the approaches taken in our case study as perfect, but seek to discover what we can learn from feminist strategies to combine evidence and advocacy in policymaking. Core among feminist critiques of the naïve EBP approach is that it frames the policymaking process as potentially objective and ignores, specifically, the gendered contexts in which knowledge is produced, used and translated into policy.

Feminist insight into evidence and advocacy

To understand feminist perspectives and critiques of the use of evidence in policymaking, a brief background in feminist epistemologies of science is required. Feminist philosophies of science offer diverse theories and perspectives on the practice of science, but they are united in their rejection of the popular understanding of scientific objectivity as ‘value-free’. Feminist philosophers of science argue that science can never be separated from social influences, and further, that the notion of value-free science should not be held as an ideal. Instead, they argue that science works best when its operating values are acknowledged, examined and utilised effectively to produce good quality scientific work.

Goldenberg ( 2015 ) identifies two streams of feminist epistemologies of science: (1) the ‘community-based social knowledge’ position, spearheaded by Helen Longino and Lynn Nelson, and (2) the ‘values as evidence’ position, led by Elizabeth Anderson and Sharyn Clough. The distinction is useful because it highlights differences over what constitutes validity of evidence. For the first ‘community-based social knowledge’ position, Longino ( 2002 ) and Nelson ( 1990 ) maintain that valid evidence is born of ideal scientific communities that maintain a diversity of viewpoints to uphold objectivity (Goldenberg, 2015 ). It is important to note that Longino ( 2002 ) and Nelson ( 1990 ) provide an ‘aspirational’ picture of scientific inquiry which is not grounded in a value-free ideal, but rather generated through rigorous critical inquiry with a diverse community of researchers who are able to engage in equitable debate and disagreement. To this end, Longino ( 2002 ) provides a set of norms for scientific communities that can promote objectivity, such as discursive interaction. Goldenberg ( 2015 ) argues that these idealised accounts of scientific communities are not useful in the face of actual scientific communities which do not, practically, function according to these ideals.

For the second ‘values as evidence’ position, Anderson ( 2004 ) and Clough ( 2003 ) offer a different understanding of how evidence is considered valid. Anderson argues, along with other feminist empiricists, that value judgements affect the way that evidence is produced, but she goes further to argue that we can determine if the use of value judgements in science is legitimate or not (Anderson, 2004 ; Goldenberg, 2015 ). It is important to note that Anderson does not describe science as a mere reflection of power interests, but rather she sets out criteria for determining the legitimacy of value judgements used in scientific inquiry. According to Anderson, the illegitimate application of value judgements in science occurs when values are used to reach a forgone conclusion or dogmatic position (Anderson, 2004 ). In her case of feminist research on divorce, she demonstrates a legitimate use of gender informed values (and theory) to guide scientific inquiry in support of more contextually informed conclusions (Anderson, 2004 ). For Anderson, the legitimate use of values in evidence lies in open-ended inquiry, rather than through an appeal to a diversity of viewpoints (in contrast to the work of Longino and others in the ‘community-based social knowledge’ stream).

Intemann ( 2010 ) describes what feminist empiricists can learn from feminist standpoint theory, another feminist philosophy of science. Feminist empiricism debates the legitimate use of values in evidence production, whereas feminist standpoint theory extends to the use of evidence in policymaking. Feminist standpoint theory, exemplified by Harding ( 1987 ) and Wylie ( 1987 ), emphasises that the knowledge included in policy formation should be that which is considered relevant from the standpoint of the subordinate group in a particular situation. Examples of such groups include women, people of colour, non-binary people, people of lower socioeconomic status, survivors of intimate partner violence, and so on. By encouraging the consideration of the standpoint of a subordinate in a particular situation, feminist standpoint theory prioritises context sensitive evidence and the subversion of the ‘hierarchy of evidence’ approach to policymaking. The feminist standpoint perspective encourages us to consider the perceived legitimacy of evidence in the eyes of policymakers and the public, and what the exclusion of certain evidence reveals about the assumptions and representations of a policy problem (Bacchi and Eveline, 2010 ). Questions of 'Whose evidence? For what purpose?' should be asked of all attempts to use evidence to influence policymaking (Witkins and Harrison, 2001 ).

Evidence that is sensitive to gendered contexts

As in the discussion of feminist philosophies of science, feminist critiques of evidence based policy offer a diversity of perspectives on evidence in policy. Some of these feminist critiques align with other critiques of EBP (for example Parsons, 2002 ), but what is distinct about feminist critiques is their emphasis and sensivitity to the gendered contexts in which evidence is produced and used in policymaking.

Many feminist critiques of the notion of EBP are drawn from feminist critiques of evidence based medicine, from which EBP originated (see Goldenberg, 2015 ; Rogers, 2004 ; Davies, 2003 ). For example, Goldenberg ( 2015 ) draws on Anderson’s work to show how physicians can choose between legitimate and illigimate medical information without use of the communities of practice espoused by Longino. Rogers ( 2004 ) provides a detailed account of the ways in which women’s health is marginalised by the evidence based medicine approach, resulting in ‘gender blindness’ which leaves medical science overwhelmingly focused on women’s reproductive health, with less attention paid to other crucial women’s health matters such as depression, diabetes, heart disease and HIV/AIDS. Rogers highlights the importance of context, demonstrating that 'the biomedical model of health that underpins most of the medical research used by EBM ignores the social and political context which contributes so much to the ill-health of women' (2003, p. 50).

Davies ( 2003 , p. 1) argues that attempts to work with evidence based practice, and by extension EBP, signify ‘death to critique and dissent’. This particular criticism of EBP is levelled at the exclusions that can occur when taking the ‘hierarchy of evidence’ approach, which has historically excluded marginalised voices in the production of evidence and in decisions about which evidence is considered to be valid for decision making (Davies, 2003 ). Such silencing of dissent does not fit well with Longino ( 2002 ) and Nelson’s ( 1990 ) ideal depictions of science as comprised of a diversity of viewpoints to uphold objectivity.

Feminist empiricists argue that the value-laden understanding of science has better potential for distinguishing nuanced, context specific science (and evidence) from unsound uses of values in science (and evidence): Anderson’s ( 2004 ) work on the production of evidence provides tools for explaining why context sensitive research is better than context insensitive work. The value-laden nature of evidence (Anderson, 2004 ) means that additional critical feminist attention is required to interrogate the ways in which it is and can be used for particular political purposes. Feminist critiques of EBP direct us towards the production and use of evidence that is sensitive to the gendered contexts in which knowledge is produced, used and translated into policy.

The importance of normative argument

Considerations about the validity of evidence have been the focus of feminist empiricist work, but when considering feminist accounts of evidence in EBP we must also consider how evidence is used by advocates in policymaking. Evidence cannot 'speak for itself' in a vacuum of objectivity, it needs political actors to give it voice and meaning. Policymakers and bureaucrats themselves are not likely to mistake the policymaking process as objective or apolitical, rather it is advocates and researchers that have the most to lose by conceptualising the policy process as linear. Crammond and Carey ( 2015 , 2017 ) present empirical work showing that researchers who do not offer a values informed normative argument alongside their evidence run the risk of being ignored. Values, more than evidence, set political agendas because most political problems are in the realm of the normative or moral, such as the promotion of health equity, welfare support or climate change mitigation. However, it is precisely when working within these realms of the normative and moral that 'the accumulation of further evidence is highly unlikely to persuade politicians to act because it necessarily fails to explain why they should be persuaded to act' (Crammond and Carey, 2017 , p. 371–372). Researchers who attempt to present only evidence based arguments, and ignore normative based arguments that explain why a politician should act, risk their evidence being ignored or disregarded. Normative argument is the space in which the gender sensitive context of evidence can be explained, and the value-laden nature of this evidence articulated to policymakers.

We now turn to a case study of feminist engagement in the use of evidence in policymaking. We pay explicit attention to the ways that feminist researchers and advocates have highlighted the importance of gender context-sensitive evidence, and normative arguments to accompany evidence, in their critiques of the Conflict Tactics Scale.

The context of counting incidents: feminist empirical critiques of the Conflict Tactics Scale

This section presents an argument against the validity of context-insensitive research, using the Conflict Tactics Scale (CTS) as a case study. The CTS has been used extensively in domestic, family and intimate partner violence research, and studies employing it appear to show ‘gender symmetry’ in violence perpetration. We draw on the theoretical criticisms of the CTS as a blunt instrument missing vital contextual information (such as power dynamics, patterns of behaviour, and perpetrators’ and victims’ intentions and interpretations), and trace empirical efforts to compare CTS-based research results with those from other methodologies that include this contextual information. When context is added, gender asymmetry in perpetration and experience again emerges, showing the importance of understanding and attempting to measure the contextual gender and power dynamics underlying domestic and family violence.

The story of attempts to measure and respond to violence in families has its roots in the earliest feminist responses to the problem, when women’s movement activists worked to expose the existence of private gendered violence and make what was commonly termed ‘domestic violence’ a social issue requiring legislative and policy responses. Previously, domestic violence had been viewed as the private problem of a limited number of 'dysfunctional couples', with victims often doubted and receiving minimal support, and perpetrators experiencing little or no punishment (Renzetti and Bergen, 2005 ). Early research in this area, coming as it did from a feminist perspective, and focusing on agenda setting and consciousness raising, was mainly qualitative and based on clinical and refuge samples - i.e., participants had by definition experienced significant partner abuse. Unsurprisingly, results supported the feminist viewpoint that domestic and family violence was mainly perpetrated by men in order to control women and their children.

When researchers began using quantitative tools to measure domestic and family violence in the general population (e.g., the US National Family Violence Surveys of 1975 and 1985), the figures appeared to tell a different story (Allen, 2011 ). A team of researchers at the Family Research Laboratory developed and began using a tool known as the CTS (Straus, 1979 ). It is based on conflict theory, which sees conflict as an inevitable part of human relationships, and violence as a tactic used to deal with conflict (Straus et al., 1996 ). Study after study employing the CTS, and later the CTS2 (Straus et al., 1996 ), found that violence in heterosexual relationships was roughly equally perpetrated by men and women—or even that women were more violent than men. This was unexpected, given that hospital and shelter statistics all indicated that intimate partner violence by men against women constituted the major part of the problem.

The CTS’ relative brevity and its ease of administration saw it become the dominant tool for research on the 'prevalence, predictors, correlates, outcomes, and treatment of IPV [intimate partner violence]' (Lehrner and Allen, 2014 , p. 477). By 2002, more than 100 empirical studies using the CTS or similar tools supported the gender symmetry hypothesis (Kimmel, 2002 ). Straus ( 2007 ) reported that between 1973 and 2005, approximately 600 papers and at least 10 books had been published based on the CTS. Two US National Family Violence Surveys (1975 and 1985) had also been based on the CTS, and were subject to considerable secondary analysis, forming the basis of much theorising (Walby and Myhill, 2001 ). But perhaps the most influential publication supporting the gender symmetry hypothesis has been Archer’s ( 2000 ) meta-analysis of studies totalling n60,000, most of which had used the CTS- with only a small number of studies using any other type of quantitative measure. Archer concluded that although the effect size was small and women suffered more severe injuries than men, 'women were significantly more likely than men to have used physical aggression toward their partners and to have used it more frequently' (p. 664).

As a consequence of these studies, many researchers reject feminist theories of intimate partner violence in favour of other explanations such as individual psychopathology or intergenerational transmission (learned behaviour) (Corvo and Johnson, 2013 ). This is the context for more than '30 years of sometimes acrimonious scholarly debate' over whether domestic and family violence is gender symmetrical (Johnson, 2005 , p. 1129; Dutton, 2010 ).

For as long as the CTS has been in use, feminist activist researchers have been criticising its validity (Myhill, 2017 ). The main criticism is that it misses—and in fact is not intended to measure—contextual factors that are crucial to establishing patterns of coercive control (Allen, 2011 ; Nixon, 2007 ). According to Currie ( 1998 ), researchers from the family conflict tradition consistently 'obscure the importance of gender' (p. 101) and its implications for existing power dynamics in intimate relationships, assuming that violence stems from conflict and that parties in conflict are equally powerful. The CTS asks participants to report the use or experience of 39 verbally/emotionally or physically violent behaviours in response to a conflict or anger situation during the previous 12 months. Instructions to participants ask them to think about different ways couples have of settling their differences, or spats and fights (Straus et al., 1996 ). Crucially, critics note that it counts the number of incidents but does not record the substantive issue that led to the violence, or any other pertinent context (Allen, 2011 ; Braaf and Meyering, 2013 ). There is no way to report whether incidents occurred in the context of self-defence, or assess the impact of violent incidents (although a scale was added in the CTS2 with the aim of measuring injury levels) (Hester et al., 2010 ). It also instructs respondents to consider only conflict or argument-instigated violence, revealing the assumption that all violence is used expressively , i.e., in anger and thus potentially missing instrumental violence used to control individuals, and violence that doesn’t stem from an identifiable cause (Flood, 2006 ; DeKeseredy and Schwartz, 2011 ). Patterns of instrumental violence, also known as 'coercive control' or 'intimate terrorism', have been shown by many researchers to be overwhelmingly gendered (Anderson, 2009 ; Johnson, 2005 ).

Further, it overlooks a continuum of violence and excludes commonly-recognised abusive behaviours such as economic abuse, isolation of victims, manipulation involving children, and stalking (DeKeseredy and Schwartz, 2011 ). Post-separation violence, which is a major component of domestic and family violence, especially for women (Kimmel, 2002 ; Hester, 2011 ), is not measured by the CTS (Flood, 2006 ). Finally, the CTS does not measure fear or intimidation, which many studies have found to be a significant component of domestic and family violence (Allen, 2011 ). In the words of Flood ( 2006 ), due to the 'highly decontextualised and abstracted' treatment of violence by the CTS, 'this acts-based method actually produces findings of gender equality in domestic violence' (p. 3).

To further their arguments that theories of domestic and family violence (and thus policy responses) should not be based solely on the data derived from the CTS, a number of feminist researchers have conducted research combining it with qualitative methods, or other methods that add contextual information. In doing so, their aim is to call the CTS’ validity into question using empirically based rather than epistemological critiques. When these methods are used, gender asymmetry again emerges. For example, feminist sociologist Dawn Currie ( 1998 ) added open-ended questions to the CTS, inviting participants to provide detailed accounts of violent incidents that otherwise would have been counted as abstract events. The men in her sample reported proportionally more violent incidents from female partners than the women from their male partners, as is the case in many studies employing the CTS. However, the added context enabled her to determine that men ‘upgraded’ women’s use of violence, while women tended to downplay men’s use of violence, blaming themselves and excusing men’s violence as ‘understandable’ (p. 106). Several incidents described by women were interpreted or intended as play by their partners, but not by the women themselves. In addition, violence from women that men considered to be amusing or at most annoying appeared in the CTS results, and without this contextual information would have been counted the same way as violence viewed as serious. Currie ( 1998 ) argued that these results provide empirical grounds to question the CTS’ ability to accurately measure either the extent or the nature of violence in heterosexual relationships.

Hilton et al. ( 2003 ) found in their study of interpersonal violence among high school students that the CTS yielded comparable (and gender-symmetrical) rates of violence in their sample as found in other large-scale studies of adolescents. They compared CTS results to a second measure of violence, in which students listened to fictional but lifelike scenarios of physical, emotional or sexual violence. In response to the scenarios, both boys and girls reported much lower rates of violence than found by the CTS—in other words, these results suggested that the CTS had produced over-reporting of violence. Even though both boys and girls reported lower rates of violence in this second research measure, there were sex differences: boys reported more violence perpetration than girls—especially for physical violence. The authors reported that: 'Consistent with statistics from police and hospitals (with respect to all violence) as well as from shelters (with respect to relationship violence), the scenario method suggested men are the more aggressive sex (p. 234).'

Ackerman ( 2016 ) took a different angle on the issue of over-reporting thought to be generated by the CTS. He used insights from the cognitive interviewing literature; Footnote 1 studies from this research tradition have shown that different interpretations of the meaning of survey questions (either different from each other or different from what the survey designer intended) can result in over-reporting, under-reporting, or both. Ackerman ( 2016 ) applied these insights to the CTS, inquiring of participants whether the incidents they had just described were accidents or 'joking, playful or humorous' (p. 657). He categorised incidents where these two responses were selected as 'over-reports'—as would have been the case with the baguette incident described in the introduction to this paper. Ackerman ( 2016 ) found significant over-reporting of both perpetration and victimisation from his male participants:

… males are more likely than the females to respond affirmatively in a way unintended by the survey design [and] the males do this far more often when asked whether a female has victimised them compared with when asked whether they have victimised a female (perpetrated an [intimate partner violence] event against a female) (p. 662).

Most interestingly, Lehrner and Allen’s ( 2014 ) ground-breaking study combining the CTS2 with qualitative interviews throws the CTS’ construct validity into more doubt. Noting Straus et al.’s (1996) insistence on the CTS2’s applicability for university student populations, Lehrner and Allen ( 2014 ) administered the questionnaire to 476 undergraduate women. They expected that, consistent with the CTS-based literature, about half the sample would report some level of intimate partner violence perpetration, and this was the case. The authors then grouped the women into categories based on frequency and severity of self-reported violence, ranging from level 1 (no violence) to level 4 (minor violence 6+ times or any severe violence). To contextualise participants’ CTS data, the authors conducted in-depth interviews with a random sample from each category, including 'questions about the setting, precipitating events and emotions, motives, and outcomes for any reported incidents' (p. 479). Their qualitative results showed large discrepancies with the CTS data, including misclassification of victimisation as perpetration; misidentification of mutual violence when in fact there was a victim/perpetrator dynamic; and—crucially—high levels of ‘mock’ (joking) or ‘playful’ (fun physical sparring) violence that had often been coded by the CTS as ‘severe’ violence.

Of the 10 women interviewed who were classified by the CTS as severe perpetrators, two had only used violence in self-defence, one had been severely victimised, one had used only playful violence (again the baguette comes to mind), and the others reported a combination of mock, playful and meaningful violence (p. 483). The discrepancy in categorisations between interview and CTS data affected 58% of the interview participants coded as violent by the CTS (p. 484), leading to substantial doubts about whether the CTS is actually measuring what it claims to measure. Indeed, Myhill ( 2017 ) throws doubt on the ability of people subject to ongoing abuse and coercive control to accurately remember discrete incidents at all:

This conceptualisation assumes that victims view every aspect of the abuse they experience as discrete and to some degree time-bound. …While acts of physical violence may sometimes be discrete enough to recall and ‘count’, wider abuse and especially the sense of entrapment is most often described as multifaceted, ‘continuous’ and not amenable to being counted as discrete acts or episodes (p. 40).

Described as 'feminist-advocate' researchers by Myhill ( 2017 ), it is clear that the work of these researchers is not intended merely to clarify discrepancies between different methods of measurement. They are keenly aware of the use to which research evidence on intimate partner violence is put, and seek to promote policies that take into account the inequalities and contextual factors that drive this violence. For Currie ( 1998 ), 'at stake is the provision of victim support services for battered women' (p. 99) and she notes that claims of gender symmetry in intimate partner violence had led to the reduction or blocking of services for battered women in at least two US states. Ackerman ( 2016 ) argues that gender differences in intimate partner violence over-reporting have serious implications because survey evidence affects public awareness of the problem, as well as public policy and response to the problem. He felt his results suggested that several feminist theoretical claims not previously supported by empirical data—such as the potential for the CTS to produce over-reporting—now deserve re-evaluation using 'methods that can potentially ameliorate over-reporting and other forms of systematic measurement error' (p. 662). The re-evaluation of theoretical claims based on empirical data (that was developed based on those theoretical claims) is the sort of evidence production advocated for by Anderson ( 2004 ) and the ‘values as evidence’ position of feminist empiricism (Goldenberg, 2015 ). Lehrner and Allen ( 2014 ) further argue:

Given the social significance of [intimate partner violence] and the prevention, treatment, and policy implications of its accurate assessment, continued investigation into the validity of the CTS with diverse populations and the further development of more nuanced and developmentally sensitive assessment strategies appears warranted (p. 488).

Nor do feminist advocates seek to throw the quantitative baby out with the methodological bathwater. As DeKeseredy ( 2016 ) notes in his article on the enduring relevance of feminist thought for measuring and understanding intimate partner violence, feminist scholars have led advances in victimisation survey research over the past 30 years. An example is 'progressive survey researchers' Michael Smith and Rebecca and Russell Dobash, whose contribution to the development of the Canadian National Violence Against Women Survey sought to place intimate partner violence in context to explore its meaning and impact (DeKeseredy, 2017 ; Walby and Myhill, 2001 ). With modifications, this model was subsequently used in Australia, Finland, Iceland, Sweden, Germany and Ireland (Walby and Myhill, 2001 ). More recently, Walby et al. ( 2017 ) have argued for the measurement of 'gender saturated' dimensions of interpersonal violence as a way to improve the contextual information collected by measurement approaches based on acts of violence.

The difference between feminist and non-feminist researchers and mainstream intimate violence researchers is not that they advocate for one particular method or that they eschew quantitative measurement. Rather, it is that they strive to be sensitive to power and context, do not pretend that their research is (or could be) objective or value free, and produce work that is theory-driven rather than the “abstracted empiricism” common to many studies on intimate partner violence (DeKeseredy, 2016 , 2017 ). This point was also made nearly two decades earlier by Currie ( 1998 ), who observed that the use of the CTS has been largely research-led rather than theory-driven (although the measure itself was originally derived using theoretical insights from conflict research). In fact, CTS pioneer Richard Gelles wrote in 1983 that the use of 'ideology'—meaning theories about the role of sexism and racim in domestic violence—had 'partially inhibited a serious scientific program of theory construction in this area' (p. 154). As Breines and Gordon ( 1983 ) point out, this contrasts his own 'empiricist' method of theory construction with other methods of theory construction which he finds 'ideological' and hence non-scientific, and not supported by the available empirical evidence. It indicates that accompanying the introduction of the CTS may have been notions of scientific purity and objectivity intended to counter ideologically-driven research based on gendered understandings of the problem. DeKeseredy and Dragiewicz ( 2013 ) concur, arguing that this absence of theory in intimate partner violence research is linked to calls for 'evidence based practice' in criminology, an approach which has been used 'to target feminist theories as political rather than scientific', and which claims to be atheoretical but instead works to obscure implicit theoretical assumptions (p. 303–304).

While the CTS has been extensively critiqued before, both theoretically and methodologically, the account of the ‘gender symmetry’ debate provided here brings the feminist theoretical criticisms together with the work of scholars who have applied these principles empirically to produce results that throw the construct validity of the CTS into doubt. We have shown that this was done not just in service of discovering the true nature of intimate partner violence, but because theories of what causes intimate partner violence affect the policies implemented to address them, and thus affect social outcomes. In the following section we show how, in a recent Commission of Inquiry, feminist advocate researchers have drawn on this contextually-driven research to refute claims of gender symmetry in intimate partner violence and ward off policy responses that assume most intimate partner violence is mutually perpetrated.

The CTS and the gender symmetry debate in Australian Parliament

Debates about the validity of the CTS as a measure for intimate partner violence, and the validity of the gender symmetry argument more broadly, were triggered in Australian politics in the 2014–2015 Senate Inquiry into Domestic violence in Australia (hereafter: the Inquiry) (FPARC, 2015 ). During the Inquiry, representatives for the men’s rights activist group One in Three used Straus’ work and evidence derived from the CTS measure to justify their claims that most family violence is mutual or 'common couple' violence. The following excerpt is from the official Australian Government Hansard transcript of the Inquiry:

Senator Waters: I want to take you to that part of your submission where you contend that patriarchy is not a factor in the present levels of domestic violence. You make a statement:

'Most family violence is called “common couple violence” in which the violence is committed by both people…'

That seems to me to swim against the tide of most of the evidence that we have received to date. What is your basis for suggesting that violence is mutual?

Mr Andresen [One in Three]: It is 30 years of family violence research. I would be happy to take that question on notice and provide you with study after study that shows that (Official Committee Hansard, 2014 , p. 29).

Here, Andresen is clearly referencing the family conflict stream of research discussed in the previous section to argue that patriarchy is not a factor in domestic violence and that violence in couples is generally mutual. One in Three’s ( 2014 ) submission to the Inquiry relies heavily on the work of Straus, Gelles and other CTS researchers. Andreson refers specifically to work by “the very long-term and highly esteemed family violence researcher Murray Straus” in support of his oral evidence (Official Committee Hansard, 2014 , p. 28).

However, the presentation of Straus’s work and the CTS measure was anticipated and met by feminist organisations present at the Inquiry. A representative from the feminist organisation ANROWS (Australia’s National Research Organisation for Women’s Safety) identified use of the discredited CTS measure and the gender symmetry argument:

Dr Mayet Costello: One of the key uses of data that organisations like One in Three use when they talk about gender symmetries—when they say violence is equal between men and women—is work that was done in the United States under the [CTS], which has been widely discredited across the research community for two reasons. One, the scale does not take into account context, so it does not take into account, for example, the use of retaliatory violence or violence in self-defence compared to violence that is for the purpose of controlling, intimidating or causing fear against the other party. The other key thing it fails to do is recognise either harm or the disparity between different types of violence. To use a very simple example, a slap on the hand might be considered equivalent to a punch to the face. So, whereas the potential damage done to those two activities are substantial, if you put it in the context of intent, it is very problematic (Official Committee Hansard, 2014 , p. 4).

Part of ANROWS’ strategy as a feminist advocate organisation is to highlight that the men’s rights activist group is drawing on discredited evidence, and provide argument for the use of evidence from measures that take the context of violent incidents into account. Coupled with this strategy is the presentation of normative argument as to why the Inquiry should recommend resources and research funding for domestic violence against women. Their politicisation of evidence and the presentation of normative argument gives the feminist advocate organisation influence and legitimacy in the Inquiry room:

Dr Costello: the gender symmetry debate is… exactly the same debate we have in terms of why we are producing evidence and why we want to have the best evidence of where we should direct our funding. Resources should really be directed towards where they are of most need, and we have an overwhelming quantum of evidence which shows that violence against women is prevalent and has huge impacts… The statistics as we know them now do not currently support the position that those organisations take who argue gender symmetry (Official Committee Hansard, 2014 , p. 5).

The final Inquiry report did acknowledge the need to give support to male victims of domestic and family violence, but it also accepted ANROWS’ analysis that women are most likely to experience violence in the home by a current or former partner, and men outside the home by strangers, acquaintances or neighbours (FPARC, 2015 ). It also featured ANROWS’ argument that the contributors to violence are complex and include “attitudes to women and gender roles within relationships, family and peer support for these attitudes, and social and economic gender inequality in the broader societal context” (p. 5). Included in the Inquiry’s list of recommendations is to secure at least seven years of funding to ANROWS to continue their research work, an accomplishment for the feminist research organisation (FPARC, 2015 , p. ix).

The response of the Senate Committee does not show support for the arguments of gender symmetry and the CTS measure. It does not suggest that violence in families is largely mutual or gender symmetrical, and refers constantly to the work of gender-sensitive organisations ANROWS and Our Watch. This demonstrates the contribution of feminist advocates and feminist researchers to domestic and family violence debates in Australia. As described in the introduction, the feminist perspective encourages examination of the gendered contexts of evidence, and leads us to question the perceived legitimacy of evidence in the view of policy makers, who often define the boundaries of a policy problem (see Bacchi, 1999 ; Carson and Edwards, 2011 ). In the case of the gender symmetry debate in Australia, feminist advocacy organisations and committee members ensured that the claims of One in Three and the CTS measure were scrutinised in order to highlight a framing of domestic and family violence that takes the context of violent events into consideration. In line with Anderson’s ( 2004 ) advocated approach, ANROWS showed that their evidence is more legitimate than the CTS based evidence because it is theory-driven and has better explanatory power in accounting for the gender dynamics at play. The success of this strategy is shown through the recognition that the people most vulnerable to domestic and family violence in Australia are women, especially Indigenous women, women with disability and women from culturally and linguistically diverse backgrounds.

We have outlined common critiques of EBP, and presented a feminist informed account of the role of advocacy in the evidence and policy interface. We drew on seminal texts in public policy and feminist literature to form a theoretical basis that highlights i) the importance of evidence that is sensitive to gendered contexts and ii) the importance of normative arguments in EBP. Feminist thought calls critical attention to the structure and nature of gendered power relations (Kelly, 2000 ) as well as the performance of gender in social situations (Butler, 1988 ) and as such the gendered context of policy problems remains a central concern for feminist critiques of evidence and policy. To illustrate this, we examined how feminist researchers have interacted with a problematic measure of intimate partner violence (the CTS) that is both widely used and widely critiqued, and is often employed to support arguments about ‘gender symmetry’ in intimate partner violence. Feminist advocate researchers have worked to discredit the CTS and gender symmetry arguments, to ensure that policymaking draws upon a more richly contextualised understanding of intimate partner violence. This is not simply a case of choosing the ‘right’ sort of evidence to draw on in the formation of policy; the case of feminist engagement with intimate partner violence research demonstrates that feminist researchers strive to be sensitive to power and context, are explicitly normative, and produce evidence that is theory-driven rather than the ‘abstracted empiricism’ that is common to much positivist research (Anderson, 2004 ; DeKeseredy, 2016 ; 2017 ; Goldenberg, 2015 ).

It would not have been enough for feminist researchers to simply present an alternative measure to the CTS. The accumulation of ‘more’ evidence or ‘alternative’ facts necessarily fails to explain to policy makers how to make decisions and why to act on policy issues (Crammond and Carey, 2017 ). In the case of intimate partner violence, feminist researchers could not simply present a different measure such as Dobash and Dobash’s ( 2004 ) context-sensitive measure of intimate partner violence without accompanying their evidence with normative arguments about the value of treating intimate partner violence as a gendered issue. Simply supplying or pointing out the alternative measure would fail to convince policy makers why they should consider the CTS measure as discredited, why they should consider intimate partner violence to be a gendered issue, and why they should make policy accordingly. The combination of the use of normative arguments alongside the presentation of more accurate measures of intimate partner violence (Dobash and Dobash, 2004 ) is what has progressed the conversation on intimate partner violence towards gender and context sensitivity in the evidence and policy interface. Importantly, the reason that studies based on the Dobash and Dobash ( 2004 ) measure are more accurate and constitute better evidence of intimate partner violence is because of their legitimate use of gender informed values (and theory) to reach more contextually informed conclusions (Anderson, 2004 ).

The use of evidence by researchers who employ the CTS measure and the gender symmetry argument matches Parsons general observations about the ‘hierarchy of evidence’ approach to EBP: their aim is “to de-politicise and managerialise knowledge production and its utilisation” (Parsons, 2002 , p. 56) in the debate, while also de-emphasising the importance of gendered contexts in the presentation of evidence regarding intimate partner violence. In contrast, feminst advocates draw attention to the shortcomings of the CTS measure by critiquing it both theoretically and empirically, and through the development of measures that do collect gender contextual evidence about incidents of intimate partner violence (DeKeseredy, 2017 ; Walby and Myhill, 2017 ). Feminist advocates used a gendered analysis to politicize the use of the CTS measure, allowing for critique of its use to support the gender symmetry argument in policy formation and implementation. In this way, we see that feminist advocate organisations are able to work against the silencing of dissent identified in Davies ( 2003 ) and attempt to widen the boundaries around what is considered to be legitimate knowledge for policymaking (Bacchi, 1999 ).

As highlighted in the introduction, from a feminist standpoint perspective (Wylie, 1987 ; Harding, 1987 ) the political tussle over what evidence is considered to be relevant for policy formation should be informed by knowledge relevant to those in subordinate positions of power, such as the targets of intimate partner violence (who, research shows, are more likely to be women). We examined the strategy of feminist organisation ANROWS in addressing and countering a narrative of gender symmetry in the Senate inquiry into domestic violence in Australia. This case illustrates that the combination of normative arguments and the gendered politicisation of evidence can be used to convince policymakers that certain quantitative measures are not reliable, and that resources to care for victims of domestic violence should be focussed on the women, and particularly the most vulnerable populations of women, in Australia. Other recent Australian commissions of inquiry (e.g., the Victorian Royal Commission into Family Violence and the Special Taskforce on Domestic and Family Violence in Queensland) have since reiterated the problem framing of domestic and family violence (of which intimate partner violence is the most common form) as primarily perpetrated by men against female partners and their children. This is thanks in large part to the work of committed feminist advocate researchers who refuse to accept that evidence can or should be decontextualised or depoliticized.

Feminist theorists and practitioners draw attention to the importance of anticipating and applying a feminist understanding to both policy formation and outcomes by using multiple levels of analysis, such as individual, collective and structural, as well as analysing differential impacts across intersecting axes including gender, race, sexuality, ability, and religion among others. Doing so can reveal additional layers of complexity that may otherwise be overlooked. Whilst all violence is wrong, regardless of the sex of the perpetrator, there are distinct gendered patterns in the perpetration and impact of violence. Work by critical feminists, practitioners, and men and masculinities scholars has shown that there may be similarities between male and female perpetrated violence, but they are not the same, because the causes, dynamics and outcomes of violence against women are different from those of violence against men (Yates, 2018 ; Read-Hamilton, 2014 ; Kelly, 2000 ). For example, men may fear and suffer violence from predominantly other men and some individual women, whereas women tend to face more widespread violence, both individually and structurally (Kelly, 2000 ; Kilmartin and Allison, 2007 ). The ability to interrogate policy framings and outcomes using different levels of analysis is necessary to ensure that we achieve more politically informed and context-specific understandings of policy ‘problems’ and proposed ‘solutions’.

In the introduction to this piece we made a distinction between ‘evidence hierarchy’ approaches to EBP which downplay politics and context, and a politically and contextually informed approach to thinking about EBP. The case of feminist engagement with the CTS provides an example of a gender political and contextually informed approach to EBP. Specifically, feminist researchers engaged with questions of the legitimacy of evidence. Their approach is an example of the ‘open inquiry’ that is espoused by Anderson and other feminist empiricists that consider evidence to always be value-laden, and that value-laden evidence can be used in legitimate or illegitimate ways (Anderson, 2004 ). We claim that the case of the CTS aligns with Anderson’s approach to evidence production; feminist researchers questioned the validity of the evidence that was being produced in intimate partner violence research because of their concerns about the gendered contexts of intimate partner violence. Through their value-laden motivations, and their articulation of these values, they have created a more contextualised understanding of what might be considered to be legitimate or ‘gold standard’ evidence when considering intimate partner violence. We have shown that feminist theory and practice in the combination of evidence in policymaking emphasises the need for contextualised, theory driven approaches to the policy evidence, and the importance of normative arguments when advocating for policy change. In the words of Anderson:

“Value judgments guide inquiry toward the concepts, tools, and procedures it needs to answer our value-laden questions. But facts – evidence – tell us which answers are more likely to be true. These two roles must be kept distinct, so that inquiry does not end up being rigged simply to reinforce our evaluative preconceptions” (Anderson, 2004 , p. 23).

We can recall, for the final time, the baguette incident: While it is a fact that Sophie injured her male partner with a baguette, it is clear that the injury did not occur in malice but in jest and accident, highlighting the importance of understanding the context of violent incidents in our attempts to measure them.

Data availability

Data sharing not applicable as no datasets were analysed or generated.

Cognitive interviewing involves asking participants to complete a survey and then interviewing them about their answers.

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Malbon, E., Carson, L. & Yates, S. What can policymakers learn from feminist strategies to combine contextualised evidence with advocacy?. Palgrave Commun 4 , 104 (2018). https://doi.org/10.1057/s41599-018-0160-2

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• J Eat Disord

The effectiveness of a feminist-informed, individualised counselling intervention for the treatment of eating disorders: a case series study

Jessica tone.

1 School of Public Health and Social Work, Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD 4059 Australia

Belinda Chelius

2 Eating Disorders Queensland, 51 Edmondstone Street, South Brisbane, QLD 4101 Australia

Yvette D. Miller

Associated data.

The de-identified data supporting the results of this study may be available on reasonable request to the corresponding author, subject to agreement from EDQ as the data custodian.

Currently, there is limited empirical validation of feminist-informed or individualised interventions for the treatment of eating disorders. The aim of this study was to examine the effectiveness of a feminist-informed, individually delivered counselling intervention for the treatment of eating disorders at a community-based eating disorder treatment service.

Eighty individuals aged between 17 and 64 years presenting to an outpatient eating disorder service were examined in a case series design at baseline, session 10, session 20 and end of treatment (session 30). Changes in eating disorder symptomology, depression, anxiety, stress, and mental health recovery over the course of treatment were examined in linear mixed model analyses.

The treatment intervention was effective in reducing eating disorder symptomology and stress and improving mental health recovery after 10 sessions in a sample of 80 eating disorder participants engaged with the treatment service. Reductions in eating disorder symptomology and stress and improvements to mental health recovery were maintained at session 20 and session 30.

Conclusions

The findings of this study provide preliminary support for feminist-informed and individualised interventions for the treatment of eating disorders in community-based settings.

Plain English Summary

Eating disorders can result from a variety of factors including previous trauma and sociocultural influences. Critical feminist perspectives acknowledge these influences are core contributing factors to the development and maintenance of eating disorder behaviours and postulate the exploration of the eating disorder in relation to these wider factors as crucial to the treatment process. Therefore, treatment interventions that utilise feminist frameworks and approaches that are integrative of a variety of psychological therapies to suit individual needs may be useful to address underlying factors while also managing eating disorder behaviours. However, there have been few experimental studies that have evaluated these interventions. This article aims to address this gap in current eating disorder literature by describing and evaluating the effectiveness of a counselling therapy for eating disorders that employs feminist practice and a variety of psychological therapies. The results indicate that eating disorder symptoms, stress, and mental health recovery improved after 10 sessions of the counselling intervention for a sample of 80 participants receiving eating disorder treatment. The results from this study provide initial evidence for the usefulness of feminist-informed practice and individualised counselling interventions for the treatment of eating disorders.

Eating disorders (EDs) are characterised by persistent disturbances in eating-related behaviours and attitudes, often occurring alongside body image concerns and overvaluations of body shape and weight [ 1 ]. Eating disorders are increasingly recognised as important causes of morbidity and mortality, associated with medical and psychiatric comorbidities [ 1 , 2 ], social and physical functional impairment, reduced quality of life [ 3 , 4 ], and an increased risk of all-cause and suicide mortality [ 5 – 7 ]. The aetiology of ED symptomology is complex and multifaceted, resulting from interactions between sociocultural, environmental, psychological, and biological factors [ 8 , 9 ]. The clinical presentations, sociocultural and environmental experiences, as well as social demographics of people who experience disordered eating behaviours vary greatly [ 10 , 11 ]. Moreover, adding to the complexity of EDs, traumatic environmental factors such as physical, sexual, and emotional childhood maltreatment have been associated with ED symptomology, with estimated prevalence of childhood maltreatment of 17–46% [ 12 ] and 19% of any traumatic event [ 13 ] in ED samples. In this regard, ED behaviours may emerge as maladaptive coping mechanisms to deal with distress caused by traumatic life experiences [ 14 , 15 ].

Integrative and individualised treatment approaches

Given the complexity of and variability within EDs, individualised treatment approaches ensure treatment interventions meet the needs of the individual and address both ED behaviours and the causal and maintaining factors [ 15 ]. Current practice standards and guidelines emphasise personalised implementation of evidence-based practices [ 16 ]. Evidence-based practice refers to the integration of empirically supported research, clinical expertise, and stakeholder perspectives in the context of patient characteristics, culture, and preferences [ 17 , 18 ]. Empirically supported psychotherapies for EDs include cognitive behavioural therapy (CBT), ED focused enhanced CBT (E-CBT), family-based therapy, and interpersonal psychotherapy (IPT) [ 16 , 19 , 20 ]. There is emerging evidence for the efficacy of other psychotherapies, including dialectical behavioural therapy (DBT) and acceptance and commitment therapy (ACT) [ 21 – 23 ]. The highly manualised psychotherapies implemented in clinical trials are known to be less rigorously implemented in terms of fidelity in community environments [ 24 ]. A large proportion of ED community practitioners report implementing integrative psychotherapeutic approaches (i.e., integrating multiple approaches or psychotherapies) [ 24 ]. This may reflect the substantial variations in ED patients presenting for treatment, including in ED symptomology, psychiatric comorbidities and the underlying issues contributing to their EDs [ 11 , 25 ].

Despite their widespread use there is a lack of empirical evidence describing individualised or integrative counselling interventions for community ED treatment and the effectiveness of such approaches. The limited evidence that does assess such approaches has primarily focused on inpatient and intensive day programs. For example, an intensive day program in an American ED treatment centre has been evaluated in three studies [ 17 , 26 , 27 ]. The treatment intervention offered an individualised counselling framework integrating CBT and psychodynamic frameworks with other psychotherapies including ACT, DBT, IPT, gestalt therapy, and body image therapy, completed alongside a multimodal treatment delivery of group therapy, individual therapy, family therapy, and dietetic support. Comparing pre- and post-treatment scores of participants who completed the intensive outpatient day program or partial hospitalisation program, all three studies demonstrated statistically significant decreases in ED symptomology and depression following treatment in three samples of ED patients who on average remained in the program for 13 weeks.

While these studies provide preliminary empirical evidence for the effectiveness of individualised and flexible treatment programs, to our knowledge there remains a lack of studies describing and assessing individualised counselling interventions implemented in less-intensive, community-based facilities. Furthermore, there is limited up-to-date evidence published in the last 5-years, with two of the abovementioned studies published over a decade ago. Evaluating community-based treatment programs will offer insight into the effectiveness of treatment interventions that are currently implemented for the treatment of EDs in widely accessed community treatment centres. This is important to offer insight into how empirically supported, evidence-based practices are operationalised in real-world treatment settings.

Feminist frameworks for eating disorders

The aetiology of EDs and the factors that maintain ED behaviours need to be considered for the implementation of personalised treatment interventions. Feminist perspectives postulate social, cultural, political, and environmental factors as core aetiological features of EDs [ 28 – 31 ]. These approaches differ from biomedical models in that the development and maintenance of ED symptomology is examined in relation to wider sociocultural influences instead of individual pathology [ 32 ]. Theoretical feminist models have considered the influences of cultural discourses of thinness idealisation, family, peer, and media ideologies of bodies, restricted agency in relation to gender experience, experiences of objectification, harassment, or assault, and intersections with political structures of power and oppression related to gender, race, cultural background, sexuality, and class [ 28 , 29 , 31 , 33 – 36 ]. In this regard, EDs are viewed not just as eating disturbances and body image problems, but as complex responses to environmental, sociocultural, and political stressors [ 30 ].

There is a growing empirical foundation supporting sociocultural and environmental factors as aetiological features of EDs [ 12 , 13 , 29 , 31 , 37 – 39 ]. Feminist and sociocultural perspectives have contributed to the basis of several prevention programs targeted at the sociocultural influences impacting eating behaviours and body image [ 29 , 40 ]. Nonetheless, a focus on individual pathology remains at the forefront of clinical ED interventions [ 41 ]. While a great deal has been written about EDs from feminist and sociocultural perspectives, these frameworks have seen minimal translation into contemporary ED treatment [ 31 , 41 ]. This may be due to the emphasis placed on the implementation of evidence-based practices [ 16 , 42 ], and the current lack of empirical validation for the value of feminist frameworks in ED treatment contexts [ 43 ].

The integration of feminist frameworks with evidence-based psychotherapies have been proposed in several treatment models [ 43 – 45 ]. These models aim to incorporate key aspects of feminist therapy, including exploration of wider aetiological factors, client empowerment, and promotion of egalitarian therapeutic relationships. Psychotherapies such as CBT, DBT, and IPT are used to develop alternative coping strategies, reduce ED behaviours, and improve interpersonal relationships [ 43 – 45 ]. Anecdotally, the implementation of psychotherapies underpinned by a feminist framework provides a treatment model capable of addressing the complexity of ED presentations that moves away from the dominant biomedical model of individual pathology. However, the effectiveness of these models has not been empirically substantiated. Empirical examination of such a model will offer both critical insight into alternative treatments for EDs and contribute to decreasing the empirical gap between sociocultural and biomedical paradigms [ 32 ].

Aims and objectives

Given the scarcity of empirical examination of both individualised and feminist-informed ED treatment interventions, the aim of the current study was to examine the effectiveness of a feminist-informed and individualised counselling intervention for the treatment of EDs. Eating Disorders Queensland (EDQ) is a state-wide, outpatient ED treatment service located in Brisbane, Australia. Their treatment services are underpinned by a feminist perspective, offering an alternative approach to the biomedical model in a non-clinical, community-based environment. The individual counselling frameworks are inclusive of feminist practice, employing an integrative psychotherapeutic approach and individual tailoring of treatment programs. The primary objective of this study was to evaluate the impact of this service model on the trajectory of ED treatment and recovery outcomes in a clinical sample of participants engaged in ED counselling.

Design and procedure

This retrospective observational case series study was conducted using de-identified participant data collected by EDQ as part of routine practice from July 2018 to May 2021. As part of EDQ’s intake process, all participants who engage with the service give written consent for the use of their de-identified outcome measurements and unidentifiable demographic data for research purposes, including the use of aggregated results in published research. Due to the retrospective nature of the study, participants were not given information specific to this research at the time of consenting. However, all participants who engage with EDQ’s services are given information about the opportunity to modify or withdraw consent at any time. No participants included in this study modified or withdraw their consent over the course of their treatment. Self-report outcome measures were administered by EDQ prior to the initial counselling session (pre-treatment/baseline) and then at approximately 10-session intervals in single-group, longitudinal design. Measures were electronically administered to participants via email and completed in their own time. Outcomes of interest were changes in continuous measures of ED symptomology, common co-occurring negative emotional states (depression, anxiety, stress) [ 2 ], and mental health recovery over the course of treatment.

Treatment intervention

The treatment intervention comprised up to 30 individual counselling sessions completed at an individualised rate according to participants’ needs. The total number of sessions completed also varied between participants and was determined based on a variety of factors such as ED presentation, severity, and underlying factors or trauma. As EDQ is a state-wide service, counselling sessions were carried out either face-to-face or via telehealth (over the telephone or Zoom/Microsoft Teams) for participants who resided outside of the region for accessible face-to-face delivery. Due to the Coronavirus Disease 2019 (COVID-19) pandemic, all treatments were offered via telehealth between March 2020 and August 2020. Counselling interventions were performed by EDQ’s clinical practitioner team, comprising psychologists, counsellors, and social workers.

The counselling intervention was underpinned by a feminist framework, shifting focus from individual pathology to broader sociocultural and environmental influences. This included examining the precipitating and maintaining factors of each participant’s ED through a biopsychosocial lens and tailoring treatment to further explore identified factors in relation to the ED behaviours. In treatment, the traditional focus on numbers regarding body weight and food was shifted to exploring the participant’s experience of an ED, considering social, political, and environmental impacts. Practitioners focused on building a strong therapeutic alliance through key aspects of feminist-informed practice, including client empowerment, providing information for collaborative and informed decision making, clear communication and transparency, co-creating a safe and supportive environment, and reducing power differentials within the therapeutic relationship. In line with both feminist and person-centred practice, each individual participant was placed at the centre of their treatment, with practitioners taking value from the lived experience to recognise the skills, strengths, expertise, and knowledge that individuals bring to their own lives [ 46 ].

The course of treatment typically followed an initial focus on the management and intervention of ED behaviours, followed by the identification and exploration of underlying causes and trauma through trauma-informed and feminist frameworks. A range of empirically supported and emerging psychotherapies were integrated into treatment plans to suit individual participant needs and goals in line with evidence-based practice, including CBT, DBT, ACT, narrative therapy, and expressive therapies. The use of psychotherapies varied between individual treatment plans and was based on the clinical judgement of the treating practitioner, the identified precepting and maintaining factors, and the therapeutic needs of individual participants identified through intake assessments and throughout the course of treatment. Practitioners aimed to create opportunities for participants to recognise and validate the negative experiences or trauma that the ED may have assisted in coping with, while supporting participants to implement alternative coping strategies and enhance capacity to seek support within relationships. Participants were also supported to undergo external clinical management of physical symptoms with a general practitioner (GP), through Specialist Supportive Clinical Management (SSCM) to ensure the medical comorbidities that can coincide with EDs were managed. Detailed information about the treatment approach and practice framework is available elsewhere [ 46 , 47 ].

Participants

De-identified scores on outcome measures, age, gender, and dates of measurement completion were provided by EDQ for all participants who attended an initial counselling session at EDQ for an ED or disordered eating between July 2018 and December 2020. Participant data was de-identified by EDQ by removing participant names and other identifying details such as date of birth from the data set. All participants self-referred to the treatment service. A formal ED diagnosis was not required to access treatment services at EDQ nor applied as an inclusion criterion for this study. Participants were not included in the study if they had commenced counselling at EDQ during this period but were determined to be still engaged with EDQ’s individual counselling intervention and had completed less than 10 sessions of treatment by May 2021. All other participants who commenced treatment during this time were assessed against further inclusion criteria of: (1) at least one follow-up measure after baseline and (2) had a baseline measure of ED symptom severity (Eating Disorder Examination Questionnaire [EDE-Q] Global score). Of the 111 participants identified during the first inclusion stage, 80 (72.1%) met further inclusion criteria and had adequate follow-up data for analyses. Figure  1 shows the study sample flow through the treatment service.

Participant flow through treatment

Outcome measures

Eating disorder symptomology.

The Eating Disorder Examination Questionnaire (EDE-Q) [ 48 , 49 ] is a self-reported derivative of the Eating Disorder Examination Interview (EDE) [ 50 ]. It is a 28-item measure of ED psychopathology commonly used to assess changes in ED symptomology over the course of treatment. Twenty-two of the 28 Items are scored on a 7-point, Likert scale (range = “0” to “6”), with respondents asked to rate the frequency or impact of key ED behaviours and psychological features over the past 28-days. Four subscale scores: Restraint (5 items); Eating Concern (5 items); Shape Concern (8 items); and Weight Concern (5 items; 1 item repeated from Shape Concern), and a global score are derived from these 22 items, ranging between 0 and 6. Higher scores are indicative of greater severity. The subscale and global scores of the EDE-Q have previously been shown to have acceptable internal consistency, discriminant validity, and to be a valid measure of ED symptomology [ 51 , 52 ]. In this study, Cronbach’s α values at each timepoint for the Restraint, Eating Concern, Shape Concern and Weight Concern subscales and the EDE-Q Global score ranged between 0.81 and 0.90, 0.60–0.75, 0.89–0.92, 0.81–0.86, and 0.85–0.90 respectively. Behavioural frequency items of the EDE-Q were not utilised in the current analysis as they do not contribute to subscale or overall scores.

Depression, anxiety, and stress

The Depression Anxiety Stress Scales (DASS-21) is a self-reported measure of negative emotional states. It is a short form of the original 42-item DASS [ 53 ] and consists of 21 items that form three, 7-item scales corresponding to depression, anxiety, and stress. Respondents are asked to rate the extent to which they have experienced symptomology of depression, anxiety, and stress over the past 7-days on a 4-point rating scale (range = “0” to “3”). Higher scores indicate greater experiences of symptomology (scale score range = 0 to 42). The DASS has acceptable internal consistency and convergent and discriminate validity and has been demonstrated as a valid measure of routine clinical outcomes [ 54 – 56 ]. In this study, the Cronbach’s α values for each timepoint ranged between 0.90 and 0.95 for the depression scale, 0.80–0.89 for the anxiety scale, and 0.81–0.88 for the stress scale.

Mental health recovery

The Recovery Assessment Scale–Domains and Stages (RAS-DS) [ 57 ] is a self-reported measure of mental health recovery. It consists of 38 items that are rated on a 4-point Likert scale (range = “1” to “4”). In addition to a total recovery score (range = 38 to 152), the RAS-DS generates four subscales that correspond to different recovery domains: Doing Things I Value (6 items; range = 6 to 24); Looking Forward (18 items; range = 18 to 72); Mastering My Illness (7 items; range = 7 to 28); and Connecting and Belonging (7 items; range = 7 to 28). Higher scores indicate better recovery. The RAS-DS has acceptable internal consistency and construct validity and has been demonstrated to be sensitive to changes in recovery over time [ 58 , 59 ]. In this study, Cronbach’s α values at each timepoint for the Doing Things I Value, Looking Forward, Mastering My Illness, and Connecting and Belonging subscales and the RAS-DS total score ranged between 0.77 and 0.85, 0.87–0.94, 0.73–0.91, 0.69–0.85, and 0.90–0.97 respectively.

Missing data

Eating disorder examination questionnaire.

Subscale scores were calculated if the number of missing items for a subscale were not less than half the total number of items corresponding to that subscale, following methods recommended by Fairburn and Cooper [ 60 ]. Global scores were calculated when there were at least two of the four subscale scores available.

Depression anxiety stress scales

Scale scores on the DASS-21 were calculated if participants had at least six items of the 7-item scale. Where participants had six of the 7-items, the missing item was imputed as the average of the remaining six scale items before the scale score was calculated.

Recovery assessment scale–domains and stages

Subscale scores on the RAS-DS were calculated if participants had at least half of the items within a subscale. Where participants were missing only selected items but not more than half of the items on any subscale, missing raw scores were imputed as the average from the available items before the subscale score was calculated, consistent with methods used by Hancock and colleagues [ 58 ]. There were no instances where missing items or subscale scores impacted the calculation of the total score.

Statistical analysis

All analyses were performed using IBM SPSS Statistics (version 27). To determine the effect of the intervention, separate linear mixed models (LMMs) were constructed for each continuous outcome variable. Each model was fitted with fixed effects of time in treatment (ordinal; 1 (referent) = baseline, 2 = session 10, 3 = session 20, 4 = session 30) and the EDE-Q global score at baseline to control for variations in ED symptom severity at baseline (continuous). Random effects were specified in all LMMs with a random intercept for subject and a scaled identity covariance structure. The restricted maximum likelihood (REML) estimation was used for all models. Satterwaite approximation was used to compute degrees of freedom. All main effects were considered statistically significant at an alpha level of p  < 0.05. To examine outcome trajectory, significant main effects of time in treatment were further examined using pairwise comparisons between timepoints. Pairwise comparisons were considered statistically significant at an alpha of p  < 0.01 to reduce type I error associated with multiple comparisons. Results are presented as the mean ( M ) change with 99% confidence intervals (99% CI) over the course of treatment.

Sample characteristics

The sample included 80 participants who ranged in age at baseline between 17- and 64- years ( M  = 30.24 years, SD  = 12.29 years). Seventy-three participants identified as female (91.2%) and seven identified as male (8.8%). The average treatment time-period between baseline and session 10 was 117.55 days ( SD  = 59.86 days); between session 10 and session 20 was 122.73 days ( SD  = 55.31); and between session 20 and session 30 was 153.94 days ( SD  = 53.76). After session 10, one participant completed their treatment program (1.3%), 17 participants had not yet reached their 20th session (21.3%), and 10 participants were lost to follow-up (I.e., did not fill out subsequent outcome measures) (12.5%). At session 20, 52 participants in the sample had outcome measures (65%). After session 20, one participant had completed their treatment program (1.3%), 10 participants had not yet reached their 30 th session (12.5%), and nine were lost to follow-up (11.3%). Thirty-two participants in the final sample had outcome measures at session 30 (40%) (see Fig.  1 ).

Outcome analyses

Means and standard deviations for all outcomes at each timepoint are described in Table ​ Table1. 1 . A significant main effect of time in treatment was observed for the EDE-Q global score ( F (171.26) = 25.65, p  < 0.001) and four subscales: Restraint ( F (160.51) = 23.10, p  < 0.001), Eating Concern ( F (11.40) = 165.20, p  < 0.001), Shape Concern ( F (164.64) = 15.89, p  < 0.001), and Weight Concern ( F (163.80) = 11.09, p  < 0.001), when controlling for ED symptom severity (EDE-Q global score) at baseline. Significant main effects of time in treatment were due to significant reductions in EDE-Q global score and all subscales at session 10, session 20, and session 30, in comparison to baseline (see Table ​ Table2). 2 ). Pairwise comparisons indicated that there were no significant changes between session 10, session 20, and session 30 (across all possible comparisons) for all EDE-Q outcomes (Table ​ (Table2 2 ).

Means and standard deviations for outcomes over the course of the treatment intervention

EDE-Q eating disorder examination questionnaire, RAS-DS recovery assessment scale–domains and stages

Mean change over the course of the treatment intervention

* p  < .01

a Mean change adjusting for ED severity at baseline as estimated by linear mixed models

A significant main effect of time in treatment was observed for anxiety ( F (151.41) = 10.76, p  < 0.001) and stress ( F (159.40) = 6.56, p  < 0.001), but not for depression ( F (153.68) = 2.60, p  = 0.054), when controlling for ED symptom severity at baseline. Significant main effects of time in treatment on anxiety were due to significant reductions at session 10 and session 20 in comparison to baseline. However, the mean anxiety score at session 30 was not significantly different in comparison to baseline scores, indicating a J-shaped trend between baseline and session 30 (Table ​ (Table2). 2 ). Significant main effects of time in treatment on stress were due to significant reductions at session 10, session 20, and session 30, in comparisons to baseline. Pairwise comparisons indicated that there were no significant changes in anxiety or stress between session 10, session 20, and session 30 (across all possible comparisons) (Table ​ (Table2 2 ).

A significant main effect of time in treatment was observed for the RAS-DS total score ( F (151.97) = 12.89, p  < 0.001) and subscales: Looking Forward ( F (153.07) = 6.46, p  < 0.001), Mastering My Illness ( F (156.54) = 27.89, p  < 0.001), and Connecting and Belonging ( F (149.55) = 3.59, p  = 0.015), but not for the Doing Things I Value subscale ( F (151.23) = 1.42, p  = 0.238), when controlling for ED symptom severity at baseline. Significant main effects of time in treatment on the RAS-DS total score and Looking Forward and Mastering My Illness subscales were due to significant increases at session 10, session 20, and session 30, in comparison to baseline. Pairwise comparisons indicated that there were no significant changes between session 10, session 20, and session 30 (across all possible comparisons) on both the RAS-DS total score and Looking Forward subscale (Table ​ (Table2). 2 ). However, a further significant mean increase of 2.38 (99% CI: 0.70, 4.06, p  < 0.001) on the Mastering My Illness subscale was observed between session 10 and session 30. There were no significant changes between session 10 and session 20, nor between session 20 and session 30 on the Mastering My Illness subscale. Significant main effects of time in treatment on the Connecting and Belonging subscale were due to significant increases at session 30 in comparison to baseline. There were no other significant changes observed between timepoints on the Connecting and Belonging subscale (Table ​ (Table2 2 ).

This study aimed to describe the effectiveness of a feminist-informed and individualised counselling intervention for EDs, delivered in an outpatient community-based setting. The results indicated that for the current sample, an individualised counselling intervention underpinned by a feminist framework may be effective in reducing ED symptomology within the first 10 sessions, over approximately 18 weeks. The greatest change in outcomes occurred during the first 10 sessions of treatment. The reductions observed in the ED symptomology during the initial stages of treatment are promising, with previous evidence suggesting that early response to ED treatment is associated with better ED symptomology outcomes [ 61 ]. There were no further significant changes observed beyond session 10 for ED symptomology outcomes in this study. However, improvements observed during the initial 10 sessions were maintained at later timepoints, indicating a significant reduction in ED symptomology at the conclusion of treatment. The reductions in anxiety observed at session 10 were maintained at session 20. However, improvements in anxiety were not maintained further, with mean anxiety scores over the full course of the treatment intervention following a J-shaped trend. We observed no change in depression over the course of treatment. Future consideration should be made to include additional follow-up timepoints to explore long-term treatment trajectories in relation to the observed early improvements to ED symptomology and to explore the long-term course of the J-shape trend we observed in anxiety scores.

Overall mental health recovery improved within 10 sessions. There were further improvements observed between session 10 and session 30 on the Mastering My Illness RAS-DS subscale, which reflects the patient’s sense of “control over, or management of, any residual symptoms” [ 57 , p.7]. The Connecting and Belonging RAS-DS subscale, measuring interpersonal relationships, social functioning, and societal participation, was not observed to change until session 30. Both results suggest that the full length of the treatment intervention, which allocated a larger focus on addressing the underlying factors or trauma contributing the ED, was important for improving aspects of recovery-orientated change. Eating disorder recovery should not only defined by the reduction of ED signs and symptoms [ 62 ]. Feminist-informed practice places emphasis on shifting the focus from signs and symptoms to patient experience [ 29 ]. Thus, exploration of recovery-orientated measures (e.g., the RAS-DS) are important when considering the effectiveness of ED treatment interventions and the value of feminist frameworks. The inclusion of a recovery-orientated measure in the present study extends on previous evaluation of individualised ED treatment interventions [ 17 , 26 , 27 ] that have solely focused on outcomes of ED and psychiatric symptom measurement, by demonstrating the value of an integrative, feminist-informed intervention for both reducing ED symptomology and improving features of mental health recovery. Supplementary qualitative outcome measures in future research would significantly add to the evaluation of feminist-informed ED treatment in assessing recovery-orientated impacts.

The observed reductions in ED symptomology are broadly comparable to previous studies by Schaffner and colleagues [ 17 , 26 ] and Freudenberg and colleagues [ 27 ] reporting the effects of individual, multimodal treatment interventions implemented in observation studies, in that ED symptomology was observed to reduce from pre-test to post-test. However, the delivery of the current intervention was less intensive at approximately one session per fortnight, in comparison to a minimum of one session per week and up to three sessions per day in previous studies [ 17 , 26 , 27 ]. It is important to evaluate treatment interventions outside of intensive or rigid inpatient treatment settings to ensure effective treatment is accessible to individuals who are both exiting tertiary treatment facilities and to prevent deterioration of less severe ED presentations in the community. Providing effective, ED specific community-based treatment is crucial to the Australian National Stepped Care approach, which outlines a continuum of care to ensure individuals can step up or step down the intensity of their treatment based on their current needs [ 63 , 64 ].

To our knowledge, this is the first study to evaluate the effectiveness of a feminist-informed, individual treatment intervention integrated with empirically supported psychotherapies for the reduction of ED symptomology. Theoretical feminist literature has significantly contributed to the biopsychosocial model of EDs, postulating sociocultural and relational factors as core etiological features to begin a pivotal shift in the way we think about EDs [ 65 ]. Despite this, feminist-based therapy is largely excluded from consideration as an evidence-based treatment for EDs [ 31 , 41 ]. The integration of feminist therapy through the exploration of wider sociocultural aetiological factors with psychotherapies to reduce ED behaviours and thoughts has been previously described in several treatment models [ 43 – 45 ]. The results of this study provide preliminary evidence for such models when used in community-based ED treatment settings, contributing to empirical validation of feminist treatment approaches. Ongoing evaluation of feminist treatment approaches for EDs is warranted to further substantiate this preliminary evidence and highlight the value of feminist-based perspectives in ED treatment.

The present study utilised an observational design, analysing the outcome data of participants who had undertaken treatment outside of a research setting. Effectiveness studies undertaken in systematic and dynamic environments are crucial in ensuring efficacy can be translated into real-world practice. Consequently, the preliminary findings of this study provide a basis to further substantiate ecological validity through additional evaluation. In terms of feasibility, the implementation of the intervention in a community ED treatment centre indicates that the intervention should be adaptable to other ED treatment settings. The examination of outcome trajectory allowed for identification of trends that may have otherwise been missed in a pre- to post-treatment comparison. The overall attrition rate and selection bias were also reduced by including all participants with at least one follow-up observation in outcome analyses through LMMs.

The present study is limited by an inability to compare the trajectory of outcomes with a comparison group. Future considerations should be given to comparing the treatment evaluated here against alternative treatment groups to estimate its relative effectiveness. Additionally, it remains unknown whether the 24% of clients in the final sample who were lost to follow-up completed treatment at the last recorded timepoint, completed subsequent sessions but did not complete final measures, or disengaged with the treatment service. This loss to follow up may, in part, have resulted from the data collection procedures, which required clients to complete their final outcome measures after their treatment had concluded. Consequently, it is unknown whether the clients who were lost to follow-up differed in their final outcomes of ED symptomology, psychiatric comorbidities, or recovery, and whether this impacted the completion of their final measures. Further examination into the treatment trajectory of clients who were lost to follow-up and factors related to compliance in completing measures is worth examining in future studies.

Participant characteristics could not be determined beyond age and gender identity. The clinical presentations or diagnoses of the participants and their concomitant exposure to SSCM and other additional treatment services were unknown. Identifying these characteristics in future evaluations would not only improve the generalisability of the results but allow the determination of treatment effectiveness across various ED subtypes (e.g., anorexia nervosa, bulimia nervosa, binge eating disorder) and with or without adjunct therapies. We were unable to examine differences in outcomes between treating practitioners, as the data collected on treating therapist was impacted by a data collection error. All practitioners who provided treatment in the current intervention practice under feminist and trauma-informed frameworks. Exploration of variations in treatment outcomes between different therapists should be explored in future research. Eating Disorders Queensland additionally offers subsequent treatments to individual counselling, including a variety of group therapies. Future considerations should be given to the differences between participants who engage in subsequent services and those who do not, particularly with respect to maintaining the improvements achieved, continued improvements after treatment, and incidence of relapse.

In all, individualised treatment that integrates a range of psychotherapies with a feminist framework seems to be beneficial for reducing ED symptomology and improving various features of mental health recovery when implemented in an outpatient, community-based setting. A treatment dose of 10 sessions was adequate for the reduction of ED symptomology and stress and improvement of overall mental health recovery. The present study contributes to the small body of research that supports integrative and individualised interventions as a valid intervention for the treatment of EDs. The results of this study additionally provide preliminary support for feminist-informed ED treatments, an area that is currently lacking empirical substantiation. It is crucial to continue evaluation and expansion of community-based ED treatment services to reduce ED presentations to tertiary level treatment facilities and ensure adequate treatment is available to the full spectrum of ED symptom severity. Future studies should include an additional, long-term follow-up period to further substantiate the value of integrative and feminist-informed interventions for sustained ED recovery.

Acknowledgements

We are grateful to the participants who provided the data included in this research. Thank you to the EDQ clinical team who are responsible for the collection of participant outcomes. A special thank you to EDQ practitioners Christophe Langlassé, Emma Trappett, David Langford, and Nat Scales, who provided clinical insight into the treatment intervention and assisted with retrieving participant outcome data. Thank you to Professor Michelle Gatton for statistical consultation. Thank you to Dr. Sarah Maguire and Dr. Phillip Anoud for reviewing a draft of the manuscript.

Abbreviations

Author contributions.

JT undertook a review of the literature, designed and performed statistical analyses, interpreted the results and implications, and drafted the manuscript. BC oversaw the data collection and contributed to the description of the treatment intervention, design, and procedure of the study and the clinical interpretation of results. YM oversaw the program evaluation and read and corrected all versions. All authors read and approved the final manuscript.

Authors’ Information

Belinda Chelius is a feminist senior social work clinician who holds a BA (Health Sc & Soc. Services), MSocWK degree, and an Industry Fellow of the School of Public Health & Social Work, QUT. She has practiced in the field of complex mental health, dual-diagnosis (alcohol and/or other drugs), trauma (sexual assault, domestic violence), and eating disorders for over 20-years in the non-for-profit sector.

Yvette Miller (BA(Psychology)(Honours), PhD) is an Associate Professor in Public Health at QUT with a special interest in feminist approaches to health and community service provision and evaluating services from a consumer perspective.

Jessica Tone is a recent graduate of a Master of Public health (Epidemiology and Research Methods).

Eating Disorders Queensland obtains funding from the Queensland Government to provide the individual counselling intervention evaluated in this study.

Availability of data and materials

Declarations.

Ethics approval was not sought for this research project as it was conducted as part of the ongoing quality assurance monitoring routinised at EDQ [ 66 ]. The collection of participant outcome data is coincidental to standard operating procedures at EDQ and forms part of routine clinical practice. The analyses of de-identified participant data were undertaken as part of an external program evaluation for EDQ. The analyses performed did not deviate from the purpose of which the data was obtained, and the findings reported in this study are the results of the program evaluation. All EDQ participants signed a consent form allowing the use of their participant data for research purposes before commencing treatment. There were no other triggers for ethical review as specified by the Australian National Health and Medical Research Council [ 66 ] present in the design, procedure, or analyses of the present study.

There is no individual data presented in this study. All data was de-identified before analyses were performed.

BC is the chief executive officer of EDQ. The authors have no other conflicts of interest to declare.

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Feminist Theory and Research on Family Relationships: Pluralism and Complexity

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• Published: 07 August 2015
• Volume 73 , pages 93–99, ( 2015 )

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• Katherine R. Allen 1 &
• Ana L. Jaramillo-Sierra 2  

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Feminist perspectives on family relationships begin with the critique of the idealized template of the White, middle class, heterosexually married couple and their dependent children. Feminist scholars take family diversity and complexity as their starting point, by emphasizing how power infuses all of family relationships, from the local to the global scale. As the main location for caring and productive labor, families are the primary unit for providing gendered socialization and distributing power across the generations. In this issue and two subsequent issues of Sex Roles , we have collected theoretical and empirical articles that include critical analyses, case studies, quantitative studies, and qualitative studies that focus on a wide array of substantive topics in the examination of families. These topics include variations in marital and intimate partnerships and dissolution; motherhood and fatherhood in relation to ideology and practice; intergenerational parent–child relationships and socialization practices; and paid and unpaid labor. All of the articles across the three issues are guided by a type of feminist theory (e.g., gender theory; intersectional theory; Black feminist theory; globalization theory; queer theory) and many incorporate multiple theoretical perspectives, including mainstream social and behavioral science theories. Another feature of the collection is the authors’ insistence on conducting research that makes a difference in the lives of the individuals and families they study, thereby generating a wealth of practical strategies for relevant future research and empowering social change. In this introduction, we specifically address the first six articles in the special collection on feminist perspectives on family relationships.

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Feminist Perspectives on Family Relationships: Part 3

Katherine R. Allen & Ana L. Jaramillo-Sierra

Feminism and Families

Feminist perspectives on family relationships: part 2.

Ana L. Jaramillo-Sierra & Katherine R. Allen

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• Published: 09 April 2024

Creating culturally-informed protocols for a stunting intervention using a situated values-based approach ( WeValue InSitu ): a double case study in Indonesia and Senegal

• Annabel J. Chapman 1 ,
• Chike C. Ebido 2 , 3 ,
• Rahel Neh Tening 2 ,
• Yanyan Huang 2 ,
• Ndèye Marème Sougou 4 ,
• Risatianti Kolopaking 5 , 6 ,
• Amadou H. Diallo 7 ,
• Rita Anggorowati 6 , 8 ,
• Fatou B. Dial 9 ,
• Jessica Massonnié 10 , 11 ,
• Mahsa Firoozmand 1 ,
• Cheikh El Hadji Abdoulaye Niang 9 &
• Marie K. Harder 1 , 2  

BMC Public Health volume  24 , Article number:  987 ( 2024 ) Cite this article

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International development work involves external partners bringing expertise, resources, and management for local interventions in LMICs, but there is often a gap in understandings of relevant local shared values. There is a widespread need to better design interventions which accommodate relevant elements of local culture, as emphasised by recent discussions in global health research regarding neo-colonialism. One recent innovation is the concept of producing ‘cultural protocols’ to precede and guide community engagement or intervention design, but without suggestions for generating them. This study explores and demonstrates the potential of an approach taken from another field, named WeValue InSitu , to generate local culturally-informed protocols. WeValue InSitu engages stakeholder groups in meaning-making processes which ‘crystallize’ their envelope of local shared values, making them communicable to outsiders.

Our research context is understanding and reducing child stunting, including developing interventions, carried out at the Senegal and Indonesia sites of the UKRI GCRF Action Against Stunting Hub. Each national research team involves eight health disciplines from micro-nutrition to epigenetics, and extensive collection of samples and questionnaires. Local culturally-informed protocols would be generally valuable to pre-inform engagement and intervention designs. Here we explore generating them by immediately following the group WeValue InSitu crystallization process with specialised focus group discussions exploring: what local life practices potentially have significant influence on the environments affecting child stunting, and which cultural elements do they highlight as relevant. The discussions will be framed by the shared values, and reveal linkages to them. In this study, stakeholder groups like fathers, mothers, teachers, market traders, administrators, farmers and health workers were recruited, totalling 83 participants across 20 groups. Themes found relevant for a culturally-informed protocol for locally-acceptable food interventions included: specific gender roles; social hierarchies; health service access challenges; traditional beliefs around malnutrition; and attitudes to accepting outside help. The concept of a grounded culturally-informed protocol, and the use of WeValue InSitu to generate it, has thus been demonstrated here. Future work to scope out the advantages and limitations compared to deductive culture studies, and to using other formative research methods would now be useful.

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Although progress has been made towards the SDG of ‘Zero Hunger by 2025’, the global rates of malnutrition and stunting are still high [ 1 ]. Over the past 20 years, researchers have implemented interventions to reduce undernutrition, specifically focussing on the first 1000 days of life, from conception to 24 months [ 2 ]. However, due to both differing determinants between countries [ 3 , 4 ] as well as varying contextual factors, it is clear that no single fixed approach or combination of approaches can be relied on when implementing stunting interventions [ 5 , 6 , 7 ]. Furthermore, when external researchers design interventions for local areas in Low- and Middle-Income Countries (LMICs) they can often overlook relevant local cultural factors that consequently act as barriers to intervention uptake and reduce their effectiveness, such as geographical factors and the levels of migration in certain populations [ 8 , 9 ], or social norms or perceptions relating to accepting outside help, and power dynamics related to gender [ 10 , 11 , 12 ]. The inclusion of cultural level factors in behaviour change interventions has been proposed as a requirement for effective interventions [ 13 ]. However, despite the breadth of literature highlighting the negative impacts from failing to do this, the lack of integration or even regard of local culture remains a persistent problem in Global Health Research [ 14 ], possibly hindering progress towards the SDGs. Thus, there is a need for approaches to integrate local cultural elements into intervention design.

This lack of understanding of relevant local culture, social norms and shared values also has ethical implications. The field of Global Health Ethics was predominantly developed in the Global North, in High Income Countries (HICs), embedding values common in those countries such as the prominence of individual autonomy [ 15 , 16 ]. Researchers from HICs carrying out research in LMICs may wrongly assume that values held in the Global North are universal [ 14 ] and disregard some local values, such as those related to family and collective decision making, which are core to many communities in LMICs. It is therefore important for outside researchers to have an understanding of relevant local values, culture and social norms before conducting research in LMICs so as not to impose values that do not align with local culture and inadvertently cause harm or offence [ 16 , 17 ]. The importance of this is compounded by the colonial history that is often present in relationships between research communities in HICs and LMICs, and the fact that the majority of the funding and leading institutions are still located in the Global North [ 18 , 19 ]. Thus, conscious steps must be taken to avoid neo-colonialism in Global Health Research [ 20 ]. From a health-equity perspective, it is essential to ensure that those in vulnerable communities are not hindered from involvement in interventions to improve nutrition. Encouraging uptake by such communities could be provided if salient local shared values, norms and culture were taken into account [ 21 ].

In a recent paper, Memon et al., (2021) highlight the usefulness of first creating a cultural protocol that can precede and guide subsequent stages of community engagement or intervention design to ensure that salient local values are known to external researchers coming into the community [ 16 ]. We adopt the use of the concept of a cultural protocol, referring to locally-generated guidance about key values, norms, behaviours and customs relevant to working with the local community. However, we prefer the term, ‘culturally-informed protocol’ since this relates to only cultural elements deemed salient by the researchers, and locally, rather than any comprehensive notion of culture, nor extending beyond the research context.

Memon et al. (2021), point out links between the creation of such a protocol and existing codes of practice that have already been created for some cultures such as the Te Ara Tika, a Guideline for Māori Research Ethics [ 22 ]. Currently, research and interventions in Global Health can be informed by a stage of formative research involving one-to-one interviews, focus groups or direct observations, which can sometimes be ethnographic in nature such as within Focussed Ethnographic Studies or Rapid Assessment Procedures [ 23 , 24 , 25 ]. Although these methods can be effective to inform intervention designs, they have disadvantages like: can take long periods to complete [ 26 ], can be resource intensive [ 26 ] and can lack cultural acceptability [ 27 ]. These limitations may account for the frequent neglect of their use generally, highlighted by Aubel and Chibanda (2022) [ 14 ]. Additionally, none of these methods work towards making explicit local values, or towards the creation of a culturally-informed protocol. In brief, the literature suggests a need to develop alternative methods of Formative Research for understanding locally relevant cultural elements, that are less time-consuming and can generate data that is more easily translatable to intervention design. In addition, these approaches must be applicable in different cultures. Additionally, the protocols produced must be actionable and practical not only for guiding interactions between research teams but also for guiding the initial stages of intervention design.

The work presented here aims to address several of these needs. It includes an exploration of the usefulness of the WeValue InSitu ( WVIS ) approach because that has previously been shown, in environmental management domains, to offer a way to gather in-depth values-based perspectives from a target population [ 28 , 29 ] It was first created through action research, and co-designed to enable civil society organisations to better understand and measure the values-based aspects of their work [ 30 ]. The core WeValue InSitu process (detailed in Table 1 ) involves the crystallization of shared values, with a facilitator guiding a group of participants with shared experiences, through cycles of tacit meaning-making (using a stage of photo-elicitation and triggering) [ 31 ], until they can articulate more explicitly their shared values, in concise and precise statements. These statements are then linked together in a framework by the participants. In an example case in Nigeria, the results of the WVIS approach hinted at the creation of a culturally-informed protocol through an analysis of the shared values frameworks to find cultural themes for the creation of an indicator tool that was used to evaluate several development scenarios based on their social acceptability [ 29 ].

Furthermore, it has been found that if a group of WVIS participants take part in a specialised focus group discussion (FGD), named Perspectives EXploration (PEX:FGD) immediately afterward the main workshop, then they easily and articulately express their perspectives on the topics raised for discussion - and with allusions to the shared values they had crystallised just prior. In an example from Shanghai, the PEX:FGDs focussed on eliciting perspectives on climate change, which were shown to be closely linked with the cultural themes existing within the shared values frameworks produced immediately prior [ 32 ]. In that case, the PEX:FGDs allowed the cultural themes generated during the main WVIS workshop to be linked more closely to the research question. Those results suggested that the WVIS plus PEX:FGD approach could be used to create a specialised culturally-informed protocol for improved intervention design.

In the study presented here, the WVIS approach was explored for the purpose of creating culturally-informed protocols to inform the planning of interventions within two localities of the UKRI GCRF Action Against Stunting Hub [ 33 ]. The work was carried out in two parts. Firstly, the WVIS main workshop was used to elicit cultural themes within the target communities, indicating key elements to consider to ensure ethical engagement. Secondly, the PEX focus group discussions focussed on life practices related to stunting which we explored for the purpose of tailoring the culturally-informed protocols to the specific purpose of improving the design of an example intervention. The Action Against Stunting Hub works across three sites where stunting is highly prevalent but via different determinants: East Lombok in Indonesia (estimated 36% of under-fives stunted), Kaffrine in Senegal (estimated 16% of under-fives stunted) and Hyderabad in India (estimated 48% of under-fives stunted) [ 34 ]. We propose that, the information about local shared values in a given site could be used to inform the design of several interventions, but for our specific exploration the focus here is a proposed ‘egg intervention’, in which pregnant women would be provided with an egg three times per week as supplement to their diet. This study proposes that identifying shared values within a community, alongside information about local life practices, provides critical cultural information on the potential acceptability and uptake of this intervention which can be used to generate culturally-informed protocols consisting of recommendations for improved intervention design.

In this paper we aim to explore the use of the WVIS approach to create culturally-informed protocols to guide engagement and inform the design of localised egg interventions to alleviate stunting in East Lombok, Indonesia and Kaffrine, Senegal. We do this by analysing data about local shared values that are crystallized using the WeValue InSitu ( WVIS ) process to provide clear articulation of local values, followed by an analysis of life practices discussed during PEX:FGD to tailor the culturally-informed protocols for the specific intervention design.

Study setting

This research was exploratory rather than explanatory in nature. The emphasis was on demonstrating the usefulness of the WeValue InSitu ( WVIS ) approach to develop culturally-informed protocols of practical use in intervention design, in different cultural sites. This study was set within a broader shared-values workstream within the UKRI GCRF Action Against Stunting Hub project [ 33 ]. The Hub project, which was co-designed and co-researched by researchers from UK, Indonesia, Senegal and India, involves cohorts of 500 women and their babies in each site through pregnancy to 24 months old, using cross-disciplinary studies across gut health, nutrition, food systems, micro-nutrition, home environment, WASH, epigenetics and child development to develop a typology of stunting. Alongside these health studies are studies of the shared values of the communities, obtained via the WVIS approach described here, to understand the cultural contexts of that diverse health data. In this study the data from East Lombok, Indonesia and Kaffrine, Senegal were used: India’s data were not yet ready, and these two countries were deemed sufficient for this exploratory investigation.

The WVIS approach

The WVIS approach is a grounded scaffolding process which facilitates groups of people to make explicit their shared values in their own vocabulary and within their own frames (details in Fig. 1 and activities in Table 1 ). The first stage of the WVIS is Contextualisation, whereby the group identifies themselves and set the context of their shared experiences, for example, as ‘mothers in East Lombok, Indonesia’. Subsequently, there is a stage of Photo Elicitation, in which the group are first asked to consider what is important, meaningful or worthwhile to them about their context (e.g., ‘being mothers in East Lombok, Indonesia’) and then asked to choose photos from a localised set that they can use as props to help describe their answer to the group [ 29 ]. After this, a localised Trigger List is used. This Trigger List consists of 109 values statements that act as prompts for the group. Examples of these values statements are included below but all the statements begin with “it is important to me/us that…”. The group are asked to choose which statements within the trigger list resonate with them, and those are taken forward for group intersubjective discussion. After a topic of their shared values has been explored, the group begin to articulate and write down their own unique statements of them. These also all begin with “It is important to me/us that…”. After discussing all pressing topics, the group links the written statements on the table into a unique Framework, and one member provides a narrative to communicate it to ‘outsiders’. The WVIS provides a lens of each group’s local shared values, and it is through this lens that they view the topics in the focus group discussions which immediately follow, termed Perspectives EXplorations (PEX:FGDs).

Schematic of the macro-level activities carried out during the WeValue InSitu ( WVIS ) main workshop session

This results in very grounded perspectives being offered, of a different nature to those obtained in questionnaires or using external frameworks [ 31 ]. The specific PEX:FGD topics are chosen as pertinent to stunting contextual issues, including eating habits, food systems and environments, early educational environments, and perceptions of stunting. The local researchers ensured that all topics were handled sensitively, with none that could cause distress to the participants. The data for this study were collected over 2 weeks within December 2019–January 2020 in workshops in East Lombok, Indonesia, and 2 weeks within December 2020 in Kaffrine, Senegal.

The PEX:FGDs were kept open-ended so that participants could dictate the direction of the discussion, which allowed for topics that may not have been pre-considered by the facilitators to arise. Sessions were facilitated by local indigenous researchers, guided in process by researchers more experienced in the approach, and were carried out in the local languages, Bahasa in East Lombok, Indonesia and French or Wolof in Kaffrine, Senegal.

Development of localised WVIS materials

Important to the WVIS approach is the development of localised materials (Table 1 ). The main trigger list has been found applicable in globalised places where English is the first language, but otherwise the trigger lists are locally generated in the local language, incorporating local vocabulary and ways of thinking. To generate these, 5–8 specific interviews are taken with local community members, by indigenous university researchers, eliciting local phrases and ways of thinking. This is a necessary step because shared tacit values cannot be easily accessed without using local language. Examples of localised Trigger Statements produced this way are given below: (they all start with: “It is important to me/us that…”):

…there is solidarity and mutual aid between the people

…I can still be in communication with my children, even if far away

…husbands are responsible for the care of their wives and family

…the town council fulfils its responsibility to meet our needs

…people are not afraid of hard, and even manual work

Study participants

The group participants targeted for recruitment, were selected by local country Hub co-researchers to meet two sets of requirements. For suitability for the WVIS approach they should be between 3 and 12 in number; belong to naturally existing groups that have some history of shared experiences; are over 18 years old; do not include members holding significantly more power than others; and speak the same native language. For suitability in the PEX:FGD to offer life practices with relevance to the research topic of stunting, the groups were chosen to represent stakeholders with connections to the food or learning environment of children (which the Action Against Stunting Hub refer to as the Whole Child approach) [ 33 ]. The university researchers specialising in shared values from the UK, and Senegal and Indonesia respectively, discussed together which stakeholder groups might be appropriate to recruit. The local researchers made the final decisions. Each group was taken through both a WVIS workshop and the immediately-subsequent PEX:FGD.

Data collection and analysis

Standard data output from the WeValue session includes i) the jointly-negotiated bespoke Statements of shared values, linked together in their unique Framework, and ii) an oral recording of a descriptive Narrative of it, given by the group. These were digitized to produce a single presentation for each group as in Fig. 2 . It represents the synthesised culmination of the crystallisation process: a portrait of what was ‘important’ to each stakeholder group. Separately, statements from the group about the authenticity/ownership of the statements are collected.

An illustrative example of one digitized Shared Values Framework and accompanying Narrative from a teacher’s group in East Lombok, Indonesia. The “…” refers to each statement being preceded by “It is important to us that…”

When these Frameworks of ‘Statements of Shared Values’ are viewed across all the groups from one locality (Locality Shared Values Statements), they provide portraits of ‘what is important’ to people living there, often in intimate detail and language. They can be used to communicate to ‘outsiders’ what the general cultural shared values are. In this work the researchers thematically coded them using Charmaz constructionist grounded theory coding [ 35 ] to find broad Major Cultural Themes within each separate locality.

The second area of data collection was in the post- WVIS event: the PEX:FGD for each group. A translator/interpreter provided a running commentary during these discussions, which was audio recorded and then transcribed. The specific topics raised for each group to discuss varied depending on their local expertise. This required completely separate workstreams of coding of the dataset with respect to each topic. This was carried out independently by two researchers: one from UK (using NVivo software (Release 1.3.1)) and one from the local country, who resolved any small differences. All the transcripts were then collated and inductively, interpretively analysed to draw out insights that should be relayed back to the Action Against Stunting Hub teams as contextual material.

The extracts of discussion which were identified as relevant within a particular Hub theme (e.g. hygiene) were then meta-ethnographically synthesised [ 36 ] into ‘Hub Theme Statements’ on each topic, which became the core data for later communication and interrogation by other researchers within the Action Against Stunting Hub. These statements are interpretations of participants’ intended meanings, and links from each of them to data quotes were maintained, enabling future interpretations to refer to them for consistency checks between received and intended meaning.

In this investigation, those Hub Theme Statements (derived from PEX:FGD transcripts) were then deductively coded with respect to any topics with potential implications of the egg intervention. Literature regarding barriers and facilitators to nutrition interventions indicated the following topics could be relevant: attitudes to accepting help; community interactions; cooking and eating habits; traditional beliefs about malnutrition; sharing; social hierarchies [ 12 , 37 , 38 ] to which we added anything related to pregnancy or eggs. This analysis produced our Egg Intervention Themes from the data.

The Major Cultural Themes and Egg Intervention Themes were then used to create a set of culture-based recommendations and intervention specific recommendations respectively for each locality. These recommendations were then combined to form specialized culturally-informed protocols for the egg intervention in each locality: East Lombok, Indonesia and Kaffrine, Senegal. The process is displayed schematically in Fig.  3 .

Schematic representation of the method of production of the culturally-informed protocol for each locality

The preparation of the localised WVIS materials at each site took 6 hours of interview field work, and 40 person hours for analysis. The 10 workshops and data summaries were concluded within 10 workdays by two people (80 person hours). The analysis of the PEX:FGD data took a further 80 person hours. Thus, the total research time was approximately 200 person hours.

The stakeholder group types are summarised in Table 2 . The data is presented in three parts. Firstly, the Major Cultural Themes found in East Lombok, Indonesia and in Kaffrine, Senegal are described – the ones most heavily emphasised by participants. Then, the Egg Intervention Themes and finally, the combined set of Recommendations to comprise a culturally-informed protocol for intervention design for each location. Quotations are labelled INDO or SEN for East Lombok, Indonesia and Kaffrine, Senegal, respectively.

Major cultural themes from frameworks and narratives

These were derived from the Locality Shared Values Statements produced in the WVIS .

East Lombok, Indonesia

Religious values.

Islamic values were crucially important for participants from East Lombok, Indonesia and to their way of life. Through living by the Quran, participating in Islamic community practices, and teaching Islamic values to their children, participants felt they develop their spirituality and guarantee a better afterlife for themselves and their children. Participants stated the Quran tells them to breastfeed their children for 2 years, so they do. Despite no explicit religious official curriculum in Kindergarten, the teachers stated that it was important to incorporate religious teaching.

“East Lombok people always uphold the religious values of all aspects of social life.”

“It is important for me to still teach religious values even though they are not clearly stated in the curriculum.” – Workshop 1 INDO (teachers).

“In Quran for instance, we are told to breastfeed our kids for 2 years. We can even learn about that ” – Workshop 3 INDO (mothers).

Related to this was the importance of teaching manners to children and preventing them from saying harsh words. Teachers stated that it was important to create a happy environment for the children and to ensure that they are polite and well-behaved. Similarly, mothers emphasised the need to teach their children good religious values to ensure they will be polite and helpful to their elders.

“Children don’t speak harsh words.”

“My children can help me like what I did to my parents”.

– Workshop 8 INDO (mothers).

Togetherness within families and the community

The Locality Shared Values Frameworks stressed the importance of togetherness, both within family and community. Comments mentioned it being important that people rely heavily on their family and come together in times of need to support each other and provide motivation. This was also important more broadly, in that people in society should support each other, and that children grow up to contribute to society. This was also reflected in comments around roles within the family. Despite women being primary care givers, and men working to finance the family, participants stated that they follow a process of consultation to make decisions, and when facing hardships.

“that we have the sense of kinship throughout our society”.

“We have togetherness as mothers”.

“For the family side, whatever happens we need to be able to be united as a whole family. We need to have the [sense of] forgiveness for the sake of the children” – Workshop 2 INDO (mothers).

Attitudes about extra-marital pregnancy

In East Lombok, Indonesia, it was essential to both mothers and fathers that pregnancy happened within a marriage, this was to ensure that the honour of the family was upheld and that the lineage of the child was clear. The potential danger to health that early pregnancies can cause was also acknowledged.

“If they don’t listen to parents’ advice, there will be the possibility of pre-marital pregnancy happening, which will affect the family [so much].

The affect is going to be ruining the good name, honour and family dignity. When the children [are] born outside [of] marriage, she or he will have many difficulties like getting a birth certificate [and] having a hard time when registering to school or family” - Workshop 4 INDO (mothers).

“ To make sure that our children avoid getting married at a very young age and moreover [avoid] having free sex so that they will not get pregnant before the marriage” - Workshop 9 INDO (fathers).

Kaffrine, Senegal

The Major Cultural Themes which emerged from the Kaffrine data are described below. As these are grounded themes, they are different than those seen in East Lombok, Indonesia.

Access to healthcare

A recurring theme amongst the groups in Kaffrine were aspirations of affordable and easy-to-access healthcare. Community health workers stated the importance of encouraging women to give birth in hospitals and spoke of the importance of preventing early pregnancy which result from early marriages. Giving birth in hospitals was also a concern for Public Office Administrators who highlighted that this leads to subsequent issues with registering children for school. Mothers and fathers stated the importance of being able to afford health insurance and access healthcare so that they could take care of themselves.

“That the women give birth in the hospital” – Workshop 11 SEN (CHWS).

“To have affordable health insurance ” – Workshop 10 SEN (mothers).

“To have access to health care ” – Workshop 3 SEN (fathers).

“It is important that women give birth in the hospital in order to be able to have a certificate that allows us to establish the civil status” – Workshop 9 SEN (administrators).

Additionally, Community health workers spoke of their aspiration to have enough supplements to provide to their community so as to avoid frustration at the lack of supply, and mothers spoke of their desire to be provided with supplements.

“To have dietary supplements in large quantities to give them to all those who need them, so as not to create frustration” – Workshop 11 SEN (CHWS).

Another aspect of access to healthcare, was mistrust between fathers and community health workers. Community health workers explained that sometimes men can blame them when things go wrong in a pregnancy or consider their ideas to be too progressive. Thus, to these community health workers the quality of endurance was very important.

“Endurance (Sometimes men can accuse us of influencing their wives when they have difficulties in conceiving)” – Workshop 5 SEN (CHWs).

Another recurring theme was the importance of having secure employment and a means to support themselves; that there were also jobs available for young people, and that women had opportunities to make money to help support the family. This included preventing early marriages so girls could stay in school. Having jobs was stated as essential for survival and important to enable being useful to the community and society.

“To have more means of survival (subsistence) to be able to feed our families”.

“To have a regular and permanent job”.

“We assure a good training and education for our children so that they will become useful to us and the community”.

“ Our women should have access to activities that will support us and lessen our burden” – Workshop 3 SEN (fathers).

It was considered very important to have a religious education and respect for religious elders. Moreover, living by, and teaching, religious values such as being hard working, humble and offering mutual aid to others, was significant for people in Kaffrine.

“Have an education in the Islamic Culture (Education that aligns with the culture of Islam)”.

“Respect toward religious leaders” – Workshop 3 SEN (fathers).

“ To organize religious discussions to develop our knowledge about Islam ” - Workshop 10 SEN (mothers).

“ Have belief and be prayerful and give good counselling to people ” - Workshop 4 SEN (grandmothers).

Egg intervention themes from each country from perspectives EXplorations focus group discussion data

Below are results of analyses of comments made during the PEX:FGDs in East Lombok, Indonesia and Kaffrine, Senegal. The following codes were used deductively: attitudes to accepting outside help, traditional gender roles, food sharing, traditional beliefs, social hierarchies and understanding of stunting and Other. These topics were spoken about during open discussion and were not the subject of direct questions. For example, topics relating to traditional gender roles came up in East Lombok, during conversations around the daily routine. Thus, in order to more accurately reflect the intended meaning of the participants, these were labelled food practices, under the “Other” theme. If any of the themes were not present in the discussion, they are not shown below.

Attitudes to accepting outside help

Few mentions were made that focussed on participants attitudes to accepting outside help, but participants were sure that they would not make changes to their menus based on the advice of outside experts. Additionally, teachers mentioned that they are used to accepting help from local organisations that could to help them to identify under-developed children.

“ We don’t believe that [the outsiders are] going to change our eating habits or our various menus ” – Workshop 3 INDO (Mothers).

Traditional gender roles

In East Lombok, mothers spoke about how their husbands go to work and then provide them with daily money to buy the food for the day. However, this was discussed in relation to why food is bought daily and is thus discussed below in the topics Other – Food practices.

Food sharing

In East Lombok, Indonesia, in times when they have extra food, they share it with neighbours, in the hope that when they face times of hardship, their neighbours will share with them. Within the household, they mentioned sharing food from their plate with infants and encouraging children to share. Some mothers mentioned the importance of weekly meetings with other mothers to share food and sharing food during celebrations.

“ Sometimes we share our food with our family. So, when we cook extra food, we will probably send over the food to our neighbour, to our families. So, sometimes, with the hope that when we don’t have anything to eat, our neighbour will pay for it and will [share with] us.” – Workshop 3 INDO (Mothers).

“Even they serve food for the kids who come along to the house. So, they teach the kids to share with their friends. They provide some food. So, whenever they play [at their] house, they will [eat] the same.” – Workshop 2 INDO (Mothers).

Understanding of stunting

The teachers in East Lombok were aware of child stunting through Children’s Development Cards provided by local healthcare organizations. They stated that they recognise children with nutrition problems as having no patience period, no expression, no energy for activities and less desire to socialise and play with other children. The teachers said that stunted children do not develop the same as other children and are not as independent as children who are the proper height and weight for their development. They also stated that they recognise stunted children by their posture, pale faces and bloated stomachs. They explained how they usually use the same teaching methods for stunting children, but will sometimes allow them to do some activities, like singing, later, once the other children are leaving.

“ They have no patience period, don’t have any energy to do any of the activities. No expression, only sitting down and not mingling around with the kids. They are different way to learn. They are much slower than the other kids .” – Workshop 1 INDO (teachers).

“ When they are passive in singing, they will do it later when everyone else is leaving, they just do it [by] themselves ” – Workshop 1 INDO (teachers).

Specific views on eggs

In East Lombok, Indonesia, there were no superstitions or traditional beliefs around the consumption of eggs. When asked specifically on their views of eggs, and if they would like to be provided with eggs, women in East Lombok said that they would be happy to accept eggs. They also mentioned that eggs were a food they commonly eat, feed to children and use for convenience. Eggs were considered healthy and were common in their house.

“ We choose eggs instead. If we don’t have time, we just probably do some omelettes or sunny side up. So, it happens, actually when we get up late, we don’t have much time to be able to escort our kids to the school, then we fry the eggs or cook the instant noodles. And it happens to all mothers. So, if my kids are being cranky, that’s what happens, I’m not going to cook proper meals so, probably just eggs and instant noodles.” – Workshop 3 INDO (Mothers).

Other important topics – food practices

Some detailed themes about food practices were heard in East Lombok, Indonesia. The women were responsible for buying and preparing the food, which they purchased daily mainly due to the cost (their husbands were paid daily and so provided them with a daily allowance) and lack of storage facilities. They also bought from mobile vendors who came to the street, because they could buy very small amounts and get occasional credit. The mother decided the menu for the family and cooked once per day in the morning: the family then took from this dish throughout the day. Mothers always washed their fruits and vegetables and tried to include protein in their meals when funds allowed: either meat, eggs, tofu or tempeh.

“ One meal a day. They [the mothers] cook one time and they [the children] can eat it all day long. Yes, they can take it all day long. They find that they like [to take the food], because they tend to feel hungry.” – Workshop 6 INDO (Mothers).

“ They shop every day because they don’t have any storage in their house and the other factor is because the husband has a daily wage. They don’t have monthly wage. In the morning, the husband gives the ladies the money and the ladies go to the shop for the food. ” – Workshop 4 INDO (Mothers).

In Kaffrine, the following themes emerged relating to an egg intervention: they were different in content and emphasis to Lombok and contained uniquely local cultural emphases.

Mothers were welcoming of eggs as a supplement to improve their health during pregnancy and acknowledged the importance of good nutrition during pregnancy. However, they also mentioned that their husbands can sometimes be resistant to accepting outside help and provided an example of a vaccination programme in which fathers were hesitant to participate. However, participants stated that the Government should be the source of assistance to them (but currently was not perceived to be so).

“But if these eggs are brought by external bodies, we will hesitate to take it. For example, concerning vaccination some fathers hesitate to vaccinate their children even if they are locals who are doing it. So, educating the fathers to accept this is really a challenge” – Workshop 11 SEN (CHWs).

Some traditional gender roles were found to be strong. The participants emphasised that men are considered the head of the household, as expected in Islam, with the mother as primary caregiver for children. This is reflected in the comments from participants regarding the importance of Islam and living their religious values. The men thus made the family decisions and would need to be informed and agree to any family participation in any intervention – regardless of the education level of the mother. The paternal grandmother also played a very important role in the family and may also make decisions for the family in the place of the father. Community Health Workers emphasised that educating paternal grandmothers was essential to improve access to healthcare for women.

“There are people who are not flexible with their wives and need to be informed. Sometimes the mother-in-law can decide the place of the husband. But still, the husband’s [permission] is still necessary.” – Workshop 1 SEN (CHWs).

“[We recommend] communication with mothers-in-law and the community. Raise awareness through information, emphasizing the well-being of women and children.” – Workshop 1 SEN (CHWs).

“The [grand]mothers take care of the children so that the daughters in-law will take care of them in return So it’s very bad for a daughter in law not to take care of her mother in-law. Society does not like people who distance themselves from children.” – Workshop 4 SEN (grandmothers).

Social hierarchies

In addition to hierarchies relating to gender/position in the family such as grandmothers have decision making power, there was some mention of social hierarchies in Kaffrine, Senegal. For example, during times of food stress it was said that political groups distribute food and elected officials who choose the neighbourhoods in which the food will be distributed. Neighbourhood leaders then decide to whom the food is distributed, meaning there is a feeling that some people are being left out.

“ It’s political groups that come to distribute food or for political purposes…organizations that often come to distribute food aid, but in general it is always subject to a selection on the part of elected officials, in particular the neighbourhood leaders, who select the people they like and who leave the others ” – Workshop 11 SEN (CHWs).

Participants explained that during mealtimes, the family will share food from one large plate from which the father will eat first as a sign of respect and courtesy. Sometimes, children would also eat in their neighbour’s house to encourage them to eat.

“ Yes, it happens that we use that strategy so that children can eat. Note that children like to imitate so that’s why we [send them to the neighbour’s house]” – Workshop 11 SEN (CHWs)”.

Traditional beliefs about malnutrition

In Kaffrine, Senegal, some participants spoke of traditional beliefs relating to malnutrition, which are believed by fewer people these days. For example, uncovered food might attract bad spirits, and any person who eats it will become ill. There were a number of food taboos spoken of which were thought to have negative consequences for the baby, for example watermelon and grilled meat which were though to lead to birth complications and bleeding. Furthermore, cold water was thought to negatively impact the baby. Groups spoke of a tradition known as “bathie” in which traditional healers wash stunted children with smoke.

“ There are traditional practices called (Bathie) which are practiced by traditional healers. Parents are flexible about the practice of Bathie ” – Workshop 1 SEN (CHWs).

Causes of malnutrition and stunting were thought to be a lack of a balanced diet, lack of vitamin A, disease, intestinal worms, poor hygiene, socio-cultural issues such as non-compliance with food taboos, non-compliance with exclusive breastfeeding and close pregnancies. Malnutrition was also thought by some to be hereditary. Numerous signs of malnutrition were well known amongst the groups in Kaffrine. For example, signs of malnutrition were thought to be a big bloated belly, diarrhoea, oedema of the feet, anaemia, small limbs and hair loss as well as other symptoms such as red hair and a pale complexion. Despite this, malnutrition was thought to be hard to identify in Kaffrine as not all children will visit health centres, but mothers do try to take their babies heights and weights monthly. The groups were aware of the effect of poverty on the likelihood of stunting as impoverished parents cannot afford food. Furthermore, the groups mentioned that there is some stigma towards stunted children, and they can face mockery from other children although most local people feel pity and compassion towards them. Malnourished children are referred to as Khiibon or Lonpogne in the local language of Wolof.

“ It is poverty that is at the root of malnutrition, because parents do not have enough money [and] will have difficulty feeding their families well, so it is the situation of poverty that is the first explanatory factor of malnutrition here in Kaffrine” – Workshop 9 SEN (administrators).

“It can happen that some children are the victim of jokes for example of mockery from children of their same age, but not from adults and older ” – Workshop 9 SEN (administrators).

Pregnancy beliefs

In Kaffrine, Senegal, there were concerns around close pregnancies, and pregnancies in women who were too young, and for home births. Within the communities there was a stigma around close pregnancies, which prevented them from attending antenatal appointments. Similarly, there were superstitions around revealing early pregnancies, which again delayed attendance at health centres.

Groups acknowledged the role of good nutrition, and mentioned some forbidden foods such as salty foods, watermelon and grilled meat (which sometimes related back to a traditional belief that negative impacts would be felt in the pregnancy such as birth complications and bleeding). Similarly, drinking cold water was thought to negatively affect the baby. Beneficial foods mentioned included vegetables and meat, during pregnancy.

“ Often when a woman has close pregnancies, she can be ashamed, and this particularly delays the time of consultation” – Workshop 5 SEN (CHWs).

“Yes, there are things that are prohibited for pregnant women like salty foods” – Workshop 11 SEN (CHWs).

In Kaffrine, Senegal, some participants spoke of a traditional belief that if a pregnant woman consumes eggs then her baby might be overweight, or have problems learning how to talk. Despite this, mothers in Kaffrine said that they would be happy to accept eggs as a supplement, although if supplements are provided that require preparation (such as powdered supplements), they would be less likely to accept them.

“These restrictions are traditional, and more women no longer believe that eggs will cause a problem to the child. But if these eggs are brought by external bodies, we will hesitate to take it.” – Workshop 11 SEN (CHWs).

“They don’t eat eggs before the child starts speaking (the child only eats eggs when he starts talking). This is because it’s very heavy and can cause bloating and may also lead to intestinal problems.” – Workshop 4 SEN (grandmothers).

Other important topics – access to health services

For the participants in Kaffrine, Senegal, accessing health services was problematic, particularly for pre- and post-natal appointments, which faced frequent delays. Some women had access due to poor roads and chose to give birth at home. Access issues were further compounded by poverty and social factors, as procedures in hospitals can be costly, and women with close pregnancies (soon after an earlier one) can feel shame from society and hide their pregnancy.

“Women really have problems of lack of finances. There are social services in the hospital; but those services rarely attend to women without finances. Even when a child dies at birth they will require money to do the necessary procedure ” – Workshop 11 SEN (CHWs).

Creation of the culturally-informed protocols

Recommendations that comprise a culturally-informed protocol for intervention design in each locality are given in Table 3 .

The Major Cultural Themes, and specific Egg Intervention Themes drawn out from only 9–11 carefully planned group sessions in each country provided a rich set of recommendations towards a culturally-informed protocol for the localised design of a proposed Egg Intervention for both East Lombok, Indonesia and Kaffrine, Senegal. A culturally-informed protocol designed in this way comprises cultural insights which are worthy of consideration in local intervention design and should guide future stages of engagement and provide a platform from which good rapport and trust can be built between researchers and the community [ 16 ]. For example, in Kaffrine, Senegal, the early involvement of husbands and grandmothers is crucial, which reflects values around shared decision making within families that are noted to be more prevalent in LMICs, in contrast to individualistic values in HICs [ 16 , 39 ]. Similarly, due to strong religious values in both East Lombok, Indonesia and Kaffrine, Senegal, partnerships with Islamic leaders is likely to improve engagement. Past studies show the crucial role that religious leaders can play in determining social acceptability of interventions, particularly around taboo topics such as birth spacing [ 40 ].

The WVIS plus PEX:FGD method demonstrated here produced both broad cultural themes from shared values, which were in a concise and easy-to-understand format which could be readily communicated with the wider Action Against Stunting Hub, as well as life practices relevant to stunting in Kaffrine, Senegal and in East Lombok, Indonesia. Discussions of shared values during the WVIS main workshop provided useful cultural background within each community. PEX:FGD discussion uncovered numerous cultural factors within local life practices that could influence on the Egg Intervention engagement and acceptability. Combining themes from the WVIS workshop and PEX:FGDs allowed for specific recommendations to be made towards a culturally-informed protocol for the design of an Egg Intervention that included both broad cultural themes and specific Intervention insights (Table 3 ). For example, in Kaffrine, Senegal, to know that the husband’s authoritative family decision-making for health care (specific) is rooted in Islamic foundations (wider cultural) points to an Intervention Recommendation within the protocol, involving consultations with Islamic Leaders to lead community awareness targeting fathers. Similarly, in East Lombok, Indonesia the (specific) behaviour of breastfeeding for 2 years was underpinned by (wider cultural) shared values of living in Islam. This understanding of local values could prevent the imposition of culturally misaligned values, which Bernal and Adames (2017) caution against [ 17 ].

There are a number of interesting overlaps between values seen in the WVIS Frameworks and Narratives and the categories of Schwartz (1992) and The World Values Survey (2023) [ 41 , 42 ]. For example, in both Kaffrine, Senegal and East Lombok, Indonesia, strong religious values were found, and the groups spoke of the importance of practicing their religion with daily habits. This would align with traditional and conservation values [ 41 , 43 ]. Furthermore, in Kaffrine, Senegal participants often mentioned the importance of mutual aid within the community, and similar values of togetherness and respect in the community were found in East Lombok, Indonesia. These would seem to align with traditional, survival and conservation values [ 41 , 43 ]. However, the values mentioned by the groups in the WVIS workshops are far more specific, and it is possible that through asking what is most worthwhile, valuable and meaningful about their context, the participants are able to prioritise which aspects of their values are most salient to their daily lives. Grounded shared values such as these are generally neglected in Global Health Research, and values predominant in the Global North are often assumed to be universal [ 14 ]. Thus, by excluding the use of a predefined external framework, we minimized the risk of imposing our own ideas of values in the community, and increased the relevance, significance and local validity of the elicited information [ 28 ].

Participatory methods of engagement are an essential step in conducting Global Health Research but there is currently a paucity of specific guidance for implementing participatory methods in vulnerable communities [ 16 , 44 ]. In addition, there is acknowledgement in the literature that it is necessary to come into communities in LMICs without assumptions about their held values, and to use bottom-up participatory approaches to better understand local values [ 14 , 16 ]. The WVIS plus PEX:FGD methodology highlighted here exemplifies a method that is replicable in multiple country contexts [ 28 , 32 ] and can be used to crystallize local In Situ Shared Values which can be easily communicated to external researchers. Coupled with the specialised FGD (PEX:FGD), values-based perceptions of specific topics (in this case stunting) can be elicited leading to the creation of specific Culture-based recommendations. This therefore takes steps to answer the call by Memon and colleagues (2021) for the creation of cultural protocols ahead of conducting research in order to foster ethical research relationships [ 16 ]. We believe that the potential usefulness of the WVIS approach to guide engagement and inform intervention design is effectively demonstrated in this study and WVIS offers a method of making explicit local values in a novel and valuable way.

However, we acknowledge that our approach has several limitations. It has relied heavily on the local university researchers to debate and decide which participant stakeholder groups should be chosen, and although they did this in the context of the Whole Child approach, it would have been advantageous to have involved cultural researchers with a deeper understanding of cultural structures, to ensure sufficient opportunities for key cultural elements to emerge. This would have in particular strengthened the intervention design derived from the PEX:FGD data. For example, we retrospectively realised that our study could have been improved if grandmothers had been engaged in East Lombok. Understanding this limitation leads to suggestion for further work: to specifically investigate the overlap of this approach with disciplinary studies of culture, where social interactions and structures are taken into account via formal frameworks.

There are more minor limitations to note. For example, the WVIS approach can only be led by a trained and experienced facilitator: not all researchers can do this. A training programme is currently under development that could be made more widely available through online videos and a Handbook. Secondly, although the groups recruited do not need to be representative of the local population, the number recruited should be increased until theoretical saturation is achieved of the themes which emerge, which was not carried out in this study as we focussed on demonstrating the feasibility of the tool. Thirdly, there is a limit to the number of topics that can be explored in the PEX:FGDs within the timeframe of one focus group (depending on the stamina of the participants), and so if a wider range of topics need formative research, then more workshops are needed. Lastly, this work took place in a large, highly collaborative project involving expert researchers from local countries as well as international experts in WVIS : other teams may not have these resources. However, local researchers who train in WVIS could lead on their own (and in this Hub project such training was available).

The need for better understanding, acknowledgement and integration of local culture and shared values is increasing as the field of Global Health Research develops. This study demonstrates that the WVIS plus PEX:FGD shared values approach provides an efficient approach to contextualise and localise interventions, through eliciting and making communicable shared values and local life practices which can be used towards the formation of a culturally-informed protocols. Were this method to be used for intervention design in future, it is possible that more focus should be given to existing social structures and support systems and a greater variety of stakeholders should be engaged. This study thus contributes to the literature on methods to culturally adapt interventions. This could have significant implications for improving the uptake of nutrition interventions to reduce malnutrition through improved social acceptability, which could help progression towards the goal of Zero Hunger set within the SDGs. The transferability and generalisability of the WVIS plus PEX:FGD approach should now be investigated further in more diverse cultures and for providing formative research information for a wider range of research themes. Future studies could also focus on establishing its scaling and pragmatic usefulness as a route to conceptualising mechanisms of social acceptability, for example a mechanism may be that in communities with strong traditional religious values, social hierarchies involving religious leaders and fathers exist and their buy-in to the intervention is crucial to its social acceptability. Studies could also focus on the comparison or combination of WVIS plus PEX:FGD with other qualitative methods used for intervention design and implementation.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request [email protected], Orcid number 0000–0002–1811-4597. These include deidentified Frameworks of Shared Values and Accompanying Narrative from each Group; deidentified Hub Insight Statements of relevant themes.

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Acknowledgements

We thank the Hub PI, Claire Heffernan, for feedback on a late draft of the manuscript.

The Action Against Stunting Hub is funded by the Medical Research Council through the UK Research and Innovation (UKRI) Global Challenges Research Fund (GCRF), Grant No.: MR/S01313X/1.

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Values & Sustainability Research Group, School of Architecture, Technology and Engineering, University of Brighton, Brighton, UK

Annabel J. Chapman, Mahsa Firoozmand & Marie K. Harder

Department of Environmental Science and Engineering, Fudan University, Shanghai, People’s Republic of China

Chike C. Ebido, Rahel Neh Tening, Yanyan Huang & Marie K. Harder

Department of Zoology and Environmental Biology, University of Nigeria, Nsukka, Nigeria

Chike C. Ebido

Preventive Medicine and Public Health, Université Cheikh Anta Diop (UCAD), Dakar, Senegal

Ndèye Marème Sougou

Faculty of Psychology, Universitas Islam Negeri Syarif Hidayatullah, Jakarta, Indonesia

Risatianti Kolopaking

Southeast Asian Ministers of Education Organization Regional Centre for Food and Nutrition (SEAMEO RECFON) Universitas Indonesia, Jakarta, Indonesia

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International Research Laboratory (IRL 3189) Environnement santé et sociétés/CNRS/UCAD, Dakar, Senegal

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Contributions

MKH formulated the initial research question and study design. AJC developed the specific research question. Data collection in Senegal involved CCE, NMS, AHD, FBD, RNT, CEHAN and JM. Data collection in Indonesia involved RA, RK, YH and MKH. Cultural interpretation in Senegal Involved AHD, FBD, NMS, RNT and JM. Analysis involved AJC and MF. AJC and MKH wrote the paper.

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Correspondence to Marie K. Harder .

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Chapman, A.J., Ebido, C.C., Tening, R.N. et al. Creating culturally-informed protocols for a stunting intervention using a situated values-based approach ( WeValue InSitu ): a double case study in Indonesia and Senegal. BMC Public Health 24 , 987 (2024). https://doi.org/10.1186/s12889-024-18485-y

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The Eclipse Chaser

As millions of americans prepare to see a total solar eclipse, a retired astrophysicist known as “mr. eclipse,” discusses the celestial phenomenon..

This transcript was created using speech recognition software. While it has been reviewed by human transcribers, it may contain errors. Please review the episode audio before quoting from this transcript and email [email protected] with any questions.

Can you hear — Fred, can you hear me?

[DISTORTED SPEECH]:

The internet is a little wonky.

OK. Well, [DISTORTED SPEECH]: Arizona. So the internet speed here isn’t really fast.

I think we’re going to call — yeah, I think we’re going to call you back on a — for the first time in a really long time — a landline.

[PHONE RINGING]

Hey, Fred, it’s Michael Barbaro.

You can hear me OK?

I can hear you.

Perfect. So, Fred, where exactly am I reaching you?

I’m in Portal, Arizona, in a little community called Arizona Sky Village. And it’s a very rural community. So our internet and phone lines are not very good. And the nearest grocery store is 60 miles away.

Wow. And why would you choose to live in such a remote place with such bad internet?

Because the sky is dark. It’s like the sky was a hundred years ago before cities encroached on all of the country. I guess you’d call it an astronomy development. Mainly, amateur astronomers who have built homes here far from city lights for the express purpose of studying the sky.

[MUSIC PLAYING]

So it’s literally a community where once the sun goes down, it’s pitch black. And some, perhaps all of you, are stargazing?

Yes, exactly.

Well, I think I’m beginning to understand why you might have the nickname that you do. Can you just tell our listeners what that nickname is?

My nickname is Mr. Eclipse.

From “The New York Times,” I’m Michael Barbaro. This is “The Daily.” Today’s total solar eclipse will be watched by millions of people across North America, none of them as closely as Fred Espenak, a longtime NASA scientist who’s devoted his entire life to studying, chasing, and popularizing the wonder that is an eclipse.

It’s Monday, April 8.

Fred, help me understand how you become Mr. Eclipse, how you go from being Fred to this seemingly very hard-earned nickname of Mr. Eclipse.

Well, I was visiting my grandparents at their summer home. And it was a partial eclipse of the sun back in the early 1960s. And I was a 10 - or 12-year-old kid. I got my parents to get me a small telescope. And I watched some of the partial phases. And it was really interesting.

And I started reading about eclipses. And I found out that as interesting as a partial eclipse is, a total eclipse is far more interesting. The moon is only 1/400 the diameter of the sun. It’s tiny compared to the sun. But it’s 400 times closer to the Earth. So it’s just this incredible coincidence that the moon and sun appear to be the same size in the sky. And once in a while, the moon passes directly between the Earth and the sun. And you’re plunged into this very strange midday twilight.

But they’re limited to a very small geographic areas to see a total eclipse. And this little book I was studying had a map of the world, showing upcoming paths of total solar eclipses. And I realized that one was passing through North America about 600 miles from where I lived. And that eclipse was in 1970.

And I was reading about this in 1963, 1964. And I made a promise to myself that I was going to get to that eclipse in 1970 to see it because I thought it was a one chance in a lifetime to see a total eclipse of the sun.

So just to be very clear, you see a partial eclipse, and you immediately think to yourself, that was fine. But I need the real thing. I need a full eclipse. And you happen to find out, around this time, that a real eclipse is coming but in seven years.

Right. I mean, there were other eclipses between that time and seven years in the future. But they were in other parts of the world. And I couldn’t buy an airplane ticket and fly to Europe or Australia.

And by 1970, I’d been waiting for this. And by this point, I had just gotten a driver’s license. And I convinced my parents to let me drive the car 600 miles to get down into the path of totality to see this great event.

Wow. Wait, from where to where?

From Staten Island, New York, down to a little town in North Carolina.

How did you convince your parents to let you do that? I mean, that’s —

Well, I had seven years to work on it.

[LAUGHS]: Right.

And I was just a nerdy kid. I didn’t get into trouble. I was interested in science. I was out in the woods, studying frogs and wildlife and stuff. So this was just a natural progression of the type of things I would normally do.

Right. OK. So I wonder if you can describe this journey you end up taking from Staten Island. How does the trip unfold as you’re headed on this 600 mile?

So, I think, on March 6, 1970, it was a Friday. My friend and I left to drive to the eclipse path. We probably got on the road probably at 5:00 AM because it was going to be a very long day.

And we’ve got a detailed map in the car, which I’ve plotted the eclipse path on. And we’re just trying to get far enough south to get into the path of the eclipse, which for us is easternmost Virginia or Eastern North Carolina. And I drive and drive and drive all day long. Very long day.

We get down to North Carolina right about maybe 6:00 PM. And we just see this little town in North Carolina that we’re driving through. And it happens to have a convenient motel right in the center of the path. And that was good enough. Got a room available. And we check in. And that’s where we’re going to watch the eclipse from.

And the next morning was eclipse day. It was a bright, crisp, sunny morning. There weren’t any clouds at all in the sky. And I was amazed that outside the back of the motel, in this grassy field, there were dozens and dozens of people with telescopes out there, specifically there for the eclipse that morning.

We were really excited about this. We set up our — my telescope. And we had another camera set up to watch it. And we walked around and marveled at some of the other people and their telescopes and discussed the eclipse with them. And the eclipse started probably around noon or 1:00 in the afternoon.

Describe the actual event itself, the eclipse. How did it begin?

Well, all solar eclipses begin as a partial eclipse. And the sun is gradually covered by the moon as the moon takes larger and larger pieces out of the sun, as it slowly crawls across the sun’s surface. And you don’t really notice much going on with a naked eye.

It’s really only in the last 10 minutes or so that you start to notice changes in the environment because now enough of the sun has been covered, upwards of maybe 90 percent of the sun. And you start to notice the temperature falling. There’s a chill in the air.

Also, since so much of the sun is covered, the daylight starts to take on an anemic quality. It’s weak. The sun is still too bright to look at. But the surroundings, the environment is not as bright as it was a half hour earlier.

You start to notice animals reacting to the dwindling sunlight. They start acting like it’s sunset. And they start performing some of their evening rituals, like birds roosting, perhaps calling their evening songs. And plants start closing up and the dropping sunlight. And then the dropping temperatures.

And there’s an acceleration now of all these effects. The temperature drop, the drop in the sunlight, it starts happening faster and faster and getting darker and darker. And maybe about a minute before the total eclipse began, we noticed strange patterns on the ground beneath us, on the grassy field that we were on — these ripples racing across the field. And these are something called shadow bands.

They look a lot like the rippling patterns that you would see on the bottom of a swimming pool, bands of light and dark, and moving very quickly across the ground. The sky is — it’s a dark blue. And it’s getting darker rapidly in this dwindling sunlight. And you go from daylight to twilight in just 10 or 20 seconds. It’s almost like someone has the hand on the rheostat and turns the house lights down in the theater.

You just see the light just go right down.

And the sky gets dark enough that the corona, the outer atmosphere of the sun, starts emerging from the background sky. This ring or halo of gas that surrounds the sun, and it’s visible around the moon, which is in silhouette against the sun. And along one edge of the moon is this bright bead of sunlight because that’s the last remaining piece of the sun before it becomes total.

And this is the diamond ring effect because you’ve got the ring of the corona and this dazzling jewel along one edge of it. You only get to see this for 10 or 15 seconds — it’s very fleeting — before the moon completely covers the sun’s disk. And totality begins. Suddenly, you’re in this twilight of the moon’s shadow.

And you look around the horizon. And you’re seeing the colors of sunrise or sunset 360 degrees around the horizon because you’re looking out the edge of the moon’s shadow. And looking back up into the sky, the sun is gone now. And you see this black disk of the moon in silhouette surrounded by the sun’s corona.

Maybe this says more about my nature than anything else, but what you’re describing, a little bit, feels like the end of the world.

Well, I think, when you see this all transpire, you can easily understand how people thought this was the end of the world because it seems far outside of the realms of nature. It seems supernatural. So you can see how people panicked that didn’t understand what was going on.

That was not your reaction?

No. I think it’s a sense of belonging — belonging to this incredible universe, both belonging and a humbleness that how minuscule we are. And yet we’re a part of this fantastic cosmic wheel of motion in the solar system. You almost get a three-dimensional sense of the motions of the Earth and the moon around the sun when you see this clockwork displayed right in front of you, this mechanics of the eclipse taking place.

It almost lifts you up off the planet, and you can look back down at the solar system and see how it’s all put together. And you’ve only got to, in that case — in that particular eclipse, it was only 2 and 1/2 minutes to look at this.

Wow. It’s kind of a clock in your head, saying, you don’t have much of this.

You don’t have much of it. And it almost seems like time stops.

And at the same time, all of a sudden, the eclipse is over. Those 2 minutes just raced by. And it’s over. All of a sudden, the diamond ring forms again on the opposite side of the moon, as the sun starts to become uncovered at the end of totality. And the diamond ring appears. It grows incredibly bright in just a few seconds. And you can’t look at it anymore. It’s too bright. You’ve got to put your filters back on and cover your telescope with a solar filter so it doesn’t get damaged. And you’re trembling because of this event.

Everybody was cheering and shouting and yelling. I mean, you would have thought you were at a sports game, and the home team just scored a touchdown. Just everybody screaming at the top of their lungs. And I immediately started thinking that this can’t be a once in a lifetime experience. I’ve got to see this again.

We’ll be right back.

OK. So, Fred, it’s the early 1970s. And you are not Mr. Eclipse yet. You’re just a kid who felt something very big when you watched an eclipse. So how did you end up becoming the premier authority that you now are on eclipses?

Well, after that 1970 eclipse, I started looking into upcoming solar eclipses so I could get a chance to see the sun’s corona again. And the next total eclipse was in Eastern Canada in July of 1972. And I started thinking about that eclipse. And by then, I was going to be in college.

And I started planning because that one was still something I could drive to. It was 1,200 miles instead of 600 miles.

So the summer of 1972 rolls around. And I drove up to the eclipse in Quebec to see totality and was unfortunately clouded out of the eclipse. I saw some of the partial phases. But clouds moved in and obscured the sun for that view of the sun’s corona.

You were robbed.

I was robbed. And I realized, well, I’ve got to expand my outlook on what’s an acceptable distance to travel to see a total eclipse because the next total eclipse then, in 1973, was through the Sahara Desert in Northern Africa. So I traveled to the Sahara desert for the eclipse, where we had decent weather, not perfect but decent weather. And we got to see totality there.

You saw totality in the desert?

In the desert. In the Sahara Desert. After that, it was just trying to get to every total eclipse I possibly could get to.

At this point, you’re clearly starting to become an eclipse chaser. And I don’t even know if such a thing existed at that moment.

Yeah. I don’t know if it was called that then, but certainly, yeah.

And if you’ll permit me a question that might seem maybe dopey to someone in your field, after you’ve seen one or two or three of these, do they start to blend in together and become a little bit the same?

Not at all. Each one is distinctly different. The sun itself is dramatically different. The sun’s corona is different at each eclipse because the corona is a product of the sun’s magnetic field. And that magnetic field is changing every day. So the details, the fine structure in the sun’s corona is always different. So every eclipse is dramatically different. The appearance of the sun’s corona.

Right. If you look at one Renoir, it’s not the same as the next one. You’re describing the corona of each eclipse as its own work of art, basically.

Exactly. Yeah.

So as you’re chasing these eclipses around the world, what is the place of an eclipse in your day-to-day academic studies and, soon enough, your professional work?

So I went to grad school at University of Toledo and did some work at Kitt Peak National Observatory, learning the ins and outs of photometric photometry — that is, measuring the brightness of stars. And eventually, this led to a job opening at the NASA Goddard Space Flight Center.

And I got interested in the idea of predicting eclipses and started studying the mathematics of how to do this. And I took it over unofficially and started publishing these technical maps and details. And we published about a dozen books through NASA on upcoming eclipses. People would just write me a letter and say they wanted a copy of the eclipse bulletin for such and such an eclipse. And I would stuff it in an envelope and mail it to them.

So you take it upon yourself to make sure that everyone is going to know when the next eclipse is coming?

And no doubt, during this period, you keep going to each and every eclipse. And I wonder which of them stand out to you.

Well, I’ve seen total eclipses from Australia, from Africa, from the Altiplanos in Bolivia, from the ice sheet on the coast of Antarctica, and even from Northern China, on the edge of the Gobi Desert. But one of the most notable eclipses for me was I traveled to India to see a 41-second eclipse, which was very short. And besides seeing a great eclipse in India, I also met my future wife there. She was on the same trip.

I have to hear that story.

Well, she had been trying to see a total eclipse for about 25 years.

She tried to see the 1970 eclipse. But her friends who were going to drive down from Pennsylvania down to North Carolina talked her out of it at the 11th hour.

They talked her out of seeing the same eclipse that was your first total eclipse that was so important to you?

Yes. And they talked her out of it because from Pennsylvania, they were going to have maybe a 90 percent eclipse. They didn’t know any better. They thought that was good enough. And she regretted that decision.

So then she said, OK, well, I’ve got to get to the next total eclipse, which was in Quebec in 1972, the same one that was my second eclipse. And we were probably within five miles of each other in Quebec. And we were both clouded out. Then she was married. She was raising kids. She got busy with domestic life for 20 years. She became a widow.

So now, 1995, there’s this 41-second eclipse in India that is very difficult to get to. It’s halfway around the world. But she’s still itching to see a total eclipse. And we joined the same expedition, a travel group, of 30 eclipse chasers and end up in India for the eclipse. And we have fantastic weather. It’s perfect.

She was in tears after totality. She had been waiting so long to see it. And we struck up a friendship on that trip. By the time the 1998 eclipse was taking place in the Caribbean, at that point, we were together. That was our first eclipse to observe as a couple. I think our wedding cake had a big eclipse on the top of the cake.

[LAUGHS]: Perfect.

We made a music CD for the wedding that we played during the reception. And of course, all the music on the CD had sun and moon themes to it.

Nothing I can say, a total eclipse of the heart

Of course, we had “Total Eclipse of the Heart.” It was a must-have.

Had to. Had to.

It strikes me, Fred, that eclipses are such an organizing principle in your life. Your life seems to literally orbit around them. When you were a kid, you started planning for them years in advance. This work becomes central to your career. It’s how you meet your wife.

And you said, when I asked you, about each eclipse that they’re all different. And obviously, you’re different at each eclipse because time has passed. Your life has changed. And it just feels like your life is being lived in a kind of ongoing conversation with this phenomenon of the sun and the moon overlapping.

Well, the eclipses are like benchmarks that I can use to figure out what else was going on in my life during these times, because I remember the dates of every single eclipse I’ve been to. And if I see a photograph of the solar corona shot during any particular eclipse, I know what eclipse that was. I can recognize the pattern of the corona like a fingerprint.

That’s amazing.

And I the year of the eclipse. It reminds me of when Pat and I got married and between which eclipse we were getting married and had to plan our wedding so it didn’t interfere with any kind of eclipse trips.

And they just serve as benchmarks or markers for the rest of my life of when various eclipses take place. So they’re easy for marking the passage of time.

So we are, of course, talking to you a few days before this year’s eclipse, which I cannot fathom you missing. So where are you planning to watch this total eclipse?

Pat and I are leaving for Mazatlán, Mexico, actually tomorrow. And we’ve got about 80 people joining us down in Mazatlán for this eclipse in our tour group.

And for you, of course, this year’s eclipse is just the latest in a very long line of eclipses. But I think, for the rest of us — and here, I’m thinking about myself — this is really going to be my first total eclipse, at least that I can remember. And for my two little kids, it’s absolutely going to be their first.

And given the hard-earned wisdom that you’ve accumulated in all your decades of chasing eclipses around the world, I wonder if you can give us just a little bit of advice for how to best live inside this very brief window of a total solar eclipse, to make sure, not to be cliche, but that we make it count.

Well, I think one mistake that people tend to make is getting preoccupied with recording everything in their lives, what they had for lunch, what they had for dinner. And seeing the eclipse is something that you want to witness firsthand. Try to be present in seeing the eclipse in the moment of it. So don’t get preoccupied with recording every instant of it.

Sit back and try to take in the entire experience because those several minutes pass by so rapidly. But you’ll replay them in your mind over and over and over again. And you don’t want technology getting between you and that experience. And remember to take your eclipse glasses off when totality begins. Note how dark it gets during totality.

Take the glasses off because?

Well, the glasses protect your eyes from the sun’s bright disk. But when totality begins, the sun’s bright disk is gone. So if you use your solar eclipse glasses to try to look at the corona, you won’t see anything. You’ll just see blackness. You’ve got to remove the eclipse glasses in order to see the corona. And it’s completely safe.

And it’s an incredible sight to behold. But during totality, you just want to look around without the glasses on. And take in the sights. Take in the horizon, 360 degrees, surrounding you with these twilight colors and sunset colors.

You’ll easily be able to see Jupiter and Venus shining on either side of the sun during totality. And look at the details in the sun’s corona, fine, wispy textures, and any possible red prominences hugging against the moon’s disk during totality.

And let’s say it’s now the moment of totality, and you, Mr. Eclipse, can whisper one thing into someone’s ear as they’re watching. What would you say to them?

Enjoy. Just take it all in.

Well, Fred, thank you very much. We really appreciate it.

No, thank you. I hope everybody has some clear sky.

After today, the next total solar eclipse to be visible from the continental United States will occur 20 years from now, in 2044. In other words, you might as well watch today’s.

Here’s what else you need to know today. Israel has fired two officers in connection with the deadly airstrike on aid workers from the World Central Kitchen who were killed last week while delivering food to civilians in Gaza. In a report released on Friday, Israel blamed their deaths on a string of errors made by the military. The airstrike, Israel said, was based on insufficient and incorrect evidence that a passenger traveling with the workers was armed.

Meanwhile, Israel said it withdrew a division of ground troops from Southern Gaza on Sunday, leaving no soldiers actively patrolling the area. The move raises questions about Israel’s strategy as the war drags into its sixth month. In particular, it casts doubt on Israel’s plans to invade Rafah, Gaza’s southernmost city, an invasion that the United States has asked Israel not to carry out for fear of large-scale civilian casualties.

Today’s episode was produced by Alex Stern and Sydney Harper, with help from Will Reid and Jessica Cheung. It was edited by Devon Taylor; fact-checked by Susan Lee; contains original music by Dan Powell, Marion Lozano, Elisheba Ittoop, and Corey Schreppel; and sound design by Elisheba Ittoop and Dan Powell. It was engineered by Chris Wood. Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly. Special thanks to Anthony Wallace.

[THEME MUSIC]

That’s it for “The Daily.” I’m Michael Barbaro. See you tomorrow.

• April 9, 2024   •   30:48 How Tesla Planted the Seeds for Its Own Potential Downfall
• April 8, 2024   •   30:28 The Eclipse Chaser
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• April 5, 2024   •   29:11 An Engineering Experiment to Cool the Earth
• April 4, 2024   •   32:37 Israel’s Deadly Airstrike on the World Central Kitchen
• April 3, 2024   •   27:42 The Accidental Tax Cutter in Chief
• April 2, 2024   •   29:32 Kids Are Missing School at an Alarming Rate
• April 1, 2024   •   36:14 Ronna McDaniel, TV News and the Trump Problem
• March 29, 2024   •   48:42 Hamas Took Her, and Still Has Her Husband
• March 28, 2024   •   33:40 The Newest Tech Start-Up Billionaire? Donald Trump.
• March 27, 2024   •   28:06 Democrats’ Plan to Save the Republican House Speaker
• March 26, 2024   •   29:13 The United States vs. the iPhone

Hosted by Michael Barbaro

Produced by Sydney Harper and Alex Stern

With Will Reid and Jessica Cheung

Edited by Devon Taylor

Original music by Dan Powell ,  Marion Lozano ,  Elisheba Ittoop and Corey Schreppel

Sound Design by Elisheba Ittoop and Dan Powell

Engineered by Chris Wood

Listen and follow The Daily Apple Podcasts | Spotify | Amazon Music

Today, millions of Americans will have the opportunity to see a rare total solar eclipse.

Fred Espenak, a retired astrophysicist known as Mr. Eclipse, was so blown away by an eclipse he saw as a teenager that he dedicated his life to traveling the world and seeing as many as he could.

Mr. Espenak discusses the eclipses that have punctuated and defined the most important moments in his life, and explains why these celestial phenomena are such a wonder to experience.

On today’s episode

Fred Espenak, a.k.a. “Mr. Eclipse,” a former NASA astrophysicist and lifelong eclipse chaser.

Background reading

A total solar eclipse is coming. Here’s what you need to know.

Millions of people making plans to be in the path of the solar eclipse on Monday are expecting an awe-inspiring. What is that feeling?

The eclipse that ended a war and shook the gods forever.

There are a lot of ways to listen to The Daily. Here’s how.

We aim to make transcripts available the next workday after an episode’s publication. You can find them at the top of the page.

Fact-checking by Susan Lee .

Special thanks to Anthony Wallace.

The Daily is made by Rachel Quester, Lynsea Garrison, Clare Toeniskoetter, Paige Cowett, Michael Simon Johnson, Brad Fisher, Chris Wood, Jessica Cheung, Stella Tan, Alexandra Leigh Young, Lisa Chow, Eric Krupke, Marc Georges, Luke Vander Ploeg, M.J. Davis Lin, Dan Powell, Sydney Harper, Mike Benoist, Liz O. Baylen, Asthaa Chaturvedi, Rachelle Bonja, Diana Nguyen, Marion Lozano, Corey Schreppel, Rob Szypko, Elisheba Ittoop, Mooj Zadie, Patricia Willens, Rowan Niemisto, Jody Becker, Rikki Novetsky, John Ketchum, Nina Feldman, Will Reid, Carlos Prieto, Ben Calhoun, Susan Lee, Lexie Diao, Mary Wilson, Alex Stern, Dan Farrell, Sophia Lanman, Shannon Lin, Diane Wong, Devon Taylor, Alyssa Moxley, Summer Thomad, Olivia Natt, Daniel Ramirez and Brendan Klinkenberg.

Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly. Special thanks to Sam Dolnick, Paula Szuchman, Lisa Tobin, Larissa Anderson, Julia Simon, Sofia Milan, Mahima Chablani, Elizabeth Davis-Moorer, Jeffrey Miranda, Renan Borelli, Maddy Masiello, Isabella Anderson and Nina Lassam.

Corey Schreppel leads the technical team that supports all Times audio shows, including “The Daily,” “Hard Fork,” “The Run-Up,” and “Modern Love.” More about Corey Schreppel

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Case Study: How Aggressively Should a Bank Pursue AI?

• Thomas H. Davenport
• George Westerman

A Malaysia-based CEO weighs the risks and potential benefits of turning a traditional bank into an AI-first institution.

Siti Rahman, the CEO of Malaysia-based NVF Bank, faces a pivotal decision. Her head of AI innovation, a recent recruit from Google, has a bold plan. It requires a substantial investment but aims to transform the traditional bank into an AI-first institution, substantially reducing head count and the number of branches. The bank’s CFO worries they are chasing the next hype cycle and cautions against valuing efficiency above all else. Siti must weigh the bank’s mixed history with AI, the resistance to losing the human touch in banking services, and the risks of falling behind in technology against the need for a prudent, incremental approach to innovation.

Two experts offer advice: Noemie Ellezam-Danielo, the chief digital and AI strategy at Société Générale, and Sastry Durvasula, the chief information and client services officer at TIAA.

Siti Rahman, the CEO of Malaysia-headquartered NVF Bank, hurried through the corridors of the university’s computer engineering department. She had directed her driver to the wrong building—thinking of her usual talent-recruitment appearances in the finance department—and now she was running late. As she approached the room, she could hear her head of AI innovation, Michael Lim, who had joined NVF from Google 18 months earlier, breaking the ice with the students. “You know, NVF used to stand for Never Very Fast,” he said to a few giggles. “But the bank is crawling into the 21st century.”

• Thomas H. Davenport is the President’s Distinguished Professor of Information Technology and Management at Babson College, a visiting scholar at the MIT Initiative on the Digital Economy, and a senior adviser to Deloitte’s AI practice. He is a coauthor of All-in on AI: How Smart Companies Win Big with Artificial Intelligence (Harvard Business Review Press, 2023).
• George Westerman is a senior lecturer at MIT Sloan School of Management and a coauthor of Leading Digital (HBR Press, 2014).

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