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Case Study – Methods, Examples and Guide

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

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Muhammad Hassan

Researcher, Academic Writer, Web developer

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• Acknowledgments

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

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

How to Approach Writing a Case Study Research Paper

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

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

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

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

Structure and Writing Style

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

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

I.  Introduction

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

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

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

II.  Literature Review

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

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

III.  Method

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

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

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

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

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

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

IV.  Discussion

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

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

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

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

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

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

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

V.  Conclusion

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

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

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

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

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

Problems to Avoid

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

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

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

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

Writing Tip

At Least Five Misconceptions about Case Study Research

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

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

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

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

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Case Study Research Method in Psychology

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

Case studies are in-depth investigations of a person, group, event, or community. Typically, data is gathered from various sources using several methods (e.g., observations & interviews).

The case study research method originated in clinical medicine (the case history, i.e., the patient’s personal history). In psychology, case studies are often confined to the study of a particular individual.

The information is mainly biographical and relates to events in the individual’s past (i.e., retrospective), as well as to significant events that are currently occurring in his or her everyday life.

The case study is not a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies.

Freud (1909a, 1909b) conducted very detailed investigations into the private lives of his patients in an attempt to both understand and help them overcome their illnesses.

This makes it clear that the case study is a method that should only be used by a psychologist, therapist, or psychiatrist, i.e., someone with a professional qualification.

There is an ethical issue of competence. Only someone qualified to diagnose and treat a person can conduct a formal case study relating to atypical (i.e., abnormal) behavior or atypical development.

 Famous Case Studies

• Anna O – One of the most famous case studies, documenting psychoanalyst Josef Breuer’s treatment of “Anna O” (real name Bertha Pappenheim) for hysteria in the late 1800s using early psychoanalytic theory.
• Little Hans – A child psychoanalysis case study published by Sigmund Freud in 1909 analyzing his five-year-old patient Herbert Graf’s house phobia as related to the Oedipus complex.
• Bruce/Brenda – Gender identity case of the boy (Bruce) whose botched circumcision led psychologist John Money to advise gender reassignment and raise him as a girl (Brenda) in the 1960s.
• Genie Wiley – Linguistics/psychological development case of the victim of extreme isolation abuse who was studied in 1970s California for effects of early language deprivation on acquiring speech later in life.
• Phineas Gage – One of the most famous neuropsychology case studies analyzes personality changes in railroad worker Phineas Gage after an 1848 brain injury involving a tamping iron piercing his skull.

Clinical Case Studies

• Studying the effectiveness of psychotherapy approaches with an individual patient
• Assessing and treating mental illnesses like depression, anxiety disorders, PTSD
• Neuropsychological cases investigating brain injuries or disorders

Child Psychology Case Studies

• Studying psychological development from birth through adolescence
• Cases of learning disabilities, autism spectrum disorders, ADHD
• Effects of trauma, abuse, deprivation on development

Types of Case Studies

• Explanatory case studies : Used to explore causation in order to find underlying principles. Helpful for doing qualitative analysis to explain presumed causal links.
• Exploratory case studies : Used to explore situations where an intervention being evaluated has no clear set of outcomes. It helps define questions and hypotheses for future research.
• Descriptive case studies : Describe an intervention or phenomenon and the real-life context in which it occurred. It is helpful for illustrating certain topics within an evaluation.
• Multiple-case studies : Used to explore differences between cases and replicate findings across cases. Helpful for comparing and contrasting specific cases.
• Intrinsic : Used to gain a better understanding of a particular case. Helpful for capturing the complexity of a single case.
• Collective : Used to explore a general phenomenon using multiple case studies. Helpful for jointly studying a group of cases in order to inquire into the phenomenon.

Where Do You Find Data for a Case Study?

There are several places to find data for a case study. The key is to gather data from multiple sources to get a complete picture of the case and corroborate facts or findings through triangulation of evidence. Most of this information is likely qualitative (i.e., verbal description rather than measurement), but the psychologist might also collect numerical data.

1. Primary sources

• Interviews – Interviewing key people related to the case to get their perspectives and insights. The interview is an extremely effective procedure for obtaining information about an individual, and it may be used to collect comments from the person’s friends, parents, employer, workmates, and others who have a good knowledge of the person, as well as to obtain facts from the person him or herself.
• Observations – Observing behaviors, interactions, processes, etc., related to the case as they unfold in real-time.
• Documents & Records – Reviewing private documents, diaries, public records, correspondence, meeting minutes, etc., relevant to the case.

2. Secondary sources

• News/Media – News coverage of events related to the case study.
• Academic articles – Journal articles, dissertations etc. that discuss the case.
• Government reports – Official data and records related to the case context.
• Books/films – Books, documentaries or films discussing the case.

3. Archival records

Searching historical archives, museum collections and databases to find relevant documents, visual/audio records related to the case history and context.

Public archives like newspapers, organizational records, photographic collections could all include potentially relevant pieces of information to shed light on attitudes, cultural perspectives, common practices and historical contexts related to psychology.

4. Organizational records

Organizational records offer the advantage of often having large datasets collected over time that can reveal or confirm psychological insights.

Of course, privacy and ethical concerns regarding confidential data must be navigated carefully.

However, with proper protocols, organizational records can provide invaluable context and empirical depth to qualitative case studies exploring the intersection of psychology and organizations.

• Organizational/industrial psychology research : Organizational records like employee surveys, turnover/retention data, policies, incident reports etc. may provide insight into topics like job satisfaction, workplace culture and dynamics, leadership issues, employee behaviors etc.
• Clinical psychology : Therapists/hospitals may grant access to anonymized medical records to study aspects like assessments, diagnoses, treatment plans etc. This could shed light on clinical practices.
• School psychology : Studies could utilize anonymized student records like test scores, grades, disciplinary issues, and counseling referrals to study child development, learning barriers, effectiveness of support programs, and more.

How do I Write a Case Study in Psychology?

Follow specified case study guidelines provided by a journal or your psychology tutor. General components of clinical case studies include: background, symptoms, assessments, diagnosis, treatment, and outcomes. Interpreting the information means the researcher decides what to include or leave out. A good case study should always clarify which information is the factual description and which is an inference or the researcher’s opinion.

1. Introduction

• Provide background on the case context and why it is of interest, presenting background information like demographics, relevant history, and presenting problem.
• Compare briefly to similar published cases if applicable. Clearly state the focus/importance of the case.

2. Case Presentation

• Describe the presenting problem in detail, including symptoms, duration,and impact on daily life.
• Include client demographics like age and gender, information about social relationships, and mental health history.
• Describe all physical, emotional, and/or sensory symptoms reported by the client.
• Use patient quotes to describe the initial complaint verbatim. Follow with full-sentence summaries of relevant history details gathered, including key components that led to a working diagnosis.
• Summarize clinical exam results, namely orthopedic/neurological tests, imaging, lab tests, etc. Note actual results rather than subjective conclusions. Provide images if clearly reproducible/anonymized.
• Clearly state the working diagnosis or clinical impression before transitioning to management.

3. Management and Outcome

• Indicate the total duration of care and number of treatments given over what timeframe. Use specific names/descriptions for any therapies/interventions applied.
• Present the results of the intervention,including any quantitative or qualitative data collected.
• For outcomes, utilize visual analog scales for pain, medication usage logs, etc., if possible. Include patient self-reports of improvement/worsening of symptoms. Note the reason for discharge/end of care.

4. Discussion

• Analyze the case, exploring contributing factors, limitations of the study, and connections to existing research.
• Analyze the effectiveness of the intervention,considering factors like participant adherence, limitations of the study, and potential alternative explanations for the results.
• Identify any questions raised in the case analysis and relate insights to established theories and current research if applicable. Avoid definitive claims about physiological explanations.
• Offer clinical implications, and suggest future research directions.

5. Additional Items

• Thank specific assistants for writing support only. No patient acknowledgments.
• References should directly support any key claims or quotes included.
• Use tables/figures/images only if substantially informative. Include permissions and legends/explanatory notes.
• Provides detailed (rich qualitative) information.
• Provides insight for further research.
• Permitting investigation of otherwise impractical (or unethical) situations.

Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of ‘averaging’.

Because of their in-depth, multi-sided approach, case studies often shed light on aspects of human thinking and behavior that would be unethical or impractical to study in other ways.

Research that only looks into the measurable aspects of human behavior is not likely to give us insights into the subjective dimension of experience, which is important to psychoanalytic and humanistic psychologists.

Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person’s life are related to each other.

The method is, therefore, important for psychologists who adopt a holistic point of view (i.e., humanistic psychologists ).

Limitations

• Lacking scientific rigor and providing little basis for generalization of results to the wider population.
• Researchers’ own subjective feelings may influence the case study (researcher bias).
• Difficult to replicate.
• Time-consuming and expensive.
• The volume of data, together with the time restrictions in place, impacted the depth of analysis that was possible within the available resources.

Because a case study deals with only one person/event/group, we can never be sure if the case study investigated is representative of the wider body of “similar” instances. This means the conclusions drawn from a particular case may not be transferable to other settings.

Because case studies are based on the analysis of qualitative (i.e., descriptive) data , a lot depends on the psychologist’s interpretation of the information she has acquired.

This means that there is a lot of scope for Anna O , and it could be that the subjective opinions of the psychologist intrude in the assessment of what the data means.

For example, Freud has been criticized for producing case studies in which the information was sometimes distorted to fit particular behavioral theories (e.g., Little Hans ).

This is also true of Money’s interpretation of the Bruce/Brenda case study (Diamond, 1997) when he ignored evidence that went against his theory.

Breuer, J., & Freud, S. (1895).  Studies on hysteria . Standard Edition 2: London.

Curtiss, S. (1981). Genie: The case of a modern wild child .

Diamond, M., & Sigmundson, K. (1997). Sex Reassignment at Birth: Long-term Review and Clinical Implications. Archives of Pediatrics & Adolescent Medicine , 151(3), 298-304

Freud, S. (1909a). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Freud, S. (1909b). Bemerkungen über einen Fall von Zwangsneurose (Der “Rattenmann”). Jb. psychoanal. psychopathol. Forsch ., I, p. 357-421; GW, VII, p. 379-463; Notes upon a case of obsessional neurosis, SE , 10: 151-318.

Harlow J. M. (1848). Passage of an iron rod through the head.  Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868).  Recovery from the Passage of an Iron Bar through the Head .  Publications of the Massachusetts Medical Society. 2  (3), 327-347.

Money, J., & Ehrhardt, A. A. (1972).  Man & Woman, Boy & Girl : The Differentiation and Dimorphism of Gender Identity from Conception to Maturity. Baltimore, Maryland: Johns Hopkins University Press.

Money, J., & Tucker, P. (1975). Sexual signatures: On being a man or a woman.

Further Information

• Case Study Approach
• Case Study Method
• Enhancing the Quality of Case Studies in Health Services Research
• “We do things together” A case study of “couplehood” in dementia
• Using mixed methods for evaluating an integrative approach to cancer care: a case study

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• Case Study | Definition, Examples & Methods

Case Study | Definition, Examples & Methods

Published on 5 May 2022 by Shona McCombes . Revised on 30 January 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organisation, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating, and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyse the case.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

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Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

• Provide new or unexpected insights into the subject
• Challenge or complicate existing assumptions and theories
• Propose practical courses of action to resolve a problem
• Open up new directions for future research

Unlike quantitative or experimental research, a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

If you find yourself aiming to simultaneously investigate and solve an issue, consider conducting action research . As its name suggests, action research conducts research and takes action at the same time, and is highly iterative and flexible. 

However, you can also choose a more common or representative case to exemplify a particular category, experience, or phenomenon.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

• Exemplify a theory by showing how it explains the case under investigation
• Expand on a theory by uncovering new concepts and ideas that need to be incorporated
• Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews, observations, and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data .

The aim is to gain as thorough an understanding as possible of the case and its context.

In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis, with separate sections or chapters for the methods , results , and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyse its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

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Key Study Skills

• Assignment Calculator
• Managing nervousness
• Allocating time and using the marking system
• Using the reading time effectively
• Answering multi-choice and short answer questions
• Answering essay and case study questions in exams
• Managing exam stress
• Academic Skills for Success

Answering essay questions in exams

Writing an essay in an exam is similar in many ways to writing an essay for an assignment: It needs to be clearly structured, and your ideas need to be linked and supported by evidence.

Essay questions in exams

• Read the question through carefully to make sure you are answering what has been asked.  Missing one part of a question can cost you a lot of marks.
• Make a quick plan of the points you want to include in your answer.
• Use essay structure: introduction, points, conclusion.  But if you run out of time, it can be a good idea to write notes.
• Get right to the point from the beginning.  Use the words from the question to write your first sentence. For example:

Question: What do you think is the most important intercultural communication issue in New Zealand? First sentence: At present in New Zealand the most important intercultural communication issue is...

• Remember to include one idea per paragraph, and to begin each paragraph with a clear topic sentence.
• Make sure your writing is legible.
• Grammar, punctuation and spelling are not as important as in an assignment but should still be of a good standard.

Answering case study questions

Exam questions that ask you to anlayse case studies (also called scenarios) are usually designed to test your ability to relate theories and concepts to real-world situations.

Preparing for case studies before the exam:

• Start by identifying the theories and concepts covered in your course.  Organise and review the information you have on these theories/concepts so you understand them.
• Practice reading case studies and identifying relevant information. It's probably useful to practice doing this with a time limit as you will have one in your exam.
• Practice relating concepts and theories to real-world situations: ask lecturers and check textbooks for practice examples. It is also worth checking past exams for your course to see if there are examples of case study questions.

During the exam

• Take time to plan: Have a clear idea of how much time you have to answer the question. Then plan to spend some time reading the exam question, the case study and planning your answer. Take time to make sure you have understood the case study and know what the exam question is asking you to do:
• Read the exam question(s)
• Then skim read the case study to get the general idea. Highlight or underline key points
• Reread the question to make sure you understand it and to focus your attention when you reread the case study.
• Reread the case study carefully. Make a note of any ideas that you think of.
• Answer the question linking relevant theories and concepts to specific information from the case study. Usually you will need to write your answers in clearly formed paragraphs which have a clear topic that is well-supported with evidence and examples.
• Instead of simply describing or restating information from the case itself, use specific details or examples to support the points you are trying to make. This is where you link theory to the facts from the case study.
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Case Study Exams

Case study exams and other types of exams.

Examinations are a core part of UK degree programmes, at all levels of study. There is no need to spend hours pacing the room and biting your nails – just prepare for your exam and understand exam types, and you will have no need to worry!

When are Exams Taken

Exams in the UK are usually taken in January and April/May. For some degree programmes you might not be required to sit formal exams in both or either of these exam periods – instead you might be asked to complete coursework during this period. If you are required to sit exams, you should be aware that the exam weeks usually come at the end of holiday breaks, which gives you ample time to prepare.

Types of Exams

• Essay exams: The most common type of examination in UK undergraduate degrees is the essay exam. Exams of this nature typically require students to complete 3-4 short essays on topics that test a student’s knowledge of the course material. Students are given 2-3 hours to complete these exams. Essay answers should contain as much relevant detail from your module as possible, to demonstrate the level of your understanding.
• Multiple choice exams: These exams are comprised of a number of questions with a range of answers, or ‘choices’ provided. Students must select the answer that best fits the question. Many students consider these exams easier because they only need to identify the correct answer among a group of 3-5 possibilities. However, most lecturers will include possible answers that seem correct, as a way of testing the accuracy of students’ knowledge.
• Oral exams: Oral exams are most common to language programmes, but can also be found in many Humanities and even some Social Science subjects. Students are expected to answer questions posed to them by the examiner. This type of exam tests a student’s ability to apply the skills and knowledge from modules in an immediate, unplanned fashion. In addition, oral exams form a part of postgraduate assessments when students are asked to defend their dissertation through a presentation and question-and-answer session.
• Open Book Exams : these exams are different from most traditional types of exams because they allow students to bring a course book and/or their course notes with them to the exam.

Case Study Exams or Problem-Based Exams

We will now look at one type of exam in more detail: the Case-Based exam sometimes called a Problem-Based exam. These are different from most traditional types of the exam; They present students with a practical problem that must be solved by applying knowledge from the course material.

Advantages and Disadvantages of case study exams

The advantage of Case study exams is that they allow students to demonstrate their practical understanding of the course topic rather than requiring them to memorise information. They focus on testing a student’s skill development instead of purely theoretical knowledge. One disadvantage is that they can be particularly challenging for students who experience exam stress because they require clear thinking and an ability to make well-thought-out choices in a short period of time.

When are Case Study Exams Used?

Case study exams and Problem-Based Exams in the UK are used mostly in practical skills-based subjects like science, technology, and medicine. They are particularly useful when testing a student’s ability to solve the sort of problems they would encounter if employed in their field. For example, they might test a medical student’s ability to choose an appropriate course of treatment, or a chemistry student’s ability to conduct suitable laboratory procedures.

How Can Students Prepare for Case Study Exams?

The Problem-Based and Case Study Exams require students to review the course material very thoroughly and ensure that they understand how theoretical information can be applied in real-life situations. Students in these exams must demonstrate that they not only know the course material, but they also understand its possible applications. This requires a different study approach than simple memorisation of facts and figures. In addition to ordinary study techniques, it can be particularly useful to practise mock questions. Lecturers will often provide students with the exam questions from previous years, and you can use these to hone your ability to apply course material under pressure.

What to Bring with You

In most case study exams you will not be allowed to bring anything with you other than a pen or pencil and perhaps a bottle of water. However, in some courses students are allowed to bring their course notes.

Preparing Your Notes

If students are allowed to bring their course notes to a case study exam, they should make sure that the notes are written clearly and are well-organised. Part of your revision process should include re-writing your exam notes and organising them in a way that will allow you to find relevant information quickly. This may involve adding sticky notes to pages to identify their thematic content or creating your own ‘index’ list. Regardless, you should ensure that your notes are written very clearly and concisely, but without leaving out key information.

General Assessment Criteria

The assessment criteria for Case-Based and Problem-Based Exams will vary according to the exam subject, so check your module handbook for more details. In general, examiners will be looking for evidence of a clear understanding of the course material. In solving the case study or problem, students should try to demonstrate their detailed awareness of all relevant course material. One way to do this is to ensure that you write down all the steps in your problem-solving, referring to particular elements of the course material as you do so.

Results and Grading

Case-Based exams are usually either Pass/Fail, or they are marked according to the standard UK grading scale, as follows:

70 and above = First class (A) 60-69 = Second class, first division (B) 49-59 = Second class, second division (C) 40-48 = Third class (D) 39 or below = Fail

In many degree programmes, students will be given a chance to re-sit exams if they fail or receive a very low mark. Check your programme handbooks for specific re-assessment criteria.

Understanding the format of exams is essential in helping you prepare properly. Once you know what will be expected, you will be able to spend your time studying in an appropriate way, and this will help you feel confident and relaxed when walking into the exam room!

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What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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IRIS MABRY-HERNANDEZ, MD, MPH, Medical Officer, U.S. Preventive Services Task Force, Agency for Healthcare Research and Quality

SUSAN J. CHING, DO, Preventive Medicine Resident, Uniformed Services University of the Health Sciences

Am Fam Physician. 2024;109(5):457-458

Related editorial:   Anxiety Screening Is Unlikely to Improve Mental Health Outcomes

Related USPSTF Clinical Summary:   Screening for Anxiety Disorders in Adults

Author disclosure: No relevant financial relationships.

A 34-year-old patient (gravida 2, para 2) presents for a well-woman examination and Papanicolaou smear. She feels healthy and has no significant medical history, aside from her uncomplicated pregnancies, which did not include postpartum depression or anxiety. She reports increased stress at home due to an upcoming move and some difficulty sleeping.

Case Study Questions

1 . According to the U.S. Preventive Services Task Force (USPSTF) recommendation, which one of the following is advised for this patient?

A. Screen for anxiety disorder.

B. Assess her anxiety in 6 months.

C. Refer her to an obstetrician-gynecologist for postpartum anxiety screening.

D. Recommend melatonin.

E. Refer her to a behavioral health professional for sleep management.

2 . According to the Diagnostic and Statistical Manual of Mental Disorders , 5th ed. (DSM-5), which of the following can be categorized as anxiety disorders?

A. Generalized anxiety disorder.

B. Obsessive-compulsive disorder.

C. Separation anxiety disorder.

D. Social anxiety disorder.

3 . Which one of the following populations should be screened for anxiety disorders, according to the USPSTF recommendation?

A. People already diagnosed with anxiety or another mental health disorder.

B. People younger than 18 years.

C. People older than 65 years.

D. People with no recognized signs or symptoms of anxiety disorders.

The correct answer is A . The USPSTF recommends screening all adults 19 to 64 years of age for anxiety disorder, including those who are pregnant and postpartum. The USPSTF notes there is little evidence for the ideal timing and frequency of anxiety screening for perinatal and general adult populations. 1 However, clinical judgment, particularly considering risk factors, comorbid conditions, and life events, can determine whether additional screening of high-risk patients is warranted. There is a lack of evidence on screening rates for anxiety disorders. Underdetection appears to be common. Patients with anxiety disorders may present with other concerns, such as sleep disturbances or somatic issues.

The correct answers are A, C, and D . The DSM-5 recognizes the following types of anxiety disorders: generalized anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, specific phobias, separation anxiety disorder, selective mutism, substance or medication-induced anxiety disorder, anxiety disorder due to another medical condition, and anxiety not otherwise specified. 2 Obsessive-compulsive disorder is not considered an anxiety disorder.

The correct answer is D . The USPSTF recommendation statement applies to adults (defined as those 19 to 64 years of age), including people who are pregnant or postpartum, who do not have a diagnosed mental health disorder and are not showing recognized signs or symptoms of anxiety disorders. 2 For people 65 years or older, the USPSTF concludes that the evidence is insufficient to recommend for or against screening for anxiety disorders.

The views expressed in this work are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the U.S. Department of Defense, or the U.S. government.

This PPIP quiz is based on the recommendations of the USPSTF. More information is available in the USPSTF Recommendation Statement and supporting documents on the USPSTF website ( https://www.uspreventiveservicestaskforce.org ). The practice recommendations in this activity are available at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/anxiety-adults-screening .

O’Connor EA, Henninger ML, Perdue LA, et al. Anxiety screening: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2023;329(24):2171-2184.

Barry MJ, Nicholson WK, Silverstein M, et al. Screening for anxiety disorders in adults: US Preventive Services Task Force recommendation statement. JAMA. 2023;329(24):2163-2170.

This series is coordinated by Joanna Drowos, DO, contributing editor.

A collection of Putting Prevention Into Practice published in AFP is available at https://www.aafp.org/afp/ppip.

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A Robot-assisted real case-handling approach to improving students’ learning performances in vocational training

• Published: 14 May 2024

Cite this article

• Chun-Chun Chang 1 &
• Gwo-Jen Hwang   ORCID: orcid.org/0000-0001-5155-276X 2 , 3  

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In vocational education, cultivating students’ ability to deal with real cases is a crucial training objective. The BSFE (i.e., Brainstorming, Screening, Formation, Examination) model is a commonly adopted training procedure. Each stage is designed for guiding students to analyze and find solutions to handle real cases. However, as one teacher is generally responsible for several dozen students, it becomes challenging for the teacher to adequately address each student’s questions and individual needs. Therefore, this study proposed the robot teaching assistant-supported learning (RTAL) mode following the BSFE model to cope with this problem. This investigation assessed its efficacy through an experiment within an Acute Asthma Attack curriculum. The research involved 103 nursing students in their third year from two distinct classes at a vocational university. Fifty-three students from a class constituted the experimental group that implemented the RTAL approach, whereas the other class, comprising 50 students, was the control group utilizing the standard technology-supported learning (CTL) approach. Findings indicated that the experimental group surpassed the control group in various aspects, including learning outcomes, learning attitudes, problem-solving tedencies, critical thinking awareness, acceptance of technology, and satisfaction with the learning experience. The interview findings also revealed that the RTAL mode could cater to individualized learning needs, facilitate interaction, and serve as an auxiliary instructional tool.

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This study is supported in part by the National Science and Technology Council of Taiwan under contract numbers NSTC 112-2410-H-011-012-MY3 and MOST 111-2410-H-011 -007 -MY3. The study is also supported by the “Empower Vocational Education Research Center” of National Taiwan University of Science and Technology (NTUST) from the Featured Areas Research Center Program within the framework of the Higher Education Sprout Project by the Ministry of Education (MOE) in Taiwan.

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Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan

Chun-Chun Chang

Graduate Institute of Educational Information and Measurement, National Taichung University of Education, Taichung City, Taiwan

Gwo-Jen Hwang

Graduate Institute of Digital Learning and Education, National Taiwan University of Science and Technology, Taipei City, Taiwan

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The authors contributed to the conceptualization and design of the study. Material preparation, data collection, analysis, project management and methodology were performed by Chun-Chun Chang. Methodology and supervision were performed Gwo-Jen Hwang.

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Correspondence to Gwo-Jen Hwang .

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Chang, CC., Hwang, GJ. A Robot-assisted real case-handling approach to improving students’ learning performances in vocational training. Educ Inf Technol (2024). https://doi.org/10.1007/s10639-024-12778-w

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Does a perceptual gap lead to actions against digital misinformation? A third-person effect study among medical students

• Zongya Li   ORCID: orcid.org/0000-0002-4479-5971 1 &
• Jun Yan   ORCID: orcid.org/0000-0002-9539-8466 1  

BMC Public Health volume  24 , Article number:  1291 ( 2024 ) Cite this article

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We are making progress in the fight against health-related misinformation, but mass participation and active engagement are far from adequate. Focusing on pre-professional medical students with above-average medical knowledge, our study examined whether and how third-person perceptions (TPP), which hypothesize that people tend to perceive media messages as having a greater effect on others than on themselves, would motivate their actions against misinformation.

We collected the cross-sectional data through a self-administered paper-and-pencil survey of 1,500 medical students in China during April 2022.

Structural equation modeling (SEM) analysis, showed that TPP was negatively associated with medical students’ actions against digital misinformation, including rebuttal of misinformation and promotion of corrective information. However, self-efficacy and collectivism served as positive predictors of both actions. Additionally, we found professional identification failed to play a significant role in influencing TPP, while digital misinformation self-efficacy was found to broaden the third-person perceptual gap and collectivism tended to reduce the perceptual bias significantly.

Conclusions

Our study contributes both to theory and practice. It extends the third-person effect theory by moving beyond the examination of restrictive actions and toward the exploration of corrective and promotional actions in the context of misinformation., It also lends a new perspective to the current efforts to counter digital misinformation; involving pre-professionals (in this case, medical students) in the fight.

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Introduction

The widespread persistence of misinformation in the social media environment calls for effective strategies to mitigate the threat to our society [ 1 ]. Misinformation has received substantial scholarly attention in recent years [ 2 ], and solution-oriented explorations have long been a focus but the subject remains underexplored [ 3 ].

Health professionals, particularly physicians and nurses, are highly expected to play a role in the fight against misinformation as they serve as the most trusted information sources regarding medical topics [ 4 ]. However, some barriers, such as limitations regarding time and digital skills, greatly hinder their efforts to tackle misinformation on social media [ 5 ].

Medical students (i.e., college students majoring in health/medical science), in contrast to medical faculty, have a greater potential to become the major force in dealing with digital misinformation as they are not only equipped with basic medical knowledge but generally possess greater social media skills than the former generation [ 6 ]. Few studies, to our knowledge, have tried to explore the potential of these pre-professionals in tackling misinformation. Our research thus fills the gap by specifically exploring how these pre-professionals can be motivated to fight against digital health-related misinformation.

The third-person perception (TPP), which states that people tend to perceive media messages as having a greater effect on others than on themselves [ 7 ], has been found to play an important role in influencing individuals’ coping strategies related to misinformation. But empirical exploration from this line of studies has yielded contradictory results. Some studies revealed that individuals who perceived a greater negative influence of misinformation on others than on themselves were more likely to take corrective actions to debunk misinformation [ 8 ]. In contrast, some research found that stronger TPP reduced individuals’ willingness to engage in misinformation correction [ 9 , 10 ]. Such conflicting findings impel us to examine the association between the third-person perception and medical students’ corrective actions in response to misinformation, thus attempting to unveil the underlying mechanisms that promote or inhibit these pre-professionals’ engagement with misinformation.

Researchers have also identified several perceptual factors that motivate individuals’ actions against misinformation, especially efficacy-related concepts (e.g., self-efficacy and health literacy) and normative variables (e.g., subjective norms and perceived responsibility) [ 3 , 8 , 9 ]. However, most studies devote attention to the general population; little is known about whether and how these factors affect medical students’ intentions to deal with misinformation. We recruited Chinese medical students in order to study a social group that is mutually influenced by cultural norms (collectivism in Chinese society) and professional norms. Meanwhile, systematic education and training equip medical students with abundant clinical knowledge and good levels of eHealth literacy [ 5 ], which enable them to have potential efficacy in tackling misinformation. Our study thus aims to examine how medical students’ self-efficacy, cultural norms (i.e., collectivism) and professional norms (i.e., professional identification) impact their actions against misinformation.

Previous research has found self-efficacy to be a reliable moderator of optimistic bias, the tendency for individuals to consider themselves as less likely to experience negative events but more likely to experience positive events as compared to others [ 11 , 12 , 13 ]. As TPP is thought to be a product of optimistic bias, accordingly, self-efficacy should have the potential to influence the magnitude of third-person perception [ 14 , 15 ]. Meanwhile, scholars also suggest that the magnitude of TPP is influenced by social distance corollary [ 16 , 17 ]. Simply put, individuals tend to perceive those who are more socially distant from them to be more susceptible to the influence of undesirable media than those who are socially proximal [ 18 , 19 , 20 ]. From a social identity perspective, collectivism and professional identification might moderate the relative distance between oneself and others while the directions of such effects differ [ 21 , 22 ]. For example, collectivists tend to perceive a smaller social distance between self and others as “they are less likely to view themselves as distinct or unique from others” [ 23 ]. In contrast, individuals who are highly identified with their professional community (i.e., medical community) are more likely to perceive a larger social distance between in-group members (including themselves) and out-group members [ 24 ]. In this way, collectivism and professional identification might exert different effects on TPP. On this basis, this study aims to examine whether and how medical students’ perceptions of professional identity, self-efficacy and collectivism influence the magnitude of TPP and in turn influence their actions against misinformation.

Our study builds a model that reflects the theoretical linkages among self-efficacy, collectivism, professional identity, TPP, and actions against misinformation. The model, which clarifies the key antecedents of TPP and examines the mediating role of TPP, contribute to the third-person effect literature and offer practical contributions to countering digital misinformation.

Context of the study

As pre-professionals equipped with specialized knowledge and skills, medical students have been involved in efforts in health communication and promotion during the pandemic. For instance, thousands of medical students have participated in various volunteering activities in the fight against COVID-19, such as case data visualization [ 25 ], psychological counseling [ 26 ], and providing online consultations [ 27 ]. Due to the shortage of medical personnel and the burden of work, some medical schools also encouraged their students to participate in health care assistance in hospitals during the pandemic [ 28 , 29 ].

The flood of COVID-19 related misinformation has posed an additional threat to and burden on public health. We have an opportunity to address this issue and respond to the general public’s call for guidance from the medical community about COVID-19 by engaging medical students as a main force in the fight against coronavirus related misinformation.

Literature review

The third-person effect in the misinformation context.

Originally proposed by Davison [ 7 ], the third-person effect hypothesizes that people tend to perceive a greater effect of mass media on others than on themselves. Specifically, the TPE consists of two key components: the perceptual and the behavioral [ 16 ]. The perceptual component centers on the perceptual gap where individuals tend to perceive that others are more influenced by media messages than themselves. The behavioral component refers to the behavioral outcomes of the self-other perceptual gap in which people act in accordance with such perceptual asymmetry.

According to Perloff [ 30 ], the TPE is contingent upon situations. For instance, one general finding suggests that when media messages are considered socially undesirable, nonbeneficial, or involving risks, the TPE will get amplified [ 16 ]. Misinformation characterized as inaccurate, misleading, and even false, is regarded as undesirable in nature [ 31 ]. Based on this line of reasoning, we anticipate that people will tend to perceive that others would be more influenced by misinformation than themselves.

Recent studies also provide empirical evidence of the TPE in the context of misinformation [ 32 ]. For instance, an online survey of 511 Chinese respondents conducted by Liu and Huang [ 33 ] revealed that individuals would perceive others to be more vulnerable to the negative influence of COVID-19 digital disinformation. An examination of the TPE within a pre-professional group – the medical students–will allow our study to examine the TPE scholarship in a particular population in the context of tackling misinformation.

Why TPE occurs among medical students: a social identity perspective

Of the works that have provided explanations for the TPE, the well-known ones include self-enhancement [ 34 ], attributional bias [ 35 ], self-categorization theory [ 36 ], and the exposure hypothesis [ 19 ]. In this study, we argue for a social identity perspective as being an important explanation for third-person effects of misinformation among medical students [ 36 , 37 ].

The social identity explanation suggests that people define themselves in terms of their group memberships and seek to maintain a positive self-image through favoring the members of their own groups over members of an outgroup, which is also known as downward comparison [ 38 , 39 ]. In intergroup settings, the tendency to evaluate their ingroups more positively than the outgroups will lead to an ingroup bias [ 40 ]. Such an ingroup bias is typically described as a trigger for the third-person effect as individuals consider themselves and their group members superior and less vulnerable to undesirable media messages than are others and outgroup members [ 20 ].

In the context of our study, medical students highly identified with the medical community tend to maintain a positive social identity through an intergroup comparison that favors the ingroup and derogates the outgroup (i.e., the general public). It is likely that medical students consider themselves belonging to the medical community and thus are more knowledgeable and smarter than the general public in health-related topics, leading them to perceive the general public as more vulnerable to health-related misinformation than themselves. Accordingly, we propose the following hypothesis:

H1: As medical students’ identification with the medical community increases, the TPP concerning digital misinformation will become larger.

What influences the magnitude of TPP

Previous studies have demonstrated that the magnitude of the third-person perception is influenced by a host of factors including efficacy beliefs [ 3 ] and cultural differences in self-construal [ 22 , 23 ]. Self-construal is defined as “a constellation of thoughts, feelings, and actions concerning the relationship of the self to others, and the self as distinct from others” [ 41 ]. Markus and Kitayama (1991) identified two dimensions of self-construal: Independent and interdependent. Generally, collectivists hold an interdependent view of the self that emphasizes harmony, relatedness, and places importance on belonging, whereas individualists tend to have an independent view of the self and thus view themselves as distinct and unique from others [ 42 ]. Accordingly, cultural values such as collectivism-individualism should also play a role in shaping third-person perception due to the adjustment that people make of the self-other social identity distance [ 22 ].

Set in a Chinese context aiming to explore the potential of individual-level approaches to deal with misinformation, this study examines whether collectivism (the prevailing cultural value in China) and self-efficacy (an important determinant of ones’ behavioral intentions) would affect the magnitude of TPP concerning misinformation and how such impact in turn would influence their actions against misinformation.

The impact of self-efficacy on TPP

Bandura [ 43 ] refers to self-efficacy as one’s perceived capability to perform a desired action required to overcome barriers or manage challenging situations. He also suggests understanding self-efficacy as “a differentiated set of self-beliefs linked to distinct realms of functioning” [ 44 ]. That is to say, self-efficacy should be specifically conceptualized and operationalized in accordance with specific contexts, activities, and tasks [ 45 ]. In the context of digital misinformation, this study defines self-efficacy as one’s belief in his/her abilities to identify and verify misinformation within an affordance-bounded social media environment [ 3 ].

Previous studies have found self-efficacy to be a reliable moderator of biased optimism, which indicates that the more efficacious individuals consider themselves, the greater biased optimism will be invoked [ 12 , 23 , 46 ]. Even if self-efficacy deals only with one’s assessment of self in performing a task, it can still create the other-self perceptual gap; individuals who perceive a higher self-efficacy tend to believe that they are more capable of controlling a stressful or challenging situation [ 12 , 14 ]. As such, they are likely to consider themselves less vulnerable to negative events than are others [ 23 ]. That is, individuals with higher levels of self-efficacy tend to underestimate the impact of harmful messages on themselves, thereby widening the other-self perceptual gap.

In the context of fake news, which is closely related to misinformation, scholars have confirmed that fake news efficacy (i.e., a belief in one’s capability to evaluate fake news [ 3 ]) may lead to a larger third-person perception. Based upon previous research evidence, we thus propose the following hypothesis:

H2: As medical students’ digital misinformation self-efficacy increases, the TPP concerning digital misinformation will become larger.

The influence of collectivism on TPP

Originally conceptualized as a societal-level construct [ 47 ], collectivism reflects a culture that highlights the importance of collective goals over individual goals, defines the self in relation to the group, and places great emphasis on conformity, harmony and interdependence [ 48 ]. Some scholars propose to also examine cultural values at the individual level as culture is embedded within every individual and could vary significantly among individuals, further exerting effects on their perceptions, attitudes, and behaviors [ 49 ]. Corresponding to the construct at the macro-cultural level, micro-psychometric collectivism which reflects personality tendencies is characterized by an interdependent view of the self, a strong sense of other-orientation, and a great concern for the public good [ 50 ].

A few prior studies have indicated that collectivism might influence the magnitude of TPP. For instance, Lee and Tamborini [ 23 ] found that collectivism had a significant negative effect on the magnitude of TPP concerning Internet pornography. Such an impact can be understood in terms of biased optimism and social distance. Collectivists tend to view themselves as an integral part of a greater social whole and consider themselves less differentiated from others [ 51 ]. Collectivism thus would mitigate the third-person perception due to a smaller perceived social distance between individuals and other social members and a lower level of comparative optimism [ 22 , 23 ]. Based on this line of reasoning, we thus propose the following hypothesis:

H3: As medical students’ collectivism increases, the TPP concerning digital misinformation will become smaller.

Behavioral consequences of TPE in the misinformation context

The behavioral consequences trigged by TPE have been classified into three categories: restrictive actions refer to support for censorship or regulation of socially undesirable content such as pornography or violence on television [ 52 ]; corrective action is a specific type of behavior where people seek to voice their own opinions and correct the perceived harmful or ambiguous messages [ 53 ]; promotional actions target at media content with desirable influence, such as advocating for public service announcements [ 24 ]. In a word, restriction, correction and promotion are potential behavioral outcomes of TPE concerning messages with varying valence of social desirability [ 16 ].

Restrictive action as an outcome of third-person perceptual bias (i.e., the perceptual component of TPE positing that people tend to perceive media messages to have a greater impact on others than on themselves) has received substantial scholarly attention in past decades; scholars thus suggest that TPE scholarship to go beyond this tradition and move toward the exploration of corrective and promotional behaviors [ 16 , 24 ]. Moreover, individual-level corrective and promotional actions deserve more investigation specifically in the context of countering misinformation, as efforts from networked citizens have been documented as an important supplement beyond institutional regulations (e.g., drafting policy initiatives to counter misinformation) and platform-based measures (e.g., improving platform algorithms for detecting misinformation) [ 8 ].

In this study, corrective action specifically refers to individuals’ reactive behaviors that seek to rectify misinformation; these include such actions as debunking online misinformation by commenting, flagging, or reporting it [ 3 , 54 ]. Promotional action involves advancing correct information online, including in response to misinformation that has already been disseminated to the public [ 55 ].

The impact of TPP on corrective and promotional actions

Either paternalism theory [ 56 ] or the protective motivation theory [ 57 ] can act as an explanatory framework for behavioral outcomes triggered by third-person perception. According to these theories, people act upon TPP as they think themselves to know better and feel obligated to protect those who are more vulnerable to negative media influence [ 58 ]. That is, corrective and promotional actions as behavioral consequences of TPP might be driven by a protective concern for others and a positive sense of themselves.

To date, several empirical studies across contexts have examined the link between TPP and corrective actions. Koo et al. [ 8 ], for instance, found TPP was not only positively related to respondents’ willingness to correct misinformation propagated by others, but also was positively associated with their self-correction. Other studies suggest that TPP motivates individuals to engage in both online and offline corrective political participation [ 59 ], give a thumbs down to a biased story [ 60 ], and implement corrective behaviors concerning “problematic” TV reality shows [ 16 ]. Based on previous research evidence, we thus propose the following hypothesis:

H4: Medical students with higher degrees of TPP will report greater intentions to correct digital misinformation.

Compared to correction, promotional behavior has received less attention in the TPE research. Promotion commonly occurs in a situation where harmful messages have already been disseminated to the public and others appear to have been influenced by these messages, and it serves as a remedial action to amplify messages with positive influence which may in turn mitigate the detrimental effects of harmful messages [ 16 ].

Within this line of studies, however, empirical studies provide mixed findings. Wei and Golan [ 24 ] found a positive association between TPP of desirable political ads and promotional social media activism such as posting or linking the ad on their social media accounts. Sun et al. [ 16 ] found a negative association between TPP regarding clarity and community-connection public service announcements (PSAs) and promotion behaviors such as advocating for airing more PSAs in TV shows.

As promotional action is still underexplored in the TPE research, and existing evidence for the link between TPP and promotion is indeed mixed, we thus propose an exploratory research question:

RQ1: What is the relationship between TPP and medical students’ intentions to promote corrective information?

The impact of self-efficacy and collectivism on actions against misinformation

According to social cognitive theory, people with higher levels of self-efficacy tend to believe they are competent and capable and are more likely to execute specific actions [ 43 ]. Within the context of digital misinformation, individuals might become more willing to engage in misinformation correction if they have enough knowledge and confidence to evaluate information, and possess sufficient skills to verify information through digital tools and services [ 61 ].

Accordingly, we assumed medical students with higher levels of digital misinformation self-efficacy would be likely to become more active in the fight against misinformation.

H5: Medical students with higher levels of digital misinformation self-efficacy will report greater intentions to (a) correct misinformation and (b) promote corrective information on social media.

Social actions of collectivists are strongly guided by prevailing social norms, collective responsibilities, and common interest, goals, and obligations [ 48 ]. Hence, highly collectivistic individuals are more likely to self-sacrifice for group interests and are more oriented toward pro-social behaviors, such as adopting pro-environmental behaviors [ 62 ], sharing knowledge [ 23 ], and providing help for people in need [ 63 ].

Fighting against misinformation is also considered to comprise altruism, especially self-engaged corrective and promotional actions, as such actions are costly to the actor (i.e., taking up time and energy) but could benefit the general public [ 61 ]. Accordingly, we assume collectivism might play a role in prompting people to engage in reactive behaviors against misinformation.

It is also noted that collectivist values are deeply rooted in Chinese society and were especially strongly advocated during the outbreak of COVID-19 with an attempt to motivate prosocial behaviors [ 63 ]. Accordingly, we expected that the more the medical students were oriented toward collectivist values, the more likely they would feel personally obliged and normatively motivated to engage in misinformation correction. However, as empirical evidence was quite limited, we proposed exploratory research questions:

RQ2: Will medical students with higher levels of collectivism report greater intentions to (a) correct misinformation and (b) promote corrective information on social media?

The theoretical model

To integrate both the antecedents and consequences of TPP, we proposed a theoretical model (as shown in Fig. 1 ) to examine how professional identification, self-efficacy and collectivism would influence the magnitude of TPP, and how such impact would in turn influence medical students’ intentions to correct digital misinformation and promote corrective information. Thus, RQ3 was proposed:

RQ3: Will the TPP mediate the impact of self-efficacy and collectivism on medical students’ intentions to (a) correct misinformation, and (b) promote corrective information on social media? Fig. 1 The proposed theoretical model. DMSE = Digital Misinformation Self-efficacy; PIMC = Professional Identification with Medical Community; ICDM = Intention to Correct Digital Misinformation; IPCI = Intention to Promote Corrective Information Full size image

To examine the proposed hypotheses, this study utilized cross-sectional survey data from medical students in Tongji Medical College (TJMC) of China. TJMC is one of the birthplaces of Chinese modern medical education and among the first universities and colleges that offer eight-year curricula on clinical medicine. Further, TJMC is located in Wuhan, the epicenter of the initial COVID-19 outbreaks, thus its students might find the pandemic especially relevant – and threatening – to them.

The survey instrument was pilot tested using a convenience sample of 58 respondents, leading to minor refinements to a few items. Upon approval from the university’s Institutional Research Board (IRB), the formal investigation was launched in TJMC during April 2022. Given the challenges of reaching the whole target population and acquiring an appropriate sampling frame, this study employed purposive and convenience sampling.

We first contacted four school counselors as survey administrators through email with a letter explaining the objective of the study and requesting cooperation. All survey administrators were trained by the principal investigator to help with the data collection in four majors (i.e., basic medicine, clinical medicine, nursing, and public health). Paper-and-pencil questionnaires were distributed to students on regular weekly departmental meetings of each major as students in all grades (including undergraduates, master students, and doctoral students) were required to attend the meeting. The projected time of completion of the survey was approximately 10–15 min. The survey administrators indicated to students that participation was voluntary, their responses would remain confidential and secure, and the data would be used only for academic purposes. Though a total of 1,500 participants took the survey, 17 responses were excluded from the analysis as they failed the attention filters. Ultimately, a total of 1,483 surveys were deemed valid for analysis.

Of the 1,483 respondents, 624 (42.10%) were men and 855 (57.70%) were women, and four did not identify gender. The average age of the sample was 22.00 ( SD  = 2.54, ranging from 17 to 40). Regarding the distribution of respondents’ majors, 387 (26.10%) were in basic medicine, 390 (26.30%) in clinical medicine, 307 (20.70%) in nursing, and 399 (26.90%) in public health. In terms of university class, 1,041 (70.40%) were undergraduates, 291 (19.70%) were working on their master degrees, 146 (9.90%) were doctoral students, and five did not identify their class data.

Measurement of key variables

Perceived effects of digital misinformation on oneself and on others.

Three modified items adapted from previous research [ 33 , 64 ] were employed to measure perceived effects of digital misinformation on oneself. Respondents were asked to indicate to what extent they agreed with the following: (1) I am frequently concerned that the information about COVID-19 I read on social media might be false; (2) Misinformation on social media might misguide my understanding of the coronavirus; (3) Misinformation on social media might influence my decisions regarding COVID-19. The response categories used a 7-point scale, where 1 meant “strongly disagree” and 7 meant “strongly agree.” The measure of perceived effects of digital misinformation on others consisted of four parallel items with the same statement except replacing “I” and “my” with “the general others” and “their”. The three “self” items were averaged to create a measure of “perceived effects on oneself” ( M  = 3.98, SD  = 1.49, α  = 0.87). The three “others” items were also added and averaged to form an index of “perceived effects on others” ( M  = 4.62, SD  = 1.32, α  = 0.87).

The perceived self-other disparity (TPP)

TPP was derived by subtracting perceived effects on oneself from perceived effects on others.

Professional identification with medical community

Professional identification was measured using a three item, 7-point Likert-type scale (1 =  strongly disagree , 7 =  strongly agree ) adapted from previous studies [ 65 , 66 ] by asking respondents to indicate to what extent they agreed with the following statements: (1) I would be proud to be a medical staff member in the future; (2) I am committed to my major; and (3) I will be in an occupation that matches my current major. The three items were thus averaged to create a composite measure of professional identification ( M  = 5.34, SD  = 1.37, α  = 0.88).

Digital misinformation self-efficacy

Modified from previous studies [ 3 ], self-efficacy was measured with three items. Respondents were asked to indicate on a 7-point Linkert scale from 1 (strongly disagree) to 7 (strongly agree) their agreement with the following: (1) I think I can identify misinformation relating to COVID-19 on social media by myself; (2) I know how to verify misinformation regarding COVID-19 by using digital tools such as Tencent Jiaozhen Footnote 1 and Piyao.org.cn Footnote 2 ; (3) I am confident in my ability to identify digital misinformation relating to COVID-19. A composite measure of self-efficacy was constructed by averaging the three items ( M  = 4.38, SD  = 1.14, α  = 0.77).

• Collectivism

Collectivism was measured using four items adapted from previous research [ 67 ], in which respondents were asked to indicate their agreement with the following statements on a 7-point scale, from 1 (strongly disagree) to 7 (strongly agree): (1) Individuals should sacrifice self-interest for the group; (2) Group welfare is more important than individual rewards; (3) Group success is more important than individual success; and (4) Group loyalty should be encouraged even if individual goals suffer. Therefore, the average of the four items was used to create a composite index of collectivism ( M  = 4.47, SD  = 1.30, α  = 0.89).

Intention to correct digital misinformation

We used three items adapted from past research [ 68 ] to measure respondents’ intention to correct misinformation on social media. All items were scored on a 7-point scale from 1 (very unlikely) to 7 (very likely): (1) I will post a comment saying that the information is wrong; (2) I will message the person who posts the misinformation to tell him/her the post is wrong; (3) I will track the progress of social media platforms in dealing with the wrong post (i.e., whether it’s deleted or corrected). A composite measure of “intention to correct digital misinformation” was constructed by adding the three items and dividing by three ( M  = 3.39, SD  = 1.43, α  = 0.81).

Intention to promote corrective information

On a 7-point scale ranging from 1 (very unlikely) to 7 (very likely), respondents were asked to indicate their intentions to (1) Retweet the corrective information about coronavirus on my social media account; (2) Share the corrective information about coronavirus with others through Social Networking Services. The two items were averaged to create a composite measure of “intention to promote corrective information” ( M  = 4.60, SD  = 1.68, r  = 0.77).

Control variables

We included gender, age, class (1 = undergraduate degree; 2 = master degree; 3 = doctoral degree), and clinical internship (0 = none; 1 = less than 0.5 year; 2 = 0.5 to 1.5 years; 3 = 1.5 to 3 years; 4 = more than 3 years) as control variables in the analyses. Additionally, coronavirus-related information exposure (i.e., how frequently they were exposed to information about COVID-19 on Weibo, WeChat, and QQ) and misinformation exposure on social media (i.e., how frequently they were exposed to misinformation about COVID-19 on Weibo, WeChat, and QQ) were also assessed as control variables because previous studies [ 69 , 70 ] had found them relevant to misinformation-related behaviors. Descriptive statistics and bivariate correlations between main variables were shown in Table 1 .

Statistical analysis

We ran confirmatory factor analysis (CFA) in Mplus (version 7.4, Muthén & Muthén, 1998) to ensure the construct validity of the scales. To examine the associations between variables and tested our hypotheses, we performed structural equation modeling (SEM). Mplus was chosen over other SEM statistical package mainly because the current data set included some missing data, and the Mplus has its strength in handling missing data using full-information maximum likelihood imputation, which enabled us to include all available data [ 71 , 72 ]. Meanwhile, Mplus also shows great flexibility in modelling when simultaneously handling continuous, categorical, observed, and latent variables in a variety of models. Further, Mplus provides a variety of useful information in a concise manner [ 73 ].

Table 2 shows the model fit information for the measurement and structural models. Five latent variables were specified in the measurement model. To test the measurement model, we examined the values of Cronbach’s alpha, composite reliability (CR), and average variance extracted (AVE) (Table 1 ). Cronbach’s alpha values ranged from 0.77 to 0.89. The CRs, which ranged from 0.78 to 0.91, exceeded the level of 0.70 recommended by Fornell (1982) and thus confirmed the internal consistency. The AVE estimates, which ranged from 0.54 to 0.78, exceeded the 0.50 lower limit recommended by Fornell and Larcker (1981), and thus supported convergent validity. All the square roots of AVE were greater than the off-diagonal correlations in the corresponding rows and columns [ 74 ]. Therefore, discriminant validity was assured. In a word, our measurement model showed sufficient convergence and discriminant validity.

Five model fit indices–the relative chi-square ratio (χ 2 / df ), the comparative fit index (CFI), the Tucker–Lewis index (TLI), the root mean square error of approximation (RMSEA), and the standardized root-mean-square residual (SRMR) were used to assess the model. Specifically, the normed chi-square between 1 and 5 is acceptable [ 75 ]. TLI and CFI over 0.95 are considered acceptable, SRMR value less than 0.08 and RMSEA value less than 0.06 indicate good fit [ 76 ]. Based on these criteria, the model was found to have an acceptable fit to the data.

Figure 2 presents the results of our hypothesized model. H1 was rejected as professional identification failed to predict TPP ( β  = 0.06, p  > 0.05). Self-efficacy was positively associated with TPP ( β  = 0.14, p  < 0.001) while collectivism was negatively related to TPP ( β  = -0.10, p  < 0.01), lending support to H2 and H3.

Note. N  = 1,483. The coefficients of relationships between latent variables are standardized beta coefficients. Significant paths are indicated by solid line; non-significant paths are indicated by dotted lines. * p  < .05, ** p  < .01; *** p  < .001. DMSE = Digital Misinformation Self-efficacy; PIMC = Professional Identification with Medical Community; ICDM = Intention to Correct Digital Misinformation; IPCI = Intention to Promote Corrective Information

H4 posited that medical students with higher degrees of TPP would report greater intentions to correct digital misinformation. However, we found a negative association between TPP and intentions to correct misinformation ( β  = -0.12, p  < 0.001). H4 was thus rejected. Regarding RQ1, results revealed that TPP was negatively associated with intentions to promote corrective information ( β  = -0.08, p  < 0.05).

Further, our results supported H5 as we found that self-efficacy had a significant positive relationship with corrective intentions ( β  = 0.18, p  < 0.001) and promotional intentions ( β  = 0.32, p  < 0.001). Collectivism was also positively associated with intentions to correct misinformation ( β  = 0.14, p  < 0.001) and promote corrective information ( β  = 0.20, p  < 0.001), which answered RQ2.

Regarding RQ3 (see Table 3 ), TPP significantly mediated the relationship between self-efficacy and intentions to correct misinformation ( β  = -0.016), as well as the relationship between self-efficacy and intentions to promote corrective information ( β  = -0.011). However, TPP failed to mediate either the association between collectivism and corrective intentions ( β  = 0.011, ns ) or the association between collectivism and promotional intentions ( β  = 0.007, ns ).

Recent research has highlighted the role of health professionals and scientists in the fight against misinformation as they are considered knowledgeable, ethical, and reliable [ 5 , 77 ]. This study moved a step further by exploring the great potential of pre-professional medical students to tackle digital misinformation. Drawing on TPE theory, we investigated how medical students perceived the impact of digital misinformation, the influence of professional identification, self-efficacy and collectivism on these perceptions, and how these perceptions would in turn affect their actions against digital misinformation.

In line with prior studies [ 3 , 63 ], this research revealed that self-efficacy and collectivism played a significant role in influencing the magnitude of third-person perception, while professional identification had no significant impact on TPP. As shown in Table 1 , professional identification was positively associated with perceived effects of misinformation on oneself ( r  = 0.14, p  < 0.001) and on others ( r  = 0.20, p  < 0.001) simultaneously, which might result in a diminished TPP. What explains a shared or joint influence of professional identification on self and others? A potential explanation is that even medical staff had poor knowledge about the novel coronavirus during the initial outbreak [ 78 ]. Accordingly, identification with the medical community was insufficient to create an optimistic bias concerning identifying misinformation about COVID-19.

Our findings indicated that TPP was negatively associated with medical students’ intentions to correct misinformation and promote corrective information, which contradicted our hypotheses but was consistent with some previous TPP research conducted in the context of perceived risk [ 10 , 79 , 80 , 81 ]. For instance, Stavrositu and Kim (2014) found that increased TPP regarding cancer risk was negatively associated with behavioral intentions to engage in further cancer information search/exchange, as well as to adopt preventive lifestyle changes. Similarly, Wei et al. (2008) found concerning avian flu news that TPP negatively predicted the likelihood of engaging in actions such as seeking relevant information and getting vaccinated. In contrast, the perceived effects of avian flu news on oneself emerged as a positive predictor of intentions to take protective behavior.

Our study shows a similar pattern as perceived effects of misinformation on oneself were positively associated with intentions to correct misinformation ( r  = 0.06, p  < 0.05) and promote corrective information ( r  = 0.10, p  < 0.001, See Table 1 ). While the reasons for the behavioral patterns are rather elusive, such findings are indicative of human nature. When people perceive misinformation-related risk to be highly personally relevant, they do not take chances. However, when they perceive others to be more vulnerable than themselves, a set of sociopsychological dynamics such as self-defense mechanism, positive illusion, optimistic bias, and social comparison provide a restraint on people’s intention to engage in corrective and promotional actions against misinformation [ 81 ].

In addition to the indirect effects via TPP, our study also revealed that self-efficacy and collectivism serve as direct and powerful drivers of corrective and promotive actions. Consistent with previous literature [ 61 , 68 ], individuals will be more willing to engage in social corrections of misinformation if they possess enough knowledge, skills, abilities, and resources to identify misinformation, as correcting misinformation is difficult and their effort would not necessarily yield positive outcomes. Collectivists are also more likely to engage in misinformation correction as they are concerned for the public good and social benefits, aiming to protect vulnerable people from being misguided by misinformation [ 82 ].

This study offers some theoretical advancements. First, our study extends the TPE theory by moving beyond the examination of restrictive actions and toward the exploration of corrective and promotional actions in the context of misinformation. This exploratory investigation suggests that self-other asymmetry biased perception concerning misinformation did influence individuals’ actions against misinformation, but in an unexpected direction. The results also suggest that using TPP alone to predict behavioral outcomes was deficient as it only “focuses on differences between ‘self’ and ‘other’ while ignoring situations in which the ‘self’ and ‘other’ are jointly influenced” [ 83 ]. Future research, therefore, could provide a more sophisticated understanding of third-person effects on behavior by comparing the difference of perceived effects on oneself, perceived effects on others, and the third-person perception in the pattern and strength of the effects on behavioral outcomes.

Moreover, institutionalized corrective solutions such as government and platform regulation are non-exhaustive [ 84 , 85 ]; it thus becomes critical to tap the great potential of the crowd to engage in the fight against misinformation [ 8 ] while so far, research on the motivations underlying users’ active countering of misinformation has been scarce. The current paper helps bridge this gap by exploring the role of self-efficacy and collectivism in predicting medical students’ intentions to correct misinformation and promote corrective information. We found a parallel impact of the self-ability-related factor and the collective-responsibility-related factor on intentions to correct misinformation and promote corrective information. That is, in a collectivist society like China, cultivating a sense of collective responsibility and obligation in tackling misinformation (i.e., a persuasive story told with an emphasis on collective interests of social corrections of misinformation), in parallel with systematic medical education and digital literacy training (particularly, handling various fact-checking tools, acquiring Internet skills for information seeking and verification) would be effective methods to encourage medical students to engage in active countering behaviors against misinformation. Moreover, such an effective means of encouraging social corrections of misinformation might also be applied to the general public.

In practical terms, this study lends new perspectives to the current efforts in dealing with digital misinformation by involving pre-professionals (in this case, medical students) into the fight against misinformation. As digital natives, medical students usually spend more time online, have developed sophisticated digital competencies and are equipped with basic medical knowledge, thus possessing great potential in tackling digital misinformation. This study further sheds light on how to motivate medical students to become active in thwarting digital misinformation, which can help guide strategies to enlist pre-professionals to reduce the spread and threat of misinformation. For example, collectivism education in parallel with digital literacy training would help increase medical students’ sense of responsibility for and confidence in tackling misinformation, thus encouraging them to engage in active countering behaviors.

This study also has its limitations. First, the cross-sectional survey study did not allow us to justify causal claims. Granted, the proposed direction of causality in this study is in line with extant theorizing, but there is still a possibility of reverse causal relationships. To establish causality, experimental research or longitudinal studies would be more appropriate. Our second limitation lies in the generalizability of our findings. With the focus set on medical students in Chinese society, one should be cautious in generalizing the findings to other populations and cultures. For example, the effects of collectivism on actions against misinformation might differ in Eastern and Western cultures. Further studies would benefit from replication in diverse contexts and with diverse populations to increase the overall generalizability of our findings.

Drawing on TPE theory, our study revealed that TPP failed to motivate medical students to correct misinformation and promote corrective information. However, self-efficacy and collectivism were found to serve as direct and powerful drivers of corrective and promotive actions. Accordingly, in a collectivist society such as China’s, cultivating a sense of collective responsibility in tackling misinformation, in parallel with efficient personal efficacy interventions, would be effective methods to encourage medical students, even the general public, to actively engage in countering behaviors against misinformation.

Availability of data and materials

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

Tencent Jiaozhen Fact-Checking Platform which comprises the Tencent information verification tool allow users to check information authenticity through keyword searching. The tool is updated on a daily basis and adopts a human-machine collaboration approach to discovering, verifying, and refuting rumors and false information. For refuting rumors, Tencent Jiaozhen publishes verified content on the homepage of Tencent's rumor-refuting platform, and uses algorithms to accurately push this content to users exposed to the relevant rumors through the WeChat dispelling assistant.

Piyao.org.cn is hosted by the Internet Illegal Information Reporting Center under the Office of the Central Cyberspace Affairs Commission and operated by Xinhuanet.com. The platform is a website that collects statements from Twitter-like services, news portals and China's biggest search engine, Baidu, to refute online rumors and expose the scams of phishing websites. It has integrated over 40 local rumor-refuting platforms and uses artificial intelligence to identify rumors.

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Acknowledgements

We thank all participants and staff working for the project.

This work was supported by Humanities and Social Sciences Youth Foundation of the Ministry of Education of China (Grant No. 21YJC860012).

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Li, Z., Yan, J. Does a perceptual gap lead to actions against digital misinformation? A third-person effect study among medical students. BMC Public Health 24 , 1291 (2024). https://doi.org/10.1186/s12889-024-18763-9

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Short developmental milestone risk assessment tool to identify Duchenne muscular dystrophy in primary care

• Paula van Dommelen   ORCID: orcid.org/0000-0001-5546-6244 1 ,
• Oisín van Dijk 2 ,
• Jeroen A. de Wilde 2 &
• Paul H. Verkerk 1  

Orphanet Journal of Rare Diseases volume  19 , Article number:  192 ( 2024 ) Cite this article

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Metrics details

In patients without a family history, Duchenne muscular dystrophy (DMD) is typically diagnosed at around 4–5 years of age. It is important to diagnose DMD during infancy or toddler stage in order to have timely access to treatment, opportunities for reproductive options, prevention of potential fatal reactions to inhaled anesthetics, awareness of a child’s abilities needed for good parenting, and opportunities for enrolment in clinical trials.

We aimed to develop a short risk assessment tool based on developmental milestones that may contribute to the early detection of boys with DMD in primary care. As part of the case-control 4D-DMD study (Detection by Developmental Delay in Dutch boys with DMD), data on developmental milestones, symptoms and therapies for 76 boys with DMD and 12,414 boys from a control group were extracted from the health records of youth health care services and questionnaires. Multiple imputation, diagnostic validity and pooled backward logistic regression analyses with DMD (yes/no) as the dependent variable and attainment of 26 milestones until 36 months of age (yes/no) as the independent variable were performed. Descriptive statistics on symptoms and therapies were provided.

A tool with seven milestones assessed at specific ages between 12 and 36 months resulted in a sensitivity of 79% (95CI:67–88%), a specificity of 95.8% (95%CI:95.3–96.2), and a positive predictive value of 1:268 boys. Boys with DMD often had symptoms (e.g. 43% had calf muscle pseudohypertrophy) and were referred to therapy (e.g. 59% for physical therapy) before diagnosis.

This tool followed by the examination of other DMD-related symptoms could be used by youth health care professionals during day-to-day health assessments in the general population to flag children who require further action.

Conclusions

The majority of boys (79%) with DMD can be identified between 12 and 36 months of age with this tool. It increases the initial a priori risk of DMD from 1 in 5,000 to approximately 1 in 268 boys. We expect that other neuromuscular disorders and disabilities can also be found with this tool.

Worldwide, health care professionals often use monitoring tools to test the developmental skills of infants and toddlers [ 1 , 2 ]. An important goal of monitoring child development is the early identification of a wide range of disorders that impact child development. Typically, ‘red flags’ for milestone attainment are set at approximately the 90th percentile, i.e. with 90% of children attaining the milestone. However, if a child fails to attain a milestone, it is still uncertain if and to what extent the risk of a disorder is increased. For many disorders it is unknown how the monitoring tools can be optimally used to have a high sensitivity and specificity at field level.

One of such disorders is Duchenne muscular dystrophy (DMD). DMD is an inherited X-linked recessive neuromuscular disorder affecting approximately 1 in 5000 live male births [ 3 , 4 ]. DMD is typically diagnosed at around 4–5 years of age [ 5 , 6 , 7 ]. It is important to diagnose DMD during infancy or at the toddler stage in order to have timely access to treatment [ 8 , 9 ], opportunities for reproductive options, prevention of potential fatal reactions to inhaled anesthetics [ 10 ], awareness of a child’s abilities needed for good parenting, and opportunities for enrolment in clinical trials [ 11 ].

Previous studies have shown that more children with DMD fail to attain some developmental milestones compared to the general population [ 12 , 13 , 14 , 15 , 16 , 17 ]. Studies also recognized diagnostic delay despite parents noticing signs and symptoms in their child that are characteristic of DMD [ 5 ]. Several risk assessment tools were reported including developmental milestones for DMD [ 5 , 18 , 19 ]. These tools suggest performing a serum creatine kinase (CK) test if a child is unable to walk at 16–18 months [ 5 , 18 , 19 ], shows Gowers’ sign [ 19 ], or does not use at least ten recognizable words at 24 months of age [ 18 ]. However, the diagnostic validity of these tools was not assessed. Therefore, the tools do not indicate the increased risk of DMD given a developmental delay.

Our previous research investigated the diagnostic validity of a large number of individual milestones and showed that the milestones ‘walks well alone at 24 months’ and ‘walks smoothly at 36 months’ were most promising in detecting boys with DMD [ 17 ]. However, a tool that uses combinations of milestones may improve the diagnostic validity. Since there is a wide variation in the selection of milestones and the timing of their use worldwide, a short tool is needed to implement this in the primary care workflow to improve the early detection of DMD.

The aim of this study is to develop a short risk assessment tool based on developmental milestones for the early detection of DMD with acceptable diagnostic properties that can be easily applied during day-to-day health assessments in the general population.

Data collection

Within the 4D-DMD study (Detection by Developmental Delay in Dutch boys with DMD) with a case-control design, data were collected from: (1) health records of boys with DMD; characteristics, referrals to secondary and tertiary care, educational interventions, clinical descriptions typical of DMD, and developmental scores; (2) questionnaires completed by parents of boys with DMD; type of diagnosis, recall of developmental milestones, health care referrals, symptoms, concerns; and (3) health records of a control group of a general population of boys from the Youth Health Care (YHC) of The Hague (one boy with diagnosed DMD was excluded); characteristics, developmental scores, and referrals to other health professionals.

The diagnosis and date of diagnosis were obtained from the Dutch DMD patient registry. More information about the data collection within the 4D-DMD study is available in our previous research [ 17 ].

Developmental milestones

In the Netherlands, there is a well-organized YHC system, where 95% of all children are seen at regular visits [ 20 ]. Basic care within the Dutch YHC is supported by 35 evidence-based guidelines and validated screening tools [ 21 ], facilitating referrals as necessary. In the Netherlands, the Dutch Development Instrument (DDI) [ 22 ], a modification of the Gesell test, is used by YHC to assess the development of children. The DDI is mentioned in seven YHC guidelines, and among these, one guideline is dedicated to language development and one to motor development. However, none of these guidelines specifically address DMD. The DDI is a set of 75 developmental milestones that cover three domains of child development: (1) fine motor activity, adaptive behaviour, and personal/social behaviour; (2) communication; and (3) gross motor activity. The DDI is administered by trained YHC professionals at visits scheduled at the ages of 1, 2, 3, 6, 9, 12, 15, 18, 24, 30, 36, 42, and 48 months. For this study, we selected milestones up until 36 months of age. In many Dutch YHC services visits at 30 months are only scheduled for children considered at risk. Therefore, milestones registered during this visit were excluded. YHC professionals administer and register each milestone according to a uniform protocol. Two to seven specific milestones are registered in the health records at each visit. Some milestones may also be registered based on observations made by caregivers if the behaviour is not observed during the examination.

Statistical analysis

To develop the short risk assessment tool to identify boys with DMD that could easily be used in daily practice of primary care, we needed to determine which and to what extent the developmental milestones independently contribute to the risk of DMD. We applied the following six steps:

Pre-selection of data

Previous research within the 4D-DMD study showed that 26 milestones between 2 and 36 months were univariate significant at 0.01 level or lower between the DMD and control group [ 17 ]. For this study, we selected these 26 milestones to reduce the number of variables for the imputation in step 2, because the sample size in the DMD group does not allow a large number of variables.

From incomplete to complete data

Multiple imputation was applied in both groups (DMD, control) to predict missing data in the 26 milestones (see appendix for the observed and missing values) [ 23 ]. In total, 50 predictions were conducted to account for missing data uncertainty.

Models to obtain selection of milestones for the short risk assessment tool

We developed five age-dependent models for the early identification of DMD using milestones up until (1) 12 months, (2) 15 months, (3) 18 months, (4) 24 months, and (5) 36 months of age. For each prediction, logistic regression analyses were performed and afterwards pooled to test the impact of the milestones (independent variables) on group (DMD vs. control) outcome. Backward stepwise regression was applied on the pooled models till all remaining variables were significant at 0.05 level in the final model. We selected milestones that were statistically significantly associated with the outcome (DMD yes/no) in one or more of the final age-dependent models. Milestones that were not significant in all models (but significant in at least one model) were also taken into account, because these milestones may reduce the age of detection.

From model parameters to simple weighing factors

In order to create one practical tool that can be easily implemented in daily practice, we investigated whether simple weighting factors with integer numbers can be used instead of employing computer-intensive regression models. We tried several weighting factors (1 to 13) for each selected milestone from step 3 and calculated the sum score after weighting each milestone (with 1 point for a fail on a milestone and 0 points for a pass on a milestone or a when a milestone is not assessed) to achieve the highest predictive value. Note that a higher weight for a milestone implies a greater likelihood that the boy has DMD when the boy fails this milestone.

Predictive value of the cut-off values for the sum score

We then applied cut-off values for the sum score to calculate the sensitivity (% of referrals according to the tool within the DMD group) and specificity (% of non-referrals according to the tool within the control group), and the positive predictive value (PPV: how many boys with DMD are available within the referrals according to the tool assuming a prevalence of 1:5000 live male births). The negative predictive value (NPV: how many controls are available within the non-referrals according to the tool assuming a prevalence of 1:5000 live male births) was not calculated, because the prevalence of DMD is low and results in a NPV of almost 100%.

Selection of optimal cut-off values for the sum score

We obtained the most optimal weighting factors and cut-off value by choosing the highest sensitivity at a fixed specificity of approximately 95%. As a condition, the weighting factor for the milestone walks smoothly at 36 months was set at the highest cut-off value, because of the high risk of DMD. Also, up until 15 months of age, failures of at least two milestones were selected to reduce the number of false-positives at an early age.

All analyses were conducted in R Version 3.4.4 and SPSS Version 25.

The parents of 229 boys with DMD who met the inclusion criteria were invited to participate. In total, 87 boys with DMD and/or their parents gave written permission for retrieval of their health records. Retrieval was unsuccessful in ten cases: data were missing or not available for nine and one boy did not survive during retrieval of his records. In total, the health records of 76 boys with DMD were received. In addition, 71 parents of boys with DMD fully or partly completed the questionnaire.

Epidemiological and disease characteristics of boys with DMD and the general population are summarized in Table  1 . The proportions of boys with DMD (cases) and boys without DMD (controls) who failed the developmental milestones at each age in the observed (YHC and Questionnaire) and imputed data (YHC) are shown in the appendix .

A total of 570 referrals to 45 different healthcare providers or pedagogical interventions were extracted from the YHC records with a mean result of 7.5 referrals per boy with DMD. We combined data when data were available from both the YHC records and the Questionnaire (Q). A high number of undiagnosed boys with DMD were already referred to physiotherapy (26% aged 0-0.99y and 39% aged 1-3.99y, speech-language therapist (17%), Ear-Nose-Throat (ENT)-specialist (16%, YHC data) and preschool educational intervention (9%, YHC data). Symptoms that appeared often in DMD boys were pseudohypertrophy of the calf muscles (43%), falling more frequently compared to peers (27%, YHC data), stiff gait (19%, YHC data), a younger appearance than his chronological age (which may be related to behaviour and/or growth) (11%, YHC data). Between 0-3.99y, three in four parents of boys with DMD (77%, Q data) had concerns about their child’s developmental delay, mainly concerning their motor skills (85% out of concerned parents). Between 0-3.99y, approximately one in ten undiagnosed boys with DMD (11%, Q data) required surgery and were exposed to inhalational agents during surgery.

Table  2 shows the results from the five age-dependent pooled logistic regression models after stepwise backward regression on the developmental milestones. The footnote of Table  3 provides a detailed description of each milestone. Independent predictors of DMD were failing for ‘pulls up to standing position’, ‘reacts to a verbal request’, and ‘sits in stable position without support’ at 12 months, ‘crawls abdomen off the floor’ at 15 months, ‘walks alone’ at 18 months, ‘walks well’ at 24 months, and ‘walks smoothly’ at 36 months. Milestones before the age of 12 months were not statistically significant after adjustment for the milestones at 12 months of age. In total, seven milestones were independent predictors of DMD. As these models (with different weighing factors and an exponential component) are not easy to use in daily practice, we simplified the weighing factors (with integer numbers and a linear instead of an exponential component) in the next step of the analysis using these seven milestones.

Table  3 shows the results of the most optimal weighting factors and diagnostic value for the independent predictors of DMD. A higher sum score increased PPV and specificity, but decreased sensitivity. With this tool and a cut-off of 3 for the sum score, approximately eight out of ten boys may be identified by their development between 12 and 36 months of age and seven out of ten boys between 12 and 24 months of age. Further analyses on patients by mutation type revealed that the detection rate of the tool with a cut-off of 3 for the sum score was 73% in patients with a deletion in DMD-gene ( n  = 40), 73% with an insertion in DMD-gene ( n  = 12), 64% with a small or other mutation ( n  = 12) and 88% in patients for whom the type of mutation was unknown.

The main finding of our study was that a combination of developmental milestones (six gross motor activity and one communication) assessed at specific ages may be a useful tool for primary care to identify boys at increased risk of DMD. Our study shows that the tool has the potential to detect eight in ten boys with DMD between 12 and 36 month of age. A sum score of ≥ 3 according to the tool increases the initial a priori risk of DMD from 1 in 5,000 to approximately 1 in 268 boys. Other findings of our study are that undiagnosed boys often had symptoms (e.g. 43% had calf muscle pseudohypertrophy) and were referred to therapy (e.g. 59% for physical therapy).

Important factors when choosing values for sensitivity and specificity of the tool include the prevalence and severity of the disease, the consequences of not detecting the disease, the importance of early detection and avoiding needless parental concern. In the recommendations on developmental screening tests from the American Academy of Pediatrics, sensitivity and specificity levels of 70–80% are considered acceptable [ 24 ]. In our study we selected higher specificity levels, because a low prevalence in combination with a relatively low specificity results in a low PPV. Therefore, we decided to develop a risk assessment tool instead of a screening tool, because the majority of disorders with a low prevalence cannot easily be found with factors others than blood or gene tests. However, in the case of developmental delay, other disorders that impact development may also be included in the prevalence. In total, 0.16% of all children have a neuromuscular disorder [ 25 ] and 5% have some type of moderate to severe disability [ 26 ]. We have, therefore, selected a minimum specificity of 95%. For many of these children, further investigation of the developmental delay may be helpful, because our previous research showed that disorders that impact development cannot always be regarded as isolated disorders [ 17 , 27 ].

With the present system, many boys with DMD are detected later than desired. Implementation of this tool in the Netherlands may improve this. Our tool is constructed in such a way that it can be easily implemented in other health care systems. Several of the milestones in the short risk assessment tool (not able to walk at 18 months [ 5 , 18 , 19 ]) and further specifications (weakness, toe walking, abnormal or clumsy gait, frequent falls [ 12 , 18 , 19 ]) were also mentioned in the literature. More risk factors were previously found in other studies such as Gowers’ sign, difficulty climbing stairs [ 5 , 12 , 19 ], painful legs or joints [ 18 ], and the presence of non-motor delay such as delayed speech and language acquisition [ 12 , 13 , 18 , 19 ], poor cognition or behaviour problems [ 28 ]. Moreover, growth failure and obesity were reported more often in boys with DMD [ 29 ].

Taken all this information into account, we have several recommendations for the early detection of DMD.

Recommendations for practical use of the tool

The tool with the seven milestones (see Table  3 ) could be used by YHC professionals during day-to-day health assessments in the general population to flag children who require further action. Further investigation into the presence of symptoms for neuromuscular disorders or disabilities is needed.

Our study found that several symptoms were often reported. The following questions may, therefore, be relevant to investigate if the child (in this case a boy) has a sum score ≥ 3 according to the tool:

A family history of neuromuscular disease?

Any presence of DMD-specific symptoms (calf muscle pseudohypertrophy, stiffy gait, falls more frequently compared to peers, appears to be younger than his chronological age)?

Attend therapy for his motor and/or speech delay (physical, speech-language)? Visited an ENT-specialist?

Parental concerns about their child’s motor (and speech) delay?

Failures on other milestones (shown in the Appendix )?

Literature shows that other questions may also be relevant [ 5 , 12 , 18 , 19 , 28 , 29 , 30 , 31 , 32 ].

Increased head circumference, failure to thrive, overweight?

Difficulty with stair climbing?

Difficulty with running?

Inability to jump?

Decreased endurance?

Weakness of the proximal muscles (has to use their hands and arms to “walk” up their own body from a squatting position: Gowers’ sign)?

Toe walking?

Inability to keep up with peers?

Painful legs or joints?

Cognitive delay?

Learning and attentional issues?

Behaviour issues?

Autism spectrum disorder?

We recommend YHC professionals to register information from these questions, as well as data from other health care providers involved with the child, in the electronic health records. When the investigation is complete, one may decide to wait and monitor the development closely or consider CK testing, because CK is extremely elevated (50- to 200-fold above normal levels [ 5 ]) in boys with DMD and it is a relatively cheap and fast test. Especially in the situation where there are concerns, either by the parents or by one or more health care providers, we recommend a CK test. High levels of CK prompts referral to a pediatric neurologist, with input from a geneticist or genetic counsellor, to prevent diagnostic delay [ 5 ]. However, even with normal levels of CK, referral to a pediatric neurologist or other specialists may be necessary to reduce diagnostic delay in other neuromuscular disorders or some other type of developmental disability such as cerebral palsy, non-syndromic intellectual developmental disorder and autism. In view of the current incurability, the progressive course and the always fatal outcome of DMD, the most important therapeutic task in the early course of DMD is the medical, psychosocial and genetic counselling of families.

The tool should not be promoted as a screening tool for DMD, due to its relatively low positive predictive value, the potential for yielding abnormal results for other conditions besides DMD, and to avoid stress among families. It is important to investigate the adoption and acceptability of the tool before proceeding with implementation. One of the aspects that requires attention is the naming of the tool without emphasizing the condition DMD.

Compared to newborn screening (NBS) where CK levels are evaluated in the first screen, an advantage of this approach would be that a smaller group undergoes testing, and avoids the potential problem of NBS of elevated CK levels being elevated in newborns due to birth trauma [ 33 ]. A disadvantage is that approximately two in ten boys with DMD cannot be identified by the tool, and the tool will lead to false-positive results, although some of these may have another disorder that impact development. Moreover, our study shows that approximately one in ten undiagnosed boys with DMD had an increased risk of detrimental consequences due to the exposure to inhalational agents during surgery before they were four years of age. To prevent such risks, and given advances in diagnostics and promising therapeutic approaches, the discussion on inclusion of DMD in NBS should be continued.

Strengths and limitations

A strength of our study is that milestones were determined during real-world regular day-to-day health assessments in the general population. This increases the generalizability of our tool for use in daily practice. Furthermore, YHC professionals were mainly blinded for the diagnosis because most of the data were registered before the diagnosis of DMD was made. A limitation is that the number of observations varied between milestones and visits. Although YHC in the Netherlands is highly standardized, parents do not always attend all visits when their child is between 1 and 36 months of age. Also, health care professionals do not always register all milestones during a visit, partly, we believe, attributable to time pressure in YHC practice. However, approximately the same attendance rates and the same registration method occurred for both the DMD and the control groups. Moreover, we applied multiple imputation to adjust for missing values. Another limitation is that we were unable to explore the likelihood of referral within the current YHC setting due to the potential for concerns to arise from various sources, including YHC, parents/caregivers, childcare facilities, general practitioners, or others.

Our short risk assessment tool, which was based on combinations of developmental milestones at specific ages, combined with symptoms and referrals to therapy could be helpful in identifying boys with DMD. This tool is quick and easy to implement. A major advantage would be that it could enable the majority of boys (79%) with DMD to be identified between 12 and 36 months of age, and 71% between 12 and 24 months. We expect that other neuromuscular disorders and disabilities can also be found with this tool. With preparation and investigation into its adoption and acceptability, this tool can be integrated into the workflow of primary care practices [ 34 ]. Using a validated risk assessment tool at regular, repeated intervals, in addition to physician surveillance at well-child visits, may improve early detection [ 30 ]. We recommend more research with new datasets to validate the tool.

Data availability

It is not possible to share research data publicly, because individual privacy could be compromised.

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Acknowledgements

This research project was funded by the Duchenne Parent Project. We thank the Duchenne Parent Project and Spierziekten Nederland for their help with inclusion of the participants. We thank Ieke Ginjaar for her help with retrieving the age at diagnosis for the boys with DMD. We thank our sounding board with the following members: Jos Hendriksen, Nathalie Goemans, Selma van der Harst, the parents of boys with DMD. We thank Bettie Carmiggelt for her help with the questionnaire. We thank the YHC of The Hague for providing their data for this study. We thank all YHC workers who retrieved the health records from our boys with DMD. We thank all parents and boys with DMD who participated in our study.

Columns 1–3, 6–7 from Table 1 and columns 1–5, 9–11 from the Appendix are adapted from ‘van Dommelen P, van Dijk O, Wilde JA, Verkerk PH. Early developmental milestones in Duchenne muscular dystrophy. Dev Med Child Neurol 2020;62: 1198–1204’.

This research project was funded by the Duchenne Parent Project.

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Paula van Dommelen & Paul H. Verkerk

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PvD: substantial contributions to research design, the acquisition, analysis and interpretation of data, drafting the paper, approval of the submitted and final version. She had complete access to the study data that support the publication. OvD: substantial contributions to analysis and interpretation of data, drafting the paper, approval of the submitted and final version. He had complete access to the study data that support the publication. JAdW: substantial contributions to interpretation of data, revising the paper critically, approval of the submitted and final version. PHV: substantial contributions to research design, the acquisition, and interpretation of data, revising the paper critically, approval of the submitted and final version. He had complete access to the study data that support the publication.

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This research protocol (registration number: 2017-001) was submitted to the Nederlandse Organisatie voor toegepast-natuurwetenschappelijk onderzoek (TNO) Institutional Review Board (IRB). The IRB approved this non-interventional research proposal. In its deliberations, the IRB considered the research design and privacy aspects, in addition to the ethical aspects and the burden and the risks to the research participants. If parents and/or children (depending on the age of the child) agreed to participate, they were asked to provide written consent for collection of their health records, their date of diagnosis, and for publication of the results. We obtained permission from the Youth Health Care of The Hague to extract anonymous data from the electronic health records of all children born between 2011 and 2013 (control group).

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van Dommelen, P., van Dijk, O., de Wilde, J.A. et al. Short developmental milestone risk assessment tool to identify Duchenne muscular dystrophy in primary care. Orphanet J Rare Dis 19 , 192 (2024). https://doi.org/10.1186/s13023-024-03208-8

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DOI : https://doi.org/10.1186/s13023-024-03208-8

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• Pediatrics; neuromuscular disorder
• Child Development
• Developmental Delay
• Early Childhood Development
• Motor skills

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• Find out more

Take a look at ICAEW training films

Focusing on professional scepticism, ethics and everyday business challenges, our training films are used by firms and companies around the world to support their in-house training and business development teams.

Attract and retain the next generation of accounting and finance professionals with our world-leading accountancy qualifications. Become authorised to offer ACA training and help your business stay ahead.

CPD guidance and help

Continuing Professional Development (CPD) is an integral part of being a successful ICAEW Chartered Accountant. Find support on ICAEW's CPD requirements and access resources to help your professional development.

ICAEW flagship events

ICAEW boasts an extensive portfolio of industry-leading conferences. These flagship events offer the opportunity to hear from and interact with all the key players in the industry. Find out what's coming up.

Leadership Development Programmes

ICAEW Academy’s in-depth leadership development programmes take a holistic approach to combine insightful mentoring or coaching, to exclusive events, peer learning groups and workshops. Catering for those significant transitions in your career, these leadership development programmes are instrumental to achieving your ambitions or fulfilling your succession planning goals.

Specialist Finance Qualifications & Programmes

Whatever future path you choose, ICAEW will support the development and acceleration of your career at each stage to enhance your career.

Why a career in chartered accountancy?

If you think chartered accountants spend their lives confined to their desks, then think again. They are sitting on the boards of multinational companies, testifying in court and advising governments, as well as supporting charities and businesses from every industry all over the world.

• Why chartered accountancy?

Search for qualified ACA jobs

Matching highly skilled ICAEW members with attractive organisations seeking talented accountancy and finance professionals.

Volunteering roles

Helping skilled and in-demand chartered accountants give back and strengthen not-for-profit sector with currently over 2,300 organisations posting a variety of volunteering roles with ICAEW.

• Search for volunteer roles
• Get ahead by volunteering

Advertise with ICAEW

From as little as £495, access to a pool of highly qualified and ambitious ACA qualified members with searchable CVs.

Early careers and training

Start your ACA training with ICAEW. Find out why a career in chartered accountancy could be for you and how to become a chartered accountant.

Qualified ACA careers

Find Accountancy and Finance Jobs

Voluntary roles

Find Voluntary roles

While you pursue the most interesting and rewarding opportunities at every stage of your career, we’re here to offer you support whatever stage you are or wherever you are in the world and in whichever sector you have chosen to work.

• ACA students

"How to guides" for ACA students

• ACA student guide
• How to book an exam
• How to apply for credit for prior learning (CPL)

Exam resources

Here are some resources you will find useful while you study for the ACA qualification.

• Certificate Level
• Professional Level
• Advanced Level

Digital learning materials

All ACA learning materials are now digital only. Read our guide on how to access your learning materials on the ICAEW Bookshelf via the BibliU app, or through your browser.

• Read the guide

My online training file

Once you are registered as an ACA student, you'll be able to access your training file to log your progress throughout ACA training.

• Access your training file
• Student Insights

Fresh insights, innovative ideas and an inside look at the lives and careers of our ICAEW students and members.

• Read the latest articles

System status checks

Getting started.

Welcome to ICAEW! We have pulled together a selection of resources to help you get started with your ACA training, including our popular 'How To' series, which offers step-by-step guidance on everything from registering as an ACA student and applying for CPL, to using your online training file.

Credit for prior learning (CPL)

Credit for prior learning or CPL is our term for exemptions. High quality learning and assessment in other relevant qualifications is appropriately recognised by the award of CPL.

Apply for exams

What you need to know in order to apply for the ACA exams.

The ACA qualification has 15 modules over three levels. They are designed to complement the practical experience you will be gaining in the workplace. They will also enable you to gain in-depth knowledge across a broad range of topics in accountancy, finance and business. Here are some useful resources while you study.

Exam results

You will receive your results for all certificate level exams, the day after you take the exam and usually five weeks after a professional and advanced level exam session has taken place. access your latest and archived exam results here., training agreement.

Putting your theory work into practice is essential to complete your ACA training.

Student support and benefits

We are here to support you throughout your ACA journey. We have a range of resources and services on offer for you to unwrap, from exam resources, to student events and discount cards. Make sure you take advantage of the wealth of exclusive benefits available to you, all year round.

• Applying for membership

The ACA will open doors to limitless opportunities in all areas of accountancy, business and finance anywhere in the world. ICAEW Chartered Accountants work at the highest levels as finance directors, CEOs and partners of some of the world’s largest organisations.

ACA training FAQs

Do you have a question about the ACA training? Then look no further. Here, you can find answers to frequently asked questions relating to the ACA qualification and training. Find out more about each of the integrated components of the ACA, as well as more information on the syllabus, your training agreement, ICAEW’s rules and regulations and much more.

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Guidance and resources to help members comply with their legal and professional responsibilities around AML.

Technical releases

ICAEW Technical Releases are a source of good practice guidance on technical and practice issues relevant to ICAEW Chartered Accountants and other finance professionals.

• ICAEW Technical Releases
• Thought leadership

ICAEW's Thought Leadership reports provide clarity and insight on the current and future challenges to the accountancy profession. Our charitable trusts also provide funding for academic research into accountancy.

• Academic research funding

Technical Advisory Services helpsheets

Practical, technical and ethical guidance highlighting the most important issues for members, whether in practice or in business.

• ICAEW Technical Advisory Services helpsheets

Bloomsbury – free for eligible firms

In partnership with Bloomsbury Professional, ICAEW have provided eligible firms with free access to Bloomsbury’s comprehensive online library of around 80 titles from leading tax and accounting subject matter experts.

• Bloomsbury Accounting and Tax Service

Country resources

Our resources by country provide access to intelligence on over 170 countries and territories including economic forecasts, guides to doing business and information on the tax climate in each jurisdiction.

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Thought leadership, technical resources and professional guidance to support the professional development of members working in specific industries and sectors.

Audit and Assurance

The audit, assurance and internal audit area has information and guidance on technical and practical matters in relation to these three areas of practice. There are links to events, publications, technical help and audit representations.

The most up-to-date thought leadership, insights, technical resources and professional guidance to support ICAEW members working in and with industry with their professional development.

• Corporate Finance

Companies, advisers and investors making decisions about creating, developing and acquiring businesses – and the wide range of advisory careers that require this specialist professional expertise.

• Corporate governance

Corporate governance is the system by which companies are directed and controlled. Find out more about corporate governance principles, codes and reports, Board subcommittees, roles and responsibilities and shareholder relations. Corporate governance involves balancing the interests of a company’s many stakeholders, such as shareholders, employees, management, customers, suppliers, financiers and the community. Getting governance right is essential to build public trust in companies.

Corporate reporting

View a range of practical resources on UK GAAP, IFRS, UK regulation for company accounts and non-financial reporting. Plus find out more about the ICAEW Corporate Reporting Faculty.

Expert analysis on the latest national and international economic issues and trends, and interviews with prominent voices across the finance industry, alongside data on the state of the economy.

• Financial Services

View articles and resources on the financial services sector.

• Practice resources

For ICAEW's members in practice, this area brings together the most up-to-date thought leadership, technical resources and professional guidance to help you in your professional life.

Public Sector

Many ICAEW members work in or with the public sector to deliver public priorities and strong public finances. ICAEW acts in the public interest to support strong financial leadership and better financial management across the public sector – featuring transparency, accountability, governance and ethics – to ensure that public money is spent wisely and that public finances are sustainable.

Sustainability and climate change

Sustainability describes a world that does not live by eating into its capital, whether natural, economic or social. Members in practice, in business and private individuals all have a role to play if sustainability goals are to be met. The work being undertaken by ICAEW in this area is to change behaviour to drive sustainable outcomes.

The Tax area has information and guidance on technical and practical tax matters. There are links to events, the latest tax news and the Tax Faculty’s publications, including helpsheets, webinars and Tax representations.

Keep up-to-date with tech issues and developments, including artificial intelligence (AI), blockchain, big data, and cyber security.

Trust & Ethics

Guidance and resources on key issues, including economic crime, business law, better regulation and ethics. Read through ICAEW’s Code of Ethics and supporting information.

Communities

ICAEW Communities

Information, guidance and networking opportunities on industry sectors, professional specialisms and at various stages throughout your career. Free for ICAEW members and students.

• Discover a new community

ICAEW Faculties

The accountancy profession is facing change and uncertainty. The ICAEW Faculties can help by providing you with timely and relevant support.

• Choose to join any of the faculties

UK groups and societies

We have teams on the ground in: East of England, the Midlands, London and South East, Northern, South West, Yorkshire and Humberside, Wales and Scotland.

• Access your UK region
• Worldwide support and services

Support and services we offer our members in Africa, America, Canada, the Caribbean, Europe, Greater China, the Middle East, Oceania and South East Asia.

• Discover our services

ICAEW Faculties are 'centres of technical excellence', strongly committed to enhancing your professional development and helping you to meet your CPD requirements every year. They offer exclusive content, events and webinars, customised for your sector - which you should be able to easily record, when the time comes for the completion of your CPD declaration. Our offering isn't exclusive to Institute members. As a faculty member, the same resources are available to you to ensure you stay ahead of the competition.

Communities by industry / sector

Communities by life stage and workplace, communities by professional specialism, local groups and societies.

We aim to support you wherever in the world you work. Our regional offices and network of volunteers run events and provide access to local accounting updates in major finance centres around the globe.

• Ukraine crisis: central resource hub

Learn about the actions that ICAEW members are taking to ensure that their clients comply with sanctions imposed by different countries and jurisdictions, and read about the support available from ICAEW.

Insights pulls together the best opinion, analysis, interviews, videos and podcasts on the key issues affecting accountancy and business.

• See the latest insights
• Making COP count

This series looks at the role the accountancy profession can play in addressing the climate crisis and building a sustainable economy.

• Read more on COP28

Professional development and skills

With new requirements on ICAEW members for continuing professional development, we bring together resources to support you through the changes and look at the skills accountants need for the future.

• Visit the hub

When Chartered Accountants Save The World

Find out how chartered accountants are helping to tackle some of the most urgent social challenges within the UN Sustainable Development Goals, and explore how the profession could do even more.

• Read our major series

Insights specials

A listing of one-off Insights specials that focus on a particular subject, interviewing the key people, identifying developing trends and examining the underlying issues.

Top podcasts

Insights by topic.

ICAEW Regulation

• Regulatory News

View the latest regulatory updates and guidance and subscribe to our monthly newsletter, Regulatory & Conduct News.

• Regulatory Consultations

Strengthening trust in the profession

Our role as a world-leading improvement regulator is to strengthen trust and protect the public. We do this by enabling, evaluating and enforcing the highest standards in the profession. 

Regulatory applications

Find out how you can become authorised by ICAEW as a regulated firm. 

ICAEW codes and regulations

Professional conduct and complaints, statutory regulated services overseen by icaew, regulations for icaew practice members and firms, additional guidance and support, popular search results.

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• 10 Feb 2022

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