critical case study evaluation

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Published: 27 November 2020

Designing process evaluations using case study to explore the context of complex interventions evaluated in trials

Aileen Grant 1 ,
Carol Bugge 2 &
Mary Wells 3

Trials volume 21 , Article number: 982 ( 2020 ) Cite this article

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Process evaluations are an important component of an effectiveness evaluation as they focus on understanding the relationship between interventions and context to explain how and why interventions work or fail, and whether they can be transferred to other settings and populations. However, historically, context has not been sufficiently explored and reported resulting in the poor uptake of trial results. Therefore, suitable methodologies are needed to guide the investigation of context. Case study is one appropriate methodology, but there is little guidance about what case study design can offer the study of context in trials. We address this gap in the literature by presenting a number of important considerations for process evaluation using a case study design.

In this paper, we define context, the relationship between complex interventions and context, and describe case study design methodology. A well-designed process evaluation using case study should consider the following core components: the purpose; definition of the intervention; the trial design, the case, the theories or logic models underpinning the intervention, the sampling approach and the conceptual or theoretical framework. We describe each of these in detail and highlight with examples from recently published process evaluations.

Conclusions

Trial registration

DQIP - ClinicalTrials.gov number, NCT01425502 - OPAL - ISRCTN57746448

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Contribution to the literature

We illustrate how case study methodology can explore the complex, dynamic and uncertain relationship between context and interventions within trials.

We depict different case study designs and illustrate there is not one formula and that design needs to be tailored to the context and trial design.

Case study can support comparisons between intervention and control arms and between cases within arms to uncover and explain differences in detail.

We argue that case study can illustrate how components have evolved and been redefined through implementation.

Key issues for consideration in case study design within process evaluations are presented and illustrated with examples.

Process evaluations are an important component of an effectiveness evaluation as they focus on understanding the relationship between interventions and context to explain how and why interventions work or fail and whether they can be transferred to other settings and populations. However, historically, not all trials have had a process evaluation component, nor have they sufficiently reported aspects of context, resulting in poor uptake of trial findings [ 1 ]. Considerations of context are often absent from published process evaluations, with few studies acknowledging, taking account of or describing context during implementation, or assessing the impact of context on implementation [ 2 , 3 ]. At present, evidence from trials is not being used in a timely manner [ 4 , 5 ], and this can negatively impact on patient benefit and experience [ 6 ]. It takes on average 17 years for knowledge from research to be implemented into practice [ 7 ]. Suitable methodologies are therefore needed that allow for context to be exposed; one appropriate methodological approach is case study [ 8 , 9 ].

In 2015, the Medical Research Council (MRC) published guidance for process evaluations [ 10 ]. This was a key milestone in legitimising as well as providing tools, methods and a framework for conducting process evaluations. Nevertheless, as with all guidance, there is a need for reflection, challenge and refinement. There have been a number of critiques of the MRC guidance, including that interventions should be considered as events in systems [ 11 , 12 , 13 , 14 ]; a need for better use, critique and development of theories [ 15 , 16 , 17 ]; and a need for more guidance on integrating qualitative and quantitative data [ 18 , 19 ]. Although the MRC process evaluation guidance does consider appropriate qualitative and quantitative methods, it does not mention case study design and what it can offer the study of context in trials.

The case study methodology is ideally suited to real-world, sustainable intervention development and evaluation because it can explore and examine contemporary complex phenomena, in depth, in numerous contexts and using multiple sources of data [ 8 ]. Case study design can capture the complexity of the case, the relationship between the intervention and the context and how the intervention worked (or not) [ 8 ]. There are a number of textbooks on a case study within the social science fields [ 8 , 9 , 20 ], but there are no case study textbooks and a paucity of useful texts on how to design, conduct and report case study within the health arena. Few examples exist within the trial design and evaluation literature [ 3 , 21 ]. Therefore, guidance to enable well-designed process evaluations using case study methodology is required.

We aim to address the gap in the literature by presenting a number of important considerations for process evaluation using a case study design. First, we define the context and describe the relationship between complex health interventions and context.

What is context?

While there is growing recognition that context interacts with the intervention to impact on the intervention’s effectiveness [ 22 ], context is still poorly defined and conceptualised. There are a number of different definitions in the literature, but as Bate et al. explained ‘almost universally, we find context to be an overworked word in everyday dialogue but a massively understudied and misunderstood concept’ [ 23 ]. Ovretveit defines context as ‘everything the intervention is not’ [ 24 ]. This last definition is used by the MRC framework for process evaluations [ 25 ]; however; the problem with this definition is that it is highly dependent on how the intervention is defined. We have found Pfadenhauer et al.’s definition useful:

Context is conceptualised as a set of characteristics and circumstances that consist of active and unique factors that surround the implementation. As such it is not a backdrop for implementation but interacts, influences, modifies and facilitates or constrains the intervention and its implementation. Context is usually considered in relation to an intervention or object, with which it actively interacts. A boundary between the concepts of context and setting is discernible: setting refers to the physical, specific location in which the intervention is put into practice. Context is much more versatile, embracing not only the setting but also roles, interactions and relationships [ 22 ].

Traditionally, context has been conceptualised in terms of barriers and facilitators, but what is a barrier in one context may be a facilitator in another, so it is the relationship and dynamics between the intervention and context which are the most important [ 26 ]. There is a need for empirical research to really understand how different contextual factors relate to each other and to the intervention. At present, research studies often list common contextual factors, but without a depth of meaning and understanding, such as government or health board policies, organisational structures, professional and patient attitudes, behaviours and beliefs [ 27 ]. The case study methodology is well placed to understand the relationship between context and intervention where these boundaries may not be clearly evident. It offers a means of unpicking the contextual conditions which are pertinent to effective implementation.

The relationship between complex health interventions and context

Health interventions are generally made up of a number of different components and are considered complex due to the influence of context on their implementation and outcomes [ 3 , 28 ]. Complex interventions are often reliant on the engagement of practitioners and patients, so their attitudes, behaviours, beliefs and cultures influence whether and how an intervention is effective or not. Interventions are context-sensitive; they interact with the environment in which they are implemented. In fact, many argue that interventions are a product of their context, and indeed, outcomes are likely to be a product of the intervention and its context [ 3 , 29 ]. Within a trial, there is also the influence of the research context too—so the observed outcome could be due to the intervention alone, elements of the context within which the intervention is being delivered, elements of the research process or a combination of all three. Therefore, it can be difficult and unhelpful to separate the intervention from the context within which it was evaluated because the intervention and context are likely to have evolved together over time. As a result, the same intervention can look and behave differently in different contexts, so it is important this is known, understood and reported [ 3 ]. Finally, the intervention context is dynamic; the people, organisations and systems change over time, [ 3 ] which requires practitioners and patients to respond, and they may do this by adapting the intervention or contextual factors. So, to enable researchers to replicate successful interventions, or to explain why the intervention was not successful, it is not enough to describe the components of the intervention, they need to be described by their relationship to their context and resources [ 3 , 28 ].

What is a case study?

Case study methodology aims to provide an in-depth, holistic, balanced, detailed and complete picture of complex contemporary phenomena in its natural context [ 8 , 9 , 20 ]. In this case, the phenomena are the implementation of complex interventions in a trial. Case study methodology takes the view that the phenomena can be more than the sum of their parts and have to be understood as a whole [ 30 ]. It is differentiated from a clinical case study by its analytical focus [ 20 ].

The methodology is particularly useful when linked to trials because some of the features of the design naturally fill the gaps in knowledge generated by trials. Given the methodological focus on understanding phenomena in the round, case study methodology is typified by the use of multiple sources of data, which are more commonly qualitatively guided [ 31 ]. The case study methodology is not epistemologically specific, like realist evaluation, and can be used with different epistemologies [ 32 ], and with different theories, such as Normalisation Process Theory (which explores how staff work together to implement a new intervention) or the Consolidated Framework for Implementation Research (which provides a menu of constructs associated with effective implementation) [ 33 , 34 , 35 ]. Realist evaluation can be used to explore the relationship between context, mechanism and outcome, but case study differs from realist evaluation by its focus on a holistic and in-depth understanding of the relationship between an intervention and the contemporary context in which it was implemented [ 36 ]. Case study enables researchers to choose epistemologies and theories which suit the nature of the enquiry and their theoretical preferences.

Designing a process evaluation using case study

An important part of any study is the research design. Due to their varied philosophical positions, the seminal authors in the field of case study have different epistemic views as to how a case study should be conducted [ 8 , 9 ]. Stake takes an interpretative approach (interested in how people make sense of their world), and Yin has more positivistic leanings, arguing for objectivity, validity and generalisability [ 8 , 9 ].

Regardless of the philosophical background, a well-designed process evaluation using case study should consider the following core components: the purpose; the definition of the intervention, the trial design, the case, and the theories or logic models underpinning the intervention; the sampling approach; and the conceptual or theoretical framework [ 8 , 9 , 20 , 31 , 33 ]. We now discuss these critical components in turn, with reference to two process evaluations that used case study design, the DQIP and OPAL studies [ 21 , 37 , 38 , 39 , 40 , 41 ].

The purpose of a process evaluation is to evaluate and explain the relationship between the intervention and its components, to context and outcome. It can help inform judgements about validity (by exploring the intervention components and their relationship with one another (construct validity), the connections between intervention and outcomes (internal validity) and the relationship between intervention and context (external validity)). It can also distinguish between implementation failure (where the intervention is poorly delivered) and intervention failure (intervention design is flawed) [ 42 , 43 ]. By using a case study to explicitly understand the relationship between context and the intervention during implementation, the process evaluation can explain the intervention effects and the potential generalisability and optimisation into routine practice [ 44 ].

The DQIP process evaluation aimed to qualitatively explore how patients and GP practices responded to an intervention designed to reduce high-risk prescribing of nonsteroidal anti-inflammatory drugs (NSAIDs) and/or antiplatelet agents (see Table 1 ) and quantitatively examine how change in high-risk prescribing was associated with practice characteristics and implementation processes. The OPAL process evaluation (see Table 2 ) aimed to quantitatively understand the factors which influenced the effectiveness of a pelvic floor muscle training intervention for women with urinary incontinence and qualitatively explore the participants’ experiences of treatment and adherence.

Defining the intervention and exploring the theories or assumptions underpinning the intervention design

Process evaluations should also explore the utility of the theories or assumptions underpinning intervention design [ 49 ]. Not all theories underpinning interventions are based on a formal theory, but they based on assumptions as to how the intervention is expected to work. These can be depicted as a logic model or theory of change [ 25 ]. To capture how the intervention and context evolve requires the intervention and its expected mechanisms to be clearly defined at the outset [ 50 ]. Hawe and colleagues recommend defining interventions by function (what processes make the intervention work) rather than form (what is delivered) [ 51 ]. However, in some cases, it may be useful to know if some of the components are redundant in certain contexts or if there is a synergistic effect between all the intervention components.

The DQIP trial delivered two interventions, one intervention was delivered to professionals with high fidelity and then professionals delivered the other intervention to patients by form rather than function allowing adaptations to the local context as appropriate. The assumptions underpinning intervention delivery were prespecified in a logic model published in the process evaluation protocol [ 52 ].

Case study is well placed to challenge or reinforce the theoretical assumptions or redefine these based on the relationship between the intervention and context. Yin advocates the use of theoretical propositions; these direct attention to specific aspects of the study for investigation [ 8 ] can be based on the underlying assumptions and tested during the course of the process evaluation. In case studies, using an epistemic position more aligned with Yin can enable research questions to be designed, which seek to expose patterns of unanticipated as well as expected relationships [ 9 ]. The OPAL trial was more closely aligned with Yin, where the research team predefined some of their theoretical assumptions, based on how the intervention was expected to work. The relevant parts of the data analysis then drew on data to support or refute the theoretical propositions. This was particularly useful for the trial as the prespecified theoretical propositions linked to the mechanisms of action on which the intervention was anticipated to have an effect (or not).

Tailoring to the trial design

Process evaluations need to be tailored to the trial, the intervention and the outcomes being measured [ 45 ]. For example, in a stepped wedge design (where the intervention is delivered in a phased manner), researchers should try to ensure process data are captured at relevant time points or in a two-arm or multiple arm trial, ensure data is collected from the control group(s) as well as the intervention group(s). In the DQIP trial, a stepped wedge trial, at least one process evaluation case, was sampled per cohort. Trials often continue to measure outcomes after delivery of the intervention has ceased, so researchers should also consider capturing ‘follow-up’ data on contextual factors, which may continue to influence the outcome measure. The OPAL trial had two active treatment arms so collected process data from both arms. In addition, as the trial was interested in long-term adherence, the trial and the process evaluation collected data from participants for 2 years after the intervention was initially delivered, providing 24 months follow-up data, in line with the primary outcome for the trial.

Defining the case

Case studies can include single or multiple cases in their design. Single case studies usually sample typical or unique cases, their advantage being the depth and richness that can be achieved over a long period of time. The advantages of multiple case study design are that cases can be compared to generate a greater depth of analysis. Multiple case study sampling may be carried out in order to test for replication or contradiction [ 8 ]. Given that trials are often conducted over a number of sites, a multiple case study design is more sensible for process evaluations, as there is likely to be variation in implementation between sites. Case definition may occur at a variety of levels but is most appropriate if it reflects the trial design. For example, a case in an individual patient level trial is likely to be defined as a person/patient (e.g. a woman with urinary incontinence—OPAL trial) whereas in a cluster trial, a case is like to be a cluster, such as an organisation (e.g. a general practice—DQIP trial). Of course, the process evaluation could explore cases with less distinct boundaries, such as communities or relationships; however, the clarity with which these cases are defined is important, in order to scope the nature of the data that will be generated.

Carefully sampled cases are critical to a good case study as sampling helps inform the quality of the inferences that can be made from the data [ 53 ]. In both qualitative and quantitative research, how and how many participants to sample must be decided when planning the study. Quantitative sampling techniques generally aim to achieve a random sample. Qualitative research generally uses purposive samples to achieve data saturation, occurring when the incoming data produces little or no new information to address the research questions. The term data saturation has evolved from theoretical saturation in conventional grounded theory studies; however, its relevance to other types of studies is contentious as the term saturation seems to be widely used but poorly justified [ 54 ]. Empirical evidence suggests that for in-depth interview studies, saturation occurs at 12 interviews for thematic saturation, but typically more would be needed for a heterogenous sample higher degrees of saturation [ 55 , 56 ]. Both DQIP and OPAL case studies were huge with OPAL designed to interview each of the 40 individual cases four times and DQIP designed to interview the lead DQIP general practitioner (GP) twice (to capture change over time), another GP and the practice manager from each of the 10 organisational cases. Despite the plethora of mixed methods research textbooks, there is very little about sampling as discussions typically link to method (e.g. interviews) rather than paradigm (e.g. case study).

Purposive sampling can improve the generalisability of the process evaluation by sampling for greater contextual diversity. The typical or average case is often not the richest source of information. Outliers can often reveal more important insights, because they may reflect the implementation of the intervention using different processes. Cases can be selected from a number of criteria, which are not mutually exclusive, to enable a rich and detailed picture to be built across sites [ 53 ]. To avoid the Hawthorne effect, it is recommended that process evaluations sample from both intervention and control sites, which enables comparison and explanation. There is always a trade-off between breadth and depth in sampling, so it is important to note that often quantity does not mean quality and that carefully sampled cases can provide powerful illustrative examples of how the intervention worked in practice, the relationship between the intervention and context and how and why they evolved together. The qualitative components of both DQIP and OPAL process evaluations aimed for maximum variation sampling. Please see Table 1 for further information on how DQIP’s sampling frame was important for providing contextual information on processes influencing effective implementation of the intervention.

Conceptual and theoretical framework

A conceptual or theoretical framework helps to frame data collection and analysis [ 57 ]. Theories can also underpin propositions, which can be tested in the process evaluation. Process evaluations produce intervention-dependent knowledge, and theories help make the research findings more generalizable by providing a common language [ 16 ]. There are a number of mid-range theories which have been designed to be used with process evaluation [ 34 , 35 , 58 ]. The choice of the appropriate conceptual or theoretical framework is, however, dependent on the philosophical and professional background of the research. The two examples within this paper used our own framework for the design of process evaluations, which proposes a number of candidate processes which can be explored, for example, recruitment, delivery, response, maintenance and context [ 45 ]. This framework was published before the MRC guidance on process evaluations, and both the DQIP and OPAL process evaluations were designed before the MRC guidance was published. The DQIP process evaluation explored all candidates in the framework whereas the OPAL process evaluation selected four candidates, illustrating that process evaluations can be selective in what they explore based on the purpose, research questions and resources. Furthermore, as Kislov and colleagues argue, we also have a responsibility to critique the theoretical framework underpinning the evaluation and refine theories to advance knowledge [ 59 ].

Data collection

An important consideration is what data to collect or measure and when. Case study methodology supports a range of data collection methods, both qualitative and quantitative, to best answer the research questions. As the aim of the case study is to gain an in-depth understanding of phenomena in context, methods are more commonly qualitative or mixed method in nature. Qualitative methods such as interviews, focus groups and observation offer rich descriptions of the setting, delivery of the intervention in each site and arm, how the intervention was perceived by the professionals delivering the intervention and the patients receiving the intervention. Quantitative methods can measure recruitment, fidelity and dose and establish which characteristics are associated with adoption, delivery and effectiveness. To ensure an understanding of the complexity of the relationship between the intervention and context, the case study should rely on multiple sources of data and triangulate these to confirm and corroborate the findings [ 8 ]. Process evaluations might consider using routine data collected in the trial across all sites and additional qualitative data across carefully sampled sites for a more nuanced picture within reasonable resource constraints. Mixed methods allow researchers to ask more complex questions and collect richer data than can be collected by one method alone [ 60 ]. The use of multiple sources of data allows data triangulation, which increases a study’s internal validity but also provides a more in-depth and holistic depiction of the case [ 20 ]. For example, in the DQIP process evaluation, the quantitative component used routinely collected data from all sites participating in the trial and purposively sampled cases for a more in-depth qualitative exploration [ 21 , 38 , 39 ].

The timing of data collection is crucial to study design, especially within a process evaluation where data collection can potentially influence the trial outcome. Process evaluations are generally in parallel or retrospective to the trial. The advantage of a retrospective design is that the evaluation itself is less likely to influence the trial outcome. However, the disadvantages include recall bias, lack of sensitivity to nuances and an inability to iteratively explore the relationship between intervention and outcome as it develops. To capture the dynamic relationship between intervention and context, the process evaluation needs to be parallel and longitudinal to the trial. Longitudinal methodological design is rare, but it is needed to capture the dynamic nature of implementation [ 40 ]. How the intervention is delivered is likely to change over time as it interacts with context. For example, as professionals deliver the intervention, they become more familiar with it, and it becomes more embedded into systems. The OPAL process evaluation was a longitudinal, mixed methods process evaluation where the quantitative component had been predefined and built into trial data collection systems. Data collection in both the qualitative and quantitative components mirrored the trial data collection points, which were longitudinal to capture adherence and contextual changes over time.

There is a lot of attention in the recent literature towards a systems approach to understanding interventions in context, which suggests interventions are ‘events within systems’ [ 61 , 62 ]. This framing highlights the dynamic nature of context, suggesting that interventions are an attempt to change systems dynamics. This conceptualisation would suggest that the study design should collect contextual data before and after implementation to assess the effect of the intervention on the context and vice versa.

Data analysis

Designing a rigorous analysis plan is particularly important for multiple case studies, where researchers must decide whether their approach to analysis is case or variable based. Case-based analysis is the most common, and analytic strategies must be clearly articulated for within and across case analysis. A multiple case study design can consist of multiple cases, where each case is analysed at the case level, or of multiple embedded cases, where data from all the cases are pulled together for analysis at some level. For example, OPAL analysis was at the case level, but all the cases for the intervention and control arms were pulled together at the arm level for more in-depth analysis and comparison. For Yin, analytical strategies rely on theoretical propositions, but for Stake, analysis works from the data to develop theory. In OPAL and DQIP, case summaries were written to summarise the cases and detail within-case analysis. Each of the studies structured these differently based on the phenomena of interest and the analytic technique. DQIP applied an approach more akin to Stake [ 9 ], with the cases summarised around inductive themes whereas OPAL applied a Yin [ 8 ] type approach using theoretical propositions around which the case summaries were structured. As the data for each case had been collected through longitudinal interviews, the case summaries were able to capture changes over time. It is beyond the scope of this paper to discuss different analytic techniques; however, to ensure the holistic examination of the intervention(s) in context, it is important to clearly articulate and demonstrate how data is integrated and synthesised [ 31 ].

There are a number of approaches to process evaluation design in the literature; however, there is a paucity of research on what case study design can offer process evaluations. We argue that case study is one of the best research designs to underpin process evaluations, to capture the dynamic and complex relationship between intervention and context during implementation [ 38 ]. Case study can enable comparisons within and across intervention and control arms and enable the evolving relationship between intervention and context to be captured holistically rather than considering processes in isolation. Utilising a longitudinal design can enable the dynamic relationship between context and intervention to be captured in real time. This information is fundamental to holistically explaining what intervention was implemented, understanding how and why the intervention worked or not and informing the transferability of the intervention into routine clinical practice.

Case study designs are not prescriptive, but process evaluations using case study should consider the purpose, trial design, the theories or assumptions underpinning the intervention, and the conceptual and theoretical frameworks informing the evaluation. We have discussed each of these considerations in turn, providing a comprehensive overview of issues for process evaluations using a case study design. There is no single or best way to conduct a process evaluation or a case study, but researchers need to make informed choices about the process evaluation design. Although this paper focuses on process evaluations, we recognise that case study design could also be useful during intervention development and feasibility trials. Elements of this paper are also applicable to other study designs involving trials.

Availability of data and materials

No data and materials were used.

Abbreviations

Data-driven Quality Improvement in Primary Care

Medical Research Council

Nonsteroidal anti-inflammatory drugs

Optimizing Pelvic Floor Muscle Exercises to Achieve Long-term benefits

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We would like to thank Professor Shaun Treweek for the discussions about context in trials.

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Grant, A., Bugge, C. & Wells, M. Designing process evaluations using case study to explore the context of complex interventions evaluated in trials. Trials 21 , 982 (2020). https://doi.org/10.1186/s13063-020-04880-4

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Case study research for better evaluations of complex interventions: rationale and challenges

Sara Paparini ORCID: orcid.org/0000-0002-1909-2481 1 ,
Judith Green 2 ,
Chrysanthi Papoutsi 1 ,
Jamie Murdoch 3 ,
Mark Petticrew 4 ,
Trish Greenhalgh 1 ,
Benjamin Hanckel 5 &
Sara Shaw 1

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The need for better methods for evaluation in health research has been widely recognised. The ‘complexity turn’ has drawn attention to the limitations of relying on causal inference from randomised controlled trials alone for understanding whether, and under which conditions, interventions in complex systems improve health services or the public health, and what mechanisms might link interventions and outcomes. We argue that case study research—currently denigrated as poor evidence—is an under-utilised resource for not only providing evidence about context and transferability, but also for helping strengthen causal inferences when pathways between intervention and effects are likely to be non-linear.

Case study research, as an overall approach, is based on in-depth explorations of complex phenomena in their natural, or real-life, settings. Empirical case studies typically enable dynamic understanding of complex challenges and provide evidence about causal mechanisms and the necessary and sufficient conditions (contexts) for intervention implementation and effects. This is essential evidence not just for researchers concerned about internal and external validity, but also research users in policy and practice who need to know what the likely effects of complex programmes or interventions will be in their settings. The health sciences have much to learn from scholarship on case study methodology in the social sciences. However, there are multiple challenges in fully exploiting the potential learning from case study research. First are misconceptions that case study research can only provide exploratory or descriptive evidence. Second, there is little consensus about what a case study is, and considerable diversity in how empirical case studies are conducted and reported. Finally, as case study researchers typically (and appropriately) focus on thick description (that captures contextual detail), it can be challenging to identify the key messages related to intervention evaluation from case study reports.

Whilst the diversity of published case studies in health services and public health research is rich and productive, we recommend further clarity and specific methodological guidance for those reporting case study research for evaluation audiences.

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The need for methodological development to address the most urgent challenges in health research has been well-documented. Many of the most pressing questions for public health research, where the focus is on system-level determinants [ 1 , 2 ], and for health services research, where provisions typically vary across sites and are provided through interlocking networks of services [ 3 ], require methodological approaches that can attend to complexity. The need for methodological advance has arisen, in part, as a result of the diminishing returns from randomised controlled trials (RCTs) where they have been used to answer questions about the effects of interventions in complex systems [ 4 , 5 , 6 ]. In conditions of complexity, there is limited value in maintaining the current orientation to experimental trial designs in the health sciences as providing ‘gold standard’ evidence of effect.

There are increasing calls for methodological pluralism [ 7 , 8 ], with the recognition that complex intervention and context are not easily or usefully separated (as is often the situation when using trial design), and that system interruptions may have effects that are not reducible to linear causal pathways between intervention and outcome. These calls are reflected in a shifting and contested discourse of trial design, seen with the emergence of realist [ 9 ], adaptive and hybrid (types 1, 2 and 3) [ 10 , 11 ] trials that blend studies of effectiveness with a close consideration of the contexts of implementation. Similarly, process evaluation has now become a core component of complex healthcare intervention trials, reflected in MRC guidance on how to explore implementation, causal mechanisms and context [ 12 ].

Evidence about the context of an intervention is crucial for questions of external validity. As Woolcock [ 4 ] notes, even if RCT designs are accepted as robust for maximising internal validity, questions of transferability (how well the intervention works in different contexts) and generalisability (how well the intervention can be scaled up) remain unanswered [ 5 , 13 ]. For research evidence to have impact on policy and systems organisation, and thus to improve population and patient health, there is an urgent need for better methods for strengthening external validity, including a better understanding of the relationship between intervention and context [ 14 ].

Policymakers, healthcare commissioners and other research users require credible evidence of relevance to their settings and populations [ 15 ], to perform what Rosengarten and Savransky [ 16 ] call ‘careful abstraction’ to the locales that matter for them. They also require robust evidence for understanding complex causal pathways. Case study research, currently under-utilised in public health and health services evaluation, can offer considerable potential for strengthening faith in both external and internal validity. For example, in an empirical case study of how the policy of free bus travel had specific health effects in London, UK, a quasi-experimental evaluation (led by JG) identified how important aspects of context (a good public transport system) and intervention (that it was universal) were necessary conditions for the observed effects, thus providing useful, actionable evidence for decision-makers in other contexts [ 17 ].

The overall approach of case study research is based on the in-depth exploration of complex phenomena in their natural, or ‘real-life’, settings. Empirical case studies typically enable dynamic understanding of complex challenges rather than restricting the focus on narrow problem delineations and simple fixes. Case study research is a diverse and somewhat contested field, with multiple definitions and perspectives grounded in different ways of viewing the world, and involving different combinations of methods. In this paper, we raise awareness of such plurality and highlight the contribution that case study research can make to the evaluation of complex system-level interventions. We review some of the challenges in exploiting the current evidence base from empirical case studies and conclude by recommending that further guidance and minimum reporting criteria for evaluation using case studies, appropriate for audiences in the health sciences, can enhance the take-up of evidence from case study research.

Case study research offers evidence about context, causal inference in complex systems and implementation

Well-conducted and described empirical case studies provide evidence on context, complexity and mechanisms for understanding how, where and why interventions have their observed effects. Recognition of the importance of context for understanding the relationships between interventions and outcomes is hardly new. In 1943, Canguilhem berated an over-reliance on experimental designs for determining universal physiological laws: ‘As if one could determine a phenomenon’s essence apart from its conditions! As if conditions were a mask or frame which changed neither the face nor the picture!’ ([ 18 ] p126). More recently, a concern with context has been expressed in health systems and public health research as part of what has been called the ‘complexity turn’ [ 1 ]: a recognition that many of the most enduring challenges for developing an evidence base require a consideration of system-level effects [ 1 ] and the conceptualisation of interventions as interruptions in systems [ 19 ].

The case study approach is widely recognised as offering an invaluable resource for understanding the dynamic and evolving influence of context on complex, system-level interventions [ 20 , 21 , 22 , 23 ]. Empirically, case studies can directly inform assessments of where, when, how and for whom interventions might be successfully implemented, by helping to specify the necessary and sufficient conditions under which interventions might have effects and to consolidate learning on how interdependencies, emergence and unpredictability can be managed to achieve and sustain desired effects. Case study research has the potential to address four objectives for improving research and reporting of context recently set out by guidance on taking account of context in population health research [ 24 ], that is to (1) improve the appropriateness of intervention development for specific contexts, (2) improve understanding of ‘how’ interventions work, (3) better understand how and why impacts vary across contexts and (4) ensure reports of intervention studies are most useful for decision-makers and researchers.

However, evaluations of complex healthcare interventions have arguably not exploited the full potential of case study research and can learn much from other disciplines. For evaluative research, exploratory case studies have had a traditional role of providing data on ‘process’, or initial ‘hypothesis-generating’ scoping, but might also have an increasing salience for explanatory aims. Across the social and political sciences, different kinds of case studies are undertaken to meet diverse aims (description, exploration or explanation) and across different scales (from small N qualitative studies that aim to elucidate processes, or provide thick description, to more systematic techniques designed for medium-to-large N cases).

Case studies with explanatory aims vary in terms of their positioning within mixed-methods projects, with designs including (but not restricted to) (1) single N of 1 studies of interventions in specific contexts, where the overall design is a case study that may incorporate one or more (randomised or not) comparisons over time and between variables within the case; (2) a series of cases conducted or synthesised to provide explanation from variations between cases; and (3) case studies of particular settings within RCT or quasi-experimental designs to explore variation in effects or implementation.

Detailed qualitative research (typically done as ‘case studies’ within process evaluations) provides evidence for the plausibility of mechanisms [ 25 ], offering theoretical generalisations for how interventions may function under different conditions. Although RCT designs reduce many threats to internal validity, the mechanisms of effect remain opaque, particularly when the causal pathways between ‘intervention’ and ‘effect’ are long and potentially non-linear: case study research has a more fundamental role here, in providing detailed observational evidence for causal claims [ 26 ] as well as producing a rich, nuanced picture of tensions and multiple perspectives [ 8 ].

Longitudinal or cross-case analysis may be best suited for evidence generation in system-level evaluative research. Turner [ 27 ], for instance, reflecting on the complex processes in major system change, has argued for the need for methods that integrate learning across cases, to develop theoretical knowledge that would enable inferences beyond the single case, and to develop generalisable theory about organisational and structural change in health systems. Qualitative Comparative Analysis (QCA) [ 28 ] is one such formal method for deriving causal claims, using set theory mathematics to integrate data from empirical case studies to answer questions about the configurations of causal pathways linking conditions to outcomes [ 29 , 30 ].

Nonetheless, the single N case study, too, provides opportunities for theoretical development [ 31 ], and theoretical generalisation or analytical refinement [ 32 ]. How ‘the case’ and ‘context’ are conceptualised is crucial here. Findings from the single case may seem to be confined to its intrinsic particularities in a specific and distinct context [ 33 ]. However, if such context is viewed as exemplifying wider social and political forces, the single case can be ‘telling’, rather than ‘typical’, and offer insight into a wider issue [ 34 ]. Internal comparisons within the case can offer rich possibilities for logical inferences about causation [ 17 ]. Further, case studies of any size can be used for theory testing through refutation [ 22 ]. The potential lies, then, in utilising the strengths and plurality of case study to support theory-driven research within different methodological paradigms.

Evaluation research in health has much to learn from a range of social sciences where case study methodology has been used to develop various kinds of causal inference. For instance, Gerring [ 35 ] expands on the within-case variations utilised to make causal claims. For Gerring [ 35 ], case studies come into their own with regard to invariant or strong causal claims (such as X is a necessary and/or sufficient condition for Y) rather than for probabilistic causal claims. For the latter (where experimental methods might have an advantage in estimating effect sizes), case studies offer evidence on mechanisms: from observations of X affecting Y, from process tracing or from pattern matching. Case studies also support the study of emergent causation, that is, the multiple interacting properties that account for particular and unexpected outcomes in complex systems, such as in healthcare [ 8 ].

Finally, efficacy (or beliefs about efficacy) is not the only contributor to intervention uptake, with a range of organisational and policy contingencies affecting whether an intervention is likely to be rolled out in practice. Case study research is, therefore, invaluable for learning about contextual contingencies and identifying the conditions necessary for interventions to become normalised (i.e. implemented routinely) in practice [ 36 ].

The challenges in exploiting evidence from case study research

At present, there are significant challenges in exploiting the benefits of case study research in evaluative health research, which relate to status, definition and reporting. Case study research has been marginalised at the bottom of an evidence hierarchy, seen to offer little by way of explanatory power, if nonetheless useful for adding descriptive data on process or providing useful illustrations for policymakers [ 37 ]. This is an opportune moment to revisit this low status. As health researchers are increasingly charged with evaluating ‘natural experiments’—the use of face masks in the response to the COVID-19 pandemic being a recent example [ 38 ]—rather than interventions that take place in settings that can be controlled, research approaches using methods to strengthen causal inference that does not require randomisation become more relevant.

A second challenge for improving the use of case study evidence in evaluative health research is that, as we have seen, what is meant by ‘case study’ varies widely, not only across but also within disciplines. There is indeed little consensus amongst methodologists as to how to define ‘a case study’. Definitions focus, variously, on small sample size or lack of control over the intervention (e.g. [ 39 ] p194), on in-depth study and context [ 40 , 41 ], on the logic of inference used [ 35 ] or on distinct research strategies which incorporate a number of methods to address questions of ‘how’ and ‘why’ [ 42 ]. Moreover, definitions developed for specific disciplines do not capture the range of ways in which case study research is carried out across disciplines. Multiple definitions of case study reflect the richness and diversity of the approach. However, evidence suggests that a lack of consensus across methodologists results in some of the limitations of published reports of empirical case studies [ 43 , 44 ]. Hyett and colleagues [ 43 ], for instance, reviewing reports in qualitative journals, found little match between methodological definitions of case study research and how authors used the term.

This raises the third challenge we identify that case study reports are typically not written in ways that are accessible or useful for the evaluation research community and policymakers. Case studies may not appear in journals widely read by those in the health sciences, either because space constraints preclude the reporting of rich, thick descriptions, or because of the reported lack of willingness of some biomedical journals to publish research that uses qualitative methods [ 45 ], signalling the persistence of the aforementioned evidence hierarchy. Where they do, however, the term ‘case study’ is used to indicate, interchangeably, a qualitative study, an N of 1 sample, or a multi-method, in-depth analysis of one example from a population of phenomena. Definitions of what constitutes the ‘case’ are frequently lacking and appear to be used as a synonym for the settings in which the research is conducted. Despite offering insights for evaluation, the primary aims may not have been evaluative, so the implications may not be explicitly drawn out. Indeed, some case study reports might properly be aiming for thick description without necessarily seeking to inform about context or causality.

Acknowledging plurality and developing guidance

We recognise that definitional and methodological plurality is not only inevitable, but also a necessary and creative reflection of the very different epistemological and disciplinary origins of health researchers, and the aims they have in doing and reporting case study research. Indeed, to provide some clarity, Thomas [ 46 ] has suggested a typology of subject/purpose/approach/process for classifying aims (e.g. evaluative or exploratory), sample rationale and selection and methods for data generation of case studies. We also recognise that the diversity of methods used in case study research, and the necessary focus on narrative reporting, does not lend itself to straightforward development of formal quality or reporting criteria.

Existing checklists for reporting case study research from the social sciences—for example Lincoln and Guba’s [ 47 ] and Stake’s [ 33 ]—are primarily orientated to the quality of narrative produced, and the extent to which they encapsulate thick description, rather than the more pragmatic issues of implications for intervention effects. Those designed for clinical settings, such as the CARE (CAse REports) guidelines, provide specific reporting guidelines for medical case reports about single, or small groups of patients [ 48 ], not for case study research.

The Design of Case Study Research in Health Care (DESCARTE) model [ 44 ] suggests a series of questions to be asked of a case study researcher (including clarity about the philosophy underpinning their research), study design (with a focus on case definition) and analysis (to improve process). The model resembles toolkits for enhancing the quality and robustness of qualitative and mixed-methods research reporting, and it is usefully open-ended and non-prescriptive. However, even if it does include some reflections on context, the model does not fully address aspects of context, logic and causal inference that are perhaps most relevant for evaluative research in health.

Hence, for evaluative research where the aim is to report empirical findings in ways that are intended to be pragmatically useful for health policy and practice, this may be an opportune time to consider how to best navigate plurality around what is (minimally) important to report when publishing empirical case studies, especially with regards to the complex relationships between context and interventions, information that case study research is well placed to provide.

The conventional scientific quest for certainty, predictability and linear causality (maximised in RCT designs) has to be augmented by the study of uncertainty, unpredictability and emergent causality [ 8 ] in complex systems. This will require methodological pluralism, and openness to broadening the evidence base to better understand both causality in and the transferability of system change intervention [ 14 , 20 , 23 , 25 ]. Case study research evidence is essential, yet is currently under exploited in the health sciences. If evaluative health research is to move beyond the current impasse on methods for understanding interventions as interruptions in complex systems, we need to consider in more detail how researchers can conduct and report empirical case studies which do aim to elucidate the contextual factors which interact with interventions to produce particular effects. To this end, supported by the UK’s Medical Research Council, we are embracing the challenge to develop guidance for case study researchers studying complex interventions. Following a meta-narrative review of the literature, we are planning a Delphi study to inform guidance that will, at minimum, cover the value of case study research for evaluating the interrelationship between context and complex system-level interventions; for situating and defining ‘the case’, and generalising from case studies; as well as provide specific guidance on conducting, analysing and reporting case study research. Our hope is that such guidance can support researchers evaluating interventions in complex systems to better exploit the diversity and richness of case study research.

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Abbreviations

Qualitative comparative analysis

Quasi-experimental design

Randomised controlled trial

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This work was funded by the Medical Research Council - MRC Award MR/S014632/1 HCS: Case study, Context and Complex interventions (TRIPLE C). SP was additionally funded by the University of Oxford's Higher Education Innovation Fund (HEIF).

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Paparini, S., Green, J., Papoutsi, C. et al. Case study research for better evaluations of complex interventions: rationale and challenges. BMC Med 18 , 301 (2020). https://doi.org/10.1186/s12916-020-01777-6

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15.7 Evaluation: Presentation and Analysis of Case Study

Learning outcomes.

By the end of this section, you will be able to:

Revise writing to follow the genre conventions of case studies.
Evaluate the effectiveness and quality of a case study report.

Case studies follow a structure of background and context , methods , findings , and analysis . Body paragraphs should have main points and concrete details. In addition, case studies are written in formal language with precise wording and with a specific purpose and audience (generally other professionals in the field) in mind. Case studies also adhere to the conventions of the discipline’s formatting guide ( APA Documentation and Format in this study). Compare your case study with the following rubric as a final check.

Critical Language Awareness	Clarity and Coherence	Rhetorical Choices
The text always adheres to the “Editing Focus” of this chapter: words often confused, as discussed in Section 15.6. The text also shows ample evidence of the writer’s intent to consciously meet or challenge conventional expectations in rhetorically effective ways.	Paragraphs are unified under a single, clear topic. Abundant background and supporting details provide a sense of completeness. Evidence of qualitative and quantitative data collection is clear. Transitions and subheads connect ideas and sections, thus establishing coherence throughout. Applicable visuals clarify abstract ideas.	The writer clearly and consistently recognizes and works within the limits and purpose of the case study. The writer engages the audience by inviting them to contribute to the research and suggests ways for doing so. The implications, relevance, and consequences of the research are explained. The study shows mature command of language and consistent objectivity. Quotations from participant(s) are accurate and relevant.
The text usually adheres to the “Editing Focus” of this chapter: words often confused, as discussed in Section 15.6. The text also shows some evidence of the writer’s intent to consciously meet or challenge conventional expectations in rhetorically effective ways.	Paragraphs usually are unified under a single, clear topic. Background and supporting details provide a sense of completeness. Evidence of qualitative and quantitative data collection is clear. Transitions and subheads connect ideas and sections, thus establishing coherence. Applicable visuals clarify abstract ideas.	The writer usually recognizes and works within the limits and purpose of the case study. The writer engages the audience by inviting them to contribute to the research and usually suggests ways for doing so. The implications, relevance, and consequences of the research are explained. The study shows command of language and objectivity. Quotations from participant(s) are usually accurate and relevant.
The text generally adheres to the “Editing Focus” of this chapter: words often confused, as discussed in Section 15.6. The text also shows limited evidence of the writer’s intent to consciously meet or challenge conventional expectations in rhetorically effective ways.	Paragraphs generally are unified under a single, clear topic. Background and supporting details provide a sense of completeness. Some evidence of qualitative and quantitative data collection is clear. Some transitions and subheads connect ideas and sections, generally establishing coherence. Visuals may clarify abstract ideas or may seem irrelevant.	The writer generally recognizes and works within the limits and purpose of the case study. The writer sometimes engages the audience by inviting them to contribute to the research but may not suggest ways for doing so. The implications, relevance, and consequences of the research are explained, if not fully. The study shows some command of language and objectivity. Quotations from participant(s) are generally accurate, if not always relevant.
The text occasionally adheres to the “Editing Focus” of this chapter: words often confused, as discussed in Section 15.6. The text also shows emerging evidence of the writer’s intent to consciously meet or challenge conventional expectations in rhetorically effective ways.	Paragraphs sometimes are unified under a single, clear topic. Background and supporting details are insufficient to provide a sense of completeness. There is little evidence of qualitative or quantitative data collection. Some transitions and subheads connect ideas and sections, but coherence may be lacking. Visuals are either missing or irrelevant.	The writer occasionally recognizes and works within the limits and purpose of the case study. The writer rarely engages the audience by inviting them to contribute to the research or suggests ways for doing so. The implications, relevance, and consequences of the research are haphazardly explained, if at all. The study shows little command of language or objectivity. Quotations from participant(s) are questionable and often irrelevant.
The text does not adhere to the “Editing Focus” of this chapter: words often confused, as discussed in Section 15.6. The text also shows little to no evidence of the writer’s intent to consciously meet or challenge conventional expectations in rhetorically effective ways.	Paragraphs are not unified under a single, clear topic. Background and supporting details are insufficient to provide a sense of completeness. There is little evidence of qualitative or quantitative data collection. Transitions and subheads are missing or inappropriate to provide coherence. Visuals are either missing or irrelevant.	The writer does not recognize or work within the limits and purpose of the case study. The writer does not engage the audience by inviting them to contribute to the research. The implications, relevance, and consequences of the research are haphazardly explained, if at all. The study shows little command of language or objectivity. Quotations, if any, from participant(s) are questionable and often irrelevant.

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Guide to case studies

What is a case study.

A case study is an in depth focussed study of a person, group, or situation that has been studied over time within its real-life context.

There are different types of case study:

Illustrative case studies describe an unfamiliar situation in order to help people understand it.
Critical instance case studies focus on a unique case, without a generalised purpose.
Exploratory case studies are preliminary projects to help guide a future, larger-scale project. They aim to identify research questions and possible research approaches.

We are often looking to develop patient stories as case studies and these will use qualitative methods such as interviews to find specific details and descriptions of how your subject is affected.

Patient stories are illustrative or critical instance case studies. For example, an illustrative case study might focus on a patient with an eating disorder to provide a subjective view to better help trainee nutritionists understand the illness. A critical instance case study might focus on a patient with a very rare or uniquely complex condition or how a single patient is affected by an injury.

How do you do a case study?

1. get prepared.

Be very clear about the purpose of the case study, why you are doing it and what it will be used for?
Think about the questions you want to answer? What are your research or evaluation questions?
Determine what kind of case study will best suit your needs? Illustrative, Critical Instance or Exploratory?
Define the subject of study – is it an individual, a small group of people, or a specific situation?
Determine if you need ethical approval to conduct this case study – you may be asked to prove that the case study will do no harm to its participant(s).

2. Get designing!

Finalise your research or evaluation questions – i.e. what you want to know at the end of the study. Limit these to a manageable number – no more than 4 or 5.
Think about where you will find the information you need to answer your questions. Interviewing research subjects and/ or observing will likely be the central methods of your case study, but do you need to look to additional data sources as well? For example, desk research or evidence/literature reviewing, interviewing experts, other fieldwork and so on.
Create a plan outlining how you will gather the information you need to answer your research or evaluation questions. Include a timeframe and be clear that you have the resources and equipment to carry out the work. Depending on the nature of the case study or the topic being studied a case study may require several meetings/interviews over a period of many months, or it might need just a one off interview. What does yours need?
Decide on the exact subject of the study. Is this a specific person or a small group of people? If yes, plan how you will get in touch with them and invite them to take part in the case study. How flexible can you be in terms of time and travel? Does this limit your access to potential participants?
Design interview questions that are open and will enable the participant to provide in-depth answers. Avoid questions that can be answered with a single yes or no and make sure the questions are flexible and allow the participant to talk openly and freely.

3. Get recruiting!

You may have a specific individual in mind, or specific criteria. You will need to invite people to participate and make very clear that they are able to withdraw at any point.
You will need consent from the participants. Make sure the purpose of the case study, why you are doing it and what it will be used, the methods and time frames are extremely clear to the potential participants. You will need written consent that demonstrates that the participant understands this. Additionally, if you intend to digitally record an interview or take notes, make sure you have permission from the participants’ first.
If your central method is observation, this will be open observation – the participant must be aware of your presence and agreed to it – you are not allowed to observe without the participants’ permission!

4. Get conducting!

Interviewing – Agree a mutually suitable time and venue for the case study interview. This may be a one off or the first of many over several months. Make sure the participant is in an environment they are comfortable and able to talk in. Equally important, however is that the environment is safe for you and is conducive to conducting a case study interview – i.e. If it is a private space, are you safe? If it is a public space make sure it is not too noisy or likely to be affected by interruptions.
Decide what is the best method of recording the interview information – digital recording is less intrusive and you can engage better in the conversation, than if you attempt to just take notes. Taking notes can mean that your concentration is focused on the writing rather than the listening and you can miss vital points. It can also be off-putting for the participant if there is no eye contact because you are scribing throughout the conversation. However, some participants will not like to be digitally recorded – so it is best to discuss this with them first. If you are digitally recording always test the equipment first. Even if you are digitally recording you will still need to take notes on key points, or things that you would like to investigate further, questions that arise or points at which you don’t want to interrupt the conversation or anything that will not be captured by the recording, such as body language or other observations.
Depending on the total length of your case study, you might hold a one off interview, interview weekly, once every month or two, or just once or twice a year. Begin with the interview questions you prepared in the preparation and design phases, then iterate to dig deeper into the topics. Ask about experience and meaning — ask the participant what it’s like to go through the experience you’re studying and what the experience means to them. Later interviews are an opportunity to ask questions that fill gaps in your knowledge, or that are particularly relevant to the development of the case study or in answering your questions.
Observing – recording observation can be done manually – i.e. taking notes – or digitally via a camcorder or similar. It is important to capture detail about the subject/participant and their interactions with others and the environment, their behaviour and other context an detail that is relevant to your questions.

5. Get analysing!

Write up your notes or transcribe (Interviews), make notes (video) from your digital recording. Remember that if you are transcribing it is important to include pauses, laughter and other descriptive sounds and commentary on tone and intonation to better convey the story. Include the contextual information / the external environment and other observations that are important. Such as when and where the interview took place (you will not necessarily make this public) and any issues that arose such as interruptions that affected the interview or if there were multiple interviews anything of significance that happened in the periods between interviews.
Thematically code (look for themes) and look for key parts of the interviews that will answer your original questions. Also be very aware that the may be new or unexpected information that has come through the process that is very important or interesting.
Arrange the notes or transcriptions from the interviews and, or observations into a case study. It is not likely that you will be able to use the transcriptions without reorganising them, but if you are rewriting the story in your own words, be careful not to lose the meaning and language that reflects the participant.

6. Get sign off!

Once you have drafted your case study make sure the participant(s) have sight of it and an opportunity to say whether you have captured their story and are representing it/them as they would like.

7. Get disseminating!

Find out more about disseminating evaluations and case studies .
Remember case studies are not designed for large group studies or statistical analysis and do not aim to answer a research question definitively.
Do background/context research where possible.
Establishing trust with participants is crucial and can result in less inhibited behaviour. Observing people in their home, workplaces, or other “natural” environments may be more effective than bringing them to a laboratory or office.
Be aware that if you are observing it is likely that because subjects know they are being studied, their behaviour will change.
Take notes -Extensive notes during observation will be vital.
Take notes even if you are digitally recoding an interview to capture your own thinking, points to follow up on or observations.
In some case studies, it may be appropriate to ask the participant to record experiences in a diary – especially if there are periods between your interviews or observations that you wish to capture data on.
Stay rigorous. A case study may feel less data-driven than a medical trial or a scientific experiment, but attention to rigor and valid methodology remains vital.
When reviewing your notes, discard possible conclusions that do not have detailed observation or evidence backing them up.
A case study might reveal new and unexpected results, and lead to research taking new directions.
A case study cannot be generalised to fit a whole population.
Since you aren’t conducting a statistical analysis, you do not need to recruit a diverse cross-section of society. You should be aware of any biases in your small sample, and make them clear in your report, but they do not invalidate your research.
Useful resource: ‘Case Study Research: Design and Methods’, Robert K Yin, SAGE publications 2013.

Case studies

Find inspiration for your own evaluation with these real life examples

Guidance from a range of organisations for in-depth advice

Services and support

Knowledgeable organisations who may be able to help you

Training resources

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The Evaluation and Evidence toolkits go hand in hand. Using and generating evidence to inform decision making is vital to improving services and people’s lives.

The toolkits have been developed by the NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board (BNSSG ICB), the National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) and Health Innovation West of England .

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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

Definition and Introduction

Case analysis is a problem-based teaching and learning method that involves critically analyzing complex scenarios within an organizational setting for the purpose of placing the student in a “real world” situation and applying reflection and critical thinking skills to contemplate appropriate solutions, decisions, or recommended courses of action. It is considered a more effective teaching technique than in-class role playing or simulation activities. The analytical process is often guided by questions provided by the instructor that ask students to contemplate relationships between the facts and critical incidents described in the case.

Cases generally include both descriptive and statistical elements and rely on students applying abductive reasoning to develop and argue for preferred or best outcomes [i.e., case scenarios rarely have a single correct or perfect answer based on the evidence provided]. Rather than emphasizing theories or concepts, case analysis assignments emphasize building a bridge of relevancy between abstract thinking and practical application and, by so doing, teaches the value of both within a specific area of professional practice.

Given this, the purpose of a case analysis paper is to present a structured and logically organized format for analyzing the case situation. It can be assigned to students individually or as a small group assignment and it may include an in-class presentation component. Case analysis is predominately taught in economics and business-related courses, but it is also a method of teaching and learning found in other applied social sciences disciplines, such as, social work, public relations, education, journalism, and public administration.

Ellet, William. The Case Study Handbook: A Student's Guide . Revised Edition. Boston, MA: Harvard Business School Publishing, 2018; Christoph Rasche and Achim Seisreiner. Guidelines for Business Case Analysis . University of Potsdam; Writing a Case Analysis . Writing Center, Baruch College; Volpe, Guglielmo. "Case Teaching in Economics: History, Practice and Evidence." Cogent Economics and Finance 3 (December 2015). doi:https://doi.org/10.1080/23322039.2015.1120977.

How to Approach Writing a Case Analysis Paper

The organization and structure of a case analysis paper can vary depending on the organizational setting, the situation, and how your professor wants you to approach the assignment. Nevertheless, preparing to write a case analysis paper involves several important steps. As Hawes notes, a case analysis assignment “...is useful in developing the ability to get to the heart of a problem, analyze it thoroughly, and to indicate the appropriate solution as well as how it should be implemented” [p.48]. This statement encapsulates how you should approach preparing to write a case analysis paper.

Before you begin to write your paper, consider the following analytical procedures:

Review the case to get an overview of the situation . A case can be only a few pages in length, however, it is most often very lengthy and contains a significant amount of detailed background information and statistics, with multilayered descriptions of the scenario, the roles and behaviors of various stakeholder groups, and situational events. Therefore, a quick reading of the case will help you gain an overall sense of the situation and illuminate the types of issues and problems that you will need to address in your paper. If your professor has provided questions intended to help frame your analysis, use them to guide your initial reading of the case.
Read the case thoroughly . After gaining a general overview of the case, carefully read the content again with the purpose of understanding key circumstances, events, and behaviors among stakeholder groups. Look for information or data that appears contradictory, extraneous, or misleading. At this point, you should be taking notes as you read because this will help you develop a general outline of your paper. The aim is to obtain a complete understanding of the situation so that you can begin contemplating tentative answers to any questions your professor has provided or, if they have not provided, developing answers to your own questions about the case scenario and its connection to the course readings,lectures, and class discussions.
Determine key stakeholder groups, issues, and events and the relationships they all have to each other . As you analyze the content, pay particular attention to identifying individuals, groups, or organizations described in the case and identify evidence of any problems or issues of concern that impact the situation in a negative way. Other things to look for include identifying any assumptions being made by or about each stakeholder, potential biased explanations or actions, explicit demands or ultimatums , and the underlying concerns that motivate these behaviors among stakeholders. The goal at this stage is to develop a comprehensive understanding of the situational and behavioral dynamics of the case and the explicit and implicit consequences of each of these actions.
Identify the core problems . The next step in most case analysis assignments is to discern what the core [i.e., most damaging, detrimental, injurious] problems are within the organizational setting and to determine their implications. The purpose at this stage of preparing to write your analysis paper is to distinguish between the symptoms of core problems and the core problems themselves and to decide which of these must be addressed immediately and which problems do not appear critical but may escalate over time. Identify evidence from the case to support your decisions by determining what information or data is essential to addressing the core problems and what information is not relevant or is misleading.
Explore alternative solutions . As noted, case analysis scenarios rarely have only one correct answer. Therefore, it is important to keep in mind that the process of analyzing the case and diagnosing core problems, while based on evidence, is a subjective process open to various avenues of interpretation. This means that you must consider alternative solutions or courses of action by critically examining strengths and weaknesses, risk factors, and the differences between short and long-term solutions. For each possible solution or course of action, consider the consequences they may have related to their implementation and how these recommendations might lead to new problems. Also, consider thinking about your recommended solutions or courses of action in relation to issues of fairness, equity, and inclusion.
Decide on a final set of recommendations . The last stage in preparing to write a case analysis paper is to assert an opinion or viewpoint about the recommendations needed to help resolve the core problems as you see them and to make a persuasive argument for supporting this point of view. Prepare a clear rationale for your recommendations based on examining each element of your analysis. Anticipate possible obstacles that could derail their implementation. Consider any counter-arguments that could be made concerning the validity of your recommended actions. Finally, describe a set of criteria and measurable indicators that could be applied to evaluating the effectiveness of your implementation plan.

Use these steps as the framework for writing your paper. Remember that the more detailed you are in taking notes as you critically examine each element of the case, the more information you will have to draw from when you begin to write. This will save you time.

NOTE : If the process of preparing to write a case analysis paper is assigned as a student group project, consider having each member of the group analyze a specific element of the case, including drafting answers to the corresponding questions used by your professor to frame the analysis. This will help make the analytical process more efficient and ensure that the distribution of work is equitable. This can also facilitate who is responsible for drafting each part of the final case analysis paper and, if applicable, the in-class presentation.

Framework for Case Analysis . College of Management. University of Massachusetts; Hawes, Jon M. "Teaching is Not Telling: The Case Method as a Form of Interactive Learning." Journal for Advancement of Marketing Education 5 (Winter 2004): 47-54; Rasche, Christoph and Achim Seisreiner. Guidelines for Business Case Analysis . University of Potsdam; Writing a Case Study Analysis . University of Arizona Global Campus Writing Center; Van Ness, Raymond K. A Guide to Case Analysis . School of Business. State University of New York, Albany; Writing a Case Analysis . Business School, University of New South Wales.

Structure and Writing Style

A case analysis paper should be detailed, concise, persuasive, clearly written, and professional in tone and in the use of language . As with other forms of college-level academic writing, declarative statements that convey information, provide a fact, or offer an explanation or any recommended courses of action should be based on evidence. If allowed by your professor, any external sources used to support your analysis, such as course readings, should be properly cited under a list of references. The organization and structure of case analysis papers can vary depending on your professor’s preferred format, but its structure generally follows the steps used for analyzing the case.

Introduction

The introduction should provide a succinct but thorough descriptive overview of the main facts, issues, and core problems of the case . The introduction should also include a brief summary of the most relevant details about the situation and organizational setting. This includes defining the theoretical framework or conceptual model on which any questions were used to frame your analysis.

Following the rules of most college-level research papers, the introduction should then inform the reader how the paper will be organized. This includes describing the major sections of the paper and the order in which they will be presented. Unless you are told to do so by your professor, you do not need to preview your final recommendations in the introduction. U nlike most college-level research papers , the introduction does not include a statement about the significance of your findings because a case analysis assignment does not involve contributing new knowledge about a research problem.

Background Analysis

Background analysis can vary depending on any guiding questions provided by your professor and the underlying concept or theory that the case is based upon. In general, however, this section of your paper should focus on:

Providing an overarching analysis of problems identified from the case scenario, including identifying events that stakeholders find challenging or troublesome,
Identifying assumptions made by each stakeholder and any apparent biases they may exhibit,
Describing any demands or claims made by or forced upon key stakeholders, and
Highlighting any issues of concern or complaints expressed by stakeholders in response to those demands or claims.

These aspects of the case are often in the form of behavioral responses expressed by individuals or groups within the organizational setting. However, note that problems in a case situation can also be reflected in data [or the lack thereof] and in the decision-making, operational, cultural, or institutional structure of the organization. Additionally, demands or claims can be either internal and external to the organization [e.g., a case analysis involving a president considering arms sales to Saudi Arabia could include managing internal demands from White House advisors as well as demands from members of Congress].

Throughout this section, present all relevant evidence from the case that supports your analysis. Do not simply claim there is a problem, an assumption, a demand, or a concern; tell the reader what part of the case informed how you identified these background elements.

Identification of Problems

In most case analysis assignments, there are problems, and then there are problems . Each problem can reflect a multitude of underlying symptoms that are detrimental to the interests of the organization. The purpose of identifying problems is to teach students how to differentiate between problems that vary in severity, impact, and relative importance. Given this, problems can be described in three general forms: those that must be addressed immediately, those that should be addressed but the impact is not severe, and those that do not require immediate attention and can be set aside for the time being.

All of the problems you identify from the case should be identified in this section of your paper, with a description based on evidence explaining the problem variances. If the assignment asks you to conduct research to further support your assessment of the problems, include this in your explanation. Remember to cite those sources in a list of references. Use specific evidence from the case and apply appropriate concepts, theories, and models discussed in class or in relevant course readings to highlight and explain the key problems [or problem] that you believe must be solved immediately and describe the underlying symptoms and why they are so critical.

Alternative Solutions

This section is where you provide specific, realistic, and evidence-based solutions to the problems you have identified and make recommendations about how to alleviate the underlying symptomatic conditions impacting the organizational setting. For each solution, you must explain why it was chosen and provide clear evidence to support your reasoning. This can include, for example, course readings and class discussions as well as research resources, such as, books, journal articles, research reports, or government documents. In some cases, your professor may encourage you to include personal, anecdotal experiences as evidence to support why you chose a particular solution or set of solutions. Using anecdotal evidence helps promote reflective thinking about the process of determining what qualifies as a core problem and relevant solution .

Throughout this part of the paper, keep in mind the entire array of problems that must be addressed and describe in detail the solutions that might be implemented to resolve these problems.

Recommended Courses of Action

In some case analysis assignments, your professor may ask you to combine the alternative solutions section with your recommended courses of action. However, it is important to know the difference between the two. A solution refers to the answer to a problem. A course of action refers to a procedure or deliberate sequence of activities adopted to proactively confront a situation, often in the context of accomplishing a goal. In this context, proposed courses of action are based on your analysis of alternative solutions. Your description and justification for pursuing each course of action should represent the overall plan for implementing your recommendations.

For each course of action, you need to explain the rationale for your recommendation in a way that confronts challenges, explains risks, and anticipates any counter-arguments from stakeholders. Do this by considering the strengths and weaknesses of each course of action framed in relation to how the action is expected to resolve the core problems presented, the possible ways the action may affect remaining problems, and how the recommended action will be perceived by each stakeholder.

In addition, you should describe the criteria needed to measure how well the implementation of these actions is working and explain which individuals or groups are responsible for ensuring your recommendations are successful. In addition, always consider the law of unintended consequences. Outline difficulties that may arise in implementing each course of action and describe how implementing the proposed courses of action [either individually or collectively] may lead to new problems [both large and small].

Throughout this section, you must consider the costs and benefits of recommending your courses of action in relation to uncertainties or missing information and the negative consequences of success.

The conclusion should be brief and introspective. Unlike a research paper, the conclusion in a case analysis paper does not include a summary of key findings and their significance, a statement about how the study contributed to existing knowledge, or indicate opportunities for future research.

Begin by synthesizing the core problems presented in the case and the relevance of your recommended solutions. This can include an explanation of what you have learned about the case in the context of your answers to the questions provided by your professor. The conclusion is also where you link what you learned from analyzing the case with the course readings or class discussions. This can further demonstrate your understanding of the relationships between the practical case situation and the theoretical and abstract content of assigned readings and other course content.

Problems to Avoid

The literature on case analysis assignments often includes examples of difficulties students have with applying methods of critical analysis and effectively reporting the results of their assessment of the situation. A common reason cited by scholars is that the application of this type of teaching and learning method is limited to applied fields of social and behavioral sciences and, as a result, writing a case analysis paper can be unfamiliar to most students entering college.

After you have drafted your paper, proofread the narrative flow and revise any of these common errors:

Unnecessary detail in the background section . The background section should highlight the essential elements of the case based on your analysis. Focus on summarizing the facts and highlighting the key factors that become relevant in the other sections of the paper by eliminating any unnecessary information.
Analysis relies too much on opinion . Your analysis is interpretive, but the narrative must be connected clearly to evidence from the case and any models and theories discussed in class or in course readings. Any positions or arguments you make should be supported by evidence.
Analysis does not focus on the most important elements of the case . Your paper should provide a thorough overview of the case. However, the analysis should focus on providing evidence about what you identify are the key events, stakeholders, issues, and problems. Emphasize what you identify as the most critical aspects of the case to be developed throughout your analysis. Be thorough but succinct.
Writing is too descriptive . A paper with too much descriptive information detracts from your analysis of the complexities of the case situation. Questions about what happened, where, when, and by whom should only be included as essential information leading to your examination of questions related to why, how, and for what purpose.
Inadequate definition of a core problem and associated symptoms . A common error found in case analysis papers is recommending a solution or course of action without adequately defining or demonstrating that you understand the problem. Make sure you have clearly described the problem and its impact and scope within the organizational setting. Ensure that you have adequately described the root causes w hen describing the symptoms of the problem.
Recommendations lack specificity . Identify any use of vague statements and indeterminate terminology, such as, “A particular experience” or “a large increase to the budget.” These statements cannot be measured and, as a result, there is no way to evaluate their successful implementation. Provide specific data and use direct language in describing recommended actions.
Unrealistic, exaggerated, or unattainable recommendations . Review your recommendations to ensure that they are based on the situational facts of the case. Your recommended solutions and courses of action must be based on realistic assumptions and fit within the constraints of the situation. Also note that the case scenario has already happened, therefore, any speculation or arguments about what could have occurred if the circumstances were different should be revised or eliminated.

Bee, Lian Song et al. "Business Students' Perspectives on Case Method Coaching for Problem-Based Learning: Impacts on Student Engagement and Learning Performance in Higher Education." Education & Training 64 (2022): 416-432; The Case Analysis . Fred Meijer Center for Writing and Michigan Authors. Grand Valley State University; Georgallis, Panikos and Kayleigh Bruijn. "Sustainability Teaching using Case-Based Debates." Journal of International Education in Business 15 (2022): 147-163; Hawes, Jon M. "Teaching is Not Telling: The Case Method as a Form of Interactive Learning." Journal for Advancement of Marketing Education 5 (Winter 2004): 47-54; Georgallis, Panikos, and Kayleigh Bruijn. "Sustainability Teaching Using Case-based Debates." Journal of International Education in Business 15 (2022): 147-163; .Dean, Kathy Lund and Charles J. Fornaciari. "How to Create and Use Experiential Case-Based Exercises in a Management Classroom." Journal of Management Education 26 (October 2002): 586-603; Klebba, Joanne M. and Janet G. Hamilton. "Structured Case Analysis: Developing Critical Thinking Skills in a Marketing Case Course." Journal of Marketing Education 29 (August 2007): 132-137, 139; Klein, Norman. "The Case Discussion Method Revisited: Some Questions about Student Skills." Exchange: The Organizational Behavior Teaching Journal 6 (November 1981): 30-32; Mukherjee, Arup. "Effective Use of In-Class Mini Case Analysis for Discovery Learning in an Undergraduate MIS Course." The Journal of Computer Information Systems 40 (Spring 2000): 15-23; Pessoa, Silviaet al. "Scaffolding the Case Analysis in an Organizational Behavior Course: Making Analytical Language Explicit." Journal of Management Education 46 (2022): 226-251: Ramsey, V. J. and L. D. Dodge. "Case Analysis: A Structured Approach." Exchange: The Organizational Behavior Teaching Journal 6 (November 1981): 27-29; Schweitzer, Karen. "How to Write and Format a Business Case Study." ThoughtCo. https://www.thoughtco.com/how-to-write-and-format-a-business-case-study-466324 (accessed December 5, 2022); Reddy, C. D. "Teaching Research Methodology: Everything's a Case." Electronic Journal of Business Research Methods 18 (December 2020): 178-188; Volpe, Guglielmo. "Case Teaching in Economics: History, Practice and Evidence." Cogent Economics and Finance 3 (December 2015). doi:https://doi.org/10.1080/23322039.2015.1120977.

Writing Tip

Ca se Study and Case Analysis Are Not the Same!

Confusion often exists between what it means to write a paper that uses a case study research design and writing a paper that analyzes a case; they are two different types of approaches to learning in the social and behavioral sciences. Professors as well as educational researchers contribute to this confusion because they often use the term "case study" when describing the subject of analysis for a case analysis paper. But you are not studying a case for the purpose of generating a comprehensive, multi-faceted understanding of a research problem. R ather, you are critically analyzing a specific scenario to argue logically for recommended solutions and courses of action that lead to optimal outcomes applicable to professional practice.

To avoid any confusion, here are twelve characteristics that delineate the differences between writing a paper using the case study research method and writing a case analysis paper:

Case study is a method of in-depth research and rigorous inquiry ; case analysis is a reliable method of teaching and learning . A case study is a modality of research that investigates a phenomenon for the purpose of creating new knowledge, solving a problem, or testing a hypothesis using empirical evidence derived from the case being studied. Often, the results are used to generalize about a larger population or within a wider context. The writing adheres to the traditional standards of a scholarly research study. A case analysis is a pedagogical tool used to teach students how to reflect and think critically about a practical, real-life problem in an organizational setting.
The researcher is responsible for identifying the case to study; a case analysis is assigned by your professor . As the researcher, you choose the case study to investigate in support of obtaining new knowledge and understanding about the research problem. The case in a case analysis assignment is almost always provided, and sometimes written, by your professor and either given to every student in class to analyze individually or to a small group of students, or students select a case to analyze from a predetermined list.
A case study is indeterminate and boundless; a case analysis is predetermined and confined . A case study can be almost anything [see item 9 below] as long as it relates directly to examining the research problem. This relationship is the only limit to what a researcher can choose as the subject of their case study. The content of a case analysis is determined by your professor and its parameters are well-defined and limited to elucidating insights of practical value applied to practice.
Case study is fact-based and describes actual events or situations; case analysis can be entirely fictional or adapted from an actual situation . The entire content of a case study must be grounded in reality to be a valid subject of investigation in an empirical research study. A case analysis only needs to set the stage for critically examining a situation in practice and, therefore, can be entirely fictional or adapted, all or in-part, from an actual situation.
Research using a case study method must adhere to principles of intellectual honesty and academic integrity; a case analysis scenario can include misleading or false information . A case study paper must report research objectively and factually to ensure that any findings are understood to be logically correct and trustworthy. A case analysis scenario may include misleading or false information intended to deliberately distract from the central issues of the case. The purpose is to teach students how to sort through conflicting or useless information in order to come up with the preferred solution. Any use of misleading or false information in academic research is considered unethical.
Case study is linked to a research problem; case analysis is linked to a practical situation or scenario . In the social sciences, the subject of an investigation is most often framed as a problem that must be researched in order to generate new knowledge leading to a solution. Case analysis narratives are grounded in real life scenarios for the purpose of examining the realities of decision-making behavior and processes within organizational settings. A case analysis assignments include a problem or set of problems to be analyzed. However, the goal is centered around the act of identifying and evaluating courses of action leading to best possible outcomes.
The purpose of a case study is to create new knowledge through research; the purpose of a case analysis is to teach new understanding . Case studies are a choice of methodological design intended to create new knowledge about resolving a research problem. A case analysis is a mode of teaching and learning intended to create new understanding and an awareness of uncertainty applied to practice through acts of critical thinking and reflection.
A case study seeks to identify the best possible solution to a research problem; case analysis can have an indeterminate set of solutions or outcomes . Your role in studying a case is to discover the most logical, evidence-based ways to address a research problem. A case analysis assignment rarely has a single correct answer because one of the goals is to force students to confront the real life dynamics of uncertainly, ambiguity, and missing or conflicting information within professional practice. Under these conditions, a perfect outcome or solution almost never exists.
Case study is unbounded and relies on gathering external information; case analysis is a self-contained subject of analysis . The scope of a case study chosen as a method of research is bounded. However, the researcher is free to gather whatever information and data is necessary to investigate its relevance to understanding the research problem. For a case analysis assignment, your professor will often ask you to examine solutions or recommended courses of action based solely on facts and information from the case.
Case study can be a person, place, object, issue, event, condition, or phenomenon; a case analysis is a carefully constructed synopsis of events, situations, and behaviors . The research problem dictates the type of case being studied and, therefore, the design can encompass almost anything tangible as long as it fulfills the objective of generating new knowledge and understanding. A case analysis is in the form of a narrative containing descriptions of facts, situations, processes, rules, and behaviors within a particular setting and under a specific set of circumstances.
Case study can represent an open-ended subject of inquiry; a case analysis is a narrative about something that has happened in the past . A case study is not restricted by time and can encompass an event or issue with no temporal limit or end. For example, the current war in Ukraine can be used as a case study of how medical personnel help civilians during a large military conflict, even though circumstances around this event are still evolving. A case analysis can be used to elicit critical thinking about current or future situations in practice, but the case itself is a narrative about something finite and that has taken place in the past.
Multiple case studies can be used in a research study; case analysis involves examining a single scenario . Case study research can use two or more cases to examine a problem, often for the purpose of conducting a comparative investigation intended to discover hidden relationships, document emerging trends, or determine variations among different examples. A case analysis assignment typically describes a stand-alone, self-contained situation and any comparisons among cases are conducted during in-class discussions and/or student presentations.

The Case Analysis . Fred Meijer Center for Writing and Michigan Authors. Grand Valley State University; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Ramsey, V. J. and L. D. Dodge. "Case Analysis: A Structured Approach." Exchange: The Organizational Behavior Teaching Journal 6 (November 1981): 27-29; Yin, Robert K. Case Study Research and Applications: Design and Methods . 6th edition. Thousand Oaks, CA: Sage, 2017; Crowe, Sarah et al. “The Case Study Approach.” BMC Medical Research Methodology 11 (2011): doi: 10.1186/1471-2288-11-100; Yin, Robert K. Case Study Research: Design and Methods . 4th edition. Thousand Oaks, CA: Sage Publishing; 1994.

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Case Study Analysis: Examples + How-to Guide & Writing Tips

A case study analysis is a typical assignment in business management courses. The task aims to show high school and college students how to analyze a current situation, determine what problems exist, and develop the best possible strategy to achieve the desired outcome.

Many students feel anxious about writing case analyses because being told to analyze a case study and provide a solution can seem like a big task. That is especially so when working with real-life scenarios. However, you can rest assured writing a case analysis paper is easier than you think. Just keep reading this article and you will find case study examples for students and the advice provided by Custom-writing experts!

👣 Main Steps
🕵 Preparing the Case

🔬 Analyzing the Case

📑 Format & Structure
🙅 Things to Avoid
🏁 Conclusion

🔗 References

👣 writing a case study analysis: main steps.

Business management is built on case analysis. Every single economic result shows that the methods and instruments employed were either well-timed and expedient, in the event of success, or not, in case of failure. These two options indicate whether the strategy is efficient (and should be followed) or requires corrections (or complete change). Such an approach to the case study will make your writing piece more proficient and valuable for the reader. The following steps will direct your plan for writing a case study analysis.

Step 1: Preliminary work

Make notes and highlight the numbers and ideas that could be quoted.
Single out as many problems as you can, and briefly mark their underlying issues. Then make a note of those responsible. In the report, you will use two to five of the problems, so you will have a selection to choose from.
Outline a possible solution to each of the problems you found. Course readings and outside research shall be used here. Highlight your best and worst solution for further reference.

Case Study Analysis Includes Three Main Steps: Preparing the Case, Drafring the Case, and Finalizing the Case.

Step 2: Drafting the Case

Provide a general description of the situation and its history.
Name all the problems you are going to discuss.
Specify the theory used for the analysis.
Present the assumptions that emerged during the analysis, if any.
Describe the detected problems in more detail.
Indicate their link to, and effect on, the general situation.
Explain why the problems emerged and persist.
List realistic and feasible solutions to the problems you outlined, in the order of importance.
Specify your predicted results of such changes.
Support your choice with reliable evidence (i.e., textbook readings, the experience of famous companies, and other external research).
Define the strategies required to fulfill your proposed solution.
Indicate the responsible people and the realistic terms for its implementation.
Recommend the issues for further analysis and supervision.

Step 3: Finalizing the Case

Like any other piece of writing, a case analysis requires post-editing. Carefully read it through, looking for inconsistencies and gaps in meaning. Your purpose is to make it look complete, precise, and convincing.

🕵 Preparing a Case for Analysis

Your professor might give you various case study examples from which to choose, or they may just assign you a particular case study. To conduct a thorough data analysis, you must first read the case study. This might appear to be obvious. However, you’d be surprised at how many students don’t take adequate time to complete this part.

Read the case study very thoroughly, preferably several times. Highlight, underline, flag key information, and make notes to refer to later when you are writing your analysis report.

If you don’t have a complete knowledge of the case study your professor has assigned, you won’t conduct a proper analysis of it. Even if you make use of a business case study template or refer to a sample analysis, it won’t help if you aren’t intimately familiar with your case study.

You will also have to conduct research. When it comes to research, you will need to do the following:

Gather hard, quantitative data (e.g. 67% of the staff participated in the meeting).
Design research tools , such as questionnaires and surveys (this will aid in gathering data).
Determine and suggest the best specific, workable solutions.

It would be best if you also learned how to analyze a case study. Once you have read through the case study, you need to determine the focus of your analysis. You can do this by doing the following:

Identify	E.g., the loss of brand identity as a problem faced by Starbucks
Analyze of the existing problem
Establish between the various factors	Starbucks’ brand image – possible sources of influence:
Formulate to address the problem

Compare your chosen solutions to the solutions offered by the experts who analyzed the case study you were given or to online assignments for students who were dealing with a similar task. The experts’ solutions will probably be more advanced than yours simply because these people are more experienced. However, don’t let this discourage you; the whole point of doing this analysis is to learn. Use the opportunity to learn from others’ valuable experience, and your results will be better next time.

If you are still in doubt, the University of South Carolina offers a great guide on forming a case study analysis.

📑 Case Analysis Format & Structure

When you are learning how to write a case study analysis, it is important to get the format of your analysis right. Understanding the case study format is vital for both the professor and the student. The person planning and handing out such an assignment should ensure that the student doesn’t have to use any external sources .

In turn, students have to remember that a well-written case analysis provides all the data, making it unnecessary for the reader to go elsewhere for information.

Regardless of whether you use a case study template, you will need to follow a clear and concise format when writing your analysis report. There are some possible case study frameworks available. Still, a case study should contain eight sections laid out in the following format:

Describe the purpose of the current case study;
Provide a summary of the company;
Briefly introduce the problems and issues found in the case study
Discuss the theory you will be using in the analysis;
Present the key points of the study and present any assumptions made during the analysis.
Present each problem you have singled out;
Justify your inclusion of each problem by providing supporting evidence from the case study and by discussing relevant theory and what you have learned from your course content;
Divide the section (and following sections) into subsections, one for each of your selected problems.
Present a summary of each problem you have identified;
Present plausible solutions for each of the problems, keeping in mind that each problem will likely have more than one possible solution;
Provide the pros and cons of each solution in a way that is practical.
Conclusion . This is a summary of your findings and discussion.
Decide which solution best fits each of the issues you identified;
Explain why you chose this solution and how it will effectively solve the problem;
Be persuasive when you write this section so that you can drive your point home;
Be sure to bring together theory and what you have learned throughout your course to support your recommendations.
Provide an explanation of what must be done, who should take action, and when the solution should be carried out;
Where relevant, you should provide an estimate of the cost in implementing the solution, including both the financial investment and the cost in terms of time.
References. While you generally do not need to refer to many external sources when writing a case study analysis, you might use a few. When you do, you will need to properly reference these sources, which is most often done in one of the main citation styles, including APA, MLA, or Harvard. There is plenty of help when citing references, and you can follow these APA guidelines , these MLA guidelines , or these Harvard guidelines .
Appendices. This is the section you include after your case study analysis if you used any original data in the report. These data, presented as charts, graphs, and tables, are included here because to present them in the main body of the analysis would be disruptive to the reader. The University of Southern California provides a great description of appendices and when to make use of them.

When you’ve finished your first draft, be sure to proofread it. Look not only for potential grammar and spelling errors but also for discrepancies or holes in your argument.

You should also know what you need to avoid when writing your analysis.

🙅 Things to Avoid in Case Analysis

Whenever you deal with a case study, remember that there are some pitfalls to avoid! Beware of the following mistakes:

Excessive use of colloquial language . Even though it is a study of an actual case, it should sound formal.
Lack of statistical data . Give all the important data, both in percentages and in numbers.
Excessive details. State only the most significant facts, rather than drowning the reader in every fact you find.
Inconsistency in the methods you have used . In a case study, theory plays a relatively small part, so you must develop a specific case study research methodology.
Trivial means of research . It is critical that you design your own case study research method in whatever form best suits your analysis, such as questionnaires and surveys.

It is useful to see a few examples of case analysis papers. After all, a sample case study report can provide you with some context so you can see how to approach each aspect of your paper.

👀 Case Study Examples for Students

It might be easier to understand how a case study analysis works if you have an example to look at. Fortunately, examples of case studies are easy to come by. Take a look at this video for a sample case study analysis for the Coca-Cola Company.

If you want another example, then take a look at the one below!

Business Case Analysis: Example

CRM’s primary focus is customers and customer perception of the brand or the company. The focus may shift depending on customers’ needs. The main points that Center Parcs should consider are an increase in customer satisfaction and its market share. Both of these points will enhance customer perception of the product as a product of value. Increased customer satisfaction will indicate that the company provides quality services, and increased market share can reduce the number of switching (or leaving) customers, thus fostering customer loyalty.

Case Study Topics

Equifax case study: the importance of cybersecurity measures.
Study a case illustrating ethical issues of medical research.
Examine the case describing the complications connected with nursing and residential care.
Analyze the competitive strategy of Delta Airlines .
Present a case study of an ethical dilemma showing the conflict between the spirit and the letter of the law.
Explore the aspects of Starbucks’ marketing strategyin a case study.
Research a case of community-based clinic organization and development.
Customer service of United Airlines: a case study .
Analyze a specific schizophrenia case and provide your recommendations.
Provide a case study of a patient with hyperglycemia.
Examine the growth strategy of United Healthcare.
Present a case study demonstrating ethical issues in business.
Study a case of the 5% shareholding rule application and its impact on the company.
Case study of post-traumatic stress disorder .
Analyze a case examining the issues of cross-cultural management .
Write a case study exploring the ethical issues the finance manager of a long-term care facility can face and the possible reaction to them.
Write a case study analyzing the aspects of a new president of a firm election.
Discuss the specifics of supply chain management in the case of Tehindo company.
Study a case of a life crisis in a family and the ways to cope with it.
Case study of Tea Leaves and More: supply chain issues.
Explore the case of ketogenic diet implementation among sportspeople.
Analyze the case of Webster Jewelry shop and suggest some changes.
Examine the unique aspects of Tea and More brand management.
Adidas case study: an ethical dilemma .
Research the challenges of Brazos Valley Food Bank and suggest possible solutions.
Describe the case of dark web monitoring for business.
Study a case of permissive parenting style .
Case study of Starbucks employees.
Analyze a case of workplace discrimination and suggest a strategy to avoid it.
Examine a case of the consumer decision-making process and define the factors that influence it.
Present a case study of Netflix illustrating the crucial role of management innovation for company development.
Discuss a case describing a workplace ethical issue and propose ways to resolve it.
Case study of the 2008 financial crisis: Graham’s value investing principles in the modern economic climate.
Write a case study analyzing the harmful consequences of communication issues in a virtual team.
Analyze a case that highlights the importance of a proper functional currency choice.
Examine the case of Hitachi Power Systems management.
Present a case study of medication research in a healthcare facility.
Study the case of Fiji Water and the challenges the brand faces.
Research a social problem case and suggest a solution.
Analyze a case that reveals the connection between alcohol use and borderline personality disorder.
Transglobal Airline case study: break-even analysis.
Examine the case of Chiquita Brands International from the moral and business ethics points of view.
Present a case study of applying for Social Security benefits.
Study the case of a mass hacker attack on Microsoft clients and suggest possible ways to prevent future attacks.
Case study of leadership effectiveness.
Analyze a case presenting a clinical moral dilemma and propose ways to resolve it.
Describe the case of Cowbell Brewing Company and discuss the strategy that made them successful.
Write a case study of WeWork company and analyze the strengths and weaknesses of its strategy.
Case study of medical ethical decision-making.
Study the case of The Georges hotel and suggest ways to overcome its managerial issues.

🏁 Concluding Remarks

Writing a case study analysis can seem incredibly overwhelming, especially if you have never done it before. Just remember, you can do it provided you follow a plan, keep to the format described here, and study at least one case analysis example.

If you still need help analyzing a case study, your professor is always available to answer your questions and point you in the right direction. You can also get help with any aspect of the project from a custom writing company. Just tackle the research and hand over the writing, write a rough draft and have it checked by a professional, or completely hand the project off to an expert writer.

Regardless of the path you choose, you will turn in something of which you can be proud!

✏️ Case Study Analysis FAQ

Students (especially those who study business) often need to write a case study analysis. It is a kind of report that describes a business case. It includes multiple aspects, for example, the problems that exist, possible solutions, forecasts, etc.

There should be 3 main points covered in a case study analysis:

The challenge(s) description,
Possible solutions,
Outcomes (real and/or foreseen).

Firstly, study some examples available online and in the library. Case study analysis should be a well-structured paper with all the integral components in place. Thus, you might want to use a template and/or an outline to start correctly.

A case study analysis is a popular task for business students. They typically hand it in the format of a paper with several integral components:

Description of the problem
Possible ways out
Results and/or forecasts

Students sometimes tell about the outcome of their research within an oral presentation.

Case Study: Academia
Windows of vulnerability: a case study analysis (IEEE)
A (Very) Brief Refresher on the Case Study Method: SAGE
The case study approach: Medical Research Methodology
Strengths and Limitations of Case Studies: Stanford University
A Sample APA Paper: Radford University
How to Write a Case Study APA Style: Seattle PI
The Case Analysis: GVSU
How to Outline: Purdue OWL
Incorporating Interview Data: UW-Madison Writing Center
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Quite an impressive piece The steps and procedures outlined here are well detailed and the examples facilitates understanding.

it was very helpful. I have an assessment to write where in I need to mention different effective components that are needed to compile a high quality case study assessment.

It is very important and helpful.

Thanks a lot. A knowledge shared with a structured template. Stay the course

Thanks for this valuable knowledge.I loved this. keep sharing. to know more about click Air India Case Study – Why Air India failed ?

This is going to be a great help in my monthly analysis requirements for my subject. Thank you so much.

Thank you very much for this insightful guidelines… It has really been a great tool for writing my project. Thanks once again.

This article was very helpful, even though I’ll have a clearer mind only after I do the case study myself but I felt very much motivated after reading this, as now I can at least have a plan of what to do compared to the clueless me I was before I read it. I hope if I have any questions or doubts about doing a case study I can clear it out here.

Digitalizing Smallholder Farmer Agri-Food Supply Chains: A Case Study from a Developing Economy

Conference paper
First Online: 07 September 2024
Cite this conference paper

W. Madushan Fernando ORCID: orcid.org/0000-0003-4505-980X 19 , 20 ,
Amila Thibbotuwawa ORCID: orcid.org/0000-0002-5443-8839 20 ,
R. M. Chandima Ratnayake ORCID: orcid.org/0000-0003-2222-8199 19 &
H. Niles Perera ORCID: orcid.org/0000-0001-6329-5967 20

Part of the book series: IFIP Advances in Information and Communication Technology ((IFIPAICT,volume 731))

Included in the following conference series:

IFIP International Conference on Advances in Production Management Systems

Smallholder farming is critical to ensuring food security and alleviating rural poverty. Poor agricultural practices, supply chain inefficiencies, weather challenges, and market disruptions all diminish productivity in this sector. As modern technology and digitalization reshape agriculture, there is a significant augmentation of stakeholder connectivity within smallholder farmer Agri-Food Supply Chains (AFSCs). The progress of technology allows smallholder farmers to gain access to high-quality farming inputs while expanding their market reach. While there are proven benefits of digitally transforming smallholder farmer AFSCs, there is still a significant knowledge gap in effectively assessing the potential of digital technologies from a supply chain perspective. As the overall approach in this paper, we used the case study research method along with inductive reasoning. We combined the AHP and Technique for Order Preference by Similarity to Ideal Solution (TOPSIS) methods to include both industry practitioners and academic perspectives in the decision-making process. The process involved using AHP to analyze supply chain inefficiencies, with a focus on their impact on yield, harvest quality, and farmer livelihood, and then using the TOPSIS method to prioritize digital solutions for the chosen case study. The case study revealed that 61% of inefficiencies arose in the early supply chain stages, notably in regulation (28.26%) and farm input supply (33.03%), emphasizing the critical need for prioritizing digital farm record-keeping and registration for improved efficiency. This study emphasizes practical digital solutions for smallholder farming supply chains while integrating industry and academic perspectives, offering a systematic approach to prioritizing interventions.

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Kuizinaitė, J., Morkūnas, M., Volkov, A.: Assessment of the most appropriate measures for mitigation of risks in the agri-food supply chain. Sustainability (Switzerland) 15 (12) (2023). https://doi.org/10.3390/su15129378

Yi, Z., Wang, Y., Chen, Y.J.: Financing an agricultural supply chain with a capital-constrained smallholder farmer in developing economies. Prod. Oper. Manag. 30 (7), 2102–2121 (2021). https://doi.org/10.1111/poms.13357

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Acknowledgment

The authors would like to acknowledge the financial support given by the Norwegian Program for Capacity Development in Higher Education and Research for Development (NORHED II – Project number 68085), the “Politics and Economic Governance” sub-theme, the project “Enhancing Lean Practices in Supply Chains: Digitalization”, which is a collaboration between the University of Stavanger (Norway), ITB (Indonesia), and the University of Moratuwa (Sri Lanka).

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Fernando, W.M., Thibbotuwawa, A., Ratnayake, R.M.C., Perera, H.N. (2024). Digitalizing Smallholder Farmer Agri-Food Supply Chains: A Case Study from a Developing Economy. In: Thürer, M., Riedel, R., von Cieminski, G., Romero, D. (eds) Advances in Production Management Systems. Production Management Systems for Volatile, Uncertain, Complex, and Ambiguous Environments. APMS 2024. IFIP Advances in Information and Communication Technology, vol 731. Springer, Cham. https://doi.org/10.1007/978-3-031-71633-1_12

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Critical factors driving construction project performance in integrated 5d building information modeling.

1. Introduction

2. materials and methods, 2.1. procedure for the systematic literature review, 2.2. search strategy, 2.3. tools and software, 2.4. data resources, 2.5. prisma flow for systematic review, 2.6. network analysis, 3.1. development trends for 5d bim in the construction industry, 3.1.1. publications per year, 3.1.2. major countries or regions undertaking research, 3.1.3. key productive authors, 3.1.4. keyword co-occurrence and cluster identification, 3.2. factors significantly affecting the adoption of 5d bim, 3.3. key project performance factors affected by the implementation of 5d bim, 4. discussion, 4.1. evolution of 5d bim in the construction industry, 4.1.1. citation bursts and trend evaluation, 4.1.2. cluster analysis, 4.2. critical factors influencing the implementation of 5d bim, 4.2.1. technology factors, 4.2.2. organizational factors, 4.2.3. environmental factors, 4.2.4. operator factors, 4.2.5. project factors, 4.2.6. government policy, 4.3. key performance indicators affected by the implementation of 5d bim, 4.3.1. project cost performance, 4.3.2. project time performance, 4.3.3. project quality performance, 5. limitations and future research directions, 6. conclusions, author contributions, data availability statement, conflicts of interest.

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Click here to enlarge figure

No.	Questions
1	How has 5D BIM evolved in the construction industry over the past decade?
2	Which factors significantly influence the adoption of 5D BIM in the construction industry?
3	In what ways does 5D BIM impact project performance indicators?

Search string

(TITLE-ABS-KEY (“5D BIM”) OR TITLE-ABS-KEY (“BIM 5D”) OR TITLE-ABS-KEY (“5D Building Information Modeling”) OR TITLE-ABS-KEY (“the fifth dimension of BIM”) OR TITLE-ABS-KEY(“5 Dimensional Building Information Modeling”) OR TITLE-ABS-KEY(“Building Information Modeling 5D”) OR TITLE-ABS-KEY (“5D”) AND TITLE-ABS-KEY (“BIM”)) AND ((EXCLUDE (PUBYEAR, 2007) OR EXCLUDE (PUBYEAR, 2008) OR EXCLUDE (PUBYEAR, 2010) OR EXCLUDE (PUBYEAR, 2011) OR EXCLUDE (PUBYEAR, 2012) OR EXCLUDE (PUBYEAR, 2013) OR EXCLUDE (PUBYEAR, 2024))

No.	Eligibility for Inclusion
1	Studies addressing the topic of 5D BIM or other synonyms
2	Studies published in the English language
3	Studies directly related to construction
4	Peer-reviewed publications (to ensure the inclusion of high-quality research)
5	Studies with a length of at least three pages
6	Articles with an explicit research title, abstract, and keywords

Software/Tool	Function (s)	Reference
VOSviewer 1.6.20	Visualization and analysis of SLR data	[ ]
CiteSpace v.6.2.R6 (64-bit) Advanced	SLR cluster analysis/development path recording	[ ]
Microsoft Excel	Gathering, preserving, and displaying data	[ ]
Zotero 6.0.36	Literature management	[ ]

Author	Documents	Total Citations	Proportion
Hosseini, M. Reza	6	285	2.70%
Abrishami, Sepehr	5	273	2.25%
Elghaish, Faris	5	224	2.25%
Gaterell, Mark	3	100	1.35%
Li, Hua	3	27	1.35%
Brioso, Xavier	3	13	1.35%
Pan, Yangshao	3	9	1.35%
Guan, Changsheng	3	2	1.35%
Vitasek, Stanislav	3	6	1.35%

Factor Category	Sub-Categories	References
People/operational factors	Experts with training in operating tools	[ , , , , , , ]
	Awareness of the project’s scope	[ , , , ]
	Prior experience partnering on 5D BIM projects	[ , ]
	Willingness to use 5D BIM	[ , , , , ]
	Collaboration concept among relevant stakeholders	[ , , , , , , ]
Technological factors	Capacity of technology infrastructure	[ , , , ]
	Conflicting implementation strategies of conventional approaches and 5D BIM	[ , , ]
	Availability of IT support	[ , , ]
	Compatibility with current industry standards	[ , ]
	Compatibility between software	[ , , , ]
Organizational factors	Awareness of company	[ , , , , ]
	Rationalization of the organizational structure of construction projects	[ , ]
	Constructability	[ , ]
	Level of project data management	[ , ]
	Costs related to BIM technology	[ , , , , , ]
Project-related factors	Provision of 3D modeling/design	[ , , , ]
	Provision of 4D modeling/schedule of constructionactivities	[ , ]
	Difficulty in checking documents caused by conflict detection	[ , , ]
	Incomplete/inaccurate data	[ , , , ]
	Predictability of project outcomes	[ , , ]
Environmental factors	Market demand	[ , ]
	Increasing competition in the construction industry	[ , ]
	Demand for sustainable urbanization	[ , , ]
	Business situation	[ , ]
	Cultural resistance preventing adoption	[ , , ]
Strategy/government policy	Standards and guidelines related to BIM	[ , , , , , , , , ]
	Contract standards for projects with BIM	[ , , , , ]
	Dispute settlement mechanisms for projects with BIM	[ , , ]
	Publicity and promotion for BIM	[ , , , ]
	Protection for intellectual property rights related to 5D BIM	[ , , ]

Factor Category	Sub-Category	References
Project cost performance	Cost estimation	[ , , , , , , , , , , , , , , , , , ]
	Cost control	[ , , , , , , , , , , , , , , ]
	Cost budgeting	[ , , , , , , , , , , ]
	Quantity takeoff	[ , , , , , , , ]
	Claims	[ , , , ]
Project time performance	Enhanced decision making	[ , , , ]
	Scheduled variance analysis	[ , , , , , , ]
	Shorter project times through coordination	[ , , ]
	Time risk management	[ , , , , , , ]
	Time-efficient construction delivery	[ , ]
Project quality performance	Sustainable development of the construction project	[ , ]
	Continuous improvement/process optimization	[ , , , ]
	Quality of data documentation	[ , , , ]
	Reductions in defects and quality errors	[ , ]
	Satisfactory workplace environment	[ , , ]

Category	KPIs	References
Project cost performance indicators	Cost performance	[ , ]
	Cost predictability	[ , ]
	Project cost growth	[ ]
	Change cost factor	[ , ]
	Project budget factor	[ , ]
Project time performance indicators	Time predictability	[ , ]
	Schedule performance	[ , ]
	Change in project schedule	[ , ]
Project quality performance indicators	Quality/high-quality performance	[ , ]
	Rework	[ , ]
	Defects and quality errors	[ , ]

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Sun, H.; Khoo, T.J.; Esa, M.; Mahdiyar, A.; Li, J. Critical Factors Driving Construction Project Performance in Integrated 5D Building Information Modeling. Buildings 2024 , 14 , 2807. https://doi.org/10.3390/buildings14092807

Sun H, Khoo TJ, Esa M, Mahdiyar A, Li J. Critical Factors Driving Construction Project Performance in Integrated 5D Building Information Modeling. Buildings . 2024; 14(9):2807. https://doi.org/10.3390/buildings14092807

Sun, Hui, Terh Jing Khoo, Muneera Esa, Amir Mahdiyar, and Jiguang Li. 2024. "Critical Factors Driving Construction Project Performance in Integrated 5D Building Information Modeling" Buildings 14, no. 9: 2807. https://doi.org/10.3390/buildings14092807

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Published: 04 September 2024

Palatal groove associated with periodontal lesions: a systematic review illustrated by a decisional tree for management

Yvan Gaudex 1 , 2 ,
Vianney Gandillot 1 , 2 , 7 ,
Isabelle Fontanille 3 ,
Philippe Bouchard 1 , 2 ,
Stephane Kerner 1 , 2 , 4 , 5 &
Maria Clotilde Carra 1 , 2 , 6

BMC Oral Health volume 24 , Article number: 1037 ( 2024 ) Cite this article

Metrics details

Palatal groove represents a relatively uncommon developmental root anomaly, usually found on the palatal aspect of maxillary incisors. While its origin is controversial, its presence predisposes to severe periodontal defects.

This study aimed to provide a systematic review of the literature focusing on the varied diagnostic techniques and treatment modalities for periodontal lesions arising from the presence of palatal groove. Based on the existing evidence and knowledge, the study also provides a comprehensive decisional tree, guiding clinicians in the challenging decision-making process face to a palatal groove.

The literature search was conducted on Medline and Cochrane databases by two independent reviewers, who also performed the screening and selection process, looking for English written articles reporting on diagnosis and management (all treatment approaches) of periodontal lesion(s) associated with a palatal groove. Based on this literature, a comprehensive decisional tree, including a standardized palatal groove evaluation and tailored treatment approaches, is proposed. Moreover, a clinical case is described to demonstrate the practical application of the developed decisional tree.

Over a total of 451 articles initially identified, 34 were selected, describing 40 patients with 40 periodontal lesions associated with palatal grooves. The case report illustrates a deep, large, circumferential intra-bony defect on the palatal side of the tooth #22 associated with a shallow, moderately long palatal groove in an 18-year-old male patient. Following reevaluation, a single flap surgery was deemed necessary, combined with a regenerative procedure. At 2 years post-treatment, the tooth #22 is healthy, in a functional and esthetic position. The decision-making process, based on local and systemic patient’s conditions, should allow an early and precise diagnosis to prevent further complications and undertake an adequate treatment.

Palatal grooves are relatively rare; however, they are frequently associated with severe periodontal defects. The identification, diagnosis, prompt, and tailored management of the associated lesion is essential to mitigate potential periodontal and endodontic complications related to the presence of palatal groove.

Systematic Review Registration

[ https://www.crd.york.ac.uk/prospero/ ], identifier [C CRD42022363194].

Peer Review reports

Introduction

Palatal groove (PG) is defined as an anatomic anomaly characterized by the presence of a developmental groove on a dental root that, when present, is usually found on the palatal aspect of maxillary incisors [ 1 ]. Over the years, several terms have been used to describe this anomaly, including palatal or palate-gingival groove [ 2 , 3 ], developmental radicular anomaly [ 4 ], distolingual groove [ 5 ], radicular lingual groove [ 6 , 7 ], palatoradicular groove [ 8 , 9 ], radicular groove [ 10 ], and cinguloradicular groove [ 11 ].

The origin of the PG is controversial, but it is assumed to be related to the infolding of the enamel organ or Hertwig epithelial root sheath during the tooth development [ 12 ]. Additional hypogenetic root formation [ 13 , 14 ] as well as an altered genetic mechanism [ 15 ] have also been suggested.

PG is relatively rare. Everett et al. [ 5 ] reported a prevalence of PG on 2.8% of lateral incisors whereas Withers et al. [ 16 ] observed a PG on 2.3% of maxillary incisors (4.4% of maxillary laterals and 0.28% of maxillary centrals). Kogon et al. [ 8 ] examined 3168 extracted maxillary central and lateral incisors and found PG on 4.6% of them (3.4% of maxillary centrals and 5.6% of maxillary lateral incisors), with over half of the PG extending more than 5 mm apical to the cementoenamel junction leading to a localized periodontal lesion. The most recent study by Mazzi-Chevez et al. [ 17 ] observed 150 maxillary central incisors, lateral incisors, and canines with a micro-CT and found that PG affected 2% of central incisors and 4% of lateral incisors. In 100% of cases, the PG originated in the enamel.

As the term implies, PG is formed around the cingulum of the tooth and continues apically down from the cementoenamel junction, terminating at various depths and length along the root [ 18 ]. In contrast to maxillary bicuspids, incisors generally display a U-shaped groove.

This anatomic anomaly is frequently associated with a breakdown of the periodontal attachment involving the groove; a self-sustaining localized periodontal pocket can develop [ 4 ], where the PG itself provides a site for bacterial accumulation. The subsequent progressive inflammation along the PG and its apical portion may lead to periodontal and endodontic pathologic conditions [ 19 ]. Furthermore, there may be communication between the pulp canal system and the periodontium through the pulp cavity and/or accessory canals, which may also lead to combined endodontic-periodontal lesions [ 20 ]. According to the 2017 classification of periodontal and peri-implant diseases and conditions [ 21 ], PG can be classified as a localized tooth-related factor that modifies or predisposes to plaque-induced gingival diseases/periodontitis [ 22 ], and can be associated with periodontal abscess in non-periodontitis patients.

The prognosis for teeth with PG extending apically is often poor [ 12 ], highlighting the critical need for prompt and accurate diagnosis to avert further periodontal and endodontic complications, ultimately preventing tooth extraction. This study is fundamentally motivated by the scarcity of consolidated guidelines for managing such complex dental conditions. Hence, the objective of this study was to conduct a systematic review of the existing literature, focusing on the diagnosis and management of periodontal lesions linked to PG. Based on this review, the goal was to develop a comprehensive decisional tree, thereby proposing a standardized treatment protocol to aid in the clinical decision-making. This study also includes a clinical case report to demonstrate the practical application of the developed decisional tree, reinforcing its clinical relevance and utility.

Material and methods

Development of the systematic review protocol.

A protocol covering all aspects of the systematic review methodology was developed before starting the review. The protocol included the definition of: a focused question; the literature search strategy; the study selection criteria; the outcome measures; the screening methods; the data extraction; and the data synthesis. The protocol was registered in PROSPERO (CRD42022363194).

Defining the focused question

The research question was formulated according to the PICOS (Population, Intervention, Comparison, Outcome, Study) strategy, which identify the search and selection criteria as follows:

P: Patients with periodontal lesion(s) associated with a PG

I: PG identification (diagnosis) and management. All treatment approaches (non-surgical, surgical, with or without the adjunctive use of potentially regenerative materials, i.e. barrier membranes, grafting materials, growth factors/proteins and combinations thereof) were considered.

C: alternative treatment approach or no comparison.

O: periodontal parameters, including clinical attachment level (CAL, measure in mm), probing pocket depth (PPD, measured in mm), recession (REC, measured in mm), plaque index (PI, any validated clinical score), bleeding on probing (BOP) or other inflammatory indexes, radiographic bone loss.

S: Any type of human studies including case reports, with a minimum of 6 weeks follow-up after treatment. Only studies published in English were considered. Studies written in languages other than English, review articles, cell and/or animal studies, letters, editorials, conference summaries, commentaries, and studies considering PG with only an endodontic involvement or that used self-report assessment of treatment outcomes were not considered.

So, the focused question was formulated as follows: what is the efficacy of treatments for periodontal lesions associated with PG?

Search strategy

The literature was searched for articles published up to June 2022 on MEDLINE and Cochrane databases. Multiple combinations of pertinent search terms were employed (Supplemental Table 1). The reference lists of the included studies were also evaluated in order to identify additional articles. To ensure its reproducibility, the PRISMA guidelines were followed [ 23 ], and the PRISMA flowchart was filled [ 24 ] (Fig. 1 ).

PRISMA flow diagram on the selection process of the studies included in the systematic review

Literature screening and data extraction

The titles and abstracts of the initially identified studies were screened by two independent reviewers (Y.G. and V.G.). Then, the pre-selected studies underwent a full text evaluation to assess the final inclusion or not. All records for which inclusion was obtained “uncertain” for on reviewer, disagreement was solved by discussion between authors. Whenever needed, the authors of the selected studies were contacted to provide missing data.

Study screening and selection was carried out by using the Rayyan online software [ 25 ], which assisted the reviewers in the different step of the literature review process. Duplicate references were removed automatically using Mendeley software. Data extraction was carried out on a dedicated excel spreadsheet. The risk of bias assessment was carried out by using the Joanna Briggs Institute (JBI) scale [ 26 , 27 ].

The literature search resulted in 451 potentially relevant publications (Fig. 1 ). After the first selection step, based upon the title and abstract, 88 articles were pre-selected. After full-text evaluation, 34 articles were included and analyzed. All of them were case series and case reports. A total of 40 patients were described, of which 23 women (57.5%). The characteristics of the selected studies are presented in Table 1 . Their quality assessment is reported in Table 2 .

Qualitative synthesis of the literature

Among those 40 clinical cases, 12 cases report failed to provide a clinical description of the PG. Four studies described the PG depth alone, 17 studies described the PG length alone, and 7 studies provided a combined description of depth and length of the PG. From a periodontal point of view, the periodontal lesion morphology was correctly described (depth and width) in only 4 cases, 2 of which also reported the number of bony walls. Among the 22 cases reporting a diagnosis, 17 (77.3%) described combined endo-periodontal lesions, whereas 5 were purely periodontal lesions.

Endodontic involvement was present in 29 cases: 22 cases presented with a pulp necrosis, and 7 cases with an endodontic treatment. Pulp vitality was present in 10 cases and 1 case failed to report the endodontic status.

The endodontic treatment consisted in either a temporary filling (calcium hydroxide) later replaced by a definitive filling (gutta percha), or directly with a definitive filling (gutta percha) when indicated. Among those 29 endodontically treated teeth, 9 underwent an apicoectomy (using mineral trioxyde aggregate) at the surgical phase.

PG sealing was performed in 16 cases using mainly glass-ionomer cement but also mineral trioxide aggregate (MTA), tricalcium silicate cement, composite flow and amalgam. In 5 cases, an extra-oral filling of the groove was performed before the tooth reimplantation. In all cases, radiculoplasty was performed either for groove removal when it was shallow or by saucerization to allow a proper filling when grooves were deep.

To treat the PG associated periodontal defect, several different intervention types were described, using: allogenic bone, xenogeneic bone, alloplastic materials, barriers, growth factors and biological factors (and combinations thereof). These surgical regenerative procedures were reported in 25 cases. Only 2 cases [ 3 , 40 ], justified the use of biomaterials and flap designs in relation to the analysis of the associated periodontal lesion after PG management.

All cases reported clinical healing except for 2 cases of failures following tooth reimplantation due to external root resorption leading to tooth removal after 36 months [ 33 ] and 2 failures after 6 months following a surgery without regeneration or root filling [ 29 ]. The case with the longest follow-up (324 months) indicated that following an endodontic treatment with a periodontal regeneration and an orthodontic treatment, a recurrent periodontal breakdown occurred 11 years, leading to tooth extraction and implant placement [ 35 ].

Case-report

We describe the case of an 18-year-old male patient referred to the periodontics department of the Rothschild Hospital (AP-HP) in Paris. Written informed consent was obtained for the publication of clinical data and images included in this article. The patient was experiencing pain due to the inflammation on the palatal side of tooth #22 with intermittent suppuration. The clinical examination revealed a central, shallow, and of moderate length (up to 70% of the root length) PG on the tooth #22, with a probing pocket depth of 12 mm on the palatal side associated with a tooth mobility 3 (Mühlemann 1951). The tooth responded positively to electrical test. At the radiographic evaluation, bone loss could be noted mesially and distally of #22 (Fig. 2 ).

Case report. Clinical and radiographical initial situation of the tooth #22 presenting with a palatal groove. The periodontal charting showed deep periodontal pockets on the palatal probing sites associated with bleeding and plaque accumulation

A slight bony bridge could be distinguished between #21 and #22 in the coronal portion. Thus, a localized periodontal defect due to the presence of subgingival PG was diagnosed.

The periodontal treatment first consisted in a non-surgical debridement performed in one session. Tooth splinting was performed from #21 to #23 to minimize mobility (Fig. 3 ).

Root planning and flattening of PG on tooth #22: initial occlusal view of #22 ( a ); Manual scaling 22 ( b ); flattening of PG 22 in the coronal part ( c )

At the re-evaluation 8 weeks later, the tooth presented no superficial inflammation, but a persistent periodontal pocket of 12 mm deep on the palatal side. Surgery was indicated due to the presence of a large, deep, 3-wall intra-bony defect around tooth #22 (Fig. 4 ).

Regenerative therapy: view at the periodontal re-evaluation, 2-months after the initial treatment ( a ); large and deep 3-walls intra-bony defect ( b ); application of EMD ( c ); application of DBBM (soft tissue support, osteoconductive) ( d ); sutures ( e ); radiographic image at the 2-month follow-up ( f )

A SFA (Single Flap Approach) was designed with a surgical access limited on the palatal side for esthetic reason and optimal visualization. A full periosteal flap was raised, and the granulation tissue was removed. The aberrant local anatomy was corrected up to the most apical part and a regenerative procedure combining enamel matrix derivates with a bone substitute was applied to avoid soft tissue shrinkage and collapse. Sutures with a non-resorbable monofilament 6/0 were made using U-crossed and single points. A postoperative radiograph was taken (Fig. 4 f). An antibiotic therapy with amoxicillin (1 g twice a day for 7 days) was administered. Paracetamol was prescribed as a painkiller and a mouthwash containing 0.12% chlorhexidine gluconate were prescribed for 2 weeks postoperatively. Healing was uneventful and sutures were removed 10 days postoperatively.

At the 6 months reevaluation, the periodontal pocket was no deeper than 4 mm on the palatal side with no bleeding on probing. A recession of 1 mm was observed. Radiographically, a mineralized tissue could be observed up to both bony peaks mesially and distally to #22 (Fig. 5 ).

Re-evaluation at 6 months ( a ); 18 months ( b ) and 30 months ( c )

At the 1-year follow-up, periodontal health was maintained and an orthodontic treatment was undertaken. After 2 years of treatment, tooth #22 is still healthy with a CAL gain of 7 mm, a functional and esthetic position resulting in the patient’s satisfaction. These results support that periodontal regeneration can be effectively carried out also for deep intra-bony defect associated with PG, once the local risk factor has been adequately managed.

The results of the present systematic review indicate that PG are relatively uncommon root anomaly, but they are frequently associated with periodontal lesion that require treatment. The selected studies showed that PG can be managed concomitantly with periodontal regeneration, with or without associated endodontic treatment. It must be noted that the presence of a PG may play a significant role in exacerbating periodontal lesions. This could be explained, at least partly, by the mediation role of inflammatory factors like the TGF-B1, which is involved in the regulation of the inflammatory response and in the remodeling of periodontal tissues, as highlighted by recent studies [ 58 , 59 ]. These findings necessitate a nuanced and well-defined diagnostic and therapeutic approach, which should consider not only on the anatomical challenges linked to the presence of a PG but also on the underlying inflammatory mechanisms, in order to ensure an effective treatment and prevent potential endodontic complications.

A variety of treatments approaches has been described in case reports and case series and summarized in the present review. The appreciation of the morphology and origin of PG on maxillary incisors may be challenging and thus delay the diagnosis and treatment planning. Therefore, developing a standardized approach based on the available literature is advisable.

A PG can be classified according to its location, length along the root, and depth of the groove towards the pulp cavity [ 60 ]. The analysis of the associated periodontal lesion is also a key parameter to consider. Based on the work of Kim et al. [ 60 ], a simplified version including the groove description and the periodontal parameters has been suggested. Such a classification (Table 3 ) would provide the clinician with precise criteria to justify the therapeutic approach.

Groove location was disregarded in most cases, only one case [ 40 ] reported a distal location of the PG. It can be explained by the fact that this parameter will not affect the prognosis or the treatment sequence. In the latest study done on extracted teeth, PG appeared to originate in the distal area of the cingulum margin in most cases (65%), followed by the central fossa (25%), and the mesial area of the cingulum margin (10%) [ 61 ].

In terms of depth, only 7 cases reported a shallow PG (50%) and 7 cases reported a deep PG (50%) and no closed tube has been described. This finding is in accordance with Kogon’s study [ 8 ] where 44% percent of the PG were described as shallow depressions, 42% as deep depressions, and 4% as closed tubes.

Considering the groove length, 4 cases reported an extension in the cervical third of the groove (17%), 6 in the middle third (25%) and 14 cases in the apical third (58%). According to Pinheiro’s study [ 61 ], those grooves extended rarely only to the cervical third (5%), followed by the middle thirds (45%) and the apical thirds of the root in most cases (50%). It is of paramount importance for clinicians to understand the combination of both variations of groove depth along with their length to adapt an adequate treatment considering the fact that PG with deeper grooves and greater degree of extension are the determinants and predictors of poor prognosis periodontally and endodontically wise [ 5 , 31 , 42 ].

Considering the groove description in the selected studies, most of them failed to adequately report it. Only 7 of the 40 cases described the depth and length of the PG. This lack of analysis might result in an inadequate treatment highlighting the need for a classification.

Considering the periodontal approach of the associated intra-bony defect, the selection of the regenerative biologic principle (or material) to use with the soft tissue surgical approach dependeds on the morphology of the intra- bony defect (width, depth, and number of residual bony walls) and on the amount (and quality) of the soft tissues available to cover it [ 62 ]. As a general rule, deep and wide defects with only one residual bony wall require a mechanical stabilizer of the blood coagulum (membrane and/or bone filler), whereas in defects with lower defect angles and a greater number of bony walls, biologic mediators of the healing process (e.g. enamel matrix derivates) are indicated [ 62 ]. In the present study, only 2 cases [ 3 , 40 ] succeeded in justifying the use of their regenerative procedure based on the description and analysis of the associated intra-bony lesion. As for PG anatomy, this lack of description of the associated periodontal lesion morphology could mislead the diagnosis and result in a non-optimal treatment. The PG issue had mostly been a concern for endodontist based on those case reports coming from endodontic journals, which might explain the few periodontal parameters reported and the lack of a clear description of the intra-bony defect associated to justify the different management of the periodontal defect. Moreover, the selected case reports do not cover all potentially applicable regenerative techniques, which continue to evolve [ 63 , 64 , 65 ] and should be further investigated in the particular context, from the microbiological and inflammatory perspectives, of PG-associate lesions.

Based on the presented literature review and in order to guide clinicians towards a comprehensive and complete evaluation of PG associated lesion, we suggested a decisional tree (Fig. 6 ) that introduces the periodontal parameter in the PG assessment, after evaluating the endodontic status. Indeed, the successful management of a tooth with a PG is firstly dependent on endodontic status, which should be systematically assessed. In cases of negative pulp response and periapical lesions, an endodontic treatment has to be undertaken in the first place [ 66 ]. But, the periodontal evaluation is also cardinal to obtain a successful and long-lasting management of PG.

Decisional tree. This graph proposes a decision-making process for the management of PG-associated lesions that takes into account the endodontic status, the characteristics of the palatal groove, and the presence of intra-bony defect

The recognition and management of PG for tooth survival has been reported in details in a study done by Kim et al. [ 60 ] in 2017. In the rest of the considered literature, half of the treatments described were made without a clear initial diagnosis or proper description of the associated lesions to justify the type of regenerative strategy and flap design approached. Another interesting observation made in this review is that in the case of intentional replantation, among the 5 reported cases, 2 resulted in a failure necessitating the tooth removal [ 33 ]. This suggests that replantation strategy should be used as a the latest resort for complex cases involving a PG to the apex with a deep groove.

It must be acknowledged that the available literature and thus the present systematic review present several limitations. Firstly, as mentioned above, there is a lack of standardization in the diagnostic and treatment processes, with a high heterogeneity among the selected articles, most of the times case reports or case series. Secondly, the follow-up time was mostly set between 6 and 24 months, which may be too short to assess treatment outcomes or observed complications and relapse. Indeed, after a 36 months follow-up, failures have been reported [ 33 ] and after 10 years, a periodontal breakdown occurred on a treated tooth [ 35 ] and both resulted in the tooth removal. No re-entry surgery and/or histologic evaluations were described and no prospective longitudinal studies evaluating the stability of the clinical and radiographic parameters and the absence of the recurrence of disease were found. Thus, any conclusion about the success achieved with the treatments described in the present review should be drawn with caution as the long-term prognosis of the treatment of PG-associated lesions of teeth remains to be determined. Updates of case series and case reports that could describe results after 5, 10 and 15 years from the initial PG diagnosis are advocated. Finally, the level of the body of evidence on PG is considered as low. Although the nature of PG as rare condition may explain why mainly case reports or case series are published, future clinical and comparative studies should be designed to investigate PG management and treatment success at long term. Nonetheless, based on the currently available literature, a decisional tree (Fig. 6 ) has been proposed to guide clinicians and create a reference for PG management to respond to a patient’s health condition. This should be periodontally updated as new evidence emerges but in the meantime, it can be useful to provide a clinical guidance as well as a model for the standardization of the diagnostic and treatment processes in clinical cases dealing with PG management.

Teeth with PG represent a challenge for clinicians. Despite their rarity (2% of maxillary lateral incisors), the complexities associated with PG, such as diverse anatomical features and clinical scenarios, underscore the necessity for accurate diagnosis and tailored treatment approaches. This study provides a systematic review of pertinent literature, consisting mainly in case reports, and culminates in the proposal of a decision tree, which aims to assist clinicians in the decision-making process through a structured evaluation of the PG characteristics guiding the treatment approach. The ultimate goal is to mitigate potential periodontal and endodontic complications of PG while providing a successful management. In parallel, the present study highlights the need of future research on this topic, particularly with clinical studies with a sufficiently long follow-up to monitor the treatment outcomes and their stability over time. Indeed, further evidence is needed to develop standardized diagnostic and treatment protocols for PG.

Availability of data and materials

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

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Service of Odontology, Rothschild Hospital (AP-HP), 5 Rue Santerre, Paris, 75012, France

Yvan Gaudex, Vianney Gandillot, Philippe Bouchard, Stephane Kerner & Maria Clotilde Carra

Department of Periodontology, UFR of Odontology, Université Paris Cité, 5 Rue Garanciere, Paris, 75006, France

Service of Odontology, CH Eure Seine Hospital, Evreux, France

Isabelle Fontanille

Cordeliers Research Centre, Laboratory of Molecular Oral Physiopathology, Paris, France

Stephane Kerner

Department of Periodontology, Loma Linda University School of Dentistry, Loma Linda, CA, USA

INSERM- Sorbonne Paris Cité Epidemiology and Statistics Research Centre, Paris, France

Maria Clotilde Carra

Institution Nationale Des Invalides, Paris, France

Vianney Gandillot

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Y.G. and V.G. drafted the manuscript text, and were involved in the literature review, data acquisition, analysis, and interpretation. Y.G. and V.G. prepared Tables 1 and 2 . Y.G., P.B. and I.F. Contributed the case report and Figs. 2 , 3 , 4 and 5 M.C.C and S.K. prepared Table 3 and Fig. 6 . M.C.C., P.B. and S.K revised the draft of the manuscript and contributed to the general criticism. All authors reviewed and approved the manuscript.

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Gaudex, Y., Gandillot, V., Fontanille, I. et al. Palatal groove associated with periodontal lesions: a systematic review illustrated by a decisional tree for management. BMC Oral Health 24 , 1037 (2024). https://doi.org/10.1186/s12903-024-04771-z

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DOI : https://doi.org/10.1186/s12903-024-04771-z

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