case study of descriptive model

The Ultimate Guide to Qualitative Research - Part 1: The Basics

• Introduction and overview
• What is qualitative research?
• What is qualitative data?
• Examples of qualitative data
• Qualitative vs. quantitative research
• Mixed methods
• Qualitative research preparation
• Theoretical perspective
• Theoretical framework
• Literature reviews

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

Applications for case study research, what is a good case study, process of case study design, benefits and limitations of case studies.

• Ethnographical research
• Ethical considerations
• Confidentiality and privacy
• Power dynamics
• Reflexivity

Case studies

Case studies are essential to qualitative research , offering a lens through which researchers can investigate complex phenomena within their real-life contexts. This chapter explores the concept, purpose, applications, examples, and types of case studies and provides guidance on how to conduct case study research effectively.

Whereas quantitative methods look at phenomena at scale, case study research looks at a concept or phenomenon in considerable detail. While analyzing a single case can help understand one perspective regarding the object of research inquiry, analyzing multiple cases can help obtain a more holistic sense of the topic or issue. Let's provide a basic definition of a case study, then explore its characteristics and role in the qualitative research process.

Definition of a case study

A case study in qualitative research is a strategy of inquiry that involves an in-depth investigation of a phenomenon within its real-world context. It provides researchers with the opportunity to acquire an in-depth understanding of intricate details that might not be as apparent or accessible through other methods of research. The specific case or cases being studied can be a single person, group, or organization – demarcating what constitutes a relevant case worth studying depends on the researcher and their research question .

Among qualitative research methods , a case study relies on multiple sources of evidence, such as documents, artifacts, interviews , or observations , to present a complete and nuanced understanding of the phenomenon under investigation. The objective is to illuminate the readers' understanding of the phenomenon beyond its abstract statistical or theoretical explanations.

Characteristics of case studies

Case studies typically possess a number of distinct characteristics that set them apart from other research methods. These characteristics include a focus on holistic description and explanation, flexibility in the design and data collection methods, reliance on multiple sources of evidence, and emphasis on the context in which the phenomenon occurs.

Furthermore, case studies can often involve a longitudinal examination of the case, meaning they study the case over a period of time. These characteristics allow case studies to yield comprehensive, in-depth, and richly contextualized insights about the phenomenon of interest.

The role of case studies in research

Case studies hold a unique position in the broader landscape of research methods aimed at theory development. They are instrumental when the primary research interest is to gain an intensive, detailed understanding of a phenomenon in its real-life context.

In addition, case studies can serve different purposes within research - they can be used for exploratory, descriptive, or explanatory purposes, depending on the research question and objectives. This flexibility and depth make case studies a valuable tool in the toolkit of qualitative researchers.

Remember, a well-conducted case study can offer a rich, insightful contribution to both academic and practical knowledge through theory development or theory verification, thus enhancing our understanding of complex phenomena in their real-world contexts.

What is the purpose of a case study?

Case study research aims for a more comprehensive understanding of phenomena, requiring various research methods to gather information for qualitative analysis . Ultimately, a case study can allow the researcher to gain insight into a particular object of inquiry and develop a theoretical framework relevant to the research inquiry.

Why use case studies in qualitative research?

Using case studies as a research strategy depends mainly on the nature of the research question and the researcher's access to the data.

Conducting case study research provides a level of detail and contextual richness that other research methods might not offer. They are beneficial when there's a need to understand complex social phenomena within their natural contexts.

The explanatory, exploratory, and descriptive roles of case studies

Case studies can take on various roles depending on the research objectives. They can be exploratory when the research aims to discover new phenomena or define new research questions; they are descriptive when the objective is to depict a phenomenon within its context in a detailed manner; and they can be explanatory if the goal is to understand specific relationships within the studied context. Thus, the versatility of case studies allows researchers to approach their topic from different angles, offering multiple ways to uncover and interpret the data .

The impact of case studies on knowledge development

Case studies play a significant role in knowledge development across various disciplines. Analysis of cases provides an avenue for researchers to explore phenomena within their context based on the collected data.

This can result in the production of rich, practical insights that can be instrumental in both theory-building and practice. Case studies allow researchers to delve into the intricacies and complexities of real-life situations, uncovering insights that might otherwise remain hidden.

Types of case studies

In qualitative research , a case study is not a one-size-fits-all approach. Depending on the nature of the research question and the specific objectives of the study, researchers might choose to use different types of case studies. These types differ in their focus, methodology, and the level of detail they provide about the phenomenon under investigation.

Understanding these types is crucial for selecting the most appropriate approach for your research project and effectively achieving your research goals. Let's briefly look at the main types of case studies.

Exploratory case studies

Exploratory case studies are typically conducted to develop a theory or framework around an understudied phenomenon. They can also serve as a precursor to a larger-scale research project. Exploratory case studies are useful when a researcher wants to identify the key issues or questions which can spur more extensive study or be used to develop propositions for further research. These case studies are characterized by flexibility, allowing researchers to explore various aspects of a phenomenon as they emerge, which can also form the foundation for subsequent studies.

Descriptive case studies

Descriptive case studies aim to provide a complete and accurate representation of a phenomenon or event within its context. These case studies are often based on an established theoretical framework, which guides how data is collected and analyzed. The researcher is concerned with describing the phenomenon in detail, as it occurs naturally, without trying to influence or manipulate it.

Explanatory case studies

Explanatory case studies are focused on explanation - they seek to clarify how or why certain phenomena occur. Often used in complex, real-life situations, they can be particularly valuable in clarifying causal relationships among concepts and understanding the interplay between different factors within a specific context.

Intrinsic, instrumental, and collective case studies

These three categories of case studies focus on the nature and purpose of the study. An intrinsic case study is conducted when a researcher has an inherent interest in the case itself. Instrumental case studies are employed when the case is used to provide insight into a particular issue or phenomenon. A collective case study, on the other hand, involves studying multiple cases simultaneously to investigate some general phenomena.

Each type of case study serves a different purpose and has its own strengths and challenges. The selection of the type should be guided by the research question and objectives, as well as the context and constraints of the research.

The flexibility, depth, and contextual richness offered by case studies make this approach an excellent research method for various fields of study. They enable researchers to investigate real-world phenomena within their specific contexts, capturing nuances that other research methods might miss. Across numerous fields, case studies provide valuable insights into complex issues.

Critical information systems research

Case studies provide a detailed understanding of the role and impact of information systems in different contexts. They offer a platform to explore how information systems are designed, implemented, and used and how they interact with various social, economic, and political factors. Case studies in this field often focus on examining the intricate relationship between technology, organizational processes, and user behavior, helping to uncover insights that can inform better system design and implementation.

Health research

Health research is another field where case studies are highly valuable. They offer a way to explore patient experiences, healthcare delivery processes, and the impact of various interventions in a real-world context.

Case studies can provide a deep understanding of a patient's journey, giving insights into the intricacies of disease progression, treatment effects, and the psychosocial aspects of health and illness.

Asthma research studies

Specifically within medical research, studies on asthma often employ case studies to explore the individual and environmental factors that influence asthma development, management, and outcomes. A case study can provide rich, detailed data about individual patients' experiences, from the triggers and symptoms they experience to the effectiveness of various management strategies. This can be crucial for developing patient-centered asthma care approaches.

Other fields

Apart from the fields mentioned, case studies are also extensively used in business and management research, education research, and political sciences, among many others. They provide an opportunity to delve into the intricacies of real-world situations, allowing for a comprehensive understanding of various phenomena.

Case studies, with their depth and contextual focus, offer unique insights across these varied fields. They allow researchers to illuminate the complexities of real-life situations, contributing to both theory and practice.

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Understanding the key elements of case study design is crucial for conducting rigorous and impactful case study research. A well-structured design guides the researcher through the process, ensuring that the study is methodologically sound and its findings are reliable and valid. The main elements of case study design include the research question , propositions, units of analysis, and the logic linking the data to the propositions.

The research question is the foundation of any research study. A good research question guides the direction of the study and informs the selection of the case, the methods of collecting data, and the analysis techniques. A well-formulated research question in case study research is typically clear, focused, and complex enough to merit further detailed examination of the relevant case(s).

Propositions

Propositions, though not necessary in every case study, provide a direction by stating what we might expect to find in the data collected. They guide how data is collected and analyzed by helping researchers focus on specific aspects of the case. They are particularly important in explanatory case studies, which seek to understand the relationships among concepts within the studied phenomenon.

Units of analysis

The unit of analysis refers to the case, or the main entity or entities that are being analyzed in the study. In case study research, the unit of analysis can be an individual, a group, an organization, a decision, an event, or even a time period. It's crucial to clearly define the unit of analysis, as it shapes the qualitative data analysis process by allowing the researcher to analyze a particular case and synthesize analysis across multiple case studies to draw conclusions.

Argumentation

This refers to the inferential model that allows researchers to draw conclusions from the data. The researcher needs to ensure that there is a clear link between the data, the propositions (if any), and the conclusions drawn. This argumentation is what enables the researcher to make valid and credible inferences about the phenomenon under study.

Understanding and carefully considering these elements in the design phase of a case study can significantly enhance the quality of the research. It can help ensure that the study is methodologically sound and its findings contribute meaningful insights about the case.

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Conducting a case study involves several steps, from defining the research question and selecting the case to collecting and analyzing data . This section outlines these key stages, providing a practical guide on how to conduct case study research.

Defining the research question

The first step in case study research is defining a clear, focused research question. This question should guide the entire research process, from case selection to analysis. It's crucial to ensure that the research question is suitable for a case study approach. Typically, such questions are exploratory or descriptive in nature and focus on understanding a phenomenon within its real-life context.

Selecting and defining the case

The selection of the case should be based on the research question and the objectives of the study. It involves choosing a unique example or a set of examples that provide rich, in-depth data about the phenomenon under investigation. After selecting the case, it's crucial to define it clearly, setting the boundaries of the case, including the time period and the specific context.

Previous research can help guide the case study design. When considering a case study, an example of a case could be taken from previous case study research and used to define cases in a new research inquiry. Considering recently published examples can help understand how to select and define cases effectively.

Developing a detailed case study protocol

A case study protocol outlines the procedures and general rules to be followed during the case study. This includes the data collection methods to be used, the sources of data, and the procedures for analysis. Having a detailed case study protocol ensures consistency and reliability in the study.

The protocol should also consider how to work with the people involved in the research context to grant the research team access to collecting data. As mentioned in previous sections of this guide, establishing rapport is an essential component of qualitative research as it shapes the overall potential for collecting and analyzing data.

Collecting data

Gathering data in case study research often involves multiple sources of evidence, including documents, archival records, interviews, observations, and physical artifacts. This allows for a comprehensive understanding of the case. The process for gathering data should be systematic and carefully documented to ensure the reliability and validity of the study.

Analyzing and interpreting data

The next step is analyzing the data. This involves organizing the data , categorizing it into themes or patterns , and interpreting these patterns to answer the research question. The analysis might also involve comparing the findings with prior research or theoretical propositions.

Writing the case study report

The final step is writing the case study report . This should provide a detailed description of the case, the data, the analysis process, and the findings. The report should be clear, organized, and carefully written to ensure that the reader can understand the case and the conclusions drawn from it.

Each of these steps is crucial in ensuring that the case study research is rigorous, reliable, and provides valuable insights about the case.

The type, depth, and quality of data in your study can significantly influence the validity and utility of the study. In case study research, data is usually collected from multiple sources to provide a comprehensive and nuanced understanding of the case. This section will outline the various methods of collecting data used in case study research and discuss considerations for ensuring the quality of the data.

Interviews are a common method of gathering data in case study research. They can provide rich, in-depth data about the perspectives, experiences, and interpretations of the individuals involved in the case. Interviews can be structured , semi-structured , or unstructured , depending on the research question and the degree of flexibility needed.

Observations

Observations involve the researcher observing the case in its natural setting, providing first-hand information about the case and its context. Observations can provide data that might not be revealed in interviews or documents, such as non-verbal cues or contextual information.

Documents and artifacts

Documents and archival records provide a valuable source of data in case study research. They can include reports, letters, memos, meeting minutes, email correspondence, and various public and private documents related to the case.

These records can provide historical context, corroborate evidence from other sources, and offer insights into the case that might not be apparent from interviews or observations.

Physical artifacts refer to any physical evidence related to the case, such as tools, products, or physical environments. These artifacts can provide tangible insights into the case, complementing the data gathered from other sources.

Ensuring the quality of data collection

Determining the quality of data in case study research requires careful planning and execution. It's crucial to ensure that the data is reliable, accurate, and relevant to the research question. This involves selecting appropriate methods of collecting data, properly training interviewers or observers, and systematically recording and storing the data. It also includes considering ethical issues related to collecting and handling data, such as obtaining informed consent and ensuring the privacy and confidentiality of the participants.

Data analysis

Analyzing case study research involves making sense of the rich, detailed data to answer the research question. This process can be challenging due to the volume and complexity of case study data. However, a systematic and rigorous approach to analysis can ensure that the findings are credible and meaningful. This section outlines the main steps and considerations in analyzing data in case study research.

Organizing the data

The first step in the analysis is organizing the data. This involves sorting the data into manageable sections, often according to the data source or the theme. This step can also involve transcribing interviews, digitizing physical artifacts, or organizing observational data.

Categorizing and coding the data

Once the data is organized, the next step is to categorize or code the data. This involves identifying common themes, patterns, or concepts in the data and assigning codes to relevant data segments. Coding can be done manually or with the help of software tools, and in either case, qualitative analysis software can greatly facilitate the entire coding process. Coding helps to reduce the data to a set of themes or categories that can be more easily analyzed.

Identifying patterns and themes

After coding the data, the researcher looks for patterns or themes in the coded data. This involves comparing and contrasting the codes and looking for relationships or patterns among them. The identified patterns and themes should help answer the research question.

Interpreting the data

Once patterns and themes have been identified, the next step is to interpret these findings. This involves explaining what the patterns or themes mean in the context of the research question and the case. This interpretation should be grounded in the data, but it can also involve drawing on theoretical concepts or prior research.

Verification of the data

The last step in the analysis is verification. This involves checking the accuracy and consistency of the analysis process and confirming that the findings are supported by the data. This can involve re-checking the original data, checking the consistency of codes, or seeking feedback from research participants or peers.

Like any research method , case study research has its strengths and limitations. Researchers must be aware of these, as they can influence the design, conduct, and interpretation of the study.

Understanding the strengths and limitations of case study research can also guide researchers in deciding whether this approach is suitable for their research question . This section outlines some of the key strengths and limitations of case study research.

Benefits include the following:

• Rich, detailed data: One of the main strengths of case study research is that it can generate rich, detailed data about the case. This can provide a deep understanding of the case and its context, which can be valuable in exploring complex phenomena.
• Flexibility: Case study research is flexible in terms of design , data collection , and analysis . A sufficient degree of flexibility allows the researcher to adapt the study according to the case and the emerging findings.
• Real-world context: Case study research involves studying the case in its real-world context, which can provide valuable insights into the interplay between the case and its context.
• Multiple sources of evidence: Case study research often involves collecting data from multiple sources , which can enhance the robustness and validity of the findings.

On the other hand, researchers should consider the following limitations:

• Generalizability: A common criticism of case study research is that its findings might not be generalizable to other cases due to the specificity and uniqueness of each case.
• Time and resource intensive: Case study research can be time and resource intensive due to the depth of the investigation and the amount of collected data.
• Complexity of analysis: The rich, detailed data generated in case study research can make analyzing the data challenging.
• Subjectivity: Given the nature of case study research, there may be a higher degree of subjectivity in interpreting the data , so researchers need to reflect on this and transparently convey to audiences how the research was conducted.

Being aware of these strengths and limitations can help researchers design and conduct case study research effectively and interpret and report the findings appropriately.

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Case Study – Methods, Examples and Guide

Table of Contents

A case study is a research method that involves an in-depth examination and analysis of a particular phenomenon or case, such as an individual, organization, community, event, or situation.

It is a qualitative research approach that aims to provide a detailed and comprehensive understanding of the case being studied. Case studies typically involve multiple sources of data, including interviews, observations, documents, and artifacts, which are analyzed using various techniques, such as content analysis, thematic analysis, and grounded theory. The findings of a case study are often used to develop theories, inform policy or practice, or generate new research questions.

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

A single-case study is an in-depth analysis of a single case. This type of case study is useful when the researcher wants to understand a specific phenomenon in detail.

For Example , A researcher might conduct a single-case study on a particular individual to understand their experiences with a particular health condition or a specific organization to explore their management practices. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a single-case study are often used to generate new research questions, develop theories, or inform policy or practice.

Multiple-Case Study

A multiple-case study involves the analysis of several cases that are similar in nature. This type of case study is useful when the researcher wants to identify similarities and differences between the cases.

For Example, a researcher might conduct a multiple-case study on several companies to explore the factors that contribute to their success or failure. The researcher collects data from each case, compares and contrasts the findings, and uses various techniques to analyze the data, such as comparative analysis or pattern-matching. The findings of a multiple-case study can be used to develop theories, inform policy or practice, or generate new research questions.

Exploratory Case Study

An exploratory case study is used to explore a new or understudied phenomenon. This type of case study is useful when the researcher wants to generate hypotheses or theories about the phenomenon.

For Example, a researcher might conduct an exploratory case study on a new technology to understand its potential impact on society. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as grounded theory or content analysis. The findings of an exploratory case study can be used to generate new research questions, develop theories, or inform policy or practice.

Descriptive Case Study

A descriptive case study is used to describe a particular phenomenon in detail. This type of case study is useful when the researcher wants to provide a comprehensive account of the phenomenon.

For Example, a researcher might conduct a descriptive case study on a particular community to understand its social and economic characteristics. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a descriptive case study can be used to inform policy or practice or generate new research questions.

Instrumental Case Study

An instrumental case study is used to understand a particular phenomenon that is instrumental in achieving a particular goal. This type of case study is useful when the researcher wants to understand the role of the phenomenon in achieving the goal.

For Example, a researcher might conduct an instrumental case study on a particular policy to understand its impact on achieving a particular goal, such as reducing poverty. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of an instrumental case study can be used to inform policy or practice or generate new research questions.

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

Interviews involve asking questions to individuals who have knowledge or experience relevant to the case study. Interviews can be structured (where the same questions are asked to all participants) or unstructured (where the interviewer follows up on the responses with further questions). Interviews can be conducted in person, over the phone, or through video conferencing.

Observations

Observations involve watching and recording the behavior and activities of individuals or groups relevant to the case study. Observations can be participant (where the researcher actively participates in the activities) or non-participant (where the researcher observes from a distance). Observations can be recorded using notes, audio or video recordings, or photographs.

Documents can be used as a source of information for case studies. Documents can include reports, memos, emails, letters, and other written materials related to the case study. Documents can be collected from the case study participants or from public sources.

Surveys involve asking a set of questions to a sample of individuals relevant to the case study. Surveys can be administered in person, over the phone, through mail or email, or online. Surveys can be used to gather information on attitudes, opinions, or behaviors related to the case study.

Artifacts are physical objects relevant to the case study. Artifacts can include tools, equipment, products, or other objects that provide insights into the case study phenomenon.

How to conduct Case Study Research

Conducting a case study research involves several steps that need to be followed to ensure the quality and rigor of the study. Here are the steps to conduct case study research:

• Define the research questions: The first step in conducting a case study research is to define the research questions. The research questions should be specific, measurable, and relevant to the case study phenomenon under investigation.
• Select the case: The next step is to select the case or cases to be studied. The case should be relevant to the research questions and should provide rich and diverse data that can be used to answer the research questions.
• Collect data: Data can be collected using various methods, such as interviews, observations, documents, surveys, and artifacts. The data collection method should be selected based on the research questions and the nature of the case study phenomenon.
• Analyze the data: The data collected from the case study should be analyzed using various techniques, such as content analysis, thematic analysis, or grounded theory. The analysis should be guided by the research questions and should aim to provide insights and conclusions relevant to the research questions.
• Draw conclusions: The conclusions drawn from the case study should be based on the data analysis and should be relevant to the research questions. The conclusions should be supported by evidence and should be clearly stated.
• Validate the findings: The findings of the case study should be validated by reviewing the data and the analysis with participants or other experts in the field. This helps to ensure the validity and reliability of the findings.
• Write the report: The final step is to write the report of the case study research. The report should provide a clear description of the case study phenomenon, the research questions, the data collection methods, the data analysis, the findings, and the conclusions. The report should be written in a clear and concise manner and should follow the guidelines for academic writing.

Examples of Case Study

Here are some examples of case study research:

• The Hawthorne Studies : Conducted between 1924 and 1932, the Hawthorne Studies were a series of case studies conducted by Elton Mayo and his colleagues to examine the impact of work environment on employee productivity. The studies were conducted at the Hawthorne Works plant of the Western Electric Company in Chicago and included interviews, observations, and experiments.
• The Stanford Prison Experiment: Conducted in 1971, the Stanford Prison Experiment was a case study conducted by Philip Zimbardo to examine the psychological effects of power and authority. The study involved simulating a prison environment and assigning participants to the role of guards or prisoners. The study was controversial due to the ethical issues it raised.
• The Challenger Disaster: The Challenger Disaster was a case study conducted to examine the causes of the Space Shuttle Challenger explosion in 1986. The study included interviews, observations, and analysis of data to identify the technical, organizational, and cultural factors that contributed to the disaster.
• The Enron Scandal: The Enron Scandal was a case study conducted to examine the causes of the Enron Corporation’s bankruptcy in 2001. The study included interviews, analysis of financial data, and review of documents to identify the accounting practices, corporate culture, and ethical issues that led to the company’s downfall.
• The Fukushima Nuclear Disaster : The Fukushima Nuclear Disaster was a case study conducted to examine the causes of the nuclear accident that occurred at the Fukushima Daiichi Nuclear Power Plant in Japan in 2011. The study included interviews, analysis of data, and review of documents to identify the technical, organizational, and cultural factors that contributed to the disaster.

Application of Case Study

Case studies have a wide range of applications across various fields and industries. Here are some examples:

Business and Management

Case studies are widely used in business and management to examine real-life situations and develop problem-solving skills. Case studies can help students and professionals to develop a deep understanding of business concepts, theories, and best practices.

Case studies are used in healthcare to examine patient care, treatment options, and outcomes. Case studies can help healthcare professionals to develop critical thinking skills, diagnose complex medical conditions, and develop effective treatment plans.

Case studies are used in education to examine teaching and learning practices. Case studies can help educators to develop effective teaching strategies, evaluate student progress, and identify areas for improvement.

Social Sciences

Case studies are widely used in social sciences to examine human behavior, social phenomena, and cultural practices. Case studies can help researchers to develop theories, test hypotheses, and gain insights into complex social issues.

Law and Ethics

Case studies are used in law and ethics to examine legal and ethical dilemmas. Case studies can help lawyers, policymakers, and ethical professionals to develop critical thinking skills, analyze complex cases, and make informed decisions.

Purpose of Case Study

The purpose of a case study is to provide a detailed analysis of a specific phenomenon, issue, or problem in its real-life context. A case study is a qualitative research method that involves the in-depth exploration and analysis of a particular case, which can be an individual, group, organization, event, or community.

The primary purpose of a case study is to generate a comprehensive and nuanced understanding of the case, including its history, context, and dynamics. Case studies can help researchers to identify and examine the underlying factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and detailed understanding of the case, which can inform future research, practice, or policy.

Case studies can also serve other purposes, including:

• Illustrating a theory or concept: Case studies can be used to illustrate and explain theoretical concepts and frameworks, providing concrete examples of how they can be applied in real-life situations.
• Developing hypotheses: Case studies can help to generate hypotheses about the causal relationships between different factors and outcomes, which can be tested through further research.
• Providing insight into complex issues: Case studies can provide insights into complex and multifaceted issues, which may be difficult to understand through other research methods.
• Informing practice or policy: Case studies can be used to inform practice or policy by identifying best practices, lessons learned, or areas for improvement.

Advantages of Case Study Research

There are several advantages of case study research, including:

• In-depth exploration: Case study research allows for a detailed exploration and analysis of a specific phenomenon, issue, or problem in its real-life context. This can provide a comprehensive understanding of the case and its dynamics, which may not be possible through other research methods.
• Rich data: Case study research can generate rich and detailed data, including qualitative data such as interviews, observations, and documents. This can provide a nuanced understanding of the case and its complexity.
• Holistic perspective: Case study research allows for a holistic perspective of the case, taking into account the various factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and comprehensive understanding of the case.
• Theory development: Case study research can help to develop and refine theories and concepts by providing empirical evidence and concrete examples of how they can be applied in real-life situations.
• Practical application: Case study research can inform practice or policy by identifying best practices, lessons learned, or areas for improvement.
• Contextualization: Case study research takes into account the specific context in which the case is situated, which can help to understand how the case is influenced by the social, cultural, and historical factors of its environment.

Limitations of Case Study Research

There are several limitations of case study research, including:

• Limited generalizability : Case studies are typically focused on a single case or a small number of cases, which limits the generalizability of the findings. The unique characteristics of the case may not be applicable to other contexts or populations, which may limit the external validity of the research.
• Biased sampling: Case studies may rely on purposive or convenience sampling, which can introduce bias into the sample selection process. This may limit the representativeness of the sample and the generalizability of the findings.
• Subjectivity: Case studies rely on the interpretation of the researcher, which can introduce subjectivity into the analysis. The researcher’s own biases, assumptions, and perspectives may influence the findings, which may limit the objectivity of the research.
• Limited control: Case studies are typically conducted in naturalistic settings, which limits the control that the researcher has over the environment and the variables being studied. This may limit the ability to establish causal relationships between variables.
• Time-consuming: Case studies can be time-consuming to conduct, as they typically involve a detailed exploration and analysis of a specific case. This may limit the feasibility of conducting multiple case studies or conducting case studies in a timely manner.
• Resource-intensive: Case studies may require significant resources, including time, funding, and expertise. This may limit the ability of researchers to conduct case studies in resource-constrained settings.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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Designing and Conducting Case Studies

This guide examines case studies, a form of qualitative descriptive research that is used to look at individuals, a small group of participants, or a group as a whole. Researchers collect data about participants using participant and direct observations, interviews, protocols, tests, examinations of records, and collections of writing samples. Starting with a definition of the case study, the guide moves to a brief history of this research method. Using several well documented case studies, the guide then looks at applications and methods including data collection and analysis. A discussion of ways to handle validity, reliability, and generalizability follows, with special attention to case studies as they are applied to composition studies. Finally, this guide examines the strengths and weaknesses of case studies.

Definition and Overview

Case study refers to the collection and presentation of detailed information about a particular participant or small group, frequently including the accounts of subjects themselves. A form of qualitative descriptive research, the case study looks intensely at an individual or small participant pool, drawing conclusions only about that participant or group and only in that specific context. Researchers do not focus on the discovery of a universal, generalizable truth, nor do they typically look for cause-effect relationships; instead, emphasis is placed on exploration and description.

Case studies typically examine the interplay of all variables in order to provide as complete an understanding of an event or situation as possible. This type of comprehensive understanding is arrived at through a process known as thick description, which involves an in-depth description of the entity being evaluated, the circumstances under which it is used, the characteristics of the people involved in it, and the nature of the community in which it is located. Thick description also involves interpreting the meaning of demographic and descriptive data such as cultural norms and mores, community values, ingrained attitudes, and motives.

Unlike quantitative methods of research, like the survey, which focus on the questions of who, what, where, how much, and how many, and archival analysis, which often situates the participant in some form of historical context, case studies are the preferred strategy when how or why questions are asked. Likewise, they are the preferred method when the researcher has little control over the events, and when there is a contemporary focus within a real life context. In addition, unlike more specifically directed experiments, case studies require a problem that seeks a holistic understanding of the event or situation in question using inductive logic--reasoning from specific to more general terms.

In scholarly circles, case studies are frequently discussed within the context of qualitative research and naturalistic inquiry. Case studies are often referred to interchangeably with ethnography, field study, and participant observation. The underlying philosophical assumptions in the case are similar to these types of qualitative research because each takes place in a natural setting (such as a classroom, neighborhood, or private home), and strives for a more holistic interpretation of the event or situation under study.

Unlike more statistically-based studies which search for quantifiable data, the goal of a case study is to offer new variables and questions for further research. F.H. Giddings, a sociologist in the early part of the century, compares statistical methods to the case study on the basis that the former are concerned with the distribution of a particular trait, or a small number of traits, in a population, whereas the case study is concerned with the whole variety of traits to be found in a particular instance" (Hammersley 95).

Case studies are not a new form of research; naturalistic inquiry was the primary research tool until the development of the scientific method. The fields of sociology and anthropology are credited with the primary shaping of the concept as we know it today. However, case study research has drawn from a number of other areas as well: the clinical methods of doctors; the casework technique being developed by social workers; the methods of historians and anthropologists, plus the qualitative descriptions provided by quantitative researchers like LePlay; and, in the case of Robert Park, the techniques of newspaper reporters and novelists.

Park was an ex-newspaper reporter and editor who became very influential in developing sociological case studies at the University of Chicago in the 1920s. As a newspaper professional he coined the term "scientific" or "depth" reporting: the description of local events in a way that pointed to major social trends. Park viewed the sociologist as "merely a more accurate, responsible, and scientific reporter." Park stressed the variety and value of human experience. He believed that sociology sought to arrive at natural, but fluid, laws and generalizations in regard to human nature and society. These laws weren't static laws of the kind sought by many positivists and natural law theorists, but rather, they were laws of becoming--with a constant possibility of change. Park encouraged students to get out of the library, to quit looking at papers and books, and to view the constant experiment of human experience. He writes, "Go and sit in the lounges of the luxury hotels and on the doorsteps of the flophouses; sit on the Gold Coast settees and on the slum shakedowns; sit in the Orchestra Hall and in the Star and Garter Burlesque. In short, gentlemen [sic], go get the seats of your pants dirty in real research."

But over the years, case studies have drawn their share of criticism. In fact, the method had its detractors from the start. In the 1920s, the debate between pro-qualitative and pro-quantitative became quite heated. Case studies, when compared to statistics, were considered by many to be unscientific. From the 1930's on, the rise of positivism had a growing influence on quantitative methods in sociology. People wanted static, generalizable laws in science. The sociological positivists were looking for stable laws of social phenomena. They criticized case study research because it failed to provide evidence of inter subjective agreement. Also, they condemned it because of the few number of cases studied and that the under-standardized character of their descriptions made generalization impossible. By the 1950s, quantitative methods, in the form of survey research, had become the dominant sociological approach and case study had become a minority practice.

Educational Applications

The 1950's marked the dawning of a new era in case study research, namely that of the utilization of the case study as a teaching method. "Instituted at Harvard Business School in the 1950s as a primary method of teaching, cases have since been used in classrooms and lecture halls alike, either as part of a course of study or as the main focus of the course to which other teaching material is added" (Armisted 1984). The basic purpose of instituting the case method as a teaching strategy was "to transfer much of the responsibility for learning from the teacher on to the student, whose role, as a result, shifts away from passive absorption toward active construction" (Boehrer 1990). Through careful examination and discussion of various cases, "students learn to identify actual problems, to recognize key players and their agendas, and to become aware of those aspects of the situation that contribute to the problem" (Merseth 1991). In addition, students are encouraged to "generate their own analysis of the problems under consideration, to develop their own solutions, and to practically apply their own knowledge of theory to these problems" (Boyce 1993). Along the way, students also develop "the power to analyze and to master a tangled circumstance by identifying and delineating important factors; the ability to utilize ideas, to test them against facts, and to throw them into fresh combinations" (Merseth 1991).

In addition to the practical application and testing of scholarly knowledge, case discussions can also help students prepare for real-world problems, situations and crises by providing an approximation of various professional environments (i.e. classroom, board room, courtroom, or hospital). Thus, through the examination of specific cases, students are given the opportunity to work out their own professional issues through the trials, tribulations, experiences, and research findings of others. An obvious advantage to this mode of instruction is that it allows students the exposure to settings and contexts that they might not otherwise experience. For example, a student interested in studying the effects of poverty on minority secondary student's grade point averages and S.A.T. scores could access and analyze information from schools as geographically diverse as Los Angeles, New York City, Miami, and New Mexico without ever having to leave the classroom.

The case study method also incorporates the idea that students can learn from one another "by engaging with each other and with each other's ideas, by asserting something and then having it questioned, challenged and thrown back at them so that they can reflect on what they hear, and then refine what they say" (Boehrer 1990). In summary, students can direct their own learning by formulating questions and taking responsibility for the study.

Types and Design Concerns

Researchers use multiple methods and approaches to conduct case studies.

Types of Case Studies

Under the more generalized category of case study exist several subdivisions, each of which is custom selected for use depending upon the goals and/or objectives of the investigator. These types of case study include the following:

Illustrative Case Studies These are primarily descriptive studies. They typically utilize one or two instances of an event to show what a situation is like. Illustrative case studies serve primarily to make the unfamiliar familiar and to give readers a common language about the topic in question.

Exploratory (or pilot) Case Studies These are condensed case studies performed before implementing a large scale investigation. Their basic function is to help identify questions and select types of measurement prior to the main investigation. The primary pitfall of this type of study is that initial findings may seem convincing enough to be released prematurely as conclusions.

Cumulative Case Studies These serve to aggregate information from several sites collected at different times. The idea behind these studies is the collection of past studies will allow for greater generalization without additional cost or time being expended on new, possibly repetitive studies.

Critical Instance Case Studies These examine one or more sites for either the purpose of examining a situation of unique interest with little to no interest in generalizability, or to call into question or challenge a highly generalized or universal assertion. This method is useful for answering cause and effect questions.

Identifying a Theoretical Perspective

Much of the case study's design is inherently determined for researchers, depending on the field from which they are working. In composition studies, researchers are typically working from a qualitative, descriptive standpoint. In contrast, physicists will approach their research from a more quantitative perspective. Still, in designing the study, researchers need to make explicit the questions to be explored and the theoretical perspective from which they will approach the case. The three most commonly adopted theories are listed below:

Individual Theories These focus primarily on the individual development, cognitive behavior, personality, learning and disability, and interpersonal interactions of a particular subject.

Organizational Theories These focus on bureaucracies, institutions, organizational structure and functions, or excellence in organizational performance.

Social Theories These focus on urban development, group behavior, cultural institutions, or marketplace functions.

Two examples of case studies are used consistently throughout this chapter. The first, a study produced by Berkenkotter, Huckin, and Ackerman (1988), looks at a first year graduate student's initiation into an academic writing program. The study uses participant-observer and linguistic data collecting techniques to assess the student's knowledge of appropriate discourse conventions. Using the pseudonym Nate to refer to the subject, the study sought to illuminate the particular experience rather than to generalize about the experience of fledgling academic writers collectively.

For example, in Berkenkotter, Huckin, and Ackerman's (1988) study we are told that the researchers are interested in disciplinary communities. In the first paragraph, they ask what constitutes membership in a disciplinary community and how achieving membership might affect a writer's understanding and production of texts. In the third paragraph they state that researchers must negotiate their claims "within the context of his sub specialty's accepted knowledge and methodology." In the next paragraph they ask, "How is literacy acquired? What is the process through which novices gain community membership? And what factors either aid or hinder students learning the requisite linguistic behaviors?" This introductory section ends with a paragraph in which the study's authors claim that during the course of the study, the subject, Nate, successfully makes the transition from "skilled novice" to become an initiated member of the academic discourse community and that his texts exhibit linguistic changes which indicate this transition. In the next section the authors make explicit the sociolinguistic theoretical and methodological assumptions on which the study is based (1988). Thus the reader has a good understanding of the authors' theoretical background and purpose in conducting the study even before it is explicitly stated on the fourth page of the study. "Our purpose was to examine the effects of the educational context on one graduate student's production of texts as he wrote in different courses and for different faculty members over the academic year 1984-85." The goal of the study then, was to explore the idea that writers must be initiated into a writing community, and that this initiation will change the way one writes.

The second example is Janet Emig's (1971) study of the composing process of a group of twelfth graders. In this study, Emig seeks to answer the question of what happens to the self as a result educational stimuli in terms of academic writing. The case study used methods such as protocol analysis, tape-recorded interviews, and discourse analysis.

In the case of Janet Emig's (1971) study of the composing process of eight twelfth graders, four specific hypotheses were made:

• Twelfth grade writers engage in two modes of composing: reflexive and extensive.
• These differences can be ascertained and characterized through having the writers compose aloud their composition process.
• A set of implied stylistic principles governs the writing process.
• For twelfth grade writers, extensive writing occurs chiefly as a school-sponsored activity, or reflexive, as a self-sponsored activity.

In this study, the chief distinction is between the two dominant modes of composing among older, secondary school students. The distinctions are:

• The reflexive mode, which focuses on the writer's thoughts and feelings.
• The extensive mode, which focuses on conveying a message.

Emig also outlines the specific questions which guided the research in the opening pages of her Review of Literature , preceding the report.

Designing a Case Study

After considering the different sub categories of case study and identifying a theoretical perspective, researchers can begin to design their study. Research design is the string of logic that ultimately links the data to be collected and the conclusions to be drawn to the initial questions of the study. Typically, research designs deal with at least four problems:

• What questions to study
• What data are relevant
• What data to collect
• How to analyze that data

In other words, a research design is basically a blueprint for getting from the beginning to the end of a study. The beginning is an initial set of questions to be answered, and the end is some set of conclusions about those questions.

Because case studies are conducted on topics as diverse as Anglo-Saxon Literature (Thrane 1986) and AIDS prevention (Van Vugt 1994), it is virtually impossible to outline any strict or universal method or design for conducting the case study. However, Robert K. Yin (1993) does offer five basic components of a research design:

• A study's questions.
• A study's propositions (if any).
• A study's units of analysis.
• The logic that links the data to the propositions.
• The criteria for interpreting the findings.

In addition to these five basic components, Yin also stresses the importance of clearly articulating one's theoretical perspective, determining the goals of the study, selecting one's subject(s), selecting the appropriate method(s) of collecting data, and providing some considerations to the composition of the final report.

Conducting Case Studies

To obtain as complete a picture of the participant as possible, case study researchers can employ a variety of approaches and methods. These approaches, methods, and related issues are discussed in depth in this section.

Method: Single or Multi-modal?

To obtain as complete a picture of the participant as possible, case study researchers can employ a variety of methods. Some common methods include interviews , protocol analyses, field studies, and participant-observations. Emig (1971) chose to use several methods of data collection. Her sources included conversations with the students, protocol analysis, discrete observations of actual composition, writing samples from each student, and school records (Lauer and Asher 1988).

Berkenkotter, Huckin, and Ackerman (1988) collected data by observing classrooms, conducting faculty and student interviews, collecting self reports from the subject, and by looking at the subject's written work.

A study that was criticized for using a single method model was done by Flower and Hayes (1984). In this study that explores the ways in which writers use different forms of knowing to create space, the authors used only protocol analysis to gather data. The study came under heavy fire because of their decision to use only one method.

Participant Selection

Case studies can use one participant, or a small group of participants. However, it is important that the participant pool remain relatively small. The participants can represent a diverse cross section of society, but this isn't necessary.

For example, the Berkenkotter, Huckin, and Ackerman (1988) study looked at just one participant, Nate. By contrast, in Janet Emig's (1971) study of the composition process of twelfth graders, eight participants were selected representing a diverse cross section of the community, with volunteers from an all-white upper-middle-class suburban school, an all-black inner-city school, a racially mixed lower-middle-class school, an economically and racially mixed school, and a university school.

Often, a brief "case history" is done on the participants of the study in order to provide researchers with a clearer understanding of their participants, as well as some insight as to how their own personal histories might affect the outcome of the study. For instance, in Emig's study, the investigator had access to the school records of five of the participants, and to standardized test scores for the remaining three. Also made available to the researcher was the information that three of the eight students were selected as NCTE Achievement Award winners. These personal histories can be useful in later stages of the study when data are being analyzed and conclusions drawn.

Data Collection

There are six types of data collected in case studies:

• Archival records.
• Interviews.
• Direct observation.
• Participant observation.

In the field of composition research, these six sources might be:

• A writer's drafts.
• School records of student writers.
• Transcripts of interviews with a writer.
• Transcripts of conversations between writers (and protocols).
• Videotapes and notes from direct field observations.
• Hard copies of a writer's work on computer.

Depending on whether researchers have chosen to use a single or multi-modal approach for the case study, they may choose to collect data from one or any combination of these sources.

Protocols, that is, transcriptions of participants talking aloud about what they are doing as they do it, have been particularly common in composition case studies. For example, in Emig's (1971) study, the students were asked, in four different sessions, to give oral autobiographies of their writing experiences and to compose aloud three themes in the presence of a tape recorder and the investigator.

In some studies, only one method of data collection is conducted. For example, the Flower and Hayes (1981) report on the cognitive process theory of writing depends on protocol analysis alone. However, using multiple sources of evidence to increase the reliability and validity of the data can be advantageous.

Case studies are likely to be much more convincing and accurate if they are based on several different sources of information, following a corroborating mode. This conclusion is echoed among many composition researchers. For example, in her study of predrafting processes of high and low-apprehensive writers, Cynthia Selfe (1985) argues that because "methods of indirect observation provide only an incomplete reflection of the complex set of processes involved in composing, a combination of several such methods should be used to gather data in any one study." Thus, in this study, Selfe collected her data from protocols, observations of students role playing their writing processes, audio taped interviews with the students, and videotaped observations of the students in the process of composing.

It can be said then, that cross checking data from multiple sources can help provide a multidimensional profile of composing activities in a particular setting. Sharan Merriam (1985) suggests "checking, verifying, testing, probing, and confirming collected data as you go, arguing that this process will follow in a funnel-like design resulting in less data gathering in later phases of the study along with a congruent increase in analysis checking, verifying, and confirming."

It is important to note that in case studies, as in any qualitative descriptive research, while researchers begin their studies with one or several questions driving the inquiry (which influence the key factors the researcher will be looking for during data collection), a researcher may find new key factors emerging during data collection. These might be unexpected patterns or linguistic features which become evident only during the course of the research. While not bearing directly on the researcher's guiding questions, these variables may become the basis for new questions asked at the end of the report, thus linking to the possibility of further research.

Data Analysis

As the information is collected, researchers strive to make sense of their data. Generally, researchers interpret their data in one of two ways: holistically or through coding. Holistic analysis does not attempt to break the evidence into parts, but rather to draw conclusions based on the text as a whole. Flower and Hayes (1981), for example, make inferences from entire sections of their students' protocols, rather than searching through the transcripts to look for isolatable characteristics.

However, composition researchers commonly interpret their data by coding, that is by systematically searching data to identify and/or categorize specific observable actions or characteristics. These observable actions then become the key variables in the study. Sharan Merriam (1988) suggests seven analytic frameworks for the organization and presentation of data:

• The role of participants.
• The network analysis of formal and informal exchanges among groups.
• Historical.
• Thematical.
• Ritual and symbolism.
• Critical incidents that challenge or reinforce fundamental beliefs, practices, and values.

There are two purposes of these frameworks: to look for patterns among the data and to look for patterns that give meaning to the case study.

As stated above, while most researchers begin their case studies expecting to look for particular observable characteristics, it is not unusual for key variables to emerge during data collection. Typical variables coded in case studies of writers include pauses writers make in the production of a text, the use of specific linguistic units (such as nouns or verbs), and writing processes (planning, drafting, revising, and editing). In the Berkenkotter, Huckin, and Ackerman (1988) study, for example, researchers coded the participant's texts for use of connectives, discourse demonstratives, average sentence length, off-register words, use of the first person pronoun, and the ratio of definite articles to indefinite articles.

Since coding is inherently subjective, more than one coder is usually employed. In the Berkenkotter, Huckin, and Ackerman (1988) study, for example, three rhetoricians were employed to code the participant's texts for off-register phrases. The researchers established the agreement among the coders before concluding that the participant used fewer off-register words as the graduate program progressed.

Composing the Case Study Report

In the many forms it can take, "a case study is generically a story; it presents the concrete narrative detail of actual, or at least realistic events, it has a plot, exposition, characters, and sometimes even dialogue" (Boehrer 1990). Generally, case study reports are extensively descriptive, with "the most problematic issue often referred to as being the determination of the right combination of description and analysis" (1990). Typically, authors address each step of the research process, and attempt to give the reader as much context as possible for the decisions made in the research design and for the conclusions drawn.

This contextualization usually includes a detailed explanation of the researchers' theoretical positions, of how those theories drove the inquiry or led to the guiding research questions, of the participants' backgrounds, of the processes of data collection, of the training and limitations of the coders, along with a strong attempt to make connections between the data and the conclusions evident.

Although the Berkenkotter, Huckin, and Ackerman (1988) study does not, case study reports often include the reactions of the participants to the study or to the researchers' conclusions. Because case studies tend to be exploratory, most end with implications for further study. Here researchers may identify significant variables that emerged during the research and suggest studies related to these, or the authors may suggest further general questions that their case study generated.

For example, Emig's (1971) study concludes with a section dedicated solely to the topic of implications for further research, in which she suggests several means by which this particular study could have been improved, as well as questions and ideas raised by this study which other researchers might like to address, such as: is there a correlation between a certain personality and a certain composing process profile (e.g. is there a positive correlation between ego strength and persistence in revising)?

Also included in Emig's study is a section dedicated to implications for teaching, which outlines the pedagogical ramifications of the study's findings for teachers currently involved in high school writing programs.

Sharan Merriam (1985) also offers several suggestions for alternative presentations of data:

• Prepare specialized condensations for appropriate groups.
• Replace narrative sections with a series of answers to open-ended questions.
• Present "skimmer's" summaries at beginning of each section.
• Incorporate headlines that encapsulate information from text.
• Prepare analytic summaries with supporting data appendixes.
• Present data in colorful and/or unique graphic representations.

Issues of Validity and Reliability

Once key variables have been identified, they can be analyzed. Reliability becomes a key concern at this stage, and many case study researchers go to great lengths to ensure that their interpretations of the data will be both reliable and valid. Because issues of validity and reliability are an important part of any study in the social sciences, it is important to identify some ways of dealing with results.

Multi-modal case study researchers often balance the results of their coding with data from interviews or writer's reflections upon their own work. Consequently, the researchers' conclusions become highly contextualized. For example, in a case study which looked at the time spent in different stages of the writing process, Berkenkotter concluded that her participant, Donald Murray, spent more time planning his essays than in other writing stages. The report of this case study is followed by Murray's reply, wherein he agrees with some of Berkenkotter's conclusions and disagrees with others.

As is the case with other research methodologies, issues of external validity, construct validity, and reliability need to be carefully considered.

Commentary on Case Studies

Researchers often debate the relative merits of particular methods, among them case study. In this section, we comment on two key issues. To read the commentaries, choose any of the items below:

Strengths and Weaknesses of Case Studies

Most case study advocates point out that case studies produce much more detailed information than what is available through a statistical analysis. Advocates will also hold that while statistical methods might be able to deal with situations where behavior is homogeneous and routine, case studies are needed to deal with creativity, innovation, and context. Detractors argue that case studies are difficult to generalize because of inherent subjectivity and because they are based on qualitative subjective data, generalizable only to a particular context.

Flexibility

The case study approach is a comparatively flexible method of scientific research. Because its project designs seem to emphasize exploration rather than prescription or prediction, researchers are comparatively freer to discover and address issues as they arise in their experiments. In addition, the looser format of case studies allows researchers to begin with broad questions and narrow their focus as their experiment progresses rather than attempt to predict every possible outcome before the experiment is conducted.

Emphasis on Context

By seeking to understand as much as possible about a single subject or small group of subjects, case studies specialize in "deep data," or "thick description"--information based on particular contexts that can give research results a more human face. This emphasis can help bridge the gap between abstract research and concrete practice by allowing researchers to compare their firsthand observations with the quantitative results obtained through other methods of research.

Inherent Subjectivity

"The case study has long been stereotyped as the weak sibling among social science methods," and is often criticized as being too subjective and even pseudo-scientific. Likewise, "investigators who do case studies are often regarded as having deviated from their academic disciplines, and their investigations as having insufficient precision (that is, quantification), objectivity and rigor" (Yin 1989). Opponents cite opportunities for subjectivity in the implementation, presentation, and evaluation of case study research. The approach relies on personal interpretation of data and inferences. Results may not be generalizable, are difficult to test for validity, and rarely offer a problem-solving prescription. Simply put, relying on one or a few subjects as a basis for cognitive extrapolations runs the risk of inferring too much from what might be circumstance.

High Investment

Case studies can involve learning more about the subjects being tested than most researchers would care to know--their educational background, emotional background, perceptions of themselves and their surroundings, their likes, dislikes, and so on. Because of its emphasis on "deep data," the case study is out of reach for many large-scale research projects which look at a subject pool in the tens of thousands. A budget request of $10,000 to examine 200 subjects sounds more efficient than a similar request to examine four subjects.

Ethical Considerations

Researchers conducting case studies should consider certain ethical issues. For example, many educational case studies are often financed by people who have, either directly or indirectly, power over both those being studied and those conducting the investigation (1985). This conflict of interests can hinder the credibility of the study.

The personal integrity, sensitivity, and possible prejudices and/or biases of the investigators need to be taken into consideration as well. Personal biases can creep into how the research is conducted, alternative research methods used, and the preparation of surveys and questionnaires.

A common complaint in case study research is that investigators change direction during the course of the study unaware that their original research design was inadequate for the revised investigation. Thus, the researchers leave unknown gaps and biases in the study. To avoid this, researchers should report preliminary findings so that the likelihood of bias will be reduced.

Concerns about Reliability, Validity, and Generalizability

Merriam (1985) offers several suggestions for how case study researchers might actively combat the popular attacks on the validity, reliability, and generalizability of case studies:

• Prolong the Processes of Data Gathering on Site: This will help to insure the accuracy of the findings by providing the researcher with more concrete information upon which to formulate interpretations.
• Employ the Process of "Triangulation": Use a variety of data sources as opposed to relying solely upon one avenue of observation. One example of such a data check would be what McClintock, Brannon, and Maynard (1985) refer to as a "case cluster method," that is, when a single unit within a larger case is randomly sampled, and that data treated quantitatively." For instance, in Emig's (1971) study, the case cluster method was employed, singling out the productivity of a single student named Lynn. This cluster profile included an advanced case history of the subject, specific examination and analysis of individual compositions and protocols, and extensive interview sessions. The seven remaining students were then compared with the case of Lynn, to ascertain if there are any shared, or unique dimensions to the composing process engaged in by these eight students.
• Conduct Member Checks: Initiate and maintain an active corroboration on the interpretation of data between the researcher and those who provided the data. In other words, talk to your subjects.
• Collect Referential Materials: Complement the file of materials from the actual site with additional document support. For example, Emig (1971) supports her initial propositions with historical accounts by writers such as T.S. Eliot, James Joyce, and D.H. Lawrence. Emig also cites examples of theoretical research done with regards to the creative process, as well as examples of empirical research dealing with the writing of adolescents. Specific attention is then given to the four stages description of the composing process delineated by Helmoltz, Wallas, and Cowley, as it serves as the focal point in this study.
• Engage in Peer Consultation: Prior to composing the final draft of the report, researchers should consult with colleagues in order to establish validity through pooled judgment.

Although little can be done to combat challenges concerning the generalizability of case studies, "most writers suggest that qualitative research should be judged as credible and confirmable as opposed to valid and reliable" (Merriam 1985). Likewise, it has been argued that "rather than transplanting statistical, quantitative notions of generalizability and thus finding qualitative research inadequate, it makes more sense to develop an understanding of generalization that is congruent with the basic characteristics of qualitative inquiry" (1985). After all, criticizing the case study method for being ungeneralizable is comparable to criticizing a washing machine for not being able to tell the correct time. In other words, it is unjust to criticize a method for not being able to do something which it was never originally designed to do in the first place.

Annotated Bibliography

Armisted, C. (1984). How Useful are Case Studies. Training and Development Journal, 38 (2), 75-77.

This article looks at eight types of case studies, offers pros and cons of using case studies in the classroom, and gives suggestions for successfully writing and using case studies.

Bardovi-Harlig, K. (1997). Beyond Methods: Components of Second Language Teacher Education . New York: McGraw-Hill.

A compilation of various research essays which address issues of language teacher education. Essays included are: "Non-native reading research and theory" by Lee, "The case for Psycholinguistics" by VanPatten, and "Assessment and Second Language Teaching" by Gradman and Reed.

Bartlett, L. (1989). A Question of Good Judgment; Interpretation Theory and Qualitative Enquiry Address. 70th Annual Meeting of the American Educational Research Association. San Francisco.

Bartlett selected "quasi-historical" methodology, which focuses on the "truth" found in case records, as one that will provide "good judgments" in educational inquiry. He argues that although the method is not comprehensive, it can try to connect theory with practice.

Baydere, S. et. al. (1993). Multimedia conferencing as a tool for collaborative writing: a case study in Computer Supported Collaborative Writing. New York: Springer-Verlag.

The case study by Baydere et. al. is just one of the many essays in this book found in the series "Computer Supported Cooperative Work." Denley, Witefield and May explore similar issues in their essay, "A case study in task analysis for the design of a collaborative document production system."

Berkenkotter, C., Huckin, T., N., & Ackerman J. (1988). Conventions, Conversations, and the Writer: Case Study of a Student in a Rhetoric Ph.D. Program. Research in the Teaching of English, 22, 9-44.

The authors focused on how the writing of their subject, Nate or Ackerman, changed as he became more acquainted or familiar with his field's discourse community.

Berninger, V., W., and Gans, B., M. (1986). Language Profiles in Nonspeaking Individuals of Normal Intelligence with Severe Cerebral Palsy. Augmentative and Alternative Communication, 2, 45-50.

Argues that generalizations about language abilities in patients with severe cerebral palsy (CP) should be avoided. Standardized tests of different levels of processing oral language, of processing written language, and of producing written language were administered to 3 male participants (aged 9, 16, and 40 yrs).

Bockman, J., R., and Couture, B. (1984). The Case Method in Technical Communication: Theory and Models. Texas: Association of Teachers of Technical Writing.

Examines the study and teaching of technical writing, communication of technical information, and the case method in terms of those applications.

Boehrer, J. (1990). Teaching With Cases: Learning to Question. New Directions for Teaching and Learning, 42 41-57.

This article discusses the origins of the case method, looks at the question of what is a case, gives ideas about learning in case teaching, the purposes it can serve in the classroom, the ground rules for the case discussion, including the role of the question, and new directions for case teaching.

Bowman, W. R. (1993). Evaluating JTPA Programs for Economically Disadvantaged Adults: A Case Study of Utah and General Findings . Washington: National Commission for Employment Policy.

"To encourage state-level evaluations of JTPA, the Commission and the State of Utah co-sponsored this report on the effectiveness of JTPA Title II programs for adults in Utah. The technique used is non-experimental and the comparison group was selected from registrants with Utah's Employment Security. In a step-by-step approach, the report documents how non-experimental techniques can be applied and several specific technical issues can be addressed."

Boyce, A. (1993) The Case Study Approach for Pedagogists. Annual Meeting of the American Alliance for Health, Physical Education, Recreation and Dance. (Address). Washington DC.

This paper addresses how case studies 1) bridge the gap between teaching theory and application, 2) enable students to analyze problems and develop solutions for situations that will be encountered in the real world of teaching, and 3) helps students to evaluate the feasibility of alternatives and to understand the ramifications of a particular course of action.

Carson, J. (1993) The Case Study: Ideal Home of WAC Quantitative and Qualitative Data. Annual Meeting of the Conference on College Composition and Communication. (Address). San Diego.

"Increasingly, one of the most pressing questions for WAC advocates is how to keep [WAC] programs going in the face of numerous difficulties. Case histories offer the best chance for fashioning rhetorical arguments to keep WAC programs going because they offer the opportunity to provide a coherent narrative that contextualizes all documents and data, including what is generally considered scientific data. A case study of the WAC program, . . . at Robert Morris College in Pittsburgh demonstrates the advantages of this research method. Such studies are ideal homes for both naturalistic and positivistic data as well as both quantitative and qualitative information."

---. (1991). A Cognitive Process Theory of Writing. College Composition and Communication. 32. 365-87.

No abstract available.

Cromer, R. (1994) A Case Study of Dissociations Between Language and Cognition. Constraints on Language Acquisition: Studies of Atypical Children . Hillsdale: Lawrence Erlbaum Associates, 141-153.

Crossley, M. (1983) Case Study in Comparative and International Education: An Approach to Bridging the Theory-Practice Gap. Proceedings of the 11th Annual Conference of the Australian Comparative and International Education Society. Hamilton, NZ.

Case study research, as presented here, helps bridge the theory-practice gap in comparative and international research studies of education because it focuses on the practical, day-to-day context rather than on the national arena. The paper asserts that the case study method can be valuable at all levels of research, formation, and verification of theories in education.

Daillak, R., H., and Alkin, M., C. (1982). Qualitative Studies in Context: Reflections on the CSE Studies of Evaluation Use . California: EDRS

The report shows how the Center of the Study of Evaluation (CSE) applied qualitative techniques to a study of evaluation information use in local, Los Angeles schools. It critiques the effectiveness and the limitations of using case study, evaluation, field study, and user interview survey methodologies.

Davey, L. (1991). The Application of Case Study Evaluations. ERIC/TM Digest.

This article examines six types of case studies, the type of evaluation questions that can be answered, the functions served, some design features, and some pitfalls of the method.

Deutch, C. E. (1996). A course in research ethics for graduate students. College Teaching, 44, 2, 56-60.

This article describes a one-credit discussion course in research ethics for graduate students in biology. Case studies are focused on within the four parts of the course: 1) major issues, 2 )practical issues in scholarly work, 3) ownership of research results, and 4) training and personal decisions.

DeVoss, G. (1981). Ethics in Fieldwork Research. RIE 27p. (ERIC)

This article examines four of the ethical problems that can happen when conducting case study research: acquiring permission to do research, knowing when to stop digging, the pitfalls of doing collaborative research, and preserving the integrity of the participants.

Driscoll, A. (1985). Case Study of a Research Intervention: the University of Utah’s Collaborative Approach . San Francisco: Far West Library for Educational Research Development.

Paper presented at the annual meeting of the American Association of Colleges of Teacher Education, Denver, CO, March 1985. Offers information of in-service training, specifically case studies application.

Ellram, L. M. (1996). The Use of the Case Study Method in Logistics Research. Journal of Business Logistics, 17, 2, 93.

This article discusses the increased use of case study in business research, and the lack of understanding of when and how to use case study methodology in business.

Emig, J. (1971) The Composing Processes of Twelfth Graders . Urbana: NTCE.

This case study uses observation, tape recordings, writing samples, and school records to show that writing in reflexive and extensive situations caused different lengths of discourse and different clusterings of the components of the writing process.

Feagin, J. R. (1991). A Case For the Case Study . Chapel Hill: The University of North Carolina Press.

This book discusses the nature, characteristics, and basic methodological issues of the case study as a research method.

Feldman, H., Holland, A., & Keefe, K. (1989) Language Abilities after Left Hemisphere Brain Injury: A Case Study of Twins. Topics in Early Childhood Special Education, 9, 32-47.

"Describes the language abilities of 2 twin pairs in which 1 twin (the experimental) suffered brain injury to the left cerebral hemisphere around the time of birth and1 twin (the control) did not. One pair of twins was initially assessed at age 23 mo. and the other at about 30 mo.; they were subsequently evaluated in their homes 3 times at about 6-mo intervals."

Fidel, R. (1984). The Case Study Method: A Case Study. Library and Information Science Research, 6.

The article describes the use of case study methodology to systematically develop a model of online searching behavior in which study design is flexible, subject manner determines data gathering and analyses, and procedures adapt to the study's progressive change.

Flower, L., & Hayes, J. R. (1984). Images, Plans and Prose: The Representation of Meaning in Writing. Written Communication, 1, 120-160.

Explores the ways in which writers actually use different forms of knowing to create prose.

Frey, L. R. (1992). Interpreting Communication Research: A Case Study Approach Englewood Cliffs, N.J.: Prentice Hall.

The book discusses research methodologies in the Communication field. It focuses on how case studies bridge the gap between communication research, theory, and practice.

Gilbert, V. K. (1981). The Case Study as a Research Methodology: Difficulties and Advantages of Integrating the Positivistic, Phenomenological and Grounded Theory Approaches . The Annual Meeting of the Canadian Association for the Study of Educational Administration. (Address) Halifax, NS, Can.

This study on an innovative secondary school in England shows how a "low-profile" participant-observer case study was crucial to the initial observation, the testing of hypotheses, the interpretive approach, and the grounded theory.

Gilgun, J. F. (1994). A Case for Case Studies in Social Work Research. Social Work, 39, 4, 371-381.

This article defines case study research, presents guidelines for evaluation of case studies, and shows the relevance of case studies to social work research. It also looks at issues such as evaluation and interpretations of case studies.

Glennan, S. L., Sharp-Bittner, M. A. & Tullos, D. C. (1991). Augmentative and Alternative Communication Training with a Nonspeaking Adult: Lessons from MH. Augmentative and Alternative Communication, 7, 240-7.

"A response-guided case study documented changes in a nonspeaking 36-yr-old man's ability to communicate using 3 trained augmentative communication modes. . . . Data were collected in videotaped interaction sessions between the nonspeaking adult and a series of adult speaking."

Graves, D. (1981). An Examination of the Writing Processes of Seven Year Old Children. Research in the Teaching of English, 15, 113-134.

Hamel, J. (1993). Case Study Methods . Newbury Park: Sage. .

"In a most economical fashion, Hamel provides a practical guide for producing theoretically sharp and empirically sound sociological case studies. A central idea put forth by Hamel is that case studies must "locate the global in the local" thus making the careful selection of the research site the most critical decision in the analytic process."

Karthigesu, R. (1986, July). Television as a Tool for Nation-Building in the Third World: A Post-Colonial Pattern, Using Malaysia as a Case-Study. International Television Studies Conference. (Address). London, 10-12.

"The extent to which Television Malaysia, as a national mass media organization, has been able to play a role in nation building in the post-colonial period is . . . studied in two parts: how the choice of a model of nation building determines the character of the organization; and how the character of the organization influences the output of the organization."

Kenny, R. (1984). Making the Case for the Case Study. Journal of Curriculum Studies, 16, (1), 37-51.

The article looks at how and why the case study is justified as a viable and valuable approach to educational research and program evaluation.

Knirk, F. (1991). Case Materials: Research and Practice. Performance Improvement Quarterly, 4 (1 ), 73-81.

The article addresses the effectiveness of case studies, subject areas where case studies are commonly used, recent examples of their use, and case study design considerations.

Klos, D. (1976). Students as Case Writers. Teaching of Psychology, 3.2, 63-66.

This article reviews a course in which students gather data for an original case study of another person. The task requires the students to design the study, collect the data, write the narrative, and interpret the findings.

Leftwich, A. (1981). The Politics of Case Study: Problems of Innovation in University Education. Higher Education Review, 13.2, 38-64.

The article discusses the use of case studies as a teaching method. Emphasis is on the instructional materials, interdisciplinarity, and the complex relationships within the university that help or hinder the method.

Mabrito, M. (1991, Oct.). Electronic Mail as a Vehicle for Peer Response: Conversations of High and Low Apprehensive Writers. Written Communication, 509-32.

McCarthy, S., J. (1955). The Influence of Classroom Discourse on Student Texts: The Case of Ella . East Lansing: Institute for Research on Teaching.

A look at how students of color become marginalized within traditional classroom discourse. The essay follows the struggles of one black student: Ella.

Matsuhashi, A., ed. (1987). Writing in Real Time: Modeling Production Processes Norwood, NJ: Ablex Publishing Corporation.

Investigates how writers plan to produce discourse for different purposes to report, to generalize, and to persuade, as well as how writers plan for sentence level units of language. To learn about planning, an observational measure of pause time was used" (ERIC).

Merriam, S. B. (1985). The Case Study in Educational Research: A Review of Selected Literature. Journal of Educational Thought, 19.3, 204-17.

The article examines the characteristics of, philosophical assumptions underlying the case study, the mechanics of conducting a case study, and the concerns about the reliability, validity, and generalizability of the method.

---. (1988). Case Study Research in Education: A Qualitative Approach San Francisco: Jossey Bass.

Merry, S. E., & Milner, N. eds. (1993). The Possibility of Popular Justice: A Case Study of Community Mediation in the United States . Ann Arbor: U of Michigan.

". . . this volume presents a case study of one experiment in popular justice, the San Francisco Community Boards. This program has made an explicit claim to create an alternative justice, or new justice, in the midst of a society ordered by state law. The contributors to this volume explore the history and experience of the program and compare it to other versions of popular justice in the United States, Europe, and the Third World."

Merseth, K. K. (1991). The Case for Cases in Teacher Education. RIE. 42p. (ERIC).

This monograph argues that the case method of instruction offers unique potential for revitalizing the field of teacher education.

Michaels, S. (1987). Text and Context: A New Approach to the Study of Classroom Writing. Discourse Processes, 10, 321-346.

"This paper argues for and illustrates an approach to the study of writing that integrates ethnographic analysis of classroom interaction with linguistic analysis of written texts and teacher/student conversational exchanges. The approach is illustrated through a case study of writing in a single sixth grade classroom during a single writing assignment."

Milburn, G. (1995). Deciphering a Code or Unraveling a Riddle: A Case Study in the Application of a Humanistic Metaphor to the Reporting of Social Studies Teaching. Theory and Research in Education, 13.

This citation serves as an example of how case studies document learning procedures in a senior-level economics course.

Milley, J. E. (1979). An Investigation of Case Study as an Approach to Program Evaluation. 19th Annual Forum of the Association for Institutional Research. (Address). San Diego.

The case study method merged a narrative report focusing on the evaluator as participant-observer with document review, interview, content analysis, attitude questionnaire survey, and sociogram analysis. Milley argues that case study program evaluation has great potential for widespread use.

Minnis, J. R. (1985, Sept.). Ethnography, Case Study, Grounded Theory, and Distance Education Research. Distance Education, 6.2.

This article describes and defines the strengths and weaknesses of ethnography, case study, and grounded theory.

Nunan, D. (1992). Collaborative language learning and teaching . New York: Cambridge University Press.

Included in this series of essays is Peter Sturman’s "Team Teaching: a case study from Japan" and David Nunan’s own "Toward a collaborative approach to curriculum development: a case study."

Nystrand, M., ed. (1982). What Writers Know: The Language, Process, and Structure of Written Discourse . New York: Academic Press.

Owenby, P. H. (1992). Making Case Studies Come Alive. Training, 29, (1), 43-46. (ERIC)

This article provides tips for writing more effective case studies.

---. (1981). Pausing and Planning: The Tempo of Writer Discourse Production. Research in the Teaching of English, 15 (2),113-34.

Perl, S. (1979). The Composing Processes of Unskilled College Writers. Research in the Teaching of English, 13, 317-336.

"Summarizes a study of five unskilled college writers, focusing especially on one of the five, and discusses the findings in light of current pedagogical practice and research design."

Pilcher J. and A. Coffey. eds. (1996). Gender and Qualitative Research . Brookfield: Aldershot, Hants, England.

This book provides a series of essays which look at gender identity research, qualitative research and applications of case study to questions of gendered pedagogy.

Pirie, B. S. (1993). The Case of Morty: A Four Year Study. Gifted Education International, 9 (2), 105-109.

This case study describes a boy from kindergarten through third grade with above average intelligence but difficulty in learning to read, write, and spell.

Popkewitz, T. (1993). Changing Patterns of Power: Social Regulation and Teacher Education Reform. Albany: SUNY Press.

Popkewitz edits this series of essays that address case studies on educational change and the training of teachers. The essays vary in terms of discipline and scope. Also, several authors include case studies of educational practices in countries other than the United States.

---. (1984). The Predrafting Processes of Four High- and Four Low Apprehensive Writers. Research in the Teaching of English, 18, (1), 45-64.

Rasmussen, P. (1985, March) A Case Study on the Evaluation of Research at the Technical University of Denmark. International Journal of Institutional Management in Higher Education, 9 (1).

This is an example of a case study methodology used to evaluate the chemistry and chemical engineering departments at the University of Denmark.

Roth, K. J. (1986). Curriculum Materials, Teacher Talk, and Student Learning: Case Studies in Fifth-Grade Science Teaching . East Lansing: Institute for Research on Teaching.

Roth offers case studies on elementary teachers, elementary school teaching, science studies and teaching, and verbal learning.

Selfe, C. L. (1985). An Apprehensive Writer Composes. When a Writer Can't Write: Studies in Writer's Block and Other Composing-Process Problems . (pp. 83-95). Ed. Mike Rose. NMY: Guilford.

Smith-Lewis, M., R. and Ford, A. (1987). A User's Perspective on Augmentative Communication. Augmentative and Alternative Communication, 3, 12-7.

"During a series of in-depth interviews, a 25-yr-old woman with cerebral palsy who utilized augmentative communication reflected on the effectiveness of the devices designed for her during her school career."

St. Pierre, R., G. (1980, April). Follow Through: A Case Study in Metaevaluation Research . 64th Annual Meeting of the American Educational Research Association. (Address).

The three approaches to metaevaluation are evaluation of primary evaluations, integrative meta-analysis with combined primary evaluation results, and re-analysis of the raw data from a primary evaluation.

Stahler, T., M. (1996, Feb.) Early Field Experiences: A Model That Worked. ERIC.

"This case study of a field and theory class examines a model designed to provide meaningful field experiences for preservice teachers while remaining consistent with the instructor's beliefs about the role of teacher education in preparing teachers for the classroom."

Stake, R. E. (1995). The Art of Case Study Research. Thousand Oaks: Sage Publications.

This book examines case study research in education and case study methodology.

Stiegelbauer, S. (1984) Community, Context, and Co-curriculum: Situational Factors Influencing School Improvements in a Study of High Schools. Presented at the annual meeting of the American Educational Research Association, New Orleans, LA.

Discussion of several case studies: one looking at high school environments, another examining educational innovations.

Stolovitch, H. (1990). Case Study Method. Performance And Instruction, 29, (9), 35-37.

This article describes the case study method as a form of simulation and presents guidelines for their use in professional training situations.

Thaller, E. (1994). Bibliography for the Case Method: Using Case Studies in Teacher Education. RIE. 37 p.

This bibliography presents approximately 450 citations on the use of case studies in teacher education from 1921-1993.

Thrane, T. (1986). On Delimiting the Senses of Near-Synonyms in Historical Semantics: A Case Study of Adjectives of 'Moral Sufficiency' in the Old English Andreas. Linguistics Across Historical and Geographical Boundaries: In Honor of Jacek Fisiak on the Occasion of his Fiftieth Birthday . Berlin: Mouton de Gruyter.

United Nations. (1975). Food and Agriculture Organization. Report on the FAO/UNFPA Seminar on Methodology, Research and Country: Case Studies on Population, Employment and Productivity . Rome: United Nations.

This example case study shows how the methodology can be used in a demographic and psychographic evaluation. At the same time, it discusses the formation and instigation of the case study methodology itself.

Van Vugt, J. P., ed. (1994). Aids Prevention and Services: Community Based Research . Westport: Bergin and Garvey.

"This volume has been five years in the making. In the process, some of the policy applications called for have met with limited success, such as free needle exchange programs in a limited number of American cities, providing condoms to prison inmates, and advertisements that depict same-sex couples. Rather than dating our chapters that deal with such subjects, such policy applications are verifications of the type of research demonstrated here. Furthermore, they indicate the critical need to continue community based research in the various communities threatened by acquired immuno-deficiency syndrome (AIDS) . . . "

Welch, W., ed. (1981, May). Case Study Methodology in Educational Evaluation. Proceedings of the Minnesota Evaluation Conference. Minnesota. (Address).

The four papers in these proceedings provide a comprehensive picture of the rationale, methodology, strengths, and limitations of case studies.

Williams, G. (1987). The Case Method: An Approach to Teaching and Learning in Educational Administration. RIE, 31p.

This paper examines the viability of the case method as a teaching and learning strategy in instructional systems geared toward the training of personnel of the administration of various aspects of educational systems.

Yin, R. K. (1993). Advancing Rigorous Methodologies: A Review of 'Towards Rigor in Reviews of Multivocal Literatures.' Review of Educational Research, 61, (3).

"R. T. Ogawa and B. Malen's article does not meet its own recommended standards for rigorous testing and presentation of its own conclusions. Use of the exploratory case study to analyze multivocal literatures is not supported, and the claim of grounded theory to analyze multivocal literatures may be stronger."

---. (1989). Case Study Research: Design and Methods. London: Sage Publications Inc.

This book discusses in great detail, the entire design process of the case study, including entire chapters on collecting evidence, analyzing evidence, composing the case study report, and designing single and multiple case studies.

Related Links

Consider the following list of related Web sites for more information on the topic of case study research. Note: although many of the links cover the general category of qualitative research, all have sections that address issues of case studies.

• Sage Publications on Qualitative Methodology: Search here for a comprehensive list of new books being published about "Qualitative Methodology" http://www.sagepub.co.uk/
• The International Journal of Qualitative Studies in Education: An on-line journal "to enhance the theory and practice of qualitative research in education." On-line submissions are welcome. http://www.tandf.co.uk/journals/tf/09518398.html
• Qualitative Research Resources on the Internet: From syllabi to home pages to bibliographies. All links relate somehow to qualitative research. http://www.nova.edu/ssss/QR/qualres.html

Becker, Bronwyn, Patrick Dawson, Karen Devine, Carla Hannum, Steve Hill, Jon Leydens, Debbie Matuskevich, Carol Traver, & Mike Palmquist. (2005). Case Studies. Writing@CSU . Colorado State University. https://writing.colostate.edu/guides/guide.cfm?guideid=60

Research Writing and Analysis

• NVivo Group and Study Sessions
• SPSS This link opens in a new window
• Statistical Analysis Group sessions
• Using Qualtrics
• Dissertation and Data Analysis Group Sessions
• Defense Schedule - Commons Calendar This link opens in a new window
• Research Process Flow Chart
• Research Alignment Chapter 1 This link opens in a new window
• Step 1: Seek Out Evidence
• Step 2: Explain
• Step 3: The Big Picture
• Step 4: Own It
• Step 5: Illustrate
• Annotated Bibliography
• Literature Review This link opens in a new window
• Systematic Reviews & Meta-Analyses
• How to Synthesize and Analyze
• Synthesis and Analysis Practice
• Synthesis and Analysis Group Sessions
• Problem Statement
• Purpose Statement
• Conceptual Framework
• Theoretical Framework
• Locating Theoretical and Conceptual Frameworks This link opens in a new window
• Quantitative Research Questions
• Qualitative Research Questions
• Trustworthiness of Qualitative Data
• Analysis and Coding Example- Qualitative Data
• Thematic Data Analysis in Qualitative Design
• Dissertation to Journal Article This link opens in a new window
• International Journal of Online Graduate Education (IJOGE) This link opens in a new window
• Journal of Research in Innovative Teaching & Learning (JRIT&L) This link opens in a new window

Writing a Case Study

What is a case study?

A Case study is: 

• An in-depth research design that primarily uses a qualitative methodology but sometimes​​ includes quantitative methodology.
• Used to examine an identifiable problem confirmed through research.
• Used to investigate an individual, group of people, organization, or event.
• Used to mostly answer "how" and "why" questions.

What are the different types of case studies?

Note: These are the primary case studies. As you continue to research and learn

about case studies you will begin to find a robust list of different types. 

Who are your case study participants?

What is triangulation ? 

Validity and credibility are an essential part of the case study. Therefore, the researcher should include triangulation to ensure trustworthiness while accurately reflecting what the researcher seeks to investigate.

How to write a Case Study?

When developing a case study, there are different ways you could present the information, but remember to include the five parts for your case study.

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Organizing Your Social Sciences Research Assignments

• Annotated Bibliography
• Analyzing a Scholarly Journal Article
• Group Presentations
• Dealing with Nervousness
• Using Visual Aids
• Grading Someone Else's Paper
• Types of Structured Group Activities
• Group Project Survival Skills
• Leading a Class Discussion
• Multiple Book Review Essay
• Reviewing Collected Works
• Writing a Case Analysis Paper
• Writing a Case Study
• About Informed Consent
• Writing Field Notes
• Writing a Policy Memo
• Writing a Reflective Paper
• Writing a Research Proposal
• Generative AI and Writing
• Acknowledgments

A case study research paper examines a person, place, event, condition, phenomenon, or other type of subject of analysis in order to extrapolate  key themes and results that help predict future trends, illuminate previously hidden issues that can be applied to practice, and/or provide a means for understanding an important research problem with greater clarity. A case study research paper usually examines a single subject of analysis, but case study papers can also be designed as a comparative investigation that shows relationships between two or more subjects. The methods used to study a case can rest within a quantitative, qualitative, or mixed-method investigative paradigm.

Case Studies. Writing@CSU. Colorado State University; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010 ; “What is a Case Study?” In Swanborn, Peter G. Case Study Research: What, Why and How? London: SAGE, 2010.

How to Approach Writing a Case Study Research Paper

General information about how to choose a topic to investigate can be found under the " Choosing a Research Problem " tab in the Organizing Your Social Sciences Research Paper writing guide. Review this page because it may help you identify a subject of analysis that can be investigated using a case study design.

However, identifying a case to investigate involves more than choosing the research problem . A case study encompasses a problem contextualized around the application of in-depth analysis, interpretation, and discussion, often resulting in specific recommendations for action or for improving existing conditions. As Seawright and Gerring note, practical considerations such as time and access to information can influence case selection, but these issues should not be the sole factors used in describing the methodological justification for identifying a particular case to study. Given this, selecting a case includes considering the following:

• The case represents an unusual or atypical example of a research problem that requires more in-depth analysis? Cases often represent a topic that rests on the fringes of prior investigations because the case may provide new ways of understanding the research problem. For example, if the research problem is to identify strategies to improve policies that support girl's access to secondary education in predominantly Muslim nations, you could consider using Azerbaijan as a case study rather than selecting a more obvious nation in the Middle East. Doing so may reveal important new insights into recommending how governments in other predominantly Muslim nations can formulate policies that support improved access to education for girls.
• The case provides important insight or illuminate a previously hidden problem? In-depth analysis of a case can be based on the hypothesis that the case study will reveal trends or issues that have not been exposed in prior research or will reveal new and important implications for practice. For example, anecdotal evidence may suggest drug use among homeless veterans is related to their patterns of travel throughout the day. Assuming prior studies have not looked at individual travel choices as a way to study access to illicit drug use, a case study that observes a homeless veteran could reveal how issues of personal mobility choices facilitate regular access to illicit drugs. Note that it is important to conduct a thorough literature review to ensure that your assumption about the need to reveal new insights or previously hidden problems is valid and evidence-based.
• The case challenges and offers a counter-point to prevailing assumptions? Over time, research on any given topic can fall into a trap of developing assumptions based on outdated studies that are still applied to new or changing conditions or the idea that something should simply be accepted as "common sense," even though the issue has not been thoroughly tested in current practice. A case study analysis may offer an opportunity to gather evidence that challenges prevailing assumptions about a research problem and provide a new set of recommendations applied to practice that have not been tested previously. For example, perhaps there has been a long practice among scholars to apply a particular theory in explaining the relationship between two subjects of analysis. Your case could challenge this assumption by applying an innovative theoretical framework [perhaps borrowed from another discipline] to explore whether this approach offers new ways of understanding the research problem. Taking a contrarian stance is one of the most important ways that new knowledge and understanding develops from existing literature.
• The case provides an opportunity to pursue action leading to the resolution of a problem? Another way to think about choosing a case to study is to consider how the results from investigating a particular case may result in findings that reveal ways in which to resolve an existing or emerging problem. For example, studying the case of an unforeseen incident, such as a fatal accident at a railroad crossing, can reveal hidden issues that could be applied to preventative measures that contribute to reducing the chance of accidents in the future. In this example, a case study investigating the accident could lead to a better understanding of where to strategically locate additional signals at other railroad crossings so as to better warn drivers of an approaching train, particularly when visibility is hindered by heavy rain, fog, or at night.
• The case offers a new direction in future research? A case study can be used as a tool for an exploratory investigation that highlights the need for further research about the problem. A case can be used when there are few studies that help predict an outcome or that establish a clear understanding about how best to proceed in addressing a problem. For example, after conducting a thorough literature review [very important!], you discover that little research exists showing the ways in which women contribute to promoting water conservation in rural communities of east central Africa. A case study of how women contribute to saving water in a rural village of Uganda can lay the foundation for understanding the need for more thorough research that documents how women in their roles as cooks and family caregivers think about water as a valuable resource within their community. This example of a case study could also point to the need for scholars to build new theoretical frameworks around the topic [e.g., applying feminist theories of work and family to the issue of water conservation].

Eisenhardt, Kathleen M. “Building Theories from Case Study Research.” Academy of Management Review 14 (October 1989): 532-550; Emmel, Nick. Sampling and Choosing Cases in Qualitative Research: A Realist Approach . Thousand Oaks, CA: SAGE Publications, 2013; Gerring, John. “What Is a Case Study and What Is It Good for?” American Political Science Review 98 (May 2004): 341-354; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Seawright, Jason and John Gerring. "Case Selection Techniques in Case Study Research." Political Research Quarterly 61 (June 2008): 294-308.

Structure and Writing Style

The purpose of a paper in the social sciences designed around a case study is to thoroughly investigate a subject of analysis in order to reveal a new understanding about the research problem and, in so doing, contributing new knowledge to what is already known from previous studies. In applied social sciences disciplines [e.g., education, social work, public administration, etc.], case studies may also be used to reveal best practices, highlight key programs, or investigate interesting aspects of professional work.

In general, the structure of a case study research paper is not all that different from a standard college-level research paper. However, there are subtle differences you should be aware of. Here are the key elements to organizing and writing a case study research paper.

I.  Introduction

As with any research paper, your introduction should serve as a roadmap for your readers to ascertain the scope and purpose of your study . The introduction to a case study research paper, however, should not only describe the research problem and its significance, but you should also succinctly describe why the case is being used and how it relates to addressing the problem. The two elements should be linked. With this in mind, a good introduction answers these four questions:

• What is being studied? Describe the research problem and describe the subject of analysis [the case] you have chosen to address the problem. Explain how they are linked and what elements of the case will help to expand knowledge and understanding about the problem.
• Why is this topic important to investigate? Describe the significance of the research problem and state why a case study design and the subject of analysis that the paper is designed around is appropriate in addressing the problem.
• What did we know about this topic before I did this study? Provide background that helps lead the reader into the more in-depth literature review to follow. If applicable, summarize prior case study research applied to the research problem and why it fails to adequately address the problem. Describe why your case will be useful. If no prior case studies have been used to address the research problem, explain why you have selected this subject of analysis.
• How will this study advance new knowledge or new ways of understanding? Explain why your case study will be suitable in helping to expand knowledge and understanding about the research problem.

Each of these questions should be addressed in no more than a few paragraphs. Exceptions to this can be when you are addressing a complex research problem or subject of analysis that requires more in-depth background information.

II.  Literature Review

The literature review for a case study research paper is generally structured the same as it is for any college-level research paper. The difference, however, is that the literature review is focused on providing background information and  enabling historical interpretation of the subject of analysis in relation to the research problem the case is intended to address . This includes synthesizing studies that help to:

• Place relevant works in the context of their contribution to understanding the case study being investigated . This would involve summarizing studies that have used a similar subject of analysis to investigate the research problem. If there is literature using the same or a very similar case to study, you need to explain why duplicating past research is important [e.g., conditions have changed; prior studies were conducted long ago, etc.].
• Describe the relationship each work has to the others under consideration that informs the reader why this case is applicable . Your literature review should include a description of any works that support using the case to investigate the research problem and the underlying research questions.
• Identify new ways to interpret prior research using the case study . If applicable, review any research that has examined the research problem using a different research design. Explain how your use of a case study design may reveal new knowledge or a new perspective or that can redirect research in an important new direction.
• Resolve conflicts amongst seemingly contradictory previous studies . This refers to synthesizing any literature that points to unresolved issues of concern about the research problem and describing how the subject of analysis that forms the case study can help resolve these existing contradictions.
• Point the way in fulfilling a need for additional research . Your review should examine any literature that lays a foundation for understanding why your case study design and the subject of analysis around which you have designed your study may reveal a new way of approaching the research problem or offer a perspective that points to the need for additional research.
• Expose any gaps that exist in the literature that the case study could help to fill . Summarize any literature that not only shows how your subject of analysis contributes to understanding the research problem, but how your case contributes to a new way of understanding the problem that prior research has failed to do.
• Locate your own research within the context of existing literature [very important!] . Collectively, your literature review should always place your case study within the larger domain of prior research about the problem. The overarching purpose of reviewing pertinent literature in a case study paper is to demonstrate that you have thoroughly identified and synthesized prior studies in relation to explaining the relevance of the case in addressing the research problem.

III.  Method

In this section, you explain why you selected a particular case [i.e., subject of analysis] and the strategy you used to identify and ultimately decide that your case was appropriate in addressing the research problem. The way you describe the methods used varies depending on the type of subject of analysis that constitutes your case study.

If your subject of analysis is an incident or event . In the social and behavioral sciences, the event or incident that represents the case to be studied is usually bounded by time and place, with a clear beginning and end and with an identifiable location or position relative to its surroundings. The subject of analysis can be a rare or critical event or it can focus on a typical or regular event. The purpose of studying a rare event is to illuminate new ways of thinking about the broader research problem or to test a hypothesis. Critical incident case studies must describe the method by which you identified the event and explain the process by which you determined the validity of this case to inform broader perspectives about the research problem or to reveal new findings. However, the event does not have to be a rare or uniquely significant to support new thinking about the research problem or to challenge an existing hypothesis. For example, Walo, Bull, and Breen conducted a case study to identify and evaluate the direct and indirect economic benefits and costs of a local sports event in the City of Lismore, New South Wales, Australia. The purpose of their study was to provide new insights from measuring the impact of a typical local sports event that prior studies could not measure well because they focused on large "mega-events." Whether the event is rare or not, the methods section should include an explanation of the following characteristics of the event: a) when did it take place; b) what were the underlying circumstances leading to the event; and, c) what were the consequences of the event in relation to the research problem.

If your subject of analysis is a person. Explain why you selected this particular individual to be studied and describe what experiences they have had that provide an opportunity to advance new understandings about the research problem. Mention any background about this person which might help the reader understand the significance of their experiences that make them worthy of study. This includes describing the relationships this person has had with other people, institutions, and/or events that support using them as the subject for a case study research paper. It is particularly important to differentiate the person as the subject of analysis from others and to succinctly explain how the person relates to examining the research problem [e.g., why is one politician in a particular local election used to show an increase in voter turnout from any other candidate running in the election]. Note that these issues apply to a specific group of people used as a case study unit of analysis [e.g., a classroom of students].

If your subject of analysis is a place. In general, a case study that investigates a place suggests a subject of analysis that is unique or special in some way and that this uniqueness can be used to build new understanding or knowledge about the research problem. A case study of a place must not only describe its various attributes relevant to the research problem [e.g., physical, social, historical, cultural, economic, political], but you must state the method by which you determined that this place will illuminate new understandings about the research problem. It is also important to articulate why a particular place as the case for study is being used if similar places also exist [i.e., if you are studying patterns of homeless encampments of veterans in open spaces, explain why you are studying Echo Park in Los Angeles rather than Griffith Park?]. If applicable, describe what type of human activity involving this place makes it a good choice to study [e.g., prior research suggests Echo Park has more homeless veterans].

If your subject of analysis is a phenomenon. A phenomenon refers to a fact, occurrence, or circumstance that can be studied or observed but with the cause or explanation to be in question. In this sense, a phenomenon that forms your subject of analysis can encompass anything that can be observed or presumed to exist but is not fully understood. In the social and behavioral sciences, the case usually focuses on human interaction within a complex physical, social, economic, cultural, or political system. For example, the phenomenon could be the observation that many vehicles used by ISIS fighters are small trucks with English language advertisements on them. The research problem could be that ISIS fighters are difficult to combat because they are highly mobile. The research questions could be how and by what means are these vehicles used by ISIS being supplied to the militants and how might supply lines to these vehicles be cut off? How might knowing the suppliers of these trucks reveal larger networks of collaborators and financial support? A case study of a phenomenon most often encompasses an in-depth analysis of a cause and effect that is grounded in an interactive relationship between people and their environment in some way.

NOTE:   The choice of the case or set of cases to study cannot appear random. Evidence that supports the method by which you identified and chose your subject of analysis should clearly support investigation of the research problem and linked to key findings from your literature review. Be sure to cite any studies that helped you determine that the case you chose was appropriate for examining the problem.

IV.  Discussion

The main elements of your discussion section are generally the same as any research paper, but centered around interpreting and drawing conclusions about the key findings from your analysis of the case study. Note that a general social sciences research paper may contain a separate section to report findings. However, in a paper designed around a case study, it is common to combine a description of the results with the discussion about their implications. The objectives of your discussion section should include the following:

Reiterate the Research Problem/State the Major Findings Briefly reiterate the research problem you are investigating and explain why the subject of analysis around which you designed the case study were used. You should then describe the findings revealed from your study of the case using direct, declarative, and succinct proclamation of the study results. Highlight any findings that were unexpected or especially profound.

Explain the Meaning of the Findings and Why They are Important Systematically explain the meaning of your case study findings and why you believe they are important. Begin this part of the section by repeating what you consider to be your most important or surprising finding first, then systematically review each finding. Be sure to thoroughly extrapolate what your analysis of the case can tell the reader about situations or conditions beyond the actual case that was studied while, at the same time, being careful not to misconstrue or conflate a finding that undermines the external validity of your conclusions.

Relate the Findings to Similar Studies No study in the social sciences is so novel or possesses such a restricted focus that it has absolutely no relation to previously published research. The discussion section should relate your case study results to those found in other studies, particularly if questions raised from prior studies served as the motivation for choosing your subject of analysis. This is important because comparing and contrasting the findings of other studies helps support the overall importance of your results and it highlights how and in what ways your case study design and the subject of analysis differs from prior research about the topic.

Consider Alternative Explanations of the Findings Remember that the purpose of social science research is to discover and not to prove. When writing the discussion section, you should carefully consider all possible explanations revealed by the case study results, rather than just those that fit your hypothesis or prior assumptions and biases. Be alert to what the in-depth analysis of the case may reveal about the research problem, including offering a contrarian perspective to what scholars have stated in prior research if that is how the findings can be interpreted from your case.

Acknowledge the Study's Limitations You can state the study's limitations in the conclusion section of your paper but describing the limitations of your subject of analysis in the discussion section provides an opportunity to identify the limitations and explain why they are not significant. This part of the discussion section should also note any unanswered questions or issues your case study could not address. More detailed information about how to document any limitations to your research can be found here .

Suggest Areas for Further Research Although your case study may offer important insights about the research problem, there are likely additional questions related to the problem that remain unanswered or findings that unexpectedly revealed themselves as a result of your in-depth analysis of the case. Be sure that the recommendations for further research are linked to the research problem and that you explain why your recommendations are valid in other contexts and based on the original assumptions of your study.

V.  Conclusion

As with any research paper, you should summarize your conclusion in clear, simple language; emphasize how the findings from your case study differs from or supports prior research and why. Do not simply reiterate the discussion section. Provide a synthesis of key findings presented in the paper to show how these converge to address the research problem. If you haven't already done so in the discussion section, be sure to document the limitations of your case study and any need for further research.

The function of your paper's conclusion is to: 1) reiterate the main argument supported by the findings from your case study; 2) state clearly the context, background, and necessity of pursuing the research problem using a case study design in relation to an issue, controversy, or a gap found from reviewing the literature; and, 3) provide a place to persuasively and succinctly restate the significance of your research problem, given that the reader has now been presented with in-depth information about the topic.

Consider the following points to help ensure your conclusion is appropriate:

• If the argument or purpose of your paper is complex, you may need to summarize these points for your reader.
• If prior to your conclusion, you have not yet explained the significance of your findings or if you are proceeding inductively, use the conclusion of your paper to describe your main points and explain their significance.
• Move from a detailed to a general level of consideration of the case study's findings that returns the topic to the context provided by the introduction or within a new context that emerges from your case study findings.

Note that, depending on the discipline you are writing in or the preferences of your professor, the concluding paragraph may contain your final reflections on the evidence presented as it applies to practice or on the essay's central research problem. However, the nature of being introspective about the subject of analysis you have investigated will depend on whether you are explicitly asked to express your observations in this way.

Problems to Avoid

Overgeneralization One of the goals of a case study is to lay a foundation for understanding broader trends and issues applied to similar circumstances. However, be careful when drawing conclusions from your case study. They must be evidence-based and grounded in the results of the study; otherwise, it is merely speculation. Looking at a prior example, it would be incorrect to state that a factor in improving girls access to education in Azerbaijan and the policy implications this may have for improving access in other Muslim nations is due to girls access to social media if there is no documentary evidence from your case study to indicate this. There may be anecdotal evidence that retention rates were better for girls who were engaged with social media, but this observation would only point to the need for further research and would not be a definitive finding if this was not a part of your original research agenda.

Failure to Document Limitations No case is going to reveal all that needs to be understood about a research problem. Therefore, just as you have to clearly state the limitations of a general research study , you must describe the specific limitations inherent in the subject of analysis. For example, the case of studying how women conceptualize the need for water conservation in a village in Uganda could have limited application in other cultural contexts or in areas where fresh water from rivers or lakes is plentiful and, therefore, conservation is understood more in terms of managing access rather than preserving access to a scarce resource.

Failure to Extrapolate All Possible Implications Just as you don't want to over-generalize from your case study findings, you also have to be thorough in the consideration of all possible outcomes or recommendations derived from your findings. If you do not, your reader may question the validity of your analysis, particularly if you failed to document an obvious outcome from your case study research. For example, in the case of studying the accident at the railroad crossing to evaluate where and what types of warning signals should be located, you failed to take into consideration speed limit signage as well as warning signals. When designing your case study, be sure you have thoroughly addressed all aspects of the problem and do not leave gaps in your analysis that leave the reader questioning the results.

Case Studies. Writing@CSU. Colorado State University; Gerring, John. Case Study Research: Principles and Practices . New York: Cambridge University Press, 2007; Merriam, Sharan B. Qualitative Research and Case Study Applications in Education . Rev. ed. San Francisco, CA: Jossey-Bass, 1998; Miller, Lisa L. “The Use of Case Studies in Law and Social Science Research.” Annual Review of Law and Social Science 14 (2018): TBD; Mills, Albert J., Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Putney, LeAnn Grogan. "Case Study." In Encyclopedia of Research Design , Neil J. Salkind, editor. (Thousand Oaks, CA: SAGE Publications, 2010), pp. 116-120; Simons, Helen. Case Study Research in Practice . London: SAGE Publications, 2009;  Kratochwill,  Thomas R. and Joel R. Levin, editors. Single-Case Research Design and Analysis: New Development for Psychology and Education .  Hilldsale, NJ: Lawrence Erlbaum Associates, 1992; Swanborn, Peter G. Case Study Research: What, Why and How? London : SAGE, 2010; Yin, Robert K. Case Study Research: Design and Methods . 6th edition. Los Angeles, CA, SAGE Publications, 2014; Walo, Maree, Adrian Bull, and Helen Breen. “Achieving Economic Benefits at Local Events: A Case Study of a Local Sports Event.” Festival Management and Event Tourism 4 (1996): 95-106.

Writing Tip

At Least Five Misconceptions about Case Study Research

Social science case studies are often perceived as limited in their ability to create new knowledge because they are not randomly selected and findings cannot be generalized to larger populations. Flyvbjerg examines five misunderstandings about case study research and systematically "corrects" each one. To quote, these are:

Misunderstanding 1 :  General, theoretical [context-independent] knowledge is more valuable than concrete, practical [context-dependent] knowledge. Misunderstanding 2 :  One cannot generalize on the basis of an individual case; therefore, the case study cannot contribute to scientific development. Misunderstanding 3 :  The case study is most useful for generating hypotheses; that is, in the first stage of a total research process, whereas other methods are more suitable for hypotheses testing and theory building. Misunderstanding 4 :  The case study contains a bias toward verification, that is, a tendency to confirm the researcher’s preconceived notions. Misunderstanding 5 :  It is often difficult to summarize and develop general propositions and theories on the basis of specific case studies [p. 221].

While writing your paper, think introspectively about how you addressed these misconceptions because to do so can help you strengthen the validity and reliability of your research by clarifying issues of case selection, the testing and challenging of existing assumptions, the interpretation of key findings, and the summation of case outcomes. Think of a case study research paper as a complete, in-depth narrative about the specific properties and key characteristics of your subject of analysis applied to the research problem.

Flyvbjerg, Bent. “Five Misunderstandings About Case-Study Research.” Qualitative Inquiry 12 (April 2006): 219-245.

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The case study approach

Sarah crowe.

1 Division of Primary Care, The University of Nottingham, Nottingham, UK

Kathrin Cresswell

2 Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK

Ann Robertson

3 School of Health in Social Science, The University of Edinburgh, Edinburgh, UK

Anthony Avery

Aziz sheikh.

The case study approach allows in-depth, multi-faceted explorations of complex issues in their real-life settings. The value of the case study approach is well recognised in the fields of business, law and policy, but somewhat less so in health services research. Based on our experiences of conducting several health-related case studies, we reflect on the different types of case study design, the specific research questions this approach can help answer, the data sources that tend to be used, and the particular advantages and disadvantages of employing this methodological approach. The paper concludes with key pointers to aid those designing and appraising proposals for conducting case study research, and a checklist to help readers assess the quality of case study reports.

Introduction

The case study approach is particularly useful to employ when there is a need to obtain an in-depth appreciation of an issue, event or phenomenon of interest, in its natural real-life context. Our aim in writing this piece is to provide insights into when to consider employing this approach and an overview of key methodological considerations in relation to the design, planning, analysis, interpretation and reporting of case studies.

The illustrative 'grand round', 'case report' and 'case series' have a long tradition in clinical practice and research. Presenting detailed critiques, typically of one or more patients, aims to provide insights into aspects of the clinical case and, in doing so, illustrate broader lessons that may be learnt. In research, the conceptually-related case study approach can be used, for example, to describe in detail a patient's episode of care, explore professional attitudes to and experiences of a new policy initiative or service development or more generally to 'investigate contemporary phenomena within its real-life context' [ 1 ]. Based on our experiences of conducting a range of case studies, we reflect on when to consider using this approach, discuss the key steps involved and illustrate, with examples, some of the practical challenges of attaining an in-depth understanding of a 'case' as an integrated whole. In keeping with previously published work, we acknowledge the importance of theory to underpin the design, selection, conduct and interpretation of case studies[ 2 ]. In so doing, we make passing reference to the different epistemological approaches used in case study research by key theoreticians and methodologists in this field of enquiry.

This paper is structured around the following main questions: What is a case study? What are case studies used for? How are case studies conducted? What are the potential pitfalls and how can these be avoided? We draw in particular on four of our own recently published examples of case studies (see Tables ​ Tables1, 1 , ​ ,2, 2 , ​ ,3 3 and ​ and4) 4 ) and those of others to illustrate our discussion[ 3 - 7 ].

Example of a case study investigating the reasons for differences in recruitment rates of minority ethnic people in asthma research[ 3 ]

Example of a case study investigating the process of planning and implementing a service in Primary Care Organisations[ 4 ]

Example of a case study investigating the introduction of the electronic health records[ 5 ]

Example of a case study investigating the formal and informal ways students learn about patient safety[ 6 ]

What is a case study?

A case study is a research approach that is used to generate an in-depth, multi-faceted understanding of a complex issue in its real-life context. It is an established research design that is used extensively in a wide variety of disciplines, particularly in the social sciences. A case study can be defined in a variety of ways (Table ​ (Table5), 5 ), the central tenet being the need to explore an event or phenomenon in depth and in its natural context. It is for this reason sometimes referred to as a "naturalistic" design; this is in contrast to an "experimental" design (such as a randomised controlled trial) in which the investigator seeks to exert control over and manipulate the variable(s) of interest.

Definitions of a case study

Stake's work has been particularly influential in defining the case study approach to scientific enquiry. He has helpfully characterised three main types of case study: intrinsic , instrumental and collective [ 8 ]. An intrinsic case study is typically undertaken to learn about a unique phenomenon. The researcher should define the uniqueness of the phenomenon, which distinguishes it from all others. In contrast, the instrumental case study uses a particular case (some of which may be better than others) to gain a broader appreciation of an issue or phenomenon. The collective case study involves studying multiple cases simultaneously or sequentially in an attempt to generate a still broader appreciation of a particular issue.

These are however not necessarily mutually exclusive categories. In the first of our examples (Table ​ (Table1), 1 ), we undertook an intrinsic case study to investigate the issue of recruitment of minority ethnic people into the specific context of asthma research studies, but it developed into a instrumental case study through seeking to understand the issue of recruitment of these marginalised populations more generally, generating a number of the findings that are potentially transferable to other disease contexts[ 3 ]. In contrast, the other three examples (see Tables ​ Tables2, 2 , ​ ,3 3 and ​ and4) 4 ) employed collective case study designs to study the introduction of workforce reconfiguration in primary care, the implementation of electronic health records into hospitals, and to understand the ways in which healthcare students learn about patient safety considerations[ 4 - 6 ]. Although our study focusing on the introduction of General Practitioners with Specialist Interests (Table ​ (Table2) 2 ) was explicitly collective in design (four contrasting primary care organisations were studied), is was also instrumental in that this particular professional group was studied as an exemplar of the more general phenomenon of workforce redesign[ 4 ].

What are case studies used for?

According to Yin, case studies can be used to explain, describe or explore events or phenomena in the everyday contexts in which they occur[ 1 ]. These can, for example, help to understand and explain causal links and pathways resulting from a new policy initiative or service development (see Tables ​ Tables2 2 and ​ and3, 3 , for example)[ 1 ]. In contrast to experimental designs, which seek to test a specific hypothesis through deliberately manipulating the environment (like, for example, in a randomised controlled trial giving a new drug to randomly selected individuals and then comparing outcomes with controls),[ 9 ] the case study approach lends itself well to capturing information on more explanatory ' how ', 'what' and ' why ' questions, such as ' how is the intervention being implemented and received on the ground?'. The case study approach can offer additional insights into what gaps exist in its delivery or why one implementation strategy might be chosen over another. This in turn can help develop or refine theory, as shown in our study of the teaching of patient safety in undergraduate curricula (Table ​ (Table4 4 )[ 6 , 10 ]. Key questions to consider when selecting the most appropriate study design are whether it is desirable or indeed possible to undertake a formal experimental investigation in which individuals and/or organisations are allocated to an intervention or control arm? Or whether the wish is to obtain a more naturalistic understanding of an issue? The former is ideally studied using a controlled experimental design, whereas the latter is more appropriately studied using a case study design.

Case studies may be approached in different ways depending on the epistemological standpoint of the researcher, that is, whether they take a critical (questioning one's own and others' assumptions), interpretivist (trying to understand individual and shared social meanings) or positivist approach (orientating towards the criteria of natural sciences, such as focusing on generalisability considerations) (Table ​ (Table6). 6 ). Whilst such a schema can be conceptually helpful, it may be appropriate to draw on more than one approach in any case study, particularly in the context of conducting health services research. Doolin has, for example, noted that in the context of undertaking interpretative case studies, researchers can usefully draw on a critical, reflective perspective which seeks to take into account the wider social and political environment that has shaped the case[ 11 ].

Example of epistemological approaches that may be used in case study research

How are case studies conducted?

Here, we focus on the main stages of research activity when planning and undertaking a case study; the crucial stages are: defining the case; selecting the case(s); collecting and analysing the data; interpreting data; and reporting the findings.

Defining the case

Carefully formulated research question(s), informed by the existing literature and a prior appreciation of the theoretical issues and setting(s), are all important in appropriately and succinctly defining the case[ 8 , 12 ]. Crucially, each case should have a pre-defined boundary which clarifies the nature and time period covered by the case study (i.e. its scope, beginning and end), the relevant social group, organisation or geographical area of interest to the investigator, the types of evidence to be collected, and the priorities for data collection and analysis (see Table ​ Table7 7 )[ 1 ]. A theory driven approach to defining the case may help generate knowledge that is potentially transferable to a range of clinical contexts and behaviours; using theory is also likely to result in a more informed appreciation of, for example, how and why interventions have succeeded or failed[ 13 ].

Example of a checklist for rating a case study proposal[ 8 ]

For example, in our evaluation of the introduction of electronic health records in English hospitals (Table ​ (Table3), 3 ), we defined our cases as the NHS Trusts that were receiving the new technology[ 5 ]. Our focus was on how the technology was being implemented. However, if the primary research interest had been on the social and organisational dimensions of implementation, we might have defined our case differently as a grouping of healthcare professionals (e.g. doctors and/or nurses). The precise beginning and end of the case may however prove difficult to define. Pursuing this same example, when does the process of implementation and adoption of an electronic health record system really begin or end? Such judgements will inevitably be influenced by a range of factors, including the research question, theory of interest, the scope and richness of the gathered data and the resources available to the research team.

Selecting the case(s)

The decision on how to select the case(s) to study is a very important one that merits some reflection. In an intrinsic case study, the case is selected on its own merits[ 8 ]. The case is selected not because it is representative of other cases, but because of its uniqueness, which is of genuine interest to the researchers. This was, for example, the case in our study of the recruitment of minority ethnic participants into asthma research (Table ​ (Table1) 1 ) as our earlier work had demonstrated the marginalisation of minority ethnic people with asthma, despite evidence of disproportionate asthma morbidity[ 14 , 15 ]. In another example of an intrinsic case study, Hellstrom et al.[ 16 ] studied an elderly married couple living with dementia to explore how dementia had impacted on their understanding of home, their everyday life and their relationships.

For an instrumental case study, selecting a "typical" case can work well[ 8 ]. In contrast to the intrinsic case study, the particular case which is chosen is of less importance than selecting a case that allows the researcher to investigate an issue or phenomenon. For example, in order to gain an understanding of doctors' responses to health policy initiatives, Som undertook an instrumental case study interviewing clinicians who had a range of responsibilities for clinical governance in one NHS acute hospital trust[ 17 ]. Sampling a "deviant" or "atypical" case may however prove even more informative, potentially enabling the researcher to identify causal processes, generate hypotheses and develop theory.

In collective or multiple case studies, a number of cases are carefully selected. This offers the advantage of allowing comparisons to be made across several cases and/or replication. Choosing a "typical" case may enable the findings to be generalised to theory (i.e. analytical generalisation) or to test theory by replicating the findings in a second or even a third case (i.e. replication logic)[ 1 ]. Yin suggests two or three literal replications (i.e. predicting similar results) if the theory is straightforward and five or more if the theory is more subtle. However, critics might argue that selecting 'cases' in this way is insufficiently reflexive and ill-suited to the complexities of contemporary healthcare organisations.

The selected case study site(s) should allow the research team access to the group of individuals, the organisation, the processes or whatever else constitutes the chosen unit of analysis for the study. Access is therefore a central consideration; the researcher needs to come to know the case study site(s) well and to work cooperatively with them. Selected cases need to be not only interesting but also hospitable to the inquiry [ 8 ] if they are to be informative and answer the research question(s). Case study sites may also be pre-selected for the researcher, with decisions being influenced by key stakeholders. For example, our selection of case study sites in the evaluation of the implementation and adoption of electronic health record systems (see Table ​ Table3) 3 ) was heavily influenced by NHS Connecting for Health, the government agency that was responsible for overseeing the National Programme for Information Technology (NPfIT)[ 5 ]. This prominent stakeholder had already selected the NHS sites (through a competitive bidding process) to be early adopters of the electronic health record systems and had negotiated contracts that detailed the deployment timelines.

It is also important to consider in advance the likely burden and risks associated with participation for those who (or the site(s) which) comprise the case study. Of particular importance is the obligation for the researcher to think through the ethical implications of the study (e.g. the risk of inadvertently breaching anonymity or confidentiality) and to ensure that potential participants/participating sites are provided with sufficient information to make an informed choice about joining the study. The outcome of providing this information might be that the emotive burden associated with participation, or the organisational disruption associated with supporting the fieldwork, is considered so high that the individuals or sites decide against participation.

In our example of evaluating implementations of electronic health record systems, given the restricted number of early adopter sites available to us, we sought purposively to select a diverse range of implementation cases among those that were available[ 5 ]. We chose a mixture of teaching, non-teaching and Foundation Trust hospitals, and examples of each of the three electronic health record systems procured centrally by the NPfIT. At one recruited site, it quickly became apparent that access was problematic because of competing demands on that organisation. Recognising the importance of full access and co-operative working for generating rich data, the research team decided not to pursue work at that site and instead to focus on other recruited sites.

Collecting the data

In order to develop a thorough understanding of the case, the case study approach usually involves the collection of multiple sources of evidence, using a range of quantitative (e.g. questionnaires, audits and analysis of routinely collected healthcare data) and more commonly qualitative techniques (e.g. interviews, focus groups and observations). The use of multiple sources of data (data triangulation) has been advocated as a way of increasing the internal validity of a study (i.e. the extent to which the method is appropriate to answer the research question)[ 8 , 18 - 21 ]. An underlying assumption is that data collected in different ways should lead to similar conclusions, and approaching the same issue from different angles can help develop a holistic picture of the phenomenon (Table ​ (Table2 2 )[ 4 ].

Brazier and colleagues used a mixed-methods case study approach to investigate the impact of a cancer care programme[ 22 ]. Here, quantitative measures were collected with questionnaires before, and five months after, the start of the intervention which did not yield any statistically significant results. Qualitative interviews with patients however helped provide an insight into potentially beneficial process-related aspects of the programme, such as greater, perceived patient involvement in care. The authors reported how this case study approach provided a number of contextual factors likely to influence the effectiveness of the intervention and which were not likely to have been obtained from quantitative methods alone.

In collective or multiple case studies, data collection needs to be flexible enough to allow a detailed description of each individual case to be developed (e.g. the nature of different cancer care programmes), before considering the emerging similarities and differences in cross-case comparisons (e.g. to explore why one programme is more effective than another). It is important that data sources from different cases are, where possible, broadly comparable for this purpose even though they may vary in nature and depth.

Analysing, interpreting and reporting case studies

Making sense and offering a coherent interpretation of the typically disparate sources of data (whether qualitative alone or together with quantitative) is far from straightforward. Repeated reviewing and sorting of the voluminous and detail-rich data are integral to the process of analysis. In collective case studies, it is helpful to analyse data relating to the individual component cases first, before making comparisons across cases. Attention needs to be paid to variations within each case and, where relevant, the relationship between different causes, effects and outcomes[ 23 ]. Data will need to be organised and coded to allow the key issues, both derived from the literature and emerging from the dataset, to be easily retrieved at a later stage. An initial coding frame can help capture these issues and can be applied systematically to the whole dataset with the aid of a qualitative data analysis software package.

The Framework approach is a practical approach, comprising of five stages (familiarisation; identifying a thematic framework; indexing; charting; mapping and interpretation) , to managing and analysing large datasets particularly if time is limited, as was the case in our study of recruitment of South Asians into asthma research (Table ​ (Table1 1 )[ 3 , 24 ]. Theoretical frameworks may also play an important role in integrating different sources of data and examining emerging themes. For example, we drew on a socio-technical framework to help explain the connections between different elements - technology; people; and the organisational settings within which they worked - in our study of the introduction of electronic health record systems (Table ​ (Table3 3 )[ 5 ]. Our study of patient safety in undergraduate curricula drew on an evaluation-based approach to design and analysis, which emphasised the importance of the academic, organisational and practice contexts through which students learn (Table ​ (Table4 4 )[ 6 ].

Case study findings can have implications both for theory development and theory testing. They may establish, strengthen or weaken historical explanations of a case and, in certain circumstances, allow theoretical (as opposed to statistical) generalisation beyond the particular cases studied[ 12 ]. These theoretical lenses should not, however, constitute a strait-jacket and the cases should not be "forced to fit" the particular theoretical framework that is being employed.

When reporting findings, it is important to provide the reader with enough contextual information to understand the processes that were followed and how the conclusions were reached. In a collective case study, researchers may choose to present the findings from individual cases separately before amalgamating across cases. Care must be taken to ensure the anonymity of both case sites and individual participants (if agreed in advance) by allocating appropriate codes or withholding descriptors. In the example given in Table ​ Table3, 3 , we decided against providing detailed information on the NHS sites and individual participants in order to avoid the risk of inadvertent disclosure of identities[ 5 , 25 ].

What are the potential pitfalls and how can these be avoided?

The case study approach is, as with all research, not without its limitations. When investigating the formal and informal ways undergraduate students learn about patient safety (Table ​ (Table4), 4 ), for example, we rapidly accumulated a large quantity of data. The volume of data, together with the time restrictions in place, impacted on the depth of analysis that was possible within the available resources. This highlights a more general point of the importance of avoiding the temptation to collect as much data as possible; adequate time also needs to be set aside for data analysis and interpretation of what are often highly complex datasets.

Case study research has sometimes been criticised for lacking scientific rigour and providing little basis for generalisation (i.e. producing findings that may be transferable to other settings)[ 1 ]. There are several ways to address these concerns, including: the use of theoretical sampling (i.e. drawing on a particular conceptual framework); respondent validation (i.e. participants checking emerging findings and the researcher's interpretation, and providing an opinion as to whether they feel these are accurate); and transparency throughout the research process (see Table ​ Table8 8 )[ 8 , 18 - 21 , 23 , 26 ]. Transparency can be achieved by describing in detail the steps involved in case selection, data collection, the reasons for the particular methods chosen, and the researcher's background and level of involvement (i.e. being explicit about how the researcher has influenced data collection and interpretation). Seeking potential, alternative explanations, and being explicit about how interpretations and conclusions were reached, help readers to judge the trustworthiness of the case study report. Stake provides a critique checklist for a case study report (Table ​ (Table9 9 )[ 8 ].

Potential pitfalls and mitigating actions when undertaking case study research

Stake's checklist for assessing the quality of a case study report[ 8 ]

Conclusions

The case study approach allows, amongst other things, critical events, interventions, policy developments and programme-based service reforms to be studied in detail in a real-life context. It should therefore be considered when an experimental design is either inappropriate to answer the research questions posed or impossible to undertake. Considering the frequency with which implementations of innovations are now taking place in healthcare settings and how well the case study approach lends itself to in-depth, complex health service research, we believe this approach should be more widely considered by researchers. Though inherently challenging, the research case study can, if carefully conceptualised and thoughtfully undertaken and reported, yield powerful insights into many important aspects of health and healthcare delivery.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

AS conceived this article. SC, KC and AR wrote this paper with GH, AA and AS all commenting on various drafts. SC and AS are guarantors.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2288/11/100/prepub

Acknowledgements

We are grateful to the participants and colleagues who contributed to the individual case studies that we have drawn on. This work received no direct funding, but it has been informed by projects funded by Asthma UK, the NHS Service Delivery Organisation, NHS Connecting for Health Evaluation Programme, and Patient Safety Research Portfolio. We would also like to thank the expert reviewers for their insightful and constructive feedback. Our thanks are also due to Dr. Allison Worth who commented on an earlier draft of this manuscript.

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Prediction of suicide attempts among persons with depression: a population-based case cohort study

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Tammy Jiang, Dávid Nagy, Anthony J Rosellini, Erzsébet Horváth-Puhó, Katherine M Keyes, Timothy L Lash, Sandro Galea, Henrik T Sørensen, Jaimie L Gradus, Prediction of suicide attempts among persons with depression: a population-based case cohort study, American Journal of Epidemiology , Volume 193, Issue 6, June 2024, Pages 827–834, https://doi.org/10.1093/aje/kwad237

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Studies have highlighted the potential importance of modeling interactions for suicide attempt prediction. This case-cohort study identified risk factors for suicide attempts among persons with depression in Denmark using statistical approaches that do (random forests) or do not (least absolute shrinkage and selection operator regression [LASSO]) model interactions. Cases made a nonfatal suicide attempt ( n  = 6032) between 1995 and 2015. The comparison subcohort was a 5% random sample of all persons in Denmark on January 1, 1995 ( n  = 11 963). We used random forests and LASSO for sex-stratified prediction of suicide attempts from demographic variables, psychiatric and somatic diagnoses, and treatments. Poisonings, psychiatric disorders, and medications were important predictors for both sexes. Area under the receiver-operating characteristic curve (AUC) values were higher in LASSO models (in men, 0.85, 95% CI, 0.84-0.86; in women, 0.89, 95% C, 0.88-0.90) than random forests (in men, 0.76, 95% CI, 0.74-0.78; in women, 0.79, 95% CI = 0.78-0.81). Automatic detection of interactions via random forests did not result in better model performance than LASSO models that did not model interactions. Due to the complex nature of psychiatric comorbidity and suicide, modeling interactions may not always be the optimal statistical approach to enhancing suicide attempt prediction in high-risk samples.

This article is part of a Special Collection on Mental Health.

Depression is the most common psychiatric disorder globally, afflicting approximately 280 million people worldwide. 1 It is an important risk factor for suicide attempts. 2 The lifetime prevalence of suicide attempts among persons with major depressive disorder is 31% (95% CI, 27-34), which is over 6 times the lifetime prevalence of suicide attempts in the general population. 3 , 4 Suicide attempts are associated with injury, psychological distress, and increased risk of dying by suicide in a future attempt. 5 A key challenge is our limited ability to predict who is at high-risk of suicide attempts and should be connected with preventive interventions. Traditional regression approaches that focus on isolating bivariate associations between single risk factors and suicide attempts have not been able to accurately predict suicide attempts. 6 To address this challenge, researchers have increasingly used novel machine learning approaches for prediction. Machine learning methods permit examination of large sets of risk factors simultaneously to develop composite prediction functions and identify the most important predictors of suicide attempts.

Recent studies suggest that machine learning methods may be better able to predict suicide attempt risk compared with traditional methods. 7 , 8 For example, Walsh et al. 7 used random forests and traditional logistic regression models to predict suicide attempts using electronic health record data. They found that the random forests area under the receiver operating characteristic curve (AUC) values ranged from 0.80 to 0.84 whereas the logistic regression AUC values ranged from 0.66 to 0.68. 7 The random forests results also showed that the variables that contributed the most to prediction accuracy for suicide attempts were poisonings, psychiatric disorders, substance use, and psychiatric medications. 7 Another study predicting suicide attempts after outpatient clinic visits 8 using electronic health records across 7 health systems found that the strongest predictors of suicide attempt were a prior suicide attempt, mental health and substance use diagnoses, and inpatient or emergency mental health care. Similarly, a study predicting suicide attempts using Danish registry data found that substance use disorders/treatment, psychiatric medications, previous poisoning diagnoses, and stress disorders were important predictors of suicide attempts. 9 Clearly, there is an increasing focus on modeling complex combinations of factors for suicide attempt prediction. 2 , 6 , 9 , - 11 At the same time, there is question in the literature as to whether machine learning approaches, including those that automatically detect interactions, are truly necessary and appropriate for all research questions. 12 Accordingly, it is becoming commonplace to compare machine learning approaches to more standard approaches as an evaluation of necessity, and this may be especially important for questions with complex relationships among the predictors and outcome, as has been shown with psychiatric comorbidity and suicide. 13

Although prior studies have used machine learning methods to predict suicide attempts among the general population, 9 few have focused on suicide attempt prediction among persons living with depression, an important subgroup among which the majority of suicide attempts are concentrated. The development of prediction models in persons with depression may yield important differences in risk factors and interactions in this high-risk subgroup compared with models developed in the general population and may be of specific interest to clinicians working with depressed patients. Using prospective Danish registry data, we developed prediction models for suicide attempts among persons diagnosed with depression using both random forests analyses, to model main effects (including nonlinear effects) and interactions, and least absolute shrinkage and selection operator regression (LASSO) models that did not model interactions between variables. The goal of this work was not to develop clinically deployable predictive models but rather to use these statistical approaches to begin to gain a fuller understanding of the variables that might be important to understanding the etiology of suicide attempts, using a data-driven approach to identify risk factors of importance. Comparing and contrasting results from these models can inform us about the extent to which modeling interactions may affect model performance. We conducted sex-stratified analyses to examine potential sex differences in patient characteristics associated with suicide attempts.

Study design and sample

We conducted a case-cohort study using national medical and administrative registries in Denmark. Denmark provides all residents with a universal health care system. 14 , 15 Cases were persons who made an incident suicide attempt between January 1, 1995, and December 31, 2015, restricted to persons with a depression diagnosis before the attempt ( n  = 6032). The comparison subcohort was a 5% random sample of all individuals born or residing in Denmark on January 1, 1995, restricted to persons who had an incident inpatient or outpatient depression diagnosis between January 1, 1995, and December 31, 2015 ( n  = 11 963). Incident suicide attempts were obtained from the Danish National Patient Registry 14 using International Classification of Diseases , Tenth Revision (ICD-10), codes X60 to X84 without a death recorded in the Danish Register of Causes of Death 16 in the subsequent 30 days. A validation study of the ICD-10 codes for suicide attempt (X60 to X84) in Denmark found that the positive predictive value for suicide attempts was approximately 73% (27% of the classified cases were reclassified as nonsuicidal events). 17 Depression diagnoses were obtained using the inpatient and outpatient ICD-10 diagnoses F32 to F39, identified from the Danish National Patient Registry and the Danish Psychiatric Central Research Register. We did not match cases and controls on any factors to enable maximum variability in the predictors included in the machine learning analyses.

We included the following predictors in our prediction models for suicide attempts: age, marital status, immigrant status, citizenship, family suicide death history (parent or spouse), employment, income, mental disorders, somatic disorders, surgeries, prescription drugs, and psychotherapy (any encounter for psychological services). Data on age, marital status, immigrant status, citizenship, and family suicide death history were obtained from the Danish Civil Registration System and the Danish Cause of Death Registry. 16 , 18 Baseline data on employment and income were obtained from the Integrated Database for Labor Market Research and Income Statistics Register. 19 , 20 Psychiatric disorder diagnoses were ascertained using 2-digit ICD-10 codes from the Danish Psychiatric Central Research Register and Danish National Patient Registry. 14 , 21 The Danish Psychiatric Central Research Register includes the recorded dates of inpatient psychiatric stays and outpatient psychiatric visits since 1995 and includes up to 20 diagnoses per psychiatric treatment episode. 21 , 22 The Danish National Patient Registry includes data on all inpatient hospitalizations in nonpsychiatric hospitals and hospital outpatient and emergency room visits since 1995. 14 We also used the Danish National Patient Registry to obtain second-level ICD-10 codes for inpatient and outpatient somatic diagnoses, surgery procedure codes (according to body system), and any encounters for psychological services. The Danish National Prescription Registry, 23 , 24 which has recorded data on all prescriptions sold in Danish pharmacies since 1995, was used to obtain data on prescription drugs recorded according to Level 3 Anatomical Therapeutic Chemical classification codes. A list of all predictor variables is provided in Table S1.

Demographic variables were defined at a single time point and diagnostic and treatment variables were treated as time-varying. Natal sex, age, employment, and income and immigrant status were defined at baseline. We examined diagnostic and treatment variables in a time-varying fashion to reflect changes in variables over time. Consistent with prior suicide-related machine learning studies, 25 , - 27 we dummy-coded variables to create time-varying predictors with intervals of 0 to 6, 0 to 12, 0 to 24, and 0 to 48 months before the date of suicide attempt. To estimate the prevalence of each predictor in the person-time of the source population that gave rise to the cases, we randomly selected a date between the depression diagnosis date and the end of follow-up for comparison subcohort members and computed the prevalence of each predictor 0 to 6, 0 to 12, 0 to 24, and 0 to 48 months before the selected date.

Statistical analyses

To reduce the risk of overfitting in the machine learning models, we removed rare predictors that had 10 or fewer observations in any cell of a 2 × 2 contingency table of the predictor and suicide attempt for men and women separately. All predictors were binary. The initial analytical dataset contained 2543 predictors. After removing rare predictors, the final number of included predictors was 841 for men and 1079 for women. Retained predictors are shown in Table S1.

To assess the extent to which interactions may contribute to accurate suicide attempt prediction, we compared the results of sex-stratified random forests with LASSO models. We used the same set of predictors for both machine learning approaches. The random forests were constructed using 1000 trees with a minimum of 10 observations needed to make a split in each tree. To decorrelate the trees, the numbers of variables sampled as split candidates at each node were 29 for men and 33 for women, corresponding with the square root of the total number of predictors for men and women. 28 Each individual tree in the random forests used equal proportions of suicide attempt observations and non–suicide attempt observations to address class imbalance. We performed 10-fold cross-validation (internal) of the random forests to generate predicted values for each individual and to calculate the mean decrease in accuracy (MDA) of each variable. We evaluated random forests’ AUC using 10-fold cross-validation and calculated the corresponding 95% CI using bootstrapping in 1000 replicates. 29

Baseline characteristics of the suicide attempt cases and the comparison subcohort, Denmark, January 1, 1995.

a Values are expressed as mean (standard deviation).

We then fitted main effects LASSO models that did not model interactions among variables. LASSO shrinks coefficient estimates towards zero and can force some of the coefficient estimates to be exactly equal to zero. We considered a variable to be selected by LASSO if the estimated coefficient in the model was nonzero. We fitted the LASSO regression models using 10-fold cross-validation with lambda equal to the minimum mean cross-validated error. We evaluated the AUC values of the LASSO regression models using 10-fold cross-validation.

For both random forests and LASSO, we calculated the proportion of all suicide attempt cases that occurred in the top 5%, 10%, and 20% of the predicted probabilities for suicide attempts. We then calculated the proportion of all non–suicide attempters that occurred in the bottom 95%, 90%, and 80% of predicted probabilities.

Analyses were conducted in SAS, version 9.4, and R, version 3.5.2. 30 , 31 We used the R packages glmnet 32 and ranger. 33 This study was determined to be exempt from review by the Boston University institutional review board and approved by the Danish Data Protection Agency (record number 2015-57-0002).

Descriptive results

There were 2093 men who made a suicide attempt and had a prior depression diagnosis and 4281 men in the corresponding comparison subcohort. Among women, there were 3939 suicide attempt cases with a prior depression diagnosis and there were 7682 women in the corresponding comparison subcohort. Table 1 displays the descriptive characteristics of the study sample. For both men and women, cases were on average younger than the comparison subcohorts and a greater proportion of cases were single and unemployed.

Random forests

In the random forests, poisoning in any time interval had the greatest impact on model accuracy for men diagnosed with depression. Other important predictors included alcohol-related disorders, reaction to severe stress and adjustment disorders, and drugs used to treat psychiatric disorders (eg, drugs used to treat addictive disorders, anxiolytics, and hypnotics and sedatives). Antithrombotic agents prescribed at several time intervals and toxic effects of substances chiefly nonmedicinal as to source emerged as important predictors. Social variables such as receipt of state pension and being single were also important to accurate prediction of suicide attempts among men diagnosed with depression. Figure 1 displays the variable importance rankings of the top 30 predictors (median MDA value of all predictors with a nonzero MDA value, 0.29 [interquartile range, 0.06]). The cross-validated AUC of the random forest was 0.76 (95% CI, 0.74-0.78).

Variable importance of suicide attempt predictors in men with depression in Denmark from 10-fold cross-validated random forests, 1995-2015. RSS and AD refers to reaction to severe stress and adjustment disorders. Poisoning refers to poisoning by, adverse effect of, and underdosing of drugs, medicaments, and biological substances. Toxic effects of substances refer to those chiefly nonmedicinal as to source. The black dots represent the mean decrease in accuracy (MDA) value from 10-fold cross-validation. The vertical line represents the median of the MDA values of all predictors with a nonzero MDA value (median, 0.29; interquartile range, 0.06).

Similar to the random forests results in men, poisoning in any time interval was the most important variable for accurate prediction of suicide attempts among women diagnosed with depression ( Figure 2 ). Psychiatric disorder diagnoses (eg, specific personality disorders, alcohol-related disorders, reaction to severe stress, and adjustment disorders) and psychiatric medication prescriptions (eg, antipsychotics, hypnotics and sedatives, and anxiolytics) at all time intervals were important predictors of suicide attempts in women. Also similar to the random forests findings in men, social variables, including receipt of state pension and remaining single at all time points, were among the top 30 most important predictors of suicide attempts. Prescription of other analgesics and antipyretics in the preceding 48 months emerged as an important predictor of suicide attempts among women. Figure 2 displays the random forest’s MDA values (median MDA value of predictors with a non-zero MDA value, 0.08 [IQR, 0.02]). The cross-validated AUC of the random forests was 0.79 (95% CI, 0.78-0.81).

Variable importance of suicide attempt predictors in women with depression in Denmark from 10-fold cross-validated random forests, 1995-2015. RSS and AD refers to reaction to severe stress and adjustment disorders. Poisoning refers to poisoning by, adverse effect of, and underdosing of drugs, medicaments, and biological substances. The black dots represent the mean decrease in accuracy (MDA) value from 10-fold cross-validation. The vertical line represents the median of the MDA values of all predictors with a non-zero MDA value (median, 0.08; interquartile range, 0.02).

In the random forests, men in the top 5%, 10%, and 20% of predicted risk accounted for 13%, 27%, and 49% of all suicide attempts among men diagnosed with depression, respectively. Men in the bottom 95%, 90%, and 80% of predicted suicide attempt risk accounted for 99%, 98%, and 94% of all men diagnosed with depression who did not make a suicide attempt, respectively. Women in the top 5%, 10%, and 20% of predicted risk accounted for 14%, 28%, and 53% of all suicide attempts among women with a depression diagnosis, respectively. Women in the bottom 95%, 90%, and 80% of predicted suicide attempt risk accounted for 100%, 99%, and 97% of all women diagnosed with depression who did not make a suicide attempt, respectively.

LASSO models

Figures 3 and 4 display the top 30 predictors of suicide attempts in the LASSO models for men and women. Although there was overlap in the top 30 predictors identified across the LASSO and random forests models for men and women (eg, poisoning, alcohol-related disorders, reaction to severe stress and adjustment disorders, anxiolytics, hypnotics and sedatives, specific personality disorders), injuries were more prominent in the LASSO results than in the random forests. The top predictors of suicide attempt in men according to the LASSO model were poisoning, toxic effects of substances, injuries (to the elbow and forearm, neck, thorax, abdomen, lower back, lumbar spine, pelvis, and external genitals, and to the wrist, hand, and fingers), and reaction to severe stress and adjustment disorders ( Figure 3 ). Out of 841 predictors included in the LASSO model for men, 127 predictors had nonzero coefficients (15%).

Variable importance of suicide attempt predictors in men with depression in Denmark from 10-fold cross-validated least absolute shrinkage and selection operator regression (LASSO) model, 1995-2015. RSS and AD refers to reaction to severe stress and adjustment disorders. Poisoning refers to poisoning by, adverse effect of, and underdosing of drugs, medicaments, and biological substances. Various injuries refers to injuries to the abdomen, lower back, lumbar spine, pelvis, and external genitals.

Variable importance of suicide attempt predictors in women with depression in Denmark from 10-fold cross-validated least absolute shrinkage and selection operator regression (LASSO) model, 1995-2015. RSS and AD refers to reaction to severe stress and adjustment disorders. Poisoning refers to poisoning by, adverse effect of, and underdosing of drugs, medicaments, and biological substances. Disorders of ocular muscles, etc., refers to disorders of ocular muscles, binocular movement, accommodation, and refraction. Disorders of glucose regulation, etc., refers to other disorders of glucose regulation and pancreatic internal secretion.

In women, the top predictors were poisoning, toxic effects of substances, schizoaffective disorders, reaction to severe stress and adjustment disorders, and injuries to the wrist, hand, and fingers ( Figure 4 ). Out of 1079 predictors included in the LASSO model for women, 130 predictors had nonzero coefficients (12%). The LASSO regression coefficients are shown in Tables S2 and S3.

The cross-validated AUC of the LASSO was 0.85 (95% CI, 0.84, 0.86) in men and 0.89 (95% CI, 0.88, 0.90) in women. Men in the top 5%, 10%, and 20% of predicted risk in the LASSO model accounted for 14%, 28%, and 50%, respectively, of all suicide attempts among men diagnosed with depression. Men in the bottom 95%, 90%, and 80% of predicted suicide attempt risk accounted for 99.5%, 99%, and 95%, respectively, of all men diagnosed with depression who did not make a suicide attempt. Women in the top 5%, 10%, and 20% of predicted risk accounted for 14%, 28%, and 53%, respectively, of all suicide attempts among women with a depression diagnosis. Women in the bottom 95%, 90%, and 80% of predicted suicide attempt risk accounted for 99.7%, 99%, and 97%, respectively, of all women diagnosed with depression who did not make a suicide attempt.

We used random forests and LASSO to predict suicide attempts among men and women diagnosed with depression. Both random forests and LASSO models identified poisonings, psychiatric disorders, and psychiatric medications as important predictors of suicide attempts. However, injuries emerged as an important predictor in the LASSO models but not in the random forests. Moreover, the LASSO regression models had higher AUC values than the random forests. These results suggest that modeling interactions between study variables using random forests did not result in more accurate prediction of suicide attempts relative to a main effects LASSO model. Prior work has shown that interactions between variables are important for suicidal behavior. 6 One potential explanation for why interactions did not play an important role in our study is that depression is such a strong risk factor for suicide attempts that it masks the effects of any weaker modifying variables. These results underscore the complexity of the relationships between depression and other risk factors (eg, psychiatric comorbidity) for suicide attempts that may lead to unexpected findings. 13 Another possible explanation is that we lacked data on precipitating stressors that may have had important interactions with diagnostic variables associated with suicide attempt risk (ie, vulnerability-stress interactions). Such stressors may be strong predictors in the days and weeks preceding suicide, 10 and lack of data on these variables may have hindered our ability to detect interactions between acute stressors and diagnostic variables necessary for accurate prediction suicide attempts.

Similar findings emerged for men and women; specific personality disorders, reaction to severe stress and adjustment disorders, prior poisonings, prescriptions for drugs used in addictive disorders, anxiolytics, hypnotics and sedatives, antipsychotics, prescriptions for antiinflammatory medications (eg, antithrombotic agents and other analgesics and antipyretics), and being single were important factors in predicting suicide attempts in men and women. However, injuries of different types were more prominent in the LASSO results for men than women. One potential explanation for these results is that prior suicide attempts may be more likely to be recorded as injuries (eg, to the hand, wrist, neck) for men than women. It is not always possible to differentiate acts of self-harm with and without intention to die. Records that do not have evidence of intention or a clear indication of intention to die are considered nonsuicidal events and may be coded as injuries. 17 Men may be more likely to have a suicide attempt incorrectly classified as a nonsuicidal injury than women. As such, prior suicide attempts recorded as injuries may be predictive of a future suicide attempt in men with depression.

We did not find any particular time interval of predictors to be strongly predictive of suicide attempts in the random forests. Poisonings, psychiatric disorders, and medications were identified as top predictors across all time periods in the random forests. However, in the LASSO models, there was greater variability in the top predictors in terms of their timing. This finding suggests that using a main effects LASSO model may allow specific time points of predictors to stand out more than others compared with random forests which model interactions. For example, a poisoning diagnosis in the 6 months prior to a suicide attempt was the most important predictor in the LASSO models for both men and women, whereas poisoning diagnoses at all time points were the top predictors in the random forests. Knowledge of the importance of the recency of a poisoning diagnosis to suicide attempt prediction may be informative for prevention. Importantly, we used overlapping time intervals for predictors so that our work was similar to previous research. Future work should be aimed at building separate models that predict short- and long-term risk. The nature of the Danish registry data allows for the thorough examination of timing of incident disorders, but not full disorder duration. Another important avenue for future research in other data sources would be a more thorough characterization of full disorder duration in prediction models. In addition, in the random forests and LASSO models, men and women in the top 20% of predicted risk accounted for approximately 50% of suicide attempts. This finding indicates that targeting prevention programs to those at highest risk could lead to a meaningful reduction in the overall burden of suicide attempts, depending on the effectiveness (and costs) of the program.

A limitation of this study is that diagnoses of poisoning and toxic effects of substances may capture a mix of previous suicide attempts, nonsuicidal self-injury, and drug overdoses and adverse reactions. Any misclassification of poisonings and toxic effects of substances is expected to be nondifferential with respect to outcome classification in the current study because these predictors were measured prior to outcome occurrence. Despite this misclassification, these variables still appeared as the top predictors of suicide attempts in the machine learning analyses, suggesting that the inclusion of broader variables for which the intent of the poisoning is unclear may be useful in prediction models for suicide attempts. Another limitation is that we did not include psychiatric and somatic diagnoses prior to 1995 given that our study period was from 1995 to 2015. We chose 1995 as the beginning of the study period because it coincided with the switch from ICD-8 to ICD-10 in Denmark and the inclusion of outpatient visits to the somatic and psychiatric registries. 14 The lack of psychiatric and somatic diagnosis data before 1995 may have had a limited impact on our results given that the largest time interval used for the time-varying predictors was 0 to 48 months prior to suicide or the randomly chosen date during the study period for the comparison subcohort. Thus, missing data prior to 1995 would only affect the small proportion of suicide cases who died within the first 4 years of the study period and subcohort members who had a random date that fell within the first 4 years of the study period. Moreover, we did not model income and employment as time-varying variables, which may have limited our ability to detect their importance to suicide attempt prediction. However, given the social safety nets in Denmark that relate to employment and income, we expect this to have little impact on our findings in this particular population. Finally, given our goal of using data-driven methods to identify novel risk factors and interactions that are important to suicide attempt prediction, it is crucial that our findings be replicated in other data sources and populations outside of Denmark to add further context and deepen knowledge on risk factors that are important to the etiology of suicidal behavior.

There is increasing focus on modeling complex combinations of variables for suicide attempt prediction. However, using data from Danish registries, we found that modeling interactions may not be necessary for prediction of suicide attempts specifically among high-risk subgroups, such as persons with depression. These results call for additional careful thought when considering appropriate approaches to statistically modeling suicidal behavior that may vary by patient population.

Supplementary material is available at the American Journal of Epidemiology online.

This work was supported by National Institute of Mental Health grants R01MH109507 (PI: J.L.G.) and R01MH110453 (PI: J.L.G.).

The authors declare no conflicts of interest.

The National Institute of Mental Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

This population study used individual-level data from Danish medical and social registries. The ethical approval of this project does not include permission to publicly share raw data. For access to data, please contact the Department of Clinical Epidemiology at Aarhus University Hospital.

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• Published: 06 June 2024

Multi-stage optimization strategy based on contextual analysis to create M-health components for case management model in breast cancer transitional care: the CMBM study as an example

• Hong Chengang 1 ,
• Wang Liping 1 ,
• Wang Shujin 1 ,
• Chen Chen 1 ,
• Yang Jiayue 1 ,
• Lu Jingjing 1 ,
• Hua Shujie 1 ,
• Wu Jieming 1 ,
• Yao Liyan 1 ,
• Zeng Ni 1 ,
• Chu Jinhui 1 &
• Sun Jiaqi 1  

BMC Nursing volume  23 , Article number:  385 ( 2024 ) Cite this article

Metrics details

None of the early M-Health applications are designed for case management care services. This study aims to describe the process of developing a M-health component for the case management model in breast cancer transitional care and to highlight methods for solving the common obstacles faced during the application of M-health nursing service.

We followed a four-step process: (a) Forming a cross-functional interdisciplinary development team containing two sub-teams, one for content development and the other for software development. (b) Applying self-management theory as the theoretical framework to develop the M-health application, using contextual analysis to gain a comprehensive understanding of the case management needs of oncology nursing specialists and the supportive care needs of out-of-hospital breast cancer patients. We validated the preliminary concepts of the framework and functionality of the M-health application through multiple interdisciplinary team discussions. (c) Adopting a multi-stage optimization strategy consisting of three progressive stages: screening, refining, and confirmation to develop and continually improve the WeChat mini-programs. (d) Following the user-centered principle throughout the development process and involving oncology nursing specialists and breast cancer patients at every stage.

Through a continuous, iterative development process and rigorous testing, we have developed patient-end and nurse-end program for breast cancer case management. The patient-end program contains four functional modules: “Information”, “Interaction”, “Management”, and “My”, while the nurse-end program includes three functional modules: “Consultation”, “Management”, and “My”. The patient-end program scored 78.75 on the System Usability Scale and showed a 100% task passing rate, indicating that the programs were easy to use.

Conclusions

Based on the contextual analysis, multi-stage optimization strategy, and interdisciplinary team work, a WeChat mini-program has been developed tailored to the requirements of the nurses and patients. This approach leverages the expertise of professionals from multiple disciplines to create effective and evidence-based solutions that can improve patient outcomes and quality of care.

Peer Review reports

Female breast cancer is the second leading cause of global cancer incidence in 2022, with an estimated 2.3 million new cases, representing 11.6% of all cancer cases [ 1 ]. Due to surgical trauma, side effects of drugs, fear of the recurrence or metastasis of breast cancer, changes in female characteristics, and lack of knowledge, patients with breast cancer frequently experience a series of physical and psychological health problems [ 2 , 3 , 4 , 5 , 6 ]. These health problems seriously affected patients’ life and work [ 7 , 8 ]. At present, community nursing in China is still in the developing stage, and the oncology specialty nursing service capacity of community nurses is not enough to deal with the health problems of breast cancer patients. It made continuous care for out-of-hospital breast cancer patients a weak link in the Chinese oncology nursing service system.

Nowadays, case management is employed to manage health problems for out-of-hospital breast cancer patients worldwide [ 9 , 10 , 11 , 12 , 13 , 14 , 15 ]. Case management involves regular telephone follow-ups and home visits by case management nurses to provide educational support to patients, thereby ensuring uninterrupted continuity of care [ 16 , 17 ]. The home visits and organization of patient information required for case management tasks consume a significant amount of time, manpower, and material resources [ 17 ]. In China, case management services are primarily undertaken by oncology nursing specialists from tertiary hospitals in their spare time [ 18 ]. However, the shortage of nurses has consistently been one of the major challenges facing the nursing industry in China, especially in tertiary hospitals [ 19 ]. Consequently, the implementation and promotion of case management in China also face great difficulties in reality [ 20 ].

The Global Observatory for eHealth (GOe) of the World Health Organization (WHO) defines mobile health (M-Health) as “medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices” [ 21 , 22 ]. With the development of digital technology and the COVID-19 pandemic in 2019, M-Health applications were further integrated into healthcare services, which increased the demand for M-Health applications in turn [ 23 , 24 ]. Compared with the traditional health service model, M-Health service model has the advantages of high-level informatization, fast response speed, freedom from time and location constraints, and resource-saving, etc. In the context of limited nursing human resources, M-Health service provides a new solution for the case management of out-of-hospital breast cancer patients [ 23 , 25 , 26 ].

Researchers have developed a range of M-Health applications targeting breast cancer patients. To our knowledge, none of these developed M-Health applications are designed for case management nursing services.

Early M-Health applications were mostly designed for single interventional goals, such as health education, medication compliance, self-monitoring, etc. Larsen et al. applied a M-Health application to monitor and adjust the dosage of oral chemotherapy drugs in breast cancer patients, and the results suggested that the treatment adherence was effectively improved [ 27 ]. Heo and his team successfully promoted self-breast-examination behavior in women under 30 years old using a M-Health application [ 28 ]. Mccarrol carried out a M-Health diet and exercise intervention in overweight breast cancer patients and found that the weight, BMI, and waist circumference of the intervention group decreased after one month [ 29 ]. Smith’s team found that their application promoted the adoption of healthy diet and exercise behaviors among breast cancer patients [ 30 ]. The application designed by Eden et al. enhanced the ability of breast cancer patients receiving chemotherapy to recognize adverse drug reactions [ 31 ]. Keohane and colleagues designed a health educational application based on the best practices and it proved effective in improving breast cancer-related knowledge [ 32 ]. The guideline-based M-Health application developed by Eden et al. optimized breast cancer patients’ individualized health decision-making regarding mammography [ 33 ].

With the progress of computer technology and the emphasis on physical and mental rehabilitation of breast cancer patients, some universities [ 34 , 35 ] in China have separately developed M-Health applications for comprehensive health management, which provide access to online communication, health education, and expert consultation.

Analyzing these developed applications deeply, three factors could be found that hindered the promotion of applications in real life. Firstly, the developing procedure usually lacks contextual analysis based on the actual usage context during the design phase. Secondly, there is a lack of consistent and long-term monitoring and operation staff in the subsequent program implementation. These factors may be the main reasons why many M-Health applications face difficulties in promotion and continuous operation after the research phase. Furthermore, as applications need to be installed on patients’ smartphones, certain hardware requirements, such as memory, may also pose restrict the adoption of M-Health applications to some extent.

In order to meet the needs of supportive care for out-of-hospital breast cancer patients and the needs of case management for oncology nurse specialists, we formed a multidisciplinary research team and collaboratively developed a WeChat mini-program for breast cancer case management in the CMBM (M-health for case management model in breast cancer transitional care) project. WeChat is chosen as the program development platform based on the following considerations. Firstly, WeChat is the most popular and widely used social software in China. As of December 31, 2020, the monthly active users of WeChat have exceeded 1.2 billion, and the daily active users of WeChat mini-programs exceeded 450 million [ 36 ]. Secondly, users can access and use the services of the mini-program directly within the WeChat platform, without the need to download or install additional mobile applications. This reduces the hardware requirements for software applications. The above two factors allow for a positive user experience and a realistic foundation for software promotion.

The purpose of this study is to describe the process of developing a tailored M-health component for the case management model in breast cancer transitional care and to highlight methods for solving the common obstacles faced during the application of M-health nursing service.

Methods and results

The development process was conducted in four steps: (a) An interdisciplinary development team was formed, consisting of two sub-teams dedicated to content and software development. (b) Using the self-management theory as the theoretical framework, contextual analysis was used to understand the case management needs of oncology nursing specialists and the supportive care needs of out-of-hospital breast cancer patients. Through iterative discussion within the interdisciplinary team, the preliminary conception of the application framework and function was formed. (c) A multi-stage optimization strategy was adopted to develop and regularly update the WeChat mini-programs, including three stages (screening, refining, and confirming). (d) During the entire development process, a user-centered principle was followed with the involvement of oncology nursing specialists and breast cancer patients, including development, testing, and iterative development phases.

The interdisciplinary team

An important prerequisite for developing M-health applications is the formation of an interdisciplinary development team. We built a multidisciplinary team consisting of researchers, oncology nursing specialists, and software developers. Each team member brought their expertise from their respective fields, and all individuals were considered members of the same team rather than separate participants with a common goal.

Two sub-teams were established, one responsible for content development, and the other for software development. The content development team consisted of researchers and six senior breast oncology nursing specialists with bachelor’s degrees and over 10 years of clinical experience. Their work included contextual analysis, functional framework design, and content review of the “Information” module. The software development team included researchers and experienced software developers. Their tasks involved developing the mini-program based on the functional framework and requirements designed by the content development team.

The development team used contextual analysis to identify the actual usage needs of two target groups for the mini-program: oncologist nurse specialists and out-of-hospital breast cancer patients.

Involvement of oncology nursing specialists and breast cancer patients following user-centered design principle

Since the oncology nursing specialists and breast cancer patients are targeted users of the mini-program, the two groups fully participated in the development according to the user-centered principle. Nursing specialists who in charge of case management were interviewed about the preliminary functional framework of the mini-program. The interview results are presented in the section “Driving the Development Process via the Contextual Analysis Findings.” Semi-structured in-depth interviews were conducted in the testing and iteration stage to gain user feedback from nursing specialists to improve the applicability and usability of the mini-program. The interview guide can be found in the supplementary material.

Breast cancer patients fully engaged in the three developing phases (Screening, Refining, and Confirming). In the Screening Phase, since the self-management theory was selected as the theoretical framework, the supportive care needs of out-of-hospital breast cancer patients were explored, and the functional framework of the mini-program was constructed accordingly. In the Refining Phase, patients were invited to evaluate the usability and practicality of the mini-program through system tests and semi-structured in-depth interviews. The results of the system test are presented in the Results of System Test section. The feedback from interviews and corresponding iterative updates are listed in Table  1 . In the Confirming Phase, our research team is conducting clinical trials in out-of-hospital breast cancer patients to find out the actual effect of the mini-program on recovery.

The theory framework of the mini-program

This study applied the self-management theory [ 37 ] as the theoretical framework. The self-management theory explains how individual factors and environmental factors influence an individual’s self-efficacy, which ultimately affects the generation and development of individual behaviors. Self-efficacy is influenced by direct experience, indirect learning, verbal persuasion, and psychological arousal. By providing individuals with sufficient knowledge, healthy beliefs, skills, and support, their self-efficacy is increased, and they are likely to engage in beneficial health behaviors and self-management. Individuals who are confident in their abilities to apply self-management behaviors and overcome obstacles by improving their self-management skills and persevere in their efforts to manage their health [ 37 ]. Self-efficacy is directly and linearly positively related to the active adoption of health management behaviors [ 38 ]. The functions of the various parts of the mini-program designed using self-management theory can broaden the pathways and levels of efficacy information generation in four ways: direct experience, indirect learning, verbal persuasion, and mental arousal. Patients with high self-efficacy will take positive steps to achieve desired goals and possess disease-adapted behaviors. The form of the mini-application function block diagram is shown in Fig.  1 .

Driving the development process via the contextual analysis findings

Contextual analysis [ 39 ] is a method of discerning the profound significance and influence of language, behavior, events, and so forth, by examining them within a particular environment or background. Rather than being an afterthought, contextual analysis sheds light on the meaning and inner dynamics of our primary subject of interest. Through contextual analysis, we can gain a deeper understanding of the user’s usage scenarios, including their motivations, goals, environment, and behavior. This helps us better understand user needs, as well as the problems and challenges they may encounter when using the software.

In this paper, we adopted contextual analysis to gain a detailed understanding of the needs of oncology nurse specialists and out-of-hospital breast cancer patients. The research team adopted a mixed research strategy to achieve contextual analysis of the target users. A cross-sectional study was conducted among 286 patients and qualitative semi-structured in-depth interviews were applied in 12 patients to find out the supportive care needs of out-of-hospital breast cancer patients. According to the contextual analysis results from patients, the functional framework of the mini-program was constructed. See Fig.  2 for details.

Supportive care needs of out-of-hospital breast cancer patients

Contextual analysis of breast cancer case management nurses was conducted through focus group interview. The interview results were listed as three themes: health information, personal self-management, and case management needs. Health information included breast cancer-related knowledge, the side effects of chemotherapy drugs, and symptom management measures. The key task of personal self-management contained temperature monitoring, weight management, functional exercise, and symptom management. Case management needs involved storage and management of patients’ medical records and development of a nurse-end program.

Based on the contextual analysis results of out-of-hospital breast cancer patients and the oncology case management nurses, the framework and functional block of the mini-program were formed. An overview of the CMBM Software development process is listed in Fig.  3 .

Overview of the CMBM software development process

Patient-end program functional modules

Using the results of the contextual analysis, we design the functional modules of the patient-end program based on the patient’s supportive care needs. For example, the “Information” section is designed to meet the “Information need” of breast cancer patients; the “social needs” and “spiritual needs” of patients suggest that breast cancer patients lack peer support, and for this reason, the"Interaction” section for patients has been added to the app to provide a communication platform for patients.

The patient-end program include four functional modules: “Information”, “Interaction”, “Management” and “My”. In the “Information” module, information about breast cancer treatment and health management are compiled based on clinical guildlines. The “Interaction” module allows patients to interact with fellow patients and consult an case management nurse. In the “Management” module, patients can record and review their self-management-related health status, including three medical parameters (temperature, blood pressure, weight) and three behavioral parameters (daily steps, medication, mindfulness excersice). The “My” module enables patients to input and edit their basic personal information and medical history. The main structure and information support module contents are listed in Fig.  4 .

The main menu of patient-end program

Nurse-end program functional modules

The design of the functional modules of the nurse-end program was also derived from the results of contextual analyses. The nurse-end program includes three functional modules: “Consultation”, “Management”, and “My”. The “Consultation” module is mainly used for online communication between case management nurses and patients. Nurses can enter the patient’s name in the search box to open a dialog box, and communicate with each other by sending text, voice and pictures. In the “Management” module, nurses can effortlessly search for patients by entering their name, WeChat nickname, or mobile phone number in the search box. This initiates a seamless dialogue, and with a simple click of the “+” button, patients can be promptly added to the “My Concerns” list. They can view the medical record information on its homepage, and add the postoperative treatment plan for the patient. The “self-management report” feature empowers nurses to stay up-to-date with patients’ recent well-being. By monitoring vital indicators like temperature, weight, and incidents of nausea or vomiting following chemotherapy, nurses can proactively ensure patients’ safety. The “clock in record” feature meticulously logs various patient activities including weight variations, exercise regimens, and medication adherence, providing a holistic view of their health journey. “Treatment monitoring Schedule” enables nurses to create customized chemotherapy schedules. With the first postoperative chemotherapy session scheduled in the calendar, the system seamlessly computes subsequent chemotherapy sessions and associated assessments. This transition to an online system marks a significant advancement from the traditional paper-based chemotherapy planning. Its automated scheduling and data tracking functions serve to alleviate the clinical nursing workload, enhancing efficiency and freeing up valuable time for focused patient care. The “My” module offers nurses the convenience of adding patients of interest or relevant content to their “My Favorites” section, enabling streamlined one-click access for viewing and management. The core structure and informational components of this module are outlined in Fig.  5 .

The main menu of nurse-end program

Driving the development process via the multi-stage optimization strategy

We adopted a multi-phase optimization strategy to drive the software development process. This strategy was proposed by Collins in 2005 and has become an important guiding theory for the development and evaluation of M-health interventions in recent years [ 40 ]. The strategy consists of three phases: Screening Phase, Refining Phase, and Confirming Phase. The Screening Phase need theories to identify and incorporate intervention elements. In this study, the initial version (1.0) development was based on self-management theory. Focusing on self-management, the results of contextual analysis, literature review and expert consultation were combined to design the mini-program version (1.0). The Refining Phase involves iterative adjustments to the previously version. In this study, the development team iteratively adjusted the mini-program version (1.0) according to users’ suggestions and test results. The Confirming Phase includes planning for clinical trials to test effect of the mini-program version (2.0) on self-management and recovery outcomes in out-of-hospital breast cancer patients.

Results of system test

Eight out-of-hospital breast cancer patients were recruited for system tests. The patient’s general information is listed in Table  2 .

The 10-item System Availability Scale (SUS)developed by Brooke was used [ 41 ]. The scale is a widely used method for quantitatively assessing user satisfaction with software systems. SUS is a Likert-5 and 10-item questionnaire (4 = strongly agree, 0 = strongly disagree), with Cronbach Alpha of 0.91. Generally, a system score above 60 on the SUS scale could be considered to be easy and simple to use, and the average score of SUS in our research is 78.75. The SUS scores of the mini-program system are presented in Fig.  6 .

System availability scale (SUS) score of patients

The research team designed the core task tests based on the typical and necessary self-management tasks of out-of-hospital patients. The core task of the “Information” module was listed as an example (Table  3 ). Functional tests include the passing rate for each task, and performance tests include the completion time of each task. More details can be found in Table  4 .

In this article, we demonstrated how to create a customized software solution for breast cancer case management practices based on a multi-stage optimization strategy, applied the contextual analysis method, and followed the user-centered principle. Preliminary test results showed satisfaction and acceptance of the WeChat mini-program among both out-of-hospital breast cancer patients and oncology nursing specialists.

Team effort

There were two typical patterns for developing M-health applications in the past. One was led by software developers, while the other was led by medical professionals. Each of these patterns has its own advantages and disadvantages. To overcome these shortcomings, some projects [ 42 ] developing M-health applications are now utilizing interdisciplinary team collaborations. This approach not only ensures the quality of the software but also makes sure that applications meet the actual needs.

In order to develop a customized software solution, our research team consisted of researchers, oncology nursing specialists, and software developers. The interdisciplinary team work dedicated to customizing software solutions together. Our team members each played to their strengths and held regular meetings to discuss and enhance our understanding and resolution of issues encountered during the software development process. Our team also included informal members: breast cancer patients, whose suggestions contributed to the practicality of the program.

Contextual analysis and user-centered design

Contextual analysis is a valuable tool that enables developers to design systems that are more relevant and user-friendly. And it allows us to understand any context-specific characteristics, practice patterns, and the openness of the target setting’s nurses and patients towards technology [ 42 ]. User-centered design can significantly reduce the cost of program iteration. More importantly, it has a profound influence on various aspects of a program including its design, functionality, information architecture, and interactive elements [ 43 ]. By analyzing different contexts, not only did we design features that better meet user needs, but we also predicted and addressed potential issues that users may encounter when using the mini-program in advance, thereby enhancing the user experience. In the iterative development stage, we discovered and improved some deficiencies in the design through core task testing and usability testing. Notably, the completion rate of the core task test reached 100%, indicating that our application is user-friendly and easy to operate.

• Multi-stage optimization strategy

In several priority areas of public health, researchers have successfully applied multi-stage optimization strategies to enhance their work, including software development and intervention programs [ 44 , 45 , 46 ]. In this study, we also apply this strategy to software development. While the multi-stage optimization strategy provides an optimization framework, it is important to note that our optimization objectives (such as software functionality and content requirements) are determined by key users involved in the research (out-of-hospital breast cancer patients and oncology nurse spescialists). This project adopts a multi-stage optimization strategy, iteratively improving the development of the mini-program through screening, refinement, and confirmation stages. Each stage aims to optimize our program.

The research team plans to explore the feasibility of mini program development program through preliminary experiment, and verify the intervention effect of mini program on self-management behavior, self-efficacy and quality of life and other indicators through formal experiment. A randomized controlled trial (IRB-2020-408) was initiated in August 2022 at a Class III hospital in Zhejiang, China, and is currently in the data collection phase.

There is no doubt that M-health will play a core role in the future of health care. However, to successfully implement and promote M-health applications in clinical setting, it is essential to analyze the needs of the target population. Additionally, it is crucial to determine who will be the driving force behind the implementation of the entire M-health project. This study demonstrates how to integrate M-health components into existing breast cancer case management care practices. In addition to providing a reference for other teams interested in developing and integrating M-health components into case management care models, this study also provides a reference for building M-health-featured care work models in practices.

In this study, the collaborative work of an interdisciplinary team with backgrounds in nursing and computer science, along with the active involvement of patients, not only facilitated the planning, developing, updating, and testing of M-health components based on the actual needs of the target population, but also increased the chances of acceptance and long-term implementation of the M-health program in practice.

This study demonstrates how to integrate M-health components into existing breast cancer case management practices. It provides insights for other reserch teams interested in developing and integrating M-health components into daily nursingt practice.

In the context of the digital age, M-health applications are rapidly becoming information sources and decision support tools for healthcare professionals and patients. However, it is crucial not to overlook the issues of information security and digital barriers for older adults.

Through interviews with outpatients with breast cancer and oncology nurses, we have gained insights into their concerns regarding information security. Some interviewees expressed concerns about information security and were worried about the risk of their personal information being leaked during app usage. Such concerns, to some extent, hinder the widespread adoption of M-health applications. Additionally, some interviewees mentioned that older patients, in general, find it challenging to learn and use the various functions of WeChat mini-programs, making it difficult to promote and apply M-health applications among the elderly population.

Solving these issues effectively is not only vital for the patients’ rights and interests but also crucial for the comprehensive implementation of M-health in practice. It is a matter that requires careful consideration in future development of M-health applications.

Data availability

The datasets generated and/or analysed during the current study are not publicly available but are available from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to express our sincere gratitude to all the breast cancer patients who participated in this research.

This study was supported by the Zhejiang Provincial Natural Science Foundation of China (LY18H160061) and Funding for innovation and entrepreneurship of high-level overseas students in Hangzhou.

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HCG conceived the entire paper framework and was responsible for writing the paper. WSJ and CC conducted all interviews and managed the mini-programs. YJY, LJJ and HSJ were responsible for the collection of clinical nurse data. CJH and SJQ were responsible for patient data collection. Data analysis was conducted by WJM, YLY and ZN. WLP was responsible for the revision, editing and approval of manuscripts. All authors have rigorously revised and edited successive drafts of the manuscript. All authors read and approved the final version of the manuscript.

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Correspondence to Wang Liping .

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The study was reviewed and approved by the Ethics Committee of ZheJiang Cancer Hospital (Ethic ID: ZJZLYY IRB-2020-408). All the participants signed written informed consent forms. This study was conducted in accordance with the 1964 Declaration of Helsinki guidelines.

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Chengang, H., Liping, W., Shujin, W. et al. Multi-stage optimization strategy based on contextual analysis to create M-health components for case management model in breast cancer transitional care: the CMBM study as an example. BMC Nurs 23 , 385 (2024). https://doi.org/10.1186/s12912-024-02049-x

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Knowledge, attitudes, and practices of primary healthcare practitioners regarding pharmacist clinics: a cross-sectional study in Shanghai

• Xinyue Zhang 1   na1 ,
• Zhijia Tang 1   na1 ,
• Yanxia Zhang 1   na1 ,
• Wai Kei Tong 1 ,
• Qian Xia 1 ,
• Bing Han 1 &
• Nan Guo 1  

BMC Health Services Research volume  24 , Article number:  677 ( 2024 ) Cite this article

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Metrics details

Pharmacist clinics offer professional pharmaceutical services that can improve public health outcomes. However, primary healthcare staff in China face various barriers and challenges in implementing such clinics. To identify existing problems and provide recommendations for the implementation of pharmacist clinics, this study aims to assess the knowledge, attitudes, and practices of pharmacist clinics among primary healthcare providers.

A cross-sectional survey based on the Knowledge-Attitude-Practice (KAP) model, was conducted in community health centers (CHCs) and private hospitals in Shanghai, China in May, 2023. Descriptive analytics and the Pareto principle were used to multiple-answer questions. Chi-square test, Fisher’s exact test, and binary logistic regression models were employed to identify factors associated with the knowledge, attitudes, and practices of pharmacist clinics.

A total of 223 primary practitioners participated in the survey. Our study revealed that most of them had limited knowledge (60.1%, n  = 134) but a positive attitude (82.9%, n  = 185) towards pharmacist clinics, with only 17.0% ( n  = 38) having implemented them. The primary goal of pharmacist clinics was to provide comprehensive medication guidance (31.5%, n  = 200), with medication education (26.3%, n  = 202) being the primary service, and special populations (24.5%, n  = 153) identified as key recipients. Logistic regression analysis revealed that education, age, occupation, position, work seniority, and institution significantly influenced their perceptions. Practitioners with bachelor’s degrees, for instance, were more likely than those with less education to recognize the importance of pharmacist clinics in medication guidance (aOR: 7.130, 95%CI: 1.809–28.099, p -value = 0.005) and prescription reviews (aOR: 4.675, 95% CI: 1.548–14.112, p -value = 0.006). Additionally, practitioners expressed positive attitudes but low confidence, with only 33.3% ( n  = 74) feeling confident in implementation. The confidence levels of male practitioners surpassed those of female practitioners ( p -value = 0.037), and practitioners from community health centers (CHCs) exhibited higher confidence compared to their counterparts in private hospitals ( p -value = 0.008). Joint physician-pharmacist clinics (36.8%, n  = 82) through collaboration with medical institutions (52.0%, n  = 116) emerged as the favored modality. Daily sessions were preferred (38.5%, n  = 86), and both registration and pharmacy service fees were considered appropriate for payment (42.2%, n  = 94). The primary challenge identified was high outpatient workload (30.9%, n  = 69).

Conclusions

Although primary healthcare practitioners held positive attitudes towards pharmacist clinics, limited knowledge, low confidence, and high workload contributed to the scarcity of their implementation. Practitioners with diverse sociodemographic characteristics, such as education, age, and institution, showed varying perceptions and practices regarding pharmacist clinics.

Peer Review reports

Pharmacist clinics are specialized healthcare facilities that offer professional pharmaceutical services, such as medication therapy management, medication reconciliation, lifestyle counseling, and immunizations, for patients with chronic diseases or managing multiple drugs [ 1 ]. Through the provision of these services, pharmacist clinics aim to improve patient access to healthcare, optimize medication use, and improve overall public health outcomes.

Pharmacist clinics originated in the 1960s in the United States and have spread globally in recent decades [ 2 ], with a growing number of countries adopting this model of care. The World Health Organization (WHO) has recognized the importance of pharmacists in primary healthcare and encouraged the integration of pharmaceutical services into broader healthcare systems [ 3 ]. This integration facilitates the rational use of medication, thereby minimizing adverse drug events and medication errors, ultimately leading to better therapeutic outcomes. Moreover, pharmacist clinics offer medication guidance and education, which adjusts optimal medication dosage [ 4 ], enhances patient adherence [ 1 , 5 ], expands access to health care [ 6 ], and reduces treatment costs [ 7 ]. These clinics effectively bridge the communication gap between physicians and pharmacists [ 8 ], fostering interdisciplinary collaboration and integrated patient care [ 1 , 9 ].

The development of pharmacist clinics in China was initiated in the late 20th century, coinciding with the introduction of healthcare reforms by the Chinese government in the early 2000s. The release of “Opinions on Deepening the Reform of the Medical and Health System” [ 10 ] in 2009 highlighted the importance of pharmacist clinics and the crucial role of pharmacists in improving the quality and accessibility of healthcare services in primary settings. In 2020, the Chinese government released a guidance document titled “Opinions on Strengthening the Pharmaceutical Management of Medical Institutions and Promoting Rational Drug Use,” encouraging provinces to actively establish pharmacist clinics [ 11 ]. However, it wasn’t until 2021 that the General Office of the National Health Commission developed the “Guidelines for Pharmaceutical Outpatient Services in Medical Institutions” to standardize these pharmacist clinics [ 12 ]. Despite the progress made, primary medical staff in both developed and developing countries face various challenges, especially in developing countries [ 13 ], including a shortage of qualified pharmacists [ 14 , 15 ], limited recognition of pharmacists’ roles among healthcare professionals and the public [ 16 , 17 ], and the need for a more standardized approach to pharmaceutical care [ 18 ]. Additionally, these clinics are predominantly located in large general hospitals or specialized medical facilities, limiting their coverage to specific areas, such as antibiotics [ 19 ] and anticoagulants [ 20 ]. In rural areas, there is scarce awareness and discussion regarding the promotion of pharmacist clinics.

To date, most research on pharmacist clinics comes from countries like the United States, the UK, Canada, and Australia, focusing primarily on the outcomes of pharmacist interventions rather than the implementation challenges [ 1 , 4 , 21 , 22 , 23 , 24 ]. In China, only a few studies have assessed the current state of pharmacist clinics. Cai et al. [ 25 ], for instance, conducted a national survey revealing that just 10.03% of hospitals had pharmacist clinics. Wu et al. [ 26 ] investigated the establishment and operational details of pharmacist-managed clinics in Taiwan. However, there is no published research exploring optimal practices for setting up pharmacist clinics in China or identifying the barriers to establishing these clinics in primary healthcare settings. In this study, we aim to assess the awareness and understanding of pharmacist clinics among primary healthcare providers. We conducted a cross-sectional survey based on the Knowledge-Attitude-Practice (KAP) model to identify knowledge gaps and develop interventions to encourage interprofessional collaboration and enhance practice efficiency. The findings may also improve patient outcomes, healthcare delivery by streamlining the implementation process, and utilization of high-quality pharmaceutical services. Our ultimate goal was to overcome barriers to advancing pharmacist clinics within China’s healthcare system and offer insights for policymakers and healthcare authorities to integrate these clinics into primary healthcare settings, not only in China but potentially in other countries as well.

Survey instrument & selection criteria

Our study employed a structural equation model based on the Knowledge, Attitude, and Practice (KAP) theory [ 27 ] and relevant literature [ 28 , 29 , 30 , 31 ] to explore the relationships between various factors. Following the KAP principles, we developed a questionnaire consisting of 21 questions across three domains: (A) knowledge of pharmacist clinics, (B) attitudes towards pharmacist clinics, and (C) practices related to pharmacist clinics. Demographic information such as gender, age, education, occupation, position, seniority, department, and institution was collected through self-reporting.

The inclusion and exclusion criteria for the sampled respondents were as follows. Inclusion criteria: (1) Full-time primary healthcare practitioners attending a continuing education course at Minhang Hospital in Shanghai, China. This included physicians, pharmacists, nurses, and other primary healthcare practitioners. (2) Willingness to participate in the study and provide informed consent. Exclusion criteria: (1) Part-time employees or interns. (2) Non-medical staff. (3) Individuals who declined to sign the informed consent form.

Study population and data source

This study used data from a cross-sectional survey conducted in May, 2023, involving primary healthcare practitioners from 10 community health centers (CHCs) and 38 private hospitals in Shanghai, China. After excluding participants from secondary or tertiary hospitals ( n  = 9), nursing homes ( n  = 6), and other facilities such as welfare homes and school clinics ( n  = 9), a total of 223 eligible subjects were included.

Data collection

The sample size was optimized to range between 105 and 210, based on the recommended ratio of 5 to 10 respondents per item [ 32 , 33 ]. We also performed a pilot study in April, 2023 to ensure linguistic clarity and readability of the questionnaire. Twenty-six student volunteers from the School of Pharmacy at Fudan University were recruited to refine the questionnaire. Additionally, face-to-face interviews were conducted to further assess their understanding of the content. The final version was electronically distributed to participants during a continuing education course using a voluntary sampling approach. The full questionnaire is available in Supplementary Table 1 , and all data were anonymized.

Statistical analysis

Categorical variables were summarized using frequency counts (weighted percentage, %). The Chi-square test and Fisher’s exact test were used to assess differences in knowledge, attitude, and practice regarding pharmacist clinics across various sociodemographic characteristics. Descriptive analytics and the Pareto principle were applied to multiple-answer questions. In case of rejection of the null hypothesis, multiple pairwise comparisons would be conducted as confirmatory post hoc analysis using Bonferroni correction. Based on the univariate analysis results, we constructed binary logistic regression models to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) to reveal factors associated with perceived goals, service scope, and target recipients of pharmacist clinics.

All statistical analyses were performed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY, USA). A two-sided p -value < 0.05 was considered statistically significant.

Demographics

As presented in Table  1 , a total of 223 primary healthcare practitioners participated in the survey, with 41.3% ( n  = 92) being male and 76.2% ( n  = 170) under 45 years old. The majority (84.3%, n  = 188) were physicians, while the remaining were pharmacists. Regarding educational qualifications, 82.5% ( n  = 184) of respondents held a bachelor’s degree or below. Furthermore, 91.9% ( n  = 205) held mid-level or lower positions, and 56.1% ( n  = 125) reported professional tenures of less than 10 years. Of these 223 practitioners, 36.8% ( n  = 82) were from public institutions (community health centers), and 63.2% ( n  = 141) were from private hospitals.

Knowledge of pharmacist clinics

Of primary care practitioners, 84.8% ( n  = 189) recognized pharmacist clinics, with 24.7% ( n  = 55) having strong familiarity. Figure  1 a-c showed practitioners’ views on the goals, services, and target recipients of these clinics. The primary goal was to provide comprehensive medication guidance (31.5%, n  = 200), with medication education (26.3%, n  = 202) being the primary service, and special populations (24.5%, n  = 153) identified as key recipients. Logistic regression results revealed several significant influential factors (Table  2 ).

Pareto chart demonstrating respondents’ knowledge of pharmacist clinics

( a ) Perceived goals: A prescription reviews, B medication guidance, C time-saving, D conflict alleviation, E patient empowerment, F cost reduction, G role enhancement, H research, I training, and J no perceived value

( b ) Perceived service scope: A drug regimen adjustments, B medication reconciliation, C medication education on dosage, side effects, and interactions, D adherence interventions, E health promotion, F patient follow-ups

( c ) Perceived target recipients: A isolated/empty-nest patients, B special populations (e.g. elderly, children, pregnant, and liver/kidney-impaired), C economically disadvantaged patients, D patients suffering from adverse reactions, E patients needing test report interpretations, F frequent drug collectors (> 20 times/year), G patients with ≥ 2 chronic diseases, H patients with any chronic diseases, I patients on ≥ 5 medications, J high-risk drug users (e.g. psychotropic drugs, hormones, injections, and inhalants), K patients under contract with family physicians, and L all patients

Compared to those with less education, practitioners with bachelor’s degrees were more likely to see the role of pharmacist clinics in medication guidance (aOR: 7.130, 95%CI: 1.809–28.099, p -value = 0.005), prescription reviews (aOR: 4.675, 95% CI: 1.548–14.112, p -value = 0.006), and serving patients on high-risk drugs (aOR: 2.824, 95% CI: 1.090–7.316, p -value = 0.033).

Besides medication guidance (aOR: 7.303, 95%CI: 1.343–39.720, p -value = 0.021), practitioners with master’s or higher degrees preferred adherence interventions (aOR: 4.221, 95%CI: 1.339–13.300, p -value = 0.014), follow-up services (aOR: 3.125, 95%CI: 1.095–8.915, p -value = 0.033), and catering to patients with ≥ 2 chronic diseases (aOR: 6.401, 95%CI: 1.233–33.223, p -value = 0.027) or ≥ 5 medications (aOR: 3.987, 95%CI: 1.250-12.717, p -value = 0.019). Higher education was also inversely associated with emphasizing patients needing test report interpretations (aOR < 1, p -value < 0.05).

Younger practitioners, aged 18 to 30, considered pharmacist clinics as tools to mitigate physician-patient conflicts through improved communication compared to those aged ≥ 46 (aOR: 0.165, 95%CI: 0.028–0.988, p -value = 0.048).

Compared to physicians, pharmacists typically addressed all patients as recipients (aOR: 3.322, 95%CI: 1.031–10.703, p -value = 0.044), but were less likely to offer drug regimen adjustments (aOR: 0.210, 95%CI: 0.088-0.500, p -value < 0.001).

Junior and intermediate-level practitioners demonstrated a greater likelihood for follow-up services (aOR 1 : 5.832, 95%CI: 1.308–25.998, p -value = 0.021; aOR 2 : 3.99, 95%CI: 1.087–14.646, p -value = 0.037), and were less likely to target patients in need of test report interpretations (aOR 1 : 0.172, 95%CI: 0.038–0.781, p -value = 0.023; aOR 2 : 0.287, 95%CI: 0.082–0.997, p -value = 0.049) than their senior counterparts.

Work seniority

Practitioners with 10–19 years of work experience were significantly more likely to consider isolated/empty-nest patients as suitable recipients compared to those with < 5 years of experience (aOR: 3.328, 95%CI: 1.021–10.849, p -value = 0.046).

Institution

Practitioners from CHCs were more likely to view frequent drug collectors as suitable recipients compared to those from private hospitals (aOR: 0.359, 95%CI: 0.134–0.966, p -value = 0.043).

Attitude of pharmacist clinics

Necessity and confidence in implementing pharmacist clinics.

Table  3 showed that 82.9% ( n  = 185) of practitioners recognized the necessity of pharmacist clinics, but only 33.3% ( n  = 75) felt confident in their implementation. Male practitioners exhibited significantly higher confidence levels compared to female practitioners ( p  = 0.037), and practitioners from community health centers (CHCs) showed greater confidence relative to those practicing in private hospitals ( p  = 0.008).

Preferred mode of pharmacist clinics

As shown in Table  4 , the favored modality was found to be joint physician-pharmacist clinics (36.8%, n  = 82), through collaboration with medical institutions (52.0%, n  = 116). Daily sessions emerged as the preferred frequency ( n  = 86, 38.5%), with both registration and pharmacy service fees considered appropriate for payment (42.2%, n  = 94).

Furthermore, we explored the influence of different sociodemographic variables. Practitioners holding a master’s degree or higher demonstrated a preference for a clinic frequency of 2–4 times per week ( p -value = 0.015), along with acceptance of both registration and pharmacy service fees ( p -value < 0.001), compared to those with lower levels of education. Conversely, those with a junior college education or below were more willing to seek free services. Practitioners from CHCs exhibited a preference for weekly or 2–4 times per week clinics, whereas those from private hospitals favored daily or monthly sessions ( p -value < 0.001).

Practice of pharmacist clinics

As shown in Table  5 , there was a limited prevalence of pharmacist clinics within primary care institutions. Only 17.0% ( n  = 38) of practitioners reported the implementation of pharmacy clinics, mostly scheduled once a week (47.4%, n  = 18), with the primary challenge being a high outpatient workload (30.9%, n  = 69). Practitioners from CHCs demonstrated a significantly higher implementation frequency compared to those from private hospitals ( p -value < 0.001).

We further explored sociodemographic factors associated with challenges. Practitioners aged over 45 years ( P  = 0.020) and occupying senior/deputy senior positions ( p -value = 0.018) were more likely to consider the absence of fee collection mechanisms as the principal difficulty, as opposed to their younger counterparts and those in lower positions.

Our study aims to evaluate the perceptions, attitudes, and practices of primary healthcare practitioners regarding pharmacist clinics and to identify necessary changes. The findings unveiled a lack of knowledge and confidence among primary care providers, who are faced with barriers including high outpatient workloads and concerns related to professionalism. Collaborative models are preferred as they align with the current emphasis on multidisciplinary approaches in modern healthcare, which aim to achieve optimal population health [ 34 ]. Additionally, our findings highlight the impact of institution and gender on the perceptions of primary care providers.

In this study, more practitioners preferred joint physician-pharmacist clinics over traditional physician-led clinics (36.8%, n  = 82 vs. 24.2%, n  = 54), which is in line with a global focus on integrating pharmacists into the provision of patient-centered, coordinated, and comprehensive care [ 1 , 35 , 36 ]. Primary care physicians are in short supply, and studies unveiled that the shortage of primary care physicians has led to increased workloads and a greater demand for medication guidance services, especially among vulnerable patients aged 65 and above [ 37 , 38 , 39 , 40 ]. Our study showed the primary goals of pharmacist clinics were found to be prescription reviews (28.9%, n  = 183) and medication guidance (31.5%, n  = 200), which are critical in addressing concerns regarding poorly managed or duplicate prescriptions [ 41 , 42 ]. Integrating pharmaceutical services into primary care offers expedited access and convenience for patients, thereby releasing physicians to focus on more complex cases and reducing their workload [ 43 , 44 ]. These services also contribute to overall savings in healthcare and medication costs, as well as reduced general physician appointments, emergency department visits, and inappropriate drug use [ 45 , 46 ]. Our findings support the potential of pharmacist-led prescription reviews in reducing duplicate prescriptions [ 47 ], drug-related problems [ 48 ], and medication costs, without increasing physicians’ workload [ 49 ]. Moreover, pharmacist-led medication guidance provided to other professionals has been shown to reduce medication errors and inappropriate prescriptions compared to standard care [ 50 , 51 ]. The development of joint physician-pharmacist clinics may be an advantageous choice for the development of pharmacist clinics in the future.

Current evidence highlights the suboptimal quality of primary care in China [ 52 ], with previous research suggesting that inadequate education and training pose significant challenges in enhancing care quality [ 53 ]. Primary healthcare providers in China have reported being too busy for continued education, dissatisfaction with course content, and having unqualified supervisors [ 54 ]. This issue seems to be consistent in the United States [ 55 ], Canada [ 56 ], and Belgium [ 57 ]. Moreover, our study has identified high workload (30.9%, n  = 69) and insufficient professionalism (25.1%, n  = 56) as the top two challenges faced by pharmacist clinics. On the other hand, insufficient knowledge may contribute to negative attitudes [ 39 ].

In this study, a minority of practitioners (24.7%, n  = 55) demonstrated strong familiarity, and only 33.3% ( n  = 75) felt confident. While some global studies did not find a significant difference in clinical competence confidence between public and private practitioners [ 58 , 59 ], our study revealed that pharmacists from CHCs exhibited greater confidence in conducting pharmacist clinics compared to those from private hospitals, partially due to their greater exposure to training. Studies have also shown that community pharmacists, through enhanced training, can acquire expanded expertise and knowledge [ 60 , 61 ], leading to improved service quality in primary care [ 62 , 63 ]. Future efforts should focus on establishing a more efficient learning and continued education system for community practitioners in China [ 52 ].

Several impediments were identified by respondents, including limited patient volume (22.0%, n  = 49) and low staff motivation (6.3%, n  = 14). Despite the positive impact of pharmacists in outpatient settings on patient outcomes, the adoption of these services remains low [ 1 ]. Recent literature has highlighted public uncertainty about primary care specialties and skepticism regarding their capacity to deliver comprehensive care [ 64 ]. Evidence suggests a lack of awareness, demand, and utilization of community pharmacy services among patients [ 65 , 66 ]. Another barrier is the prevailing focus on quantity rather than quality of care, with job content and bonuses linked more to quantity than the quality of care delivered [ 52 , 67 ]. Financial conflicts over funding and the absence of fee collection may also hinder collaboration between pharmacists and other healthcare providers [ 43 , 68 ]. Additionally, the implementation of the zero-mark-up drug policy in China in 2011 caused a substantial decrease of about 40% in drug-related incomes [ 69 ]. Institutions responded by scaling back clinical care services to offset this profit loss [ 70 ], leading to an uptick in hospital visits for minor ailments and further burdening the healthcare system [ 53 ]. It is important to expand community pharmacy services by establishing reimbursement mechanisms to relieve the burden on general practice [ 71 ]. Countries like Australia, the UK, New Zealand, and Canada have established systems for pharmacist remuneration [ 72 ]. Payment models for pharmaceutical services typically include fee-for-service, where providers are compensated based on the services delivered (as seen in Australia, Canada, Belgium, and Japan), capitation, where providers receive a fixed amount per patient (as in the US, Thailand, and Denmark), and blended funding, which combines government and private payments (as in China, Australia, New Zealand, and Canada) [ 73 ]. Despite the existence of various payment models for pharmaceutical services, there is no standardized pricing for pharmacist clinics. Among 465 hospitals with pharmacist clinics, only 98 (21.08%) owned charging mechanisms [ 25 ]. Various studies have explored the willingness to pay (WTP) for pharmaceutical services in different countries. For instance, Porteous et al. [ 74 ] found a WTP of $69.19 for community practices in the UK. Tsao et al. [ 75 ] reported a WTP of $21.26 for medication therapy management in Canada, and in Brazil, the estimated WTP for comprehensive medication management was $17.75 [ 76 ].

Our findings also revealed gender-based disparities in the perceptions and implementation of pharmacist clinics. Female practitioners exhibited lower levels of confidence in conducting the clinics compared to males, consistent with previous research indicating that women in healthcare often perceive deficiencies in their abilities despite no differences in clinical performance between genders [ 77 ]. Additionally, female medical students reported higher levels of anxiety, stress, and self-doubt about their knowledge and performance [ 78 ]. However, in Australia and Ireland, females rated themselves higher than males in self-assessment tests [ 79 , 80 ]. Further investigations to explore potential confounding factors, such as cultural influences, may contribute to understanding these variations and better address the need to tailor pharmacist-managed clinic services based on institutional needs [ 81 ].

This research is geographically confined to Shanghai and solely captures the perspectives of practitioners, potentially limiting generalizability. Future studies should broaden their scope to encompass diverse practices and include patients’ perceptions. The cross-sectional design used in this study restricts the evaluation of cause-effect relationships, emphasizing the need for longitudinal investigations. Despite these limitations, to the best of the authors’ knowledge, this is the first quantitative study that has examined the knowledge, attitudes, and practice of practitioners regarding pharmacist clinics in primary settings based on real-world data in China. The identified challenges in conducting these clinics provide valuable insights for policymakers, researchers, and institutions in this field.

Although primary healthcare practitioners generally hold positive attitudes towards pharmacist clinics, limited knowledge and confidence, high workload, and other factors lead to the scarcity of such clinics. Practitioners with diverse sociodemographic backgrounds, especially those from different institutions and genders, exhibit varying perceptions of the forms of pharmacist clinics. Further exploration with lager samples from different regions and service recipients is necessary.

Data availability

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

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Acknowledgements

We thank all the participants in this research.

This study received funding from the Shanghai Committee of Science and Technology (Grant No. 22YF1439800) and the Shanghai Municipal Health Commission (Grant No. 20194Y0234).

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Xinyue Zhang, Zhijia Tang and Yanxia Zhang contributed equally to this work.

Authors and Affiliations

Minhang Hospital & Department of Clinical Pharmacy, School of Pharmacy, Fudan University, 170 Xinsong Road, Shanghai, 201199, P.R. China

Xinyue Zhang, Zhijia Tang, Yanxia Zhang, Wai Kei Tong, Qian Xia, Bing Han & Nan Guo

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ZT and YZ designed the research, developed the questionnaire; WT and QX collected the data; XZ and ZT performed the statistical analysis and wrote the manuscript; BH and NG critically reviewed the statistical analysis, work, and this report. All authors read and approved the final manuscript.

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Correspondence to Bing Han or Nan Guo .

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Zhang, X., Tang, Z., Zhang, Y. et al. Knowledge, attitudes, and practices of primary healthcare practitioners regarding pharmacist clinics: a cross-sectional study in Shanghai. BMC Health Serv Res 24 , 677 (2024). https://doi.org/10.1186/s12913-024-11136-3

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Received : 03 February 2024

Accepted : 22 May 2024

Published : 29 May 2024

DOI : https://doi.org/10.1186/s12913-024-11136-3

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• Pharmacist clinics
• Primary care
• Cross-sectional study
• Pharmaceutical services
• Public health

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