international journal research in marketing

International Journal of Research in Marketing

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INTERNATIONAL JOURNAL OF RESEARCH IN MARKETING (IJRM)

Official Journal of the European Marketing Academy The  International Journal of Research in Marketing   is an international, double-blind peer-reviewed journal for marketing academics and practitioners.  IJRM  aims to contribute to the marketing discipline by providing high-quality, original research that advances marketing knowledge and techniques.  As marketers increasingly draw on diverse and sophisticated methods,  IJRM 's target audience is comprised of marketing scholars, practitioners (e.g., marketing research and consulting professionals) and policymakers. IJRM  aims to be at the forefront of the marketing field with a particular emphasis on bringing timely ideas to market. The journal embraces innovative research with the potential to spur future research and influence practice. Hence, it welcomes contributions in various aspects of marketing. The editors, while accepting a wide array of scholarly contributions from different disciplinary approaches, especially encourage research that is novel, visionary or pathbreaking. While valuable contributions in their own right, replications and minor methodological or theoretical improvements will generally not be publishable in  IJRM.  All submissions must be interesting, relevant to marketing, sufficiently rigorous both conceptually and methodologically, and written in clear, concise and logical manner. For non-native English speakers, the use of a copy editor is strongly encouraged.

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The overarching role of international marketing: Relevance and centrality in research and practice

• Published: 18 May 2021
• Volume 52 , pages 1429–1444, ( 2021 )

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• Saeed Samiee 1 ,
• Constantine S. Katsikeas 2 &
• G. Tomas M. Hult 3  

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Classic business literature asserts the central role of marketing as foundational to the existence of organizations, and further notes that marketing must permeate all areas of a business enterprise. Leveraging this premise, we examine marketing scholars’ contributions to the international business (IB) literature – specifically notable works in exporting and market entry. Despite the overarching role of marketing in business, our systematic examination of published works in JIBS identified only 11 marketing contributions among the top 100 most frequently cited publications. More recent Web of Science data for the most cited contributions since 2015 demonstrate a decline in the number of international marketing (IM) and IB-related contributions by marketing scholars. Our goal in this editorial is to re-emphasize marketing’s critical importance and centrality in IB research, especially with reference to its dominant role in such areas as exporting and market entry decisions, customer acquisition, and relationship management. This special issue is intended to highlight IM and to motivate more contributions by IM scholars, as well as to call for greater integration of marketing thought in IB research.

La littérature classique en management affirme le rôle central du marketing comme fondement de l'existence des organisations, et souligne en outre que le marketing doit imprégner tous les domaines d'une entreprise. Nous appuyant sur cette prémisse, nous examinons les contributions des chercheurs en marketing à la littérature du commerce international (IB – International Business ), plus spécifiquement, les travaux importants portés sur l’exportation et l’entrée sur les marchés. Malgré le rôle fondamental du marketing dans les affaires, notre examen systématique des travaux publiés dans la revue JIBS n'a identifié que 11 contributions liées au marketing parmi les 100 publications les plus fréquemment citées. Les données plus récentes sur le Web of Science liées aux contributions les plus citées depuis 2015 montrent une baisse du nombre de contributions relatives au marketing international (IM – International Marketing ) et au IB par les chercheurs en marketing. Dans cet éditorial, notre objectif est de souligner à nouveau l’importance critique et la centralité du marketing dans la recherche en IB, notamment par rapport à son rôle dominant dans les domaines tels que les décisions d’exportation et d’entrée sur les marchés, l’acquisition de clients et la gestion des relations. Ce numéro spécial a pour but de mettre en valeur le IM, de stimuler davantage de contributions de la part des chercheurs en IM, ainsi que d'appeler à une plus grande intégration de la pensée marketing dans la recherche en IB.

La literatura empresarial clásica reivindica el papel del marketing como primordial a la existencia de las organizaciones y además nota que el marketing debe permear todas las áreas de una empresa. Apalancándonos en esta premisa, examinamos las contribuciones de los académicos de marketing a la literatura de negocios internacionales – específicamente los trabajos más destacados sobre la exportación y la entrada del mercado. A pesar del papel global del marketing en los negocios, nuestro examen sistemático de los trabajos publicados en JIBS identificamos sólo 11 contribuciones de marketing entre las 100 publicaciones más citadas. Los datos más recientes de Web of Science de las contribuciones más citadas desde el 2015 demuestran una disminución en el numero de contribuciones relacionadas con marketing y negocios internacionales por parte de los estudiosos de marketing. Nuestra meta con este editorial es hacer hincapié a importancia fundamental del marketing y su centralidad en la investigación de negocios internacionales, especialmente con referencia a su papel dominante en áreas como la exportación y las decisiones de entrada al mercado, la adquisición de clientes y la gestión de relaciones. Esta edición especial busca resaltar el marketing internacional y motivar más contribuciones de académicos de marketing internacional, y también hacer un llamado a una mayor integración del pensamiento de marketing en la investigación de negocios internacionales.

A literatura clássica de negócios afirma o papel central do marketing como fundamental para a existência de organizações e, além disso, observa que o marketing deve permear todas as áreas de uma empresa. Aproveitando essa premissa, examinamos contribuições dos acadêmicos de marketing para a literatura de negócios internacionais (IB), especificamente trabalhos notáveis em exportação e entrada no mercado. Apesar do papel abrangente do marketing nos negócios, nosso exame sistemático de trabalhos publicados no JIBS identificou apenas 11 contribuições de marketing entre as 100 publicações mais citadas. Dados mais recentes da Web of Science para as contribuições mais citadas desde 2015 demonstram um declínio no número de contribuições de marketing internacional (IM) e relacionadas a IB por acadêmicos de marketing. Nosso objetivo neste editorial é reenfatizar a importância crítica e centralidade do marketing na pesquisa em IB, especialmente com referência ao seu papel dominante em áreas como exportação e decisões de entrada no mercado, aquisição de clientes e gerenciamento de relacionamento. Esta edição especial tem como objetivo destacar o IM e motivar mais contribuições de acadêmicos de IM, bem como pedir uma maior integração do pensamento de marketing na pesquisa de IB.

经典的商业文献断言市场营销对组织存在有着基础的中心的作用, 并进一步指出, 市场营销必须渗透到商业企业的所有领域。 利用这一前提, 我们研究了市场营销学者对国际商务 (IB) 文献的贡献, 特别是在出口和市场准入方面的著名作品。 尽管市场营销在商业中起着举足轻重的作用, 我们对JIBS发表的作品的系统检查发现, 在最常被引用的前100篇文章中只有11篇是市场营销的贡献。最新的Web of Science数据 (自2015年以来被引用最多的数据) 表明, 市场营销学者对国际市场营销 (IM) 和与IB相关的贡献数量有所下降。 我们这篇社论的目标是重新强调市场营销在IB研究中的至关重要性和中心地位, 尤其是参考市场营销在出口和进入市场决策、客户获取以及关系管理等领域的主导作用。 本期专刊旨在突出IM和激发IM学者做出更多的贡献, 并呼吁将市场营销思想与IB研究有更大的整合。

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INTRODUCTION

Marketing is the raison d’etre and the force that drives organizations. Among the many axioms advanced by Peter Drucker, the father of modern management, are that the purpose of a business is “to create customers”, and that an organization has only two functions: one role relates to marketing (i.e., innovation) and the other is marketing (Drucker, 1954 , p. 37; Trout, 2006 ; Webster, 2009 ). Drucker further observed that only innovation and marketing produce results (i.e., revenue streams); the rest are costs (Cohen, 2013 ). Product innovation is a key marketing strategy component and an important means of creating and keeping customers, and, hence, a central element of a successful competitive strategy. This marketing-based view is also shared by other management thought leaders. Ted Levitt ( 2006 , p. 129), for example, notes that “the entire corporation must be viewed as a customer-creating and customer-satisfying organism.”

The “marketing-based” position held by seasoned management opinion leaders underscores the “overarching” role and centrality of marketing as a philosophy that should drive virtually all organizations. In fact, McKenna ( 1991 ) takes this notion even further by claiming “…successful companies are becoming market driven, adapting their products to fit their customers’ strategies” (p. 66). Adopting market orientation and becoming a market-driven organization, in turn, require marketing to “permeate” all aspects of organizational decision-making, inclusive of international business activities, before a product is produced or externally sourced. Parenthetically, since marketing represents the interface of all businesses with their customers, it should be expected to play a central role in published academic works in business, including international business (IB) – the focus of attention in this editorial.

Many studies have examined research themes covered in IB journals. One such effort surveyed academic publications in the six leading IB-related journals, and identified and classified 112 articles with at least 20 citations each for the 1996–2006 period (Griffith, Cavusgil, & Xu, 2008 ). Collectively, with over 22% of the most-cited publications, marketing was identified as having the largest number of publications. 1 In keeping with business thought leaders’ position on the purpose of an enterprise, one would expect a higher proportion of (1) internationally oriented marketing topics and/or (2) published works on other topics, such as IB, that actively include marketing in some meaningful way. Surprisingly, much of the published research in IB excludes marketing considerations. As an example, in examining foreign market entry and expansion modes [e.g., foreign direct investment (FDI)], the ultimate goal – beyond the theoretical lens in use, efficiencies, drivers, order of market entry, and resultant models and theories – is to gain or create new customers and/or better serve current customers in markets worldwide. Such an approach constitutes a marketing-centric view of FDI.

The IB literature has demonstrated that firms engaging in FDI invest more in research and development (R&D) and innovation (e.g., Anand & Kogut, 1997 ); however, the IB literature is not explicit about why firms invest in innovation in the first place. 2 A marketing-centric view (e.g., Ellis, 2000 ; Knight & Cavusgil, 2004 ; Leonidou & Katsikeas, 1996 ) does not imply a necessity to include marketing in every (e.g., market entry) project. Rather, it consists of a researcher mindset that conceives of and fine-tunes research projects in light of the ultimate purpose of an organization (per Drucker, Levitt, and McKenna) when marketing is not an explicit aspect of the study. The business worldview from within the marketing discipline is that marketing permeates the entire organization (including innovation). IB scholars recognize the integrated nature of marketing across various firm activities in specific sectors (e.g., in the services industry per Rugman & Verbeke, 2008 , p. 409), however, creating and serving customers necessitate the broadening of this perspective across all industries, as predicated in marketing. Stated differently, framing marketing as a single value chain function, or adopting a strictly downstream view of it inhibits richer and more meaningful customer-centric, as well as increasingly more realistic conceptualizations of critical activities and decisions in IB (cf. Takeuchi & Porter, 1986 ). Among other downsides, the narrow conceptualization of marketing functions as downstream activities in the value chain undermines marketing’s true role and influence in shaping strategy formulation. Global strategy decisions envisioned and designed by the C-suite inherently involve a very significant level of marketing content, without which a sound global strategy is not possible.

Concurrently, Buckley ( 2002a ) voices concern that international marketing (IM) has neglected the proximal issue of globalization in studies of IM strategy. This concern is in line with the broader criticism that IM has also largely abandoned strategy issues (Kotabe, 2001 ). Indeed, the marketing discipline can be criticized for failing to fully embrace the influences of international and global dimensions across the many critical strategy pillars inherently thought of as marketing’s intellectual domain. An examination of research priorities published by the influential Marketing Science Institute (MSI) demonstrates the discipline’s relative inactive posture in IM/IB. In all, the 2020–2022 MSI Research Priorities report includes four internationally oriented topics among 126 research questions listed. 3 It is thus not too surprising that IM scholars have paid only scant attention to research opportunities at the intersection of IM strategy and globalization, which, in turn, has limited our understanding of the crucial role that marketing plays in establishing, developing, and sustaining effective business operations across markets worldwide. In parallel, we assert that investigations of globalization should also include marketing strategy considerations.

IM CONTRIBUTIONS TO JIBS

To develop a better understanding of the contributions of marketing scholarship to the IB literature and, more specifically, to the Journal of International Business Studies ( JIBS ), we examined all highly cited articles published in JIBS since the journal’s inception. We rank-ordered all articles by their total citation frequencies using the Web of Science (WOS) database. We identified 11 marketing articles on topics generally considered to belong to the marketing domain among the top 100 most-cited JIBS publications (Table 1 ). 4 We further observed that scholars with marketing ties have also made highly cited general IB contributions to the literature. Overall, it is evident that marketing scholars have made significant contributions in JIBS to the extant IM and IB knowledge. However, it is also apparent that the most highly cited IM publications in JIBS were published in the 1982–2002 period. This pattern raises a question about the relative impact of IM, as measured by WOS citation frequencies, in JIBS published works. We thus examined the most-cited JIBS publications since 2015 (Table 2 ). The data indicate that, in contrast to pre-2015, fewer marketing studies have been among the top 100 most-cited articles published in JIBS as of late. In addition, fewer contributions on broader IB topics are by authors with close marketing ties.

Despite the centrality and importance of marketing in business, the influence of IM scholars and IM publications in the broader IB discipline via the field’s leading journal has been on the decline. The marketing theme of this special issue of JIBS builds on business and management thought leaders’ (e.g., Drucker, Levitt) view regarding the purpose of a business enterprise; that is, we start with the premise of the critical importance of marketing to all facets of business and leverage broad-based agreement about the declining role of marketing in IB research as well as broader IB contributions by marketing scholars in JIBS . Our overarching objective in this issue is to motivate relevant and rigorous research that advances IM and, in turn, IB thought on an ongoing basis, beyond the confines of this special issue. If one subscribes to Drucker’s vision about the purpose of a business, then IM should be better integrated into and represented within IB publications, notably within JIBS , the leading and most highly cited journal in IB. To this end, our goals in this essay are to (1) highlight the role of IM within IB, (2) detail the many critical roles of marketing in today’s business enterprise, and (3) introduce the marketing contributions in this special issue.

THE ROLE OF IM WITHIN IB OVER TIME

Beyond Drucker’s view of the purpose of a business, IB at its core is inherently intertwined with marketing. For centuries, individuals and firms have sought to expand sales through exporting, which constitutes the most common foreign market entry and international expansion mode; for many firms, therefore, export marketing has defined IB. Indeed, all exporting is strictly rooted in marketing (see, for example, Anderson & Gatignon, 1986 ). 5 This view is implied in the broader perspective of export development, which emphasizes internal and external triggers to exporting (cf. Cavusgil & Nevin, 1980 ; Wiedersheim-Paul, Welch, & Olson, 1978 ), both of which are export marketing centered. Some scholars view all international market entry forms as essentially marketing driven (e.g., Douglas & Craig, 1989 ). Indeed, many early contributors to foreign market entry and the export development process are closely associated with the marketing discipline (e.g., Bilkey & Tesar, 1977 ; Cavusgil, 1980 ; Czinkota, & Johnston, 1981 ; Katsikeas, 1996 ; Samiee & Walters, 1991 ). Over time, some firms continue to reap the benefits of increased sales and profits via export marketing, whereas others, recognizing the broader and longer-term potential of global markets, have sought to establish different forms of engagement in markets abroad. For example, international leasing and licensing (i.e., limited-term rental contract of an asset) as means of foreign market entry or expansion constitute marketing activities, but they are often viewed as activities related to, for example, market expansion and operational strategy (e.g., Contractor, 1985 ; Ricks & Samiee, 1974 ). It may be that the role and critical importance of IM is widely recognized by IB scholars. However, making marketing’s presence more explicit in IB research can result in framing issues such that corresponding research findings will yield greater marketplace and marketing relevance, in line with Drucker’s and Levitt’s views on the purpose of business. In short, regardless of entry mode or a firm’s structural configuration, market expansion and increased sales via (in)direct marketing internationally is central to IB. Such a view highlights the centrality and critical role of IM activities, while emphasizing the significance of IM contributions to the broader IB field.

Interest in and focus on scholarly research in IM began to intensify during the 1980s, and empirical investigations of IM problems and challenges facing firms have received heightened research attention for decades. Initial scholarly research in IM was limited, though there is noteworthy work on export market entry triggers as well as motivations and explanations for internationalization decisions (Ford & Leonidou, 2013 ). Since this early research, IM scholars have amassed a growing, multifaceted, and well-developed body of knowledge. Despite these advances, however, the growing importance and relevance of IM remains underappreciated and understudied (Day, 1996 ). As an unfortunate outcome of this, IM topics in the top IB journals are sparse (cf. Griffith et al., 2008 ), and a current survey of several leading marketing and IB journals reveals a relative paucity of scholarly work on IM issues. 6 Given IM’s centrality to all enterprises, the primary purpose of this special issue is to reinforce IM’s broad-based importance, with a particular focus on IM in the broader IB context.

RESEARCH IN IM

A recent survey of the IM literature published in the top six IB/IM journals during the 1995–2015 period identified 1,722 published works (Leonidou, Katsikeas, Samiee, & Aykol, 2017 ). The knowledge structure on which this body of scholarly work indicates that many of the developments in IM thought are driven by 14 key knowledge nodes identified in Samiee and Chabowski ( 2012 ). 7 It is evident from the results of the investigation by Samiee and Chabowski ( 2012 ) that, in terms of knowledge base, IM has much in common with IB. A relatively high proportion (approximately 40%) of key sources used in IM research are also commonly cited in IB research, including Hofstede ( 1980 , 1991 , 2001 ), Porter ( 1980 , 1985 , 1990 ), Williamson ( 1975 , 1985 ), Buckley and Casson ( 1976 ), Bartlett and Ghoshal ( 1989 ), Nelson and Winter ( 1982 ), Penrose ( 1959 ), and Pfeffer and Salancik ( 1978 ). Of the 26 most influential works in IM, serving as foundational knowledge for the 2004–2008 period, the majority (18) were published in outlets not specifically designated as marketing-related (Samiee & Chabowski, 2012 ), thus demonstrating IM’s shared knowledge and close relationship to IB. Key IM knowledge nodes serving as the foundation of IM scholarship during this period appear in Table 3 .

IM research has evolved across numerous themes, with some areas receiving disproportionate scholarly attention over time (Leonidou et al., 2017 ). Foreign market entry and export marketing are among the oldest topics of interest for IM researchers, and these remain relevant and important. Collectively, origin-related research topics likely constitute the most popular IM theme among IM researchers and potentially the most researched area, with hundreds of publications (e.g., Kotabe, 2001 ; Papadopoulos, el Banna, Murphy, & Rojas-Méndez, 2011 ; Samiee & Chabowski, 2021 ). 8 Origin-related research – or more specifically, the country-of-origin line of research within IM – can be traced back broadly to Dichter ( 1962 ) and, more specifically, to Schooler ( 1965 ). Although the concept was applied strictly to customer product choice, it can and has been applied to other facets of IB (e.g., liability of foreignness). Beyond marketing, explicit recognition of business problems associated with nonlocal origins of firms began to emerge in the IB literature in the 1970s. For example, Buckley and Casson ( 1976 ) refer to the political problems of “foreignness,” and Boddewyn and Hansen ( 1977 , p. 550) note that “American companies were faced with handicaps due to their foreignness.” Although IB challenges related to nonlocal origins of products and firms seem intuitive, international marketers’ close proximity to markets and customers afforded them the opportunity to recognize the issue much earlier than appears to have been the case in the broader IB discipline. We highlight this issue to point to how IM and IB can and should leverage each other for a more comprehensive analysis and rapid advancement of the field.

RESEARCH OPPORTUNITIES GOING FORWARD

Much of the intellectual capital in IM works has been devoted to various aspects of buyer behavior (Kotabe, 2001 ; Leonidou et al., 2017 ). This trend is not surprising given that, in general, a large majority of MSI research priorities ( 2020 ) are focused on customer-related issues (including three of the four internationally oriented themes out of the 126 research questions posed). Among international themes, one research question pertains to gaining global perspectives on prioritizing customer value at all touchpoints during the omnichannel customer experience; another theme seeks to understand whether customer behavior is the same or different in emerging markets; and a third issue addresses ways in which firms might integrate consumer-focused strategies globally. A sharp focus on the buyer and, more specifically, the consumer and his/her behavior highlights an ongoing emphasis on behavioral issues within marketing at the expense of advancing other equally salient issues in need of development. As a result, some important IM research areas are not receiving sufficient scholarly attention. To this end, 25 years ago, Day ( 1996 , p. 15) noted that “studies of cross-cultural differences in buyer behavior or the effect of country of origin do not suffice when the big issues needing answers are about global competitive interactions, global new product development and launch practices, sharing of market insights across borders, or the coordination and integration of multicountry operations.” An overemphasis on the buyer behavior aspects of IM, frequently via experiments, has indeed curbed scholarly efforts to advance IM and the exploration of “big issues”: for example, the short- and long-term effects of radical shifts in the external environment and competitive structures on various aspects of marketing strategy, notably, global supply chain management, innovation, and global product development activities, among others. In general, innovation can be related to and affect any facet of an enterprise’s operations (e.g., processes). The key innovation concern within marketing has centered on product breakthroughs and service delivery, as well as how firms can adapt to a changing landscape often marked by disruptive technological developments. Nevertheless, studies of global innovation or R&D can benefit from cross-fertilization, with significant advances in this area within marketing.

Despite the decades-long practice of international outsourcing by firms, few IM researchers have explored this critical area (e.g., Kotabe & Murray, 1990 ; Swamidass & Kotabe, 1993 ). As a result, scant research is available within this important area to shed light on IM practices [e.g., innovate vs. import (buy) new products; make vs. buy] that can facilitate enhanced IM performance. To this end, a fourth research priority identified by MSI ( 2020 ) is the global supply chain impact of the pandemic (p. 11). Sourcing considerations, such as exporting and importing, are by nature customer-centric and marketing-based. Nevertheless, much of the research in the area is conducted within other disciplines (Buckley, Doh, & Benischke, 2017 ). The importance of a focus on the bigger picture, including the organization, human capital, capabilities, innovation, and metrics, has been stressed in marketing (Moorman & Day, 2016 ). Behavioral components should continue to play important roles in advancing marketing (and IM); however, these topics need to be examined within the context of organizational priorities and not strictly limited to consumer-based studies.

Given the commonality of direct and indirect international involvement across firms and industries, a host of new and exciting challenges related to customers, suppliers, and relationship management are raised. Today’s global marketplace is characterized by disruptive external forces, intense competition from a multitude of foreign and indigenous companies, and heterogeneous customer behavior shaped by differences across a range of host-market conditions, notably culture. Technological advances create marketplace opportunities and novel business models and segments (e.g., social media, collaborative consumption/shared economy, product cocreation), while undermining long-established global brands, product/service markets, and business patterns and processes on a global scale. For example, local and international ride-hailing services such as Ola and Uber competing with long established global car rental firms; collaboratively developed HD DVD losing the industry-wide format war to the technologically more advanced Blu-ray by Sony shortly after its debut which, in turn, lost popularity as the market shifted to streaming services; photorefractive keratectomy developed in the U.S. essentially undermined the Russian-born radial keratectomy; and MP3/FLAC and streaming services largely replaced tangible music CDs developed through an R&D joint venture between Philips and Sony. Concurrently, new technologies are promoting new forms of interaction for businesses and customers that transcend national boundaries (e.g., social media; short message service-SMS; online reviews; using proprietary consumer data via artificial intelligence activated voice recognition to drive host-market demand, as is the case with Amazon’s Alexa or Google Assistant). Concurrently, innovative breakthroughs and rapid dissemination of information have given rise to intellectual property theft on a global scale, undermining marketing strategies, global brands, and distribution network relationships and their management, while requiring all firms to canvass markets globally to identify potential abuses and to assert control over their intellectual property. 9

Although the Internet and information technology (IT) continue to have a significant influence on customers and businesses (e.g., exporters, importers, concept-testing, global marketing strategy planning), a citations-based review of the IM literature revealed that IT-related topics did not constitute a knowledge base in IM (Samiee & Chabowski, 2012 ). This finding was corroborated by Leonidou et al. ( 2017 ), who noted that less 4% of IM-related academic articles reviewed included various facets of Internet connectivity. In addition, a literature review of 29 academic journals addressing the Internet’s impact on relational approaches to foreign market entry identified only 94 published articles, constituting approximately 3% of all the articles reviewed (Watson, Weaven, Perkins, Sardana, & Palmatier, 2018 ). IT has transformed how firms enter and manage markets globally to varying degrees in ways that are often not self-evident. In addition, IT's ubiquity and intangible nature make its detection and true impact on IM difficult, thus leading to a growing knowledge gap. The paucity of IT-motivated IM research uncovered by these reviews demonstrate the need to incorporate various facets of IT in more IM projects, including initial online export/import information gathering, marketing research, market entry and development, and export customer acquisition by both manufacturers and channel intermediaries. Furthermore, a research focus on cross-border e-commerce, especially as a means of internationalizing the scope of smaller firms’ marketing, is underdeveloped. It is surprising that, while origin-related buyer behavior topics remain popular, almost no effort has been made to explore how origin affects choice in online and, in particular, international e-commerce contexts (e.g., Ulgado, 2002 ). Buckley ( 2002a ) rightfully identified e-commerce as a frontier in IM research nearly two decades ago. Firms allocate significant amounts of financial resources to adopt promising technologies to improve their marketing performance, yet little research has been devoted to assessing the performance impact of digital tools (e.g., customer relationship management software) in terms of establishing new cross-border relationships or maintaining existing ones. Although IM has generally ignored such impactful areas of research as the influence of the Internet in global marketing, the IB literature, and more specifically international management, has also been shortsighted with respect to its limited pursuit of pertinent Internet-related research topics (e.g., international human resource management, global strategy development, management of global collaborative ventures and partnerships) (Chabowski & Samiee, 2020 ).

Social media influence both the demand and the supply side of exchange. On the supply side, firms are engaging people by allowing them to participate in cocreation and product development processes. Enterprises are increasingly engaging the public in idea generation via social media (e.g., Dell IdeaStorm, LEGO World Builder), new product development, and start-up capital (e.g., Quirky, Kickstarter). The degree to which firms engage social media audiences internationally (including both global and local social media sites) for one or more aspects of cocreation, and the influence of such activity on multinational corporations’ competitiveness across markets, remain unexplored. Examining the extent to which customers from around the world participate in knowledge development processes and help firms improve their existing products and/or create innovative ones also remains a fertile research area (Bayus, 2013 ; Prahalad & Ramaswamy, 2004 ).

Equally important research issues on the demand side also warrant research attention. For example, customers located in distant parts of the world use social media, but the impact of such engagement, and the positive or negative ripple effect it creates in or across social networks with respect to local and global brands, has received insufficient research attention (McAlexander, Schouten, & Koenig, 2002 ). Furthermore, the extent to which various customer segments rely on and ways in which they use social media across markets remain unexplored. This knowledge void, in turn, impacts the development of effective international cocreation strategies on the supply side. Relatedly, the global ubiquity of the Internet and social networks has made these media a major target for cybercriminals. Regular revelations of firm and customer data breaches are bound to have a consequential impact, not only on firm image and the customer engagement process, scope, and depth but also on demands for greater privacy and protection by customers and governments. Thus, IM research should explore the impact of, for example, cross-national privacy regulations on the efficacy of relationship development and management as well as online marketing processes.

Globalization has transformed the way business relationships are formed, managed, and evaluated, and customer engagement is likely to play a prominent role in business-to-business contexts. Business relationships are complex, interpersonal, and interdependent, and relationship marketing efforts can make a difference in promoting common goals and facilitating joint activities that create value for both partners; value that each company could not achieve outside the relationship or with other partners (Palmatier, 2008 ). In an international context, companies need to manage their cross-border relationships more skillfully to address geographic separation, cultural distance, administrative (e.g., currencies, legal jurisdictions) and economic (Katsikeas, Samiee, & Theodosiou, 2006 ; Leonidou, Samiee, Aykol, & Talias, 2014 ; Samiee, Chabowski, & Hult, 2015 ) differences between local and foreign markets, and increased levels of risk and uncertainty inherent in international operations (Johanson & Vahlne, 2009 ; Katsikeas, Skarmeas, & Bello, 2009 ). How does the international environment affect the activities, strategies, structures, and decision-making processes of companies with respect to their business relationships? How can companies manage their overseas business relationships as value-bearing assets? Are cross-border business relationships part of a value-creating network that delivers superior value to the end customer? What is the role of international relationship building and management in overcoming the liability of foreignness? Likewise, the roles of overseas business partners (e.g., distributors, suppliers) in knowledge development, innovation, and goal achievement are relevant and important areas that require research attention.

The fit between IM strategy and international relationships also deserves ongoing research attention. How can companies ensure that their different suppliers and partners abroad are well-aligned with their IM strategy? Strategy standardization offers significant economies of scale in value-adding activities (e.g., R&D, production, marketing), facilitates the development of a consistent corporate/brand image across countries, enhances coordination and control of international operations, and reduces operational and managerial complexity, whereas adaptation is based on the premise that variations between countries necessitate adjustment of the marketing strategy to the idiosyncrasies of each local market. The contingency approach suggests that the appropriateness of the selected IM strategy – typically positioned between the two standardization–adaptation extremes – should be evaluated based on its alignment, or fit, with dominant factors in the international environment, as fit facilitates enhanced performance outcomes (Katsikeas et al., 2006 ). Despite long-standing traditions in these areas, sensemaking in some overarching topics is needed. For example, the pursuit of a market orientation strategy demands sensitivity to local market conditions and IM strategy adaptation. Given the importance of market orientation for many firms, there is a need to better understand how market orientation influences IM strategy. On the one hand, market and customer orientation demand more localized or adapted IM strategies. On the other hand, a high degree of IM strategy standardization seemingly impedes a high degree of market orientation. How do firms reconcile their IM strategy and market orientation efforts? Moreover, how do customer relationships in particular and business relationships in general interact with the perennial issue of adaptation or standardization of IM strategy? Do overseas business relationships help the company determine which specific strategic elements are feasible or desirable to standardize or adapt? If so, under what conditions, and to what degree? To what extent is cocreation possible and appropriate under each IM strategy scenario?

In addition, the assessment of performance in international market operations is an issue that requires particular attention in the IM literature. The relevance and importance of IM resources, strategies, and actions is reflected in the extent to which these favorably influence firm performance outcomes achieved via international market operations and, in turn, contribute to organizational performance. However, there are a large number and wide diversity of IM performance measures employed in the literature, which makes the development of a coherent cumulative body of knowledge in the field particularly challenging (Katsikeas, Morgan, Leonidou, & Hult, 2016 ). Scant attention has been given in IM as to how performance should be conceptualized and operationalized, and studies commonly do not provide a definition or any justification for the assessment of performance that is adopted and for the specific measures used in the context of foreign market operations (Katsikeas, Leonidou, & Morgan, 2000 ; Leonidou, Katsikeas, & Samiee, 2002 ). Given that performance is inherently a multidimensional construct, it is essential that IM researchers be selective in choosing specific performance dimensions, and justify their choice on the basis of some theory-based logic, conceptual framing, and/or for pragmatic reasons. Performance assessment in international market operations should be in line with the theoretical perspective(s) adopted in the study. For example, empirical research grounded in the resource-based view and/or the dynamic capabilities perspective, which underpins much of the strategy-related and competitive advantage work in IM, requires a competitor-centered assessment of performance outcomes; that is, individual performance aspects and items need to be assessed in relation to competition in the foreign market targeted by the firm’s IM strategy (see Katsikeas et al., 2016 ).

CONTRIBUTIONS TO THE SPECIAL ISSUE

The call for papers for this special issue has been received with much enthusiasm, as demonstrated by the large number of submissions covering a wide range of IM topics. Accordingly, manuscripts accepted for inclusion in this issue represent the diversity of submissions, with each making a unique contribution to the IM body of knowledge. The first article focuses on the sharing economy (SE), which is a timely and important issue that influences business operations across industries worldwide. Kozlenkova, Lee, Xiang, and Palmatier’s meta-analytic effort examines the effects of value-based (i.e., utilitarian, social, hedonic, and sustainability value) and governance-based (i.e., trust) factors on SE participation and investigates their relative effectiveness under different global contingencies (i.e., economic/competitive, cultural, societal, technological, regulatory, and demographic factors). Based on 55 empirical articles, with 60 independent samples from 15 countries, representing 123 correlations across 26,377 customers during the 2009–2019 period, the findings suggest that hedonic value exerts the largest effect on SE participation, followed by trust and utilitarian value, while social value and sustainability have the smallest effects. The analysis reveals a complex pattern of global contingency effects that firms should consider when advancing their entry strategies, formulating governance mechanisms, and evaluating promising markets. Kozlenkova et al. integrate their key insights into three tenets, reflecting the most important and surprising findings. These tenets are grounded in the vitally important roles of inequality, the hierarchy of needs, and governance mechanisms that can serve as a platform for establishing an emerging perspective of global SE participation.

Marketing metrics represent another critically important topic that has received little research attention in IM or IB. Sound managerial decisions and marketing strategy are based on quantitative measures, including outcomes (Moorman & Day, 2016 ). In their contribution to this special issue, Mintz, Currim, Steenkamp, and de Jong focus on metric use in marketing decisions across 16 countries, using a cultural perspective. The authors leverage a rich dataset containing more than 4,300 marketing decisions in more than 1,600 firms across 16 countries. Respondents chose from 24 general metrics pertinent to marketing (12) and financial (12) decisions, plus 6 metrics specific to each of 10 marketing mix decisions. The findings indicate that, for all markets combined, an average of 9 metrics are used per marketing decision. With nearly 12 metrics per decision, South Korean managers use the highest number of metrics, while Japanese managers use the fewest, with approximately 4 metrics per marketing decision. China and India, each with approximately 11 metrics, are close to Korea and are heavy users of marketing metrics, whereas France and the United States, with nearly 6 and 7, respectively, are moderate users of metrics in decision-making. Importantly, satisfaction, awareness, and return on investment are the three most commonly used metrics across markets. In addition, the study finds that metric use is affected by both firm and country culture.

Business-to-business (B2B) electronic platforms (e-platforms) play a critical role in helping exporting firms reach, serve, and penetrate foreign markets. However, the IB literature is unclear about how and under what conditions firms can use B2B e-platforms to boost their export performance outcomes. Drawing on signaling theory, Jean, Kim, Zhou, and Cavusgil propose and empirically test a model that investigates how exporters’ e-platform use affects export sales performance by boosting foreign market contact (i.e., quotations from foreign buyers) and how the institutional environment and export growth strategies influence the e-platform use–foreign market contact link. Using survey and archival lagged data on a sample of 205 exporters that subscribe to Alibaba.com, the authors reveal that e-platform use enhances foreign buyer contact and, in turn, export sales performance. The findings also suggest that the positive impact of e-platform use among exporters is further boosted when they come from regions that have less-developed market intermediaries or under conditions of high institutional distance between the home and host countries. The study also demonstrates that the effect of e-platform use on a foreign buyer contact becomes weaker under conditions of high export market diversification or high product diversification.

Platform-based mobile payments have experienced significant growth worldwide in recent years, partly because they offer unique value for both customers and companies over other digital payment methods. Kumar, Nim, and Agarwal note, however, that patterns of such payment adoption grow differently across countries, with some emerging countries (e.g., China) outperforming developed ones. The authors propose a conceptual model of mobile payment adoption, and develop hypotheses using explanations from the literature on network effects and institutional theory. Based on data collected across 30 countries (17 developed and 13 emerging), the study confirms the existence of network effects and differential influences of perceived value, inertia, and cultural factors on the mobile payment adoption of innovators and imitators. The presence of significant heterogeneity both within and between countries regarding the adoption of mobile payments, which offers additional evidence of leapfrogging by emerging markets with regard to mass mobile payment use, has important implications for theory development and marketing management practice in IB.

Global brands and perceived brand globalness (PBG) research have received much scholarly attention in the IM literature (Aaker & Joachimsthaler, 1999 ; Batra, Ramaswamy, Alden, Steenkamp, & Ramachander, 2000 ; Steenkamp et al., 2003 ). Contributing to this growing literature, Mandler, Bartsch, and Han tap the potential aversion to globalization among consumers and examine sentiments with respect to branding as the basis for corporate decisions regarding the appropriateness of global branding. The authors leverage signaling theory to conduct two studies that (1) assess brand credibility on the basis of consumer PBG and perceived brand localness (PBL) across two countries (Germany and South Korea), and (2) examine the role of three moderators (perceived country of origin, category social signaling value, and category cultural grounding). The findings demonstrate that both PBG and PBL are positively associated with brand credibility across markets; a split-sample test offers a contrast between globalized and globalizing markets, and demonstrates a relationship between brand credibility and PBL in Germany but not in South Korea, where brand credibility is associated with PBG. The study reports the impact of brand origin on brand credibility and demonstrates that effect of PBL on brand credibility does not vary with the brand’s origin in Germany, but the effect is stronger for domestic brands than for foreign brands in South Korea. The contrast between consumer perceptions in globalized and globalizing markets offers fruitful theoretical and managerial implications, while raising a series of consumer and IM strategy questions that have the potential to expand the boundaries of IM knowledge.

Origin-related research and animosity with reference to consumer perceptions, preferences, and choice have played major roles in the marketing literature (Klein, Ettenson, & Morris, 1998 ; Lu, Heslop, Thomas, & Kwan, 2016 ; Samiee, 1994 ; Verlegh & Steenkamp, 1999 ). In line with this stream of IM research, Westjohn, Magnusson, Peng, and Jung contrast animosity’s effect on product judgement versus willingness to buy. The first part of their contribution consists of a meta-analysis of 43 post–Klein et al. ( 1998 ) published works focusing on animosity, involving 18 nations, to address the inconsistencies reported in the literature. The authors follow this with an examination of the contextual role of culture on animosity effects using six experiments in the United States and China. They leverage three Hofstede dimensions (i.e., collectivism, long-term orientation, and power distance), measured at the individual level. The results indicate that collectivism and long-term orientation lessen the negative effects of animosity and support the position that animosity’s effect on willingness to buy is stronger than it is on product judgments. The findings offer useful insights for managers regarding, among others, consumers’ attitudes toward brands. Although the findings indicate that product judgements are not affected by animosity, the results indicate that product sales could be affected. In addition to demonstrating cross-cultural differences, the authors find that cultural values influence consumers’ willingness to buy.

The establishment, development, and management of cross-border interorganizational exchange relationships has received considerable research attention in the IB literature (e.g., Bello & Gilliland, 1997 ; Robson, Katsikeas, Schlegelmilch, & Pramböck, 2019 ; Skarmeas, Katsikeas, & Schlegelmilch, 2002 ). The starting point for Obadia and Robson’s study is the inconsistent findings in the literature regarding the effects of cooperation on performance in exporter–importer relationships. The authors argue that the relationship of cooperation with performance in IB associations has an inverted U shape; at high levels, the performance impact of cooperation weakens greatly and becomes negative. They also find that the importer’s specific investments mediate the link between cooperation and performance, which advances the idea that relational phenomena affect exporter performance only if they foster an importer’s productive behaviors. The study also points to the role of interdependence in moderating the inverted U-shaped relationship between cooperation and the importer’s specific investments. The findings reveal that a limited increase of interdependence enhances the impact of low to moderate levels of cooperation on the importer’s specific investments.

CONCLUDING REMARKS

Overall, criticisms of IM scholarship (e.g., Buckley, 2002a ; Douglas & Craig, 1992 ; Kotabe, 2001 ) are generally well placed and to the point. Marketing and IM are pivotal to a firm’s existence and should play overarching roles in charting firms’ management and strategy. Yet IM has largely abandoned the “big picture” by focusing on microresearch and behavioral questions, notably, country-of-origin, and cross-cultural consumer behavior topics (Day, 1996 ; Kotabe, 2001 ; Leonidou et al., 2017 ).

Much work remains for IM scholars to advance the field by placing greater emphasis and effort on strategy-related topics and exploring macro-areas of business: for example, by bridging IM strategy with regard to market entry modes and globalization and addressing issues related to disruptive external change to global supply chains and e-commerce, among others. Indeed, Buckley’s ( 2002b ) position regarding the past successes of IB scholarship in exploring international market entry (the “big picture”) may seem premature if one agrees that marketing, a central concern of which is the customer and the idiosyncrasies associated with the demand-side, is largely absent from much of this success. The relative absence of “marketing” in much of the market entry literature is a call for IB and IM scholars to leverage this critical aspect of firms’ internationalization decisions. This view is consistent with Drucker’s position that “Concern and responsibility for marketing must therefore permeate all areas of the enterprise” (Drucker, 1954 , pp. 38–39). Additionally, the fact that IB and IM are close in their fundamentals, and that the IM knowledge structure significantly taps into management scholarship (Buckley, 2002a ; Samiee & Chabowski, 2012 ), further validates marketing’s relevance and centrality in the broader international business thought. Consequently, the perceived proximity of these disciplines appears to be greater than one might expect. A major strength of IB has been its ability to embrace and integrate other business disciplines from which crucial research questions emerge (Peng, 2004 ). A more marketing- and customer-centric view of IB research is also in line with this position.

There appears to be ample research opportunity to adopt a marketing mindset in IB research and to explicitly introduce marketing considerations to achieve a marketing-based view of IB activities, most notably the macro-issues, including market entry mode choice, international expansion patterns, cross-border buyer–seller relationships, and strategic alliances. Although this special issue is primarily intended to inspire and broadly direct researchers’ focus on developing IM projects that fill key knowledge gaps in IM thought, in keeping with Drucker’s and Levitt’s positions regarding the marketing purpose of all enterprises, we very much hope that this work offers pathways for general IB scholars to embrace, leverage, and contribute to IM knowledge.

The proportion of marketing articles reported by Griffith et al. ( 2008 ) is likely inflated, as two of the six journals surveyed are dedicated entirely to international marketing topics.

This issue maybe exacerbated by the use of varying terminologies across disciplines; however, despite marketing’s centrality in business, “marketing” and “consumer” or “customer” are rare terms in much IB research (cf. Anand & Kogut, 1997 ; Hejazi, Tang, & Wang, 2020 ).

MSI is a non-profit organization led by academic researchers, in collaborations with industry, aiming to address marketing issues faced by firms. Although we do not observe an ongoing internationally related research momentum in its current list of priorities, MSI has periodically addressed selective IM-related topics.

We also calculated citation per year to account for the timing of the published works; however, as Tables 1 and 2 show, among the highly cited works, the most-cited set and the order of articles remain largely the same.

This includes intracorporate export transactions involving parts and semifinished products. International firms frequently require subsidiaries to effectively compete in quality, price, and service with other suppliers, effectively marketing themselves as the premier supplier to the internal customer. Even if intrafirm export sales were guaranteed, as is the case in some firms, the final assembled product must still compete with other firms in every respect. In other words, the marketing function of intracorporate export transactions is merely pushed to the firm assembling and selling the final product.

Several journals, led by Journal of International Marketing and International Marketing Review , are dedicated to publishing scholarly IM research.

This is based on the spatial configuration generated by multidimensional scaling for works published in 34 scholarly journals (2,709 articles) in the 2004–2008 period. Other analyses (factor analysis and clustering) produced slightly fewer knowledge groups.

Estimates of the number of publications in this IM domain vary. For example, Samiee and Chabowski ( 2021 ) identify more than 482 country-of-origin publications listed in the Web of Science database, whereas Lu et al. ( 2016 ) estimate that the number of country-of-origin-related publications exceed 600.

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Samiee, S., Katsikeas, C.S. & Hult, G.T.M. The overarching role of international marketing: Relevance and centrality in research and practice. J Int Bus Stud 52 , 1429–1444 (2021). https://doi.org/10.1057/s41267-021-00433-2

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Using a customer discovery process to enhance the potential dissemination and scalability of a family healthy weight program for rural communities and small towns

• Gwenndolyn C. Porter   ORCID: orcid.org/0000-0002-6592-9537 1 ,
• Jennie L. Hill 2 ,
• Kate A. Heelan 3 ,
• R. Todd Bartee 4 ,
• Caitlin A. Golden 2 ,
• Ali Malmkar 3 ,
• Bryce A. Abbey 3 &
• Paul A. Estabrooks 5  

International Journal of Behavioral Nutrition and Physical Activity volume  21 , Article number:  57 ( 2024 ) Cite this article

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Customer discovery, an entrepreneurial and iterative process to understand the context and needs of potential adoption agencies, may be an innovative strategy to improve broader dissemination of evidence-based interventions. This paper describes the customer discovery process for the Building Healthy Families (BHF) Online Training Resources and Program Package (BHF Resource Package) to support rural community adoption of an evidence-based, family healthy weight program.

The customer discovery process was completed as part of a SPeeding Research-tested INTerventions (SPRINT) training supported by the U.S. Centers for Disease Control and Prevention. Customer discovery interviews ( n =47) were conducted with people that could be potential resource users, economic buyers, and BHF adoption influencers to capture multiple contextual and needs-based factors related to adopting new evidence-based interventions. Qualitative analyses were completed in an iterative fashion as each interview was completed.

The BHF Resource Package was designed to be accessible to a variety of implementation organizations. However, due to different resources being available in different rural communities, customer discovery interviews suggested that focusing on rural health departments may be a consistent setting for intervention adoption. We found that local health departments prioritize childhood obesity but lacked the training and resources necessary to implement effective programming. Several intervention funding approaches were also identified including (1) program grants from local and national foundations, (2) healthcare community benefit initiatives, and (3) regional employer groups. Payment plans recommended in the customer discovery interviews included a mix of licensing and technical support fees for BHF delivery organizations, potential insurance reimbursement, and family fees based on ability to pay. Marketing a range of BHF non-weight related outcomes was also recommended during the customer discovery process to increase the likelihood of BHF scale-up and sustainability.

Conclusions

Engaging in customer discovery provided practical directions for the potential adoption, implementation, and sustainability of the BHF Resource Package. However, the inconsistent finding that health departments are both the ideal implementation organization, but also see childhood obesity treatment as a clinical service, is concerning.

The field of dissemination and implementation science has made pronounced strides in understanding barriers and facilitators related to translating efficacious interventions into practice [ 3 ]. Unfortunately, long lag times between the demonstration of intervention efficacy and use in community, public health, or healthcare settings persist [ 16 ]. Studying implementation processes and gaining an understanding of barriers to widespread uptake is a necessary, yet underutilized, tool in the pathway of moving interventions with demonstrated effectiveness into a position for broad adoption [ 23 ]. Further, the degree to which evidence-based interventions are moved into micropolitan (cities with <50,000 residents) and rural communities is an under-studied and high need area of research due to the confluence of lower socioeconomic status and health disparities [ 12 ].

Approaches such as user-centered design and community-academic partnerships attempt to speed the uptake of evidence-based interventions and close the research-practice gap [ 4 , 6 ]. Within these approaches, designing for dissemination, equity, and sustainability at the beginning of the intervention development process is hypothesized to significantly increase the likelihood that the intervention will be successfully adopted, implemented with fidelity, and sustained [ 3 , 5 , 17 ] by considering the facilitators and barriers relevant to the intended implementation setting, delivery agent, and audience intended to benefit from an evidence-based intervention. User-centered design and partnerships approaches often use backward design processes to increase the likelihood that a given intervention fits the system characteristics based on the goal of adoption and sustainability [ 24 ]. This process includes identifying key outcomes that may result from the intervention, considering user groups’ needs, the selection of required content, and, finally, the mapping of intervention content and processes to key outcomes [ 5 ].

One strategy to improve broader dissemination of evidence-based interventions, that have similar underlying principles to user-centered design and participatory approaches, is the use of a customer discovery process [ 25 ]. Customer discovery focuses on generating motivational data from a range of key people or organizations that can help to refine intervention design and dissemination strategies, while providing insight on the potential for scalability. Funding organizations have applied customer discovery processes to support scientists that have developed effective interventions to determine a product-market fit for their work [ 7 , 19 ]. Scientists involved in this process report seeing value in understanding customer segments and identifying value propositions that can guide dissemination efforts [ 7 , 19 ]. This approach has also been successful in clarifying the product-market fit and in generating intervention adaptations to better serve relevant audiences [ 25 ]. Investigative teams also improved their familiarity and comfort with the market aspects of intervention delivery, resulting in a shift of focus towards implementation, pursuing connections with small businesses, establishing companies for intervention delivery, or, in some cases, redesigning interventions [ 19 ].

The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) introduced an opportunity for research teams funded through the Childhood Obesity Research Demonstration (CORD) 3.0 project to participate in a facilitated customer discovery process. This process was adapted from the National Cancer Institute’s SPeeding Research-tested INTerventions (SPRINT) program [ 18 ] and was co-facilitated by the CDC and the AAP. All CORD 3.0 award recipients received training to facilitate the scale-up and acceptability of evidence-based, family healthy weight programs (FHWPs) with a goal to begin investigating sustainable funding and/or reimbursement structures. Participating research teams were encouraged to consider multiple customer segments – from families that could benefit from a FHWP, to community or clinical organizations that could contribute to implementation, and to agencies that could provide funding support.

This article reports on the application of a customer discovery process intended to improve future adoption, implementation, and sustainability of the Building Healthy Families (BHF) Online Training Resources and Program Package (BHF Resource Package; [ 10 ], the only CORD 3.0 project explicitly created to improve the uptake and delivery of a FHWP in rural and micropolitan areas [ 10 , 11 ]. The BHF Resource Package was developed collaboratively by (1) researchers with expertise in community-engagement, family healthy weight program development, and implementation science, (2) Building Healthy Families (BHF) program developers and implementers, and (3) a community advisory board with representation from community, public health, and healthcare organizations. During this process, intended users, various user types, product needs, and anticipated problems were discussed and used to inform the BHF Resource Package development [ 10 ]. It was hypothesized that participation in the SPRINT training would generate innovative ideas for scaling up use of the BHF Resource Package. In this paper, we report on the processes and outcomes of a customer discovery process intended to document the unique characteristics of the BHF Resource Package marketplace in micropolitan and rural community settings, strategies to enhance adoption by community organizations, potential adaptations needed to improve the context-intervention fit, and potential sustainable funding models.

Beginning in April through June of 2021, BHF team members ( n =7) participated in a dissemination and implementation accelerator program, SPRINT, to improve the uptake of evidence based FHWPs. Our process focused on the BHF Resource Package which includes, but goes beyond the evidence-based BHF FHWP program, and has components focused on the development of sustainable program recruitment strategies and channels, training on general and session specific content for program coordinators, and an integrated data portal that includes knowledge checks, fidelity assessments, and parent and child behavioral and weight outcomes (all of which are used to generate community and family reports to demonstrate progress) [ 10 , 11 ]. BHF SPRINT team members attended 10 meetings over the course of seven weeks and completed training in customer discovery, business modeling, interview techniques, and developing a translation/commercialization plan for the BHF Resource Package including dedicated modules on program revenue, costs, and market economics [ 18 ]. Each meeting included hands-on instruction on transforming evidence-based FHWPs into market-ready products and services [ 7 ]. All sessions were held synchronously using video conferencing to facilitate participation of CORD 3.0 research teams. This model allowed for peer sharing and learning across the other participating SPRINT research teams focused on translating FHWPs into sustained practice. SPRINT facilitators with expertise in customer discovery and business model planning held team-specific office hours biweekly to further develop and refine business model hypotheses. SPRINT teams generated business model hypotheses (e.g., how the BHF Resource Package would likely be disseminated and sustained in rural communities) to be tested through customer discovery interviews, which inform the creation of an operational business model – the SPRINT program’s final product. Hypotheses covered various segments of a business model, including key partners, key activities, key resources, value propositions, customer relations, communication channels, customer segments, cost structure, and revenue streams [ 20 ]. Details of the customer discovery interviews are outlined below.

The BHF resource package

The BHF Resource Package was designed using participatory methods to address the variability in available organizations and personnel that could deliver BHF, an evidence-based FHWP that focuses on supporting family changes in behavioral skills, dietary changes, and physical activity promotion in micropolitan and rural areas [ 10 ]. The BHF Resource Package development included the identification of primary (i.e., facilitators to be trained to deliver BHF), secondary (i.e., researchers/evaluators interested in tracking outcomes and implementation quality), tertiary (i.e., organizations/individuals who would support/sponsor BHF), and terminal (i.e., BHF family participants) end users. Across each of these users groups the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework [ 8 ] was used, in a backwards-design process, to describe relevant outcomes. The resultant BHF Resource Package included (1) program materials, lesson plans, PowerPoint slides, and implementation checklists, (2) overarching and session specific training modules for program coordinators and facilitators [ 10 ], (3) knowledge checks to ensure coordinator and facilitator competence, (4) fidelity assessments to track implementation quality, (5) a recruitment module to support family engagement, and (6) a data portal to track program effectiveness and family progress.

Participants

Community organizations, broadly defined as those with priorities related to childhood obesity and personnel with expertise or interest in family-based health promotion, were identified as the primary customer segment for the BHF Resource Package. This allowed for the consideration of community implementation team members from a broad range of community organizations (i.e., primary end users). Building from our primary customer segment, we created an eco-system map (Fig. 1 ) of rural FHWP. We used convenience sampling from existing professional networks to identify participants for our initial round of interviews. The eco-system map was generated to graphically represent the context of rural FHWP delivery and identify the relationships of individuals who would be involved in all aspects of the BHF Resource Package adoption, implementation, sustainment as well as those who would ultimately benefit from BHF program participation. The eco-system map identified potential customers and delivery channels (i.e., those who would support or influence BHF Resource Package implementation). The customer discovery process included interviews with individuals ( n =47) representing different aspects of the eco-system map that could have an influence on, or interest in, the BHF Resource Package adoption and implementation in rural and micropolitan areas (Table 1 ). Interview findings are presented in aggregate (i.e., not separated by stakeholder group) as the formation of an operational business model requires generalizable fit across multiple stakeholder groups within a given eco-system.

Ecosystem map for BHF - a family healthy weight program targeting rural and micropolitan communities

A broad approach with semi-structured, open-ended questions was taken with the interviews to explore and learn from potential BHF Resource Package adopters or influencers about their experiences related to addressing childhood obesity in their organization, identifying potential partners and competitors, and gaining insight about potential scale-up of BHF. The interviews were guided by an initial value proposition that was intended to incorporate key informant perceptions around things they would like to eliminate, things they would like to add, and considerations of the outcomes related to potential adoption of family healthy weight programs [ 20 ]. All participants were asked about how their organization prioritized or contributed to addressing childhood obesity, what other health promotion resources are available in the community, and community needs for addressing childhood obesity. Additional questions regarding program fit, such as, “If a childhood obesity program were to be offered by your organization, what would it look like?,” and, “What things would make it easier for your organization to offer this type of programming?” were asked during interviews. Discussions surrounding costs and revenue were central to all customer discovery interviews as the BHF SPRINT team sought to understand how best to create a sustainable pathway for the use of the BHF Resources Package and delivery of the FHWP in rural and micropolitan communities. Finally, our initial value proposition can be described as micropolitan and rural community organizations need and want to address childhood obesity, but currently do not have an easy way to do it. As such, we hypothesized that the BHF Resource Package would provide a valued, and relatively easy, turn-key approach to address childhood obesity locally.

The interview process followed an iterative approach – business model hypotheses were either confirmed – allowing testing of subsequent hypotheses – or refuted. When interview data suggested a hypothesis was incorrect or not feasible, then the business model hypotheses were revised to more closely align with the goal of creating a practical, robust, and compelling business model [ 19 ]. Of note, at the time of the interviews, the BHF Resource Package was being tested in seven micropolitan communities (and surrounding rural areas) in Nebraska with funding for program resources ($5,500/community) provided to participating communities through grant funding [ 9 ].

As the customer discovery interviews were considered activities with individuals talking about their profession and the items were limited to questions about how the BHF Resources would fit within their work or community activities, rather than about the individual characteristics of the interviewee, this work was not considered human subjects research by the University of Nebraska Medical Center IRB. However, while informed consent was not required; the research team asked all interviewees for permission to record the interview so that an accurate analysis of interview responses mapped to business model hypotheses could be completed. Interviews were conducted using phone or video conferencing and recorded using a password-protected, data-driven product management software platform that allowed for research team members to review interviews and feedback, track new discoveries, and validate (or refute) business model hypotheses. Upon completion of each interview, participants were asked for contact information of others in their network that could provide insight on their experiences addressing childhood obesity and the organizational decision-making process around adopting new evidence-based interventions.

Data analysis

A unique aspect of our approach to customer discovery interviews was the use of a rapid qualitative reduction process to analyze the research team members’ notes from each interview [ 26 ]. During this process, the research team member entered major themes from the interview into an online database and reviewed the existing hypotheses to code the interview as confirming, leaning confirming, neutral, leaning disconfirming, disconfirming, or not applicable to each hypothesis. Codes were discussed by research team members to ensure consensus. For example, if an interview yielded a major theme of fostering better clinic-community partnerships to allow for more referrals to effective FHWPs, the research team member would code that interview as “confirming” for the hypothesis that community communication and marketing resources would be a direct benefit to the customer (value proposition). Similarly, the same interview may have revealed that community health improvement plans are a contributing factor, but not the sole driver of program adoption decisions, and therefore the interview would be coded as “neutral” for the hypothesis, community health improvement plan goals are a primary driver of resource adoption (value proposition). The protected time provided by the research team’s involvement in the SPRINT program allowed for this more thorough data analysis process than what may be employed in more traditional customer discovery activities [ 19 ]. Codes for each hypothesis were quantified and used to rank order the value propositions.

Throughout the customer discovery interviews and expert consultation with the SPRINT facilitation team, we made changes to our hypotheses across all elements of our business model. If participant responses did not align with existing hypotheses, new hypotheses were created in the business model and added to subsequent interview guides. The research team met weekly to review interview progress, refine our target audience, and to discuss business model hypotheses. Hypotheses were edited, created, or removed (an activity prescribed by the customer discovery process) to reflect findings from the interviews and better capture the organizational decision-making process around adopting new evidence-based interventions. Across interviews and team discussions, emergent themes that could inform future scale up were recorded.

Customer discovery

Participants in the customer discovery interviews and the expert SPRINT facilitators indicated that identifying a specific type of community organization that was likely available across a wide variety of micropolitan and rural communities may be necessary to improve marketing and dissemination strategies for BHF program facilitators – the primary end users of the BHF Resources Package. Through the interviews, the consistent type of community organization mentioned was local health departments, and therefore potential BHF program facilitators were indicated to be local health department directors who have decision-making authority over local programming within the broader context of community health priorities. In contrast to identifying a potential single community organization for BHF implementation, interview participants identified a wide range of secondary end users (i.e., those who would support or provide funding for communities to use the BHF Resource Package). The potential supporters or funders included local employers, hospitals, and nonprofit organizations that could provide financial support for local health departments interested in adopting, implementing, and sustaining BHF.

Value propositions

Over the course of the customer discovery process, we identified nine components of value propositions related to why a customer would adopt the BHF product, how the resource would be a direct benefit to the customer, or what is unique about our solution. These are rank ordered in Table 2 based upon the degree to which they were confirmed across interviews. Specifically, based on confirming and leaning confirming responses, the most consistently confirmed value proposition across interviews was the hypothesis that communities will value the communication materials and marketing resources included in the BHF Resource Package. By rank order of confirmation, the next three value propositions all addressed the alignment of the BHF Resource Package with community priorities and need. Interviewees valued the focus on interorganizational collaboration promoted by the BHF Resource Package. While confirmed, our initial value hypothesis – that communities would value the user-friendly, comprehensive training and resource package – was rank ordered sixth in the nine value proposition hypotheses. Finally, our value hypothesis that the BHF Resource Package would be valued because it would support facilitator work by aligning with current job responsibilities was not confirmed.

Emergent themes from interviews

Findings from our customer discovery interviews illuminated insights beyond identifying local health departments as our primary customer. These themes were present across our business model hypotheses and included: 1) perceptions of responsibility among clinical and community organizations; 2) payer opportunities; and 3) marketing the benefits of the BHF Resource Package beyond child weight change.

Perceptions of responsibility among clinical and community organizations

We interviewed medical providers and clinical staff ( n =10) as well as health practitioners within the community (i.e., health department staff; n =13). What emerged from these discussions was that lifestyle programming for childhood obesity falls into a “grey area” between clinic and community systems. This also provided the context for the finding that there was a lack of alignment between the responsibilities of implementing BHF and current job descriptions of those working in micropolitan and rural communities. Specifically, several of the interview participants discussed the gap in rural communities – between which FHWPs fall – where local health departments focus on obesity prevention and rural health centers do not have the capacity to deliver FHWPs. Thus, FWHP implementation was not a consistent or specific job responsibility in rural communities. Within the potential BHF Resource Package user group, health department interviewees indicated that childhood obesity represented a clinical concern and that approaching families about childhood obesity treatment falls outside of the perceived scope of community health professionals. In contrast, healthcare professionals who were interviewed highlighted the constraints in clinical time and resources needed to deliver recommended FHWPs. Of note, interviewees suggested that there may be the potential for the public health and healthcare systems to complement one another to address childhood obesity by leveraging the patient-provider relationship to refer patients to efficacious community-based programming.

Cost, revenue, and payer opportunities

A common theme during the customer discovery interviews was the cost of providing the program and possible funding and reimbursement structures to support the sustainability of a FHWP. Interviewees identified potential grant funding or sponsorship from local or national foundations, local healthcare community benefit dollars, and employers as the most likely sources of sustainable funding for BHF. Additionally, licensing fees for adopting organizations or advertisement opportunities to offset costs, and a tiered system of customer fees (i.e., participating families) were proposed by interviewees as potential funding mechanisms. A consistent scenario was described that included a combination of a licensing fee for community organization use of the BHF Resources Package, additional fees for technical support or other methods to facilitate community organization adoption and implementation, and a small fee for participating families based on ability to pay. Finally, interviewees also discussed the potential of insurance reimbursement for family participation in BHF, similar to the reimbursement structure in place for the CDC National Diabetes Prevention Program.

Marketing the benefits of BHF beyond child weight change

As the BHF Resources Package is a FHWP, we designed the marketing and recruitment materials to highlight the health promotion aspects of BHF, specifically the focus on behavior change strategies that promote a healthy lifestyle and weight management. However, during our interviews, participants consistently emphasized the health promotion benefits of the BHF program that extend beyond weight management. Additional benefits included, but moved beyond, changes in healthful eating and physical activity to the constructive use of family time, social and emotional well-being, and quality of life. Participants explained that adopting a program like the BHF Resources Package would be more feasible if it could easily be identified as meeting several organizational health goals within nutrition, physical activity, and social and emotional well-being domains. Responses from health department professionals specifically referred to BHF aligning with Community Health Improvement Plans as being an important consideration. Finally, some interviewees highlighted the benefits of providing BHF in workplaces to promote employee well-being and reduce turnover.

Using a customer discovery process provided several critical areas for consideration when addressing the potential adoption, implementation, and sustainability of FHWPs in micropolitan and rural communities. Specifically, our findings suggested that there is a need to not only focus, but expand on the characteristics of an innovation related to designing for dissemination and scalability. Further, we identified the value held by potential delivery organizations in the resources that address issues related to reaching those in need of FHWPs and support for interorganizational collaboration. Finally, we found there is a need to address the ongoing challenges of the grey area of implementation responsibility for FHWPs and how that influences the availability of potentially sustainable funding models.

The BHF Resources Package, was designed for dissemination using a participatory and user-centered approach to create a resource that included all the program materials, training guides, and evaluation materials that micropolitan, rural, and/or under resourced communities need to implement BHF [ 10 ]. As such, we anticipated that the customer discover process would underscore that potential users of the BHF Resource Package would highly value the user-friendly comprehensive training and resource package features. This is consistent with much of the reporting on previous research teams that have used the customer discovery process that emphasizes the fit between the characteristics of the evidence-based intervention and delivery setting [ 3 ]. Our customer discovery process identified this as a value to micropolitan and rural communities, however, the relative rank of our value proposition related to designing for dissemination was rated sixth out of our nine proposed value statements. This may indicate that the user-friendly, comprehensive BHF Resource Package may be a necessary, but insufficient characteristic that communities consider in the adoption decision making process. Specifically, factors that are related to, but distinct from the characteristics of BHF Resource Package are the degree to which the goal of FHWPs aligns with community priorities, organizational missions, and degree of inter-organizational collaboration.

There are two areas in our findings that have not been explicitly addressed in other reports from the customer discovery process within the SPRINT process. First, the highest value that interviewees found in the BHF Resource Package was the inclusion of communication materials and marketing resources intended to increase the reach of the FHWP. Second, we found that interviewees also valued support for interorganizational collaboration. These findings may be due to the unique focus on micropolitan and rural communities, and align with previous research examining FHWPs in micropolitan and rural areas, where members of a community advisory board highlighted the development of sustainable referral protocols that relied on engagement across community organizations [ 1 ].

Perhaps the most daunting challenge identified through the customer discovery process is the grey area of responsibility when it comes to implementing FHWPs and the seemingly conflicting feedback we received that local health departments should be the focus of adoption efforts, but that health departments also prioritize obesity prevention over obesity treatment. Unfortunately, this is not new to our research team and is the underlying rationale for why we approached the development of the BHF Resources Package with a goal to allow for delivery by different organizations based on local systems that prioritized family healthy weights [ 11 ]. Still, focusing on local health departments served as a compass for steering our discussions with prospective partners who were also included in our customer discovery interviews and led to an approach that still valued flexibility in a local implementer while including local health departments as the primary starting place. In addition, after our completion of the customer discovery process, the CDC High Obesity Program included the implementation of FHWPs through state health departments [ 2 ] which should improve the market pull for the BHF Resource Package.

Moving forward with the intention to scale up the BHF Resource Package has been substantially informed by the findings from our customer discovery interviews and SPRINT training. Specifically, this process led to the development of more tailored descriptions of the BHF Resource Package that align with the values highlighted by our interviewees. A primary adaptation to the BHF Resource Package as a result of both the customer discover interviews and our piloting of the BHF Resource Package, was to enhance the recruitment module, introduce training for a recruitment coordinator, and provide a protocol to develop a local recruitment team. We anticipate this adaptation will be well received by communities. Yet, like other health promotion strategies intended for community, identifying potential payers for community-based lifestyle programming and moving towards commercialization is an ongoing and evolving challenge [ 15 , 19 ]. At the completion of this project, the goal of the research team was to develop a non-profit business, embedded within a host university, to provide the ability to receive payment from communities interested in using the BHF Resource Package. Challenges with this process included the time necessary to complete the process within the context of maintaining team project management, research, teaching, and service responsibilities [ 19 ]. Further, as we have moved forward, we have found that understanding the actual costs to provide the BHF Resource Package –from initiating a contract with a delivery organization to providing ongoing technical support—to be a challenge. As such, we recommend that others who are examining the potential to scale interventions like the BHF Resource Package consider using simple contractual agreements with a small number of implementation sites to better understand the costs prior to initiating commercialization processes—nonprofit or otherwise.

This project is limited by the focus specifically on micropolitan and rural communities primarily in Nebraska and the surrounding states. The findings may not be generalizable to other populations or systems outside of this region. For example, in our region, systems such as cooperative extension do not focus on childhood obesity treatment, though in other regions they do [ 13 , 14 , 21 , 22 ] and may be another potential primary user of the BHF Resource Package (or other FHWPs). This underscores the potential need to consider the variability of organizations and resources to deliver evidence-based FHWPs if a broad public health impact in rural areas is to be achieved. Finally, when contrasted with other projects that have used customer discovery processes with the SPRINT model, it appears that there are unique issues related to promoting family healthy weights in micropolitan and rural communities.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

American Academy of Pediatrics

Building Healthy Families

Centers of Disease Control and Prevention

Family Healthy Weight Program

Reach, Effectiveness, Adoption, Implementation, and Maintenance Framework

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This study was supported by the Centers for Disease Control and Prevention (CDC) (Award No: 1U18DP006431-01-00). This work is solely the responsibility of the authors and does not represent official views of the Centers for Disease Control and Prevention (CDC), Health and Human Services (HHS), or the US Government.

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Gwenndolyn C. Porter

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University of Nebraska at Kearney, Department of Biology, Kearney, NE, 68849, USA

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Porter, G.C., Hill, J.L., Heelan, K.A. et al. Using a customer discovery process to enhance the potential dissemination and scalability of a family healthy weight program for rural communities and small towns. Int J Behav Nutr Phys Act 21 , 57 (2024). https://doi.org/10.1186/s12966-024-01605-7

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Cultural Relativity and Acceptance of Embryonic Stem Cell Research

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There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities.

INTRODUCTION

Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve.

Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes. [1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research. [2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.” [3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops. [4]  Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture.

I.     Global Cultural Perspective of Embryonic Stem Cells

Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense, [5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research. [6] Consequently, global engagement in ESC research depends on social-cultural acceptability.

a.     US and Rights-Based Cultures

In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism, [7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.” [8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed. [9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field. [10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture. [11]

b.     Ubuntu and Collective Cultures

African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama , which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,” [12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth. [13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole. Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value. [14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society.

Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.” [15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail.

Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable. [16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus [17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines. [18]

Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim. [19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research. [20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF.  Their use is conditioned on consent, and available only to married couples. [21] The community's receptiveness to stem cell research depends on including communitarian African ethics.

c.     Asia

Some Asian countries also have a collective model of ethics and decision making. [22] In China, the ethics model promotes a sincere respect for life or human dignity, [23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life. [25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research. [26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions. [27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency. [28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021. [29] However, issues still need to be addressed in implementing effective IRB review and approval procedures.

The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy, [30] research ethics should also adapt to ensure respect for the values of its represented peoples.

Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies. [31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells. [32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval, [33] and in another instance, the oocyte source was unclear and possibly violated ethical standards. [34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust.

d.     Middle East

Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells, [35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research. [36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors. [37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so. [38]

Jordan has a positive research ethics culture. [39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial. [40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation. [41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.” [42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes.

e.     Europe

In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected. [43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44]

For example, in Germany, Lebenzusammenhang , or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.” [45]  Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount. [46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007. [47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization. [48] Spain’s approach differs still, with a comprehensive regulatory framework. [49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility. [50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices. [51]

II.     Religious Perspectives on ESC

Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives.

The Qur'an states:

“And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.” [52]

Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception. [53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible. [54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research. [55]

In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided. [56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden. [57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all. [58] Acceptance varies on applied beliefs and interpretations.

Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero, [59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all. [60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime. [61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit. [62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets. [63]

Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life. [64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception: [65]

“If she is found pregnant, until the fortieth day it is mere fluid,” [66]

Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation. [67] Stem cell research is accepted due to application of these religious laws.

We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory , which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions. [68] We only wish to show that the interaction with morality varies between cultures and countries.

III.     A Flexible Ethical Approach

The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities.

While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe. [69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation.

For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent. [70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context, [71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders.  This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research.

Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values. [72]

An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions. [73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion.

IV.     Concerns

Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values. [74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions.

Other concerns include medical tourism, which may promote health inequities. [75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments. [76]

For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.” [77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices. [78]

The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.” [79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds. [80]

While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research.

For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society.

This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model.

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[36] Association for the Advancement of Blood and Biotherapies.  https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia

[37] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia.  BMC medical ethics ,  21 (1), 35. https://doi.org/10.1186/s12910-020-00482-6

[38] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics , 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics , 23 (3), 260–268. https://doi.org/10.1111/dewb.12355 ; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know . Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know

[39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[41] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[42] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France.  Biotechnology Law Report ,  32 (6), 349–356. https://doi.org/10.1089/blr.2013.9865

[45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[46] Tomuschat, C., Currie, D. P., Kommers, D. P., & Kerr, R. (Trans.). (1949, May 23). Basic law for the Federal Republic of Germany. https://www.btg-bestellservice.de/pdf/80201000.pdf

[47] Regulation of Stem Cell Research in Germany . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany

[48] Regulation of Stem Cell Research in Finland . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland

[49] Regulation of Stem Cell Research in Spain . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain

[50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered:

Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110.

Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ...  Revista do Colegio Brasileiro de Cirurgioes ,  41 (5), 374–377. https://doi.org/10.1590/0100-69912014005013

Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India . Routledge.

For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe   

[51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights.  Cultura (Iasi, Romania) ,  14 (2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent?  Research Ethics ,  13 (1), 23-41.  https://doi.org/10.1177/1747016116650235

[52] The Qur'an  (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23

[53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life . Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/

[54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics , 31: 399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386

[55] Rashid, R. (2022). When does Ensoulment occur in the Human Foetus. Journal of the British Islamic Medical Association , 12 (4). ISSN 2634 8071. https://www.jbima.com/wp-content/uploads/2023/01/2-Ethics-3_-Ensoulment_Rafaqat.pdf.

[56] Sivaraman, M. & Noor, S. (2017). Ethics of embryonic stem cell research according to Buddhist, Hindu, Catholic, and Islamic religions: perspective from Malaysia. Asian Biomedicine,8(1) 43-52.  https://doi.org/10.5372/1905-7415.0801.260

[57] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[58] Lecso, P. A. (1991). The Bodhisattva Ideal and Organ Transplantation.  Journal of Religion and Health ,  30 (1), 35–41. http://www.jstor.org/stable/27510629 ; Bodhisattva, S. (n.d.). The Key of Becoming a Bodhisattva . A Guide to the Bodhisattva Way of Life. http://www.buddhism.org/Sutras/2/BodhisattvaWay.htm

[59] There is no explicit religious reference to when life begins or how to conduct research that interacts with the concept of life. However, these are relevant verses pertaining to how the fetus is viewed. (( King James Bible . (1999). Oxford University Press. (original work published 1769))

Jerimiah 1: 5 “Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee…”

In prophet Jerimiah’s insight, God set him apart as a person known before childbirth, a theme carried within the Psalm of David.

Psalm 139: 13-14 “…Thou hast covered me in my mother's womb. I will praise thee; for I am fearfully and wonderfully made…”

These verses demonstrate David’s respect for God as an entity that would know of all man’s thoughts and doings even before birth.

[60] It should be noted that abortion is not supported as well.

[61] The Vatican. (1987, February 22). Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day . Congregation For the Doctrine of the Faith. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html

[62] The Vatican. (2000, August 25). Declaration On the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells . Pontifical Academy for Life. https://www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pa_acdlife_doc_20000824_cellule-staminali_en.html ; Ohara, N. (2003). Ethical Consideration of Experimentation Using Living Human Embryos: The Catholic Church’s Position on Human Embryonic Stem Cell Research and Human Cloning. Department of Obstetrics and Gynecology . Retrieved from https://article.imrpress.com/journal/CEOG/30/2-3/pii/2003018/77-81.pdf.

[63] Smith, G. A. (2022, May 23). Like Americans overall, Catholics vary in their abortion views, with regular mass attenders most opposed . Pew Research Center. https://www.pewresearch.org/short-reads/2022/05/23/like-americans-overall-catholics-vary-in-their-abortion-views-with-regular-mass-attenders-most-opposed/

[64] Rosner, F., & Reichman, E. (2002). Embryonic stem cell research in Jewish law. Journal of halacha and contemporary society , (43), 49–68.; Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[65] Schenker J. G. (2008). The beginning of human life: status of embryo. Perspectives in Halakha (Jewish Religious Law).  Journal of assisted reproduction and genetics ,  25 (6), 271–276. https://doi.org/10.1007/s10815-008-9221-6

[66] Ruttenberg, D. (2020, May 5). The Torah of Abortion Justice (annotated source sheet) . Sefaria. https://www.sefaria.org/sheets/234926.7?lang=bi&with=all&lang2=en

[67] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[68] Gert, B. (2007). Common morality: Deciding what to do . Oxford Univ. Press.

[69] World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA , 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Declaration of Helsinki – WMA – The World Medical Association .; see also: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979).  The Belmont report: Ethical principles and guidelines for the protection of human subjects of research . U.S. Department of Health and Human Services.  https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html

[70] Zakarin Safier, L., Gumer, A., Kline, M., Egli, D., & Sauer, M. V. (2018). Compensating human subjects providing oocytes for stem cell research: 9-year experience and outcomes.  Journal of assisted reproduction and genetics ,  35 (7), 1219–1225. https://doi.org/10.1007/s10815-018-1171-z https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6063839/ see also: Riordan, N. H., & Paz Rodríguez, J. (2021). Addressing concerns regarding associated costs, transparency, and integrity of research in recent stem cell trial. Stem Cells Translational Medicine , 10 (12), 1715–1716. https://doi.org/10.1002/sctm.21-0234

[71] Klitzman, R., & Sauer, M. V. (2009). Payment of egg donors in stem cell research in the USA.  Reproductive biomedicine online ,  18 (5), 603–608. https://doi.org/10.1016/s1472-6483(10)60002-8

[72] Krosin, M. T., Klitzman, R., Levin, B., Cheng, J., & Ranney, M. L. (2006). Problems in comprehension of informed consent in rural and peri-urban Mali, West Africa.  Clinical trials (London, England) ,  3 (3), 306–313. https://doi.org/10.1191/1740774506cn150oa

[73] Veatch, Robert M.  Hippocratic, Religious, and Secular Medical Ethics: The Points of Conflict . Georgetown University Press, 2012.

[74] Msoroka, M. S., & Amundsen, D. (2018). One size fits not quite all: Universal research ethics with diversity.  Research Ethics ,  14 (3), 1-17.  https://doi.org/10.1177/1747016117739939

[75] Pirzada, N. (2022). The Expansion of Turkey’s Medical Tourism Industry.  Voices in Bioethics ,  8 . https://doi.org/10.52214/vib.v8i.9894

[76] Stem Cell Tourism: False Hope for Real Money . Harvard Stem Cell Institute (HSCI). (2023). https://hsci.harvard.edu/stem-cell-tourism , See also: Bissassar, M. (2017). Transnational Stem Cell Tourism: An ethical analysis.  Voices in Bioethics ,  3 . https://doi.org/10.7916/vib.v3i.6027

[77] Song, P. (2011) The proliferation of stem cell therapies in post-Mao China: problematizing ethical regulation,  New Genetics and Society , 30:2, 141-153, DOI:  10.1080/14636778.2011.574375

[78] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[79] International Society for Stem Cell Research. (2024). Standards in stem cell research . International Society for Stem Cell Research. https://www.isscr.org/guidelines/5-standards-in-stem-cell-research

[80] Benjamin, R. (2013). People’s science bodies and rights on the Stem Cell Frontier . Stanford University Press.

Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

MS Bioethics Columbia University (Disclosure: affiliated with Voices in Bioethics)

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